The Journey to Meaningful Use of Electronic Health Records EXECUTIVE SUMMARY The American Recovery and Reinvestment Act and its important Health Information Technology Act provision became law on February 17, 2009. Commonly referred to as “The Stimulus Bill” or “The Recovery Act,” the landmark legislation allocated $787 billion to stimulate the economy, including $147 billion to rescue and reform the nation’s seriously ailing health care industry. Of these funds, $19 billion in financial incentives were earmarked for the relatively short period of 5 years to drive reform through the use of advanced health information technology (HIT) and the adoption of electronic health records (EHRs). The incentives were intended to help health care providers purchase and implement HIT and EHR systems, and the HITECH Act also stipulated clear penalties would be imposed beyond 2015 for both hospitals and physician providers who failed to adopt use of EHRs in a meaningful way. Nurses will be integral to achieving a vision that will require a nationwide effort to adopt and implement EHR systems in a meaningful way.
2004, THOSE OF US IN nursing informatics or who follow health information technology (HIT) trends were thrilled when President George W. Bush said in his 2004 State of the Union address “…an Electronic Health Record for every American by the year 2014…by computerizing health records, we can avoid dangerous Judy Murphy medical mistakes, reduce costs, and improve care” (Bush, 2004). This was the first time a president formally recognized the value of HIT and set a deadline to do something about it! President Bush went on to establish the Office of the National
JUDY MURPHY, RN, FACMI, FHIMSS, is Vice President, Information Services, Aurora Health Care in Milwaukee, WI; a HIMSS Board Member; and a member of the federal HIT Standards Committee. Comments and suggestions can be sent to [email protected]
NOTE: Hear Judy speak on “The Economic$ for Meaningful Use of Health Information Technology” at the 4th Annual Nurse Faculty/Nurse Executive Summit, December 13-15, 2010, in Scottsdale, AZ. Visit www.nursingeconomics.net for Summit program and registration information.
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Coordinator for HIT (ONC), and Dr. David Brailer was appointed as the first coordinator by Tommy Thompson, then Secretary of the Department of Health and Human Services (HHS). The support continued. In 2005, funding from HHS was earmarked to establish organizations for standards harmonization (HIT Standards Panel) and for certification of electronic health record (EHR) systems (Certification Commission for HIT). In 2006, the Agency for Healthcare Research and Quality (AHRQ) launched its National Resource Center for HIT. Government attention persisted in 2007 with the funding of National Health Information Network prototypes. Momentum was building and there was much attention on HIT from the federal government. Fast forward to 2009. President-Elect Barack Obama says he wants the federal government to invest in EHRs so all medical records are digitized within 5 years and vows to continue to push for the 2014 deadline established by Bush. “This will cut waste, eliminate red tape, and reduce the need to repeat expensive medical tests,” he said, adding that the switch also will save lives by reducing the number of errors in medicine (Obama, 2009). President Obama then does more than talk about HIT. He works with Congress to pass the American Recovery and Reinvestment Act (ARRA), providing unprecedented funding to promote health care reform through the use of HIT. Incentives totaling $19 billion are allocated for “meaningful use” of EHRs in hospitals and ambulatory settings beginning in 2011. This sets the stage for today’s focus on the use of HIT, and the proliferation of EHR implementation projects in our clinical settings. Let’s explore the legislative background and details surrounding the federal incentives.
Legislative Background On March 23, 2010, President Obama signed into law the landmark Patient Protection and Affordable Care Act (PPACA), a federal statute that represents the most recent legislation in a sweeping health care reform agenda driven into law by the Democratic 111th Congress and the Obama Administration. The new law is dedicated to replacing a broken system with one that ensures all Americans have access to health care that is both affordable and driven by quality standards. It includes broad provisions for improving health care delivery that will take affect from the moment of enactment through 2018. For the Obama Administration, the hard-fought legislative success of PPACA turns the spotlight on
the growing recognition advanced HIT is and will be essential to support the massive amounts of electronic information exchange foundational to reform. In fact, the universal agreement that meaningful health care reform cannot be separated from the national, and arguably global, integration of HIT based on accepted, standardized, and interoperable methods of data exchange provided the linchpin for other critically important legislation that created the glide path for PPACA. This consensus resulted in the broad support and passage into law of the ARRA and its key Health Information Technology Act (HITECH) provision in the early weeks of Mr. Obama’s presidency in 2009. Backed with an allocation of over $19 billion, this legislation authorized the Centers for Medicare and Medicaid Services (CMS) to provide reimbursement incentives for hospitals and eligible providers that take steps to become “meaningful users” of certified EHR technology to improve care quality and better manage care costs. At the core of the new reform initiatives, the incentivized adoption of EHRs will improve care quality and better manage care costs, meeting clinical and business needs by capturing, storing, and displaying clinical information when and where it is needed to improve individual patient care and to provide aggregated, cross-patient data analysis. EHRs will manage health care data and information in ways that are patient centered and information rich. Improved information access and availability will increasingly enable both the provider and the patient to better manage each patient’s health by using capabilities provided by enhanced clinical decision support and customized education materials.
ARRA and its HITECH Act Provision ARRA and its important HITECH Act provision were passed into law on February 17, 2009. Commonly referred to as “The Stimulus Bill” or “The Recovery Act,” the landmark legislation allocated $787 billion to stimulate the economy, including $147 billion to rescue and reform the nation’s seriously ailing health care industry. Of these funds, $19 billion in financial incentives were earmarked for the relatively short period of 5 years to drive reform through the use of advanced HIT and the adoption of EHRs. The incentives were intended to help health care providers purchase and implement HIT and EHR systems, and the HITECH Act also stipulated clear penalties would be imposed beyond 2015 for both hospitals and physician providers who failed to adopt use of EHRs in a meaningful way. Here are some of the key components of ARRA (Murphy, 2010) and HITECH (Blumenthal, 2010; HITFHC, 2009a). Meaningful use. The majority of the HITECH funding will be used to reward hospitals and eligible
providers for “meaningful use” of certified EHRs by “meaningful users” with increased Medicare and Medicaid payments (HITFHC, 2009b; Murphy, 2009). Both programs have start dates of fiscal year 2011 (October 1, 2010) for hospitals and calendar year 2011 (January 1, 2011) for eligible providers. On December 31, 2009, the Centers for Medicare and Medicaid Services (CMS), with input from ONC and the HIT Policy and Standards Committees, published a Proposed Rule on Meaningful Use of EHRs and began a 60-day public comment period. After reviewing more than 2,000 comments, HHS issued the final rule on July 13, 2010. The final criteria for meeting “meaningful use” are divided into five initiatives: 1. Improve quality, safety, and efficiency, and reduce health disparities. 2. Engage patients and families. 3. Improve care coordination. 4. Improve population and public health. 5. Ensure adequate privacy and security protections for personal health information. Specific objectives were written to demonstrate that EHR use has a “meaningful” impact on one of the five initiatives. Under the final rule, there are 14 “core” (required) objectives for hospitals and 15 for providers. Both hospitals and providers have 10 other objectives in a “menu set” from which they must choose and comply with five. If the objectives are met during the specified year and the hospital or provider submits the appropriate measurements, then the hospitals or providers will receive the incentive payment. The hospital incentive amount is based on the Medicare and Medicaid patient volumes; the provider incentives are fixed per provider. The incentives are paid over 5 years, and the hospital or provider must submit measurement results annually during each of the years to continue to qualify. The objectives will mature every other year, with new criteria and standards being published in 2011, 2013, and 2015. Quality measures. One of the “meaningful use” criteria for both hospitals and providers is the requirement to report quality measures to either CMS (for Medicare) or to the state (for Medicaid). For providers, the final rule lists 44 measures, with a requirement to comply with six. For hospitals, the rule lists 15 measures, with a requirement to comply with them all. Because HHS will not be ready to electronically accept quality measure reporting in 2011, the Proposed Rule specifies that hospitals and eligible providers will submit summary information on clinical quality measures to CMS through attestation in 2011. HHS expects to be ready to electronically accept quality measure reporting in 2012, so hospitals and providers will be expected to submit their results on the clinical quality measures electronically beginning in 2012.
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nformatics nurses are key Iknowledge contributors to a working about how evidence-based practices The quality measurement push them to a new level of designed in information is considered one of the most sustainable health care quality systems can support and important components of the and efficiency. The communienhance clinical processes and ties are expected to generate incentive program under ARRA/HITECH, since the purlessons learned on how other decision making to improve pose of the HIT incentives is communities can achieve simpatient safety and outcomes. to promote reform in the ilar goals enabled by HIT. delivery, cost, and quality of Workforce training. Finally, health care in the United ARRA funding has also been States. Dr. David Blumenthal, designated to educate the workcurrent national coordinator force required to modernize the of HIT, emphasized this point when he said “HIT is health care system by promoting and expanding the the means, but not the end. Getting an EHR up and adoption of HIT by 2014. Four grant programs support running in health care is not the main objective behind the training and development of the necessary skilled the incentives provided by the federal government workforce: under ARRA. Improving health is. Promoting health • $32 million to establish nine university-based cercare reform is” (Blumenthal, 2009; Manos, 2009). tificate and advanced degree HIT training proResearch support. ARRA and HITECH increased grams, including one sponsored by the University funding by more than $1 billion for comparative of Colorado-Denver School of Nursing. effectiveness research through AHRQ and the • $360 million to create five regional community National Institutes of Health (NIH). In addition, NIH college consortia of more than 80 member comdesignated over $200 million for a new initiative munity colleges in all 50 states to help address the called the NIH Challenge Grants in Health and demand for skilled HIT specialists. Science Research. NIH anticipates funding 200 or • $10 million to support HIT education curriculum more grants, each up to $1 million, addressing specifdevelopment. ic scientific and health research challenges in bio• $6 million to develop an HIT competency examimedical and behavioral research. nation program. In addition, the National Library of Medicine Nursing Informatics Empowering Meaningful Use (NLM) offers applied informatics grants to healthIn this massive transformation from disconnectrelated and scientific organizations that wish to optied, inefficient, paper-based islands of care delivery to mize use of clinical and research information. These a nationwide, interconnected, and interoperable sysgrants help organizations exploit the capabilities of tem driven by EHRs and advancing HIT innovation, HIT to bring usable, useful biomedical knowledge to the importance of nurses and nursing informatics will end users by translating the findings of informatics be difficult to overstate. For decades, nurses have and information science research into practice proactively contributed resources to the developthrough novel or enhanced systems, incorporating ment, use, and evaluation of information systems. them into real-life systems and service settings. Today, they constitute the largest single group of SHARP grants. Alongside the NIH and NLM focus health care professionals, including experts who on incentivizing research, ONC also made available serve on national committees and participate in inter$60 million to support the development of Strategic operability initiatives focused on policy, standards Health IT Advanced Research Projects (SHARP). The and terminology development, standards harmonizaSHARP Program funds research focused on achieving tion, and EHR adoption. In their front-line roles, nursbreakthrough advances to address well-documented es continue to have a profound impact on the quality problems that have impeded adoption of HIT and and cost of health care and are emerging as leaders in accelerating progress toward achieving nationwide the effective use of HIT to improve the safety, quality, meaningful use of HIT in support of a high-performand efficiency of health care services. ing, continuously learning health care system. Informatics nurses are key contributors to a workBeacon communities. Also funded by HITECH, ing knowledge about how evidence-based practices the Beacon Community Program includes $250 mildesigned in information systems can support and lion in grants to build and strengthen the HIT infraenhance clinical processes and decision making to structure and HIT capabilities within 17 communiimprove patient safety and outcomes. In addition, as ties. These communities will demonstrate the future drivers in organizational planning and process rewhere hospitals, clinicians, and patients are meaningengineering to improve the health care delivery sysful users of HIT, and together the community achieves tem, informatics nurses are increasingly sought out by measurable improvements in health care quality, safenurses and nurse managers for leadership as their ty, efficiency, and population health. The funding was profession works to bring IT applications into the awarded to communities already at the cutting edge mainstream health care environment. of EHR adoption and health information exchange to
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Therefore, it will be increasingly essential to the success of today’s health care reform movement that informatics nurses are involved in every aspect of selecting, designing, testing, implementing, and developing health information systems. Further, the growing adoption of EHRs must incorporate nursing’s unique body of knowledge with the nursing process at its core.
The Future Many nursing and health care leaders agree that the future of nursing depends on a profession that will continue to innovate using HIT and informatics to play an instrumental role in patient safety, change management, and quality improvement, as evidenced by quality outcomes, enhanced workflow, and user acceptance. In an environment where the roles of all health care providers are diversifying, nurses will guide the profession from their positions as HIT project managers, consultants, educators, researchers, product developers, decision support and outcomes managers, chief clinical information officers, chief information officers, advocates, policy developers, entrepreneurs, and business owners. To achieve our nation’s health care reform goals, health care leaders must leverage the patient care technologies and information management competencies that informatics nurses provide to insure their investment in HIT and EHRs is implemented properly and effectively over coming years. In fact, in its October 2009 recommendations to the Robert Wood Johnson Foundation on the future of nursing, the Alliance for Nursing Informatics (ANI) argued nurses will be integral to achieving a vision that will require a nationwide effort to adopt and implement EHR systems in a meaningful way. “This is an incredible opportunity to build upon our understanding of effectiveness research, evidence-based practice, innovation and technology to optimize patient care and health outcomes. The future of nursing will rely on this transformation, as well as on the important role of nurses in enabling this digital revolution” (ANI, 2009, p. 9). For no professional group does the future hold more excitement and promise from so many perspectives than it does for nursing. $
Bush, G.W. (2004). State of the Union Address. (2004, January 20). Retrieved from http://whitehouse.georgebush.org/news/ 2004/012004-SOTU.asp Health Information Technology for the Future of Health and Care (HITFHC). (2009a). HITECH programs. Retrieved from http://healthit.hhs.gov/portal/server.pt?open=512&objID=14 87&parentname=CommunityPage&parentid=1&mode=2&in_ hi_userid=10741&cached=true Health Information Technology for the Future of Health and Care (HITFHC). (2009b). Meaningful use. Retrieved from http://healthit.hhs.gov/portal/server.pt?open=512&objID= 1325&mode=2 Obama, B. (2009). President-elect speaks on the need for urgent action on an American Recovery and Reinvestment Plan. Speech at George Mason University in Fairfax, Virginia, January 8, 2009. Retrieved from http://change.gov/newsroom/entry/presidentelect_obama_speaks_on_the_need_for_ urgent_action_on_an_american_r Manos, D. (2009). Healthcare IT is the means, but not the end, says Blumenthal. Healthcare IT News. Retrieved from http://www.healthcareitnews.com/news/healthcare-itmeans-not-end-says-blumenthal Murphy, J. (2010). This is our time: How ARRA changed the face of health IT. Journal of Healthcare Information Management, 24(1), 8-9. Murphy, J. (2009). Meaningful use for nursing: Six themes regarding the definition for meaningful use. Journal of Healthcare Information Management, 23(4), 9-11.
REFERENCES Alliance for Nursing Informatics (ANI). (2009). Statement to the Robert Wood Johnson Foundation Initiative Future of Nursing: Acute care, focusing on the area of technology. Retrieved from http://www.himss.org/handouts/ANI ResponsetoRWJ_IOMonTheFutureofNursing.pdf?src=winew s20091014 Blumenthal, D. (2009). National HIPAA Summit in Washington, DC. Retrieved from http://www.healthcareitnews.com/news/ healthcare-it-means-not-end-says-blumenthal Blumenthal, D. (2010). Launching HITECH. New England Journal of Medicine, 362(5), 382-385.
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