Nursing Center - Journal Issue

Keywords: Centers for Medicare and Medicaid Services EHR incentive programs, electronic health records, electronic medical records, health information technology, HITECH Act

Abstract

Overview: Health information technology (HIT) is a central aspect of current U.S. government efforts to reduce costs and improve the efficiency and safety of the health care system. A federal push to implement and enhance electronic health records (EHRs) has been supported by billions of dollars earmarked in the Health Information Technology for Economic and Clinical Health Act, passed as part of the 2009 American Recovery and Reinvestment Act. The goal has been to lay the groundwork for a HIT system that enables a more reliable exchange of information among practitioners and patients and significant improvements in the way care is delivered.

But what does this really mean for nurses? This article is the first in a series on HIT and nursing and will examine the federal policies behind efforts to expand the use of this technology as well as the implications for nurses. Subsequent articles will take a closer look at the use of EHRs to improve patient safety and quality of care, and the important role nurses are playing-and could play-in this system-wide initiative.

Health information technology (HIT) has been touted as a way to promote the free exchange of health information while protecting patients' privacy and improving the safety, efficacy, and quality of care. But these potential benefits have yet to be fully realized, in large part because there hasn't been the widespread adoption of standardized technology to create the infrastructure needed to achieve these goals. Even now, many nurses in the United States have only encountered "basic" HIT-essentially an electronic version of the paper chart.

Figure. Felita Ullah... - Click to enlarge in new window

Figure. Felita Ullah, RN, supervises nursing student Brya Ratcliff, during Ratcliff's practicum in the use of EHRs at Imperial Point Medical Center in Fort Lauderdale, Florida. Photo by Carey Wagner / ZUMA Press / Newscom.

In the past few years, the federal government has taken steps to encourage the implementation of standardized HIT with secure, interoperable systems that demonstrate "meaningful use"-described by Blumenthal and Tavenner as the use of electronic health records (EHRs) "to achieve significant improvements in care."1 These systems are designed to allow for the free exchange of information regardless of the location of the patient or provider, with the ultimate goal of creating a comprehensive national electronic health information framework that can lead to a reduction in the duplication of tests, an improvement in the cost-effectiveness of interventions, and the ability to compile a comprehensive patient history.2, 3

Supporters of HIT argue that, if broadly implemented in a meaningful way, it may prove invaluable in addressing such challenging and complex issues as steadily rising health care costs, an increasingly large uninsured population with inadequate access to care, and problems with patient safety and quality of care. A national infrastructure, it's envisioned, would allow for the exchange of health care information across settings, and clinical support tools embedded in EHRs would offer the potential to improve patient safety and quality of care while cutting costs resulting from reduced utilization.

AN OPPORTUNITY FOR NURSES

A review of several reports on nurses' attitudes toward EHRs shows varied reactions. Whereas some nurses have described the EHR as "cumbersome" and said it takes time away from direct patient care,4 others have had a more positive response, as evidenced by a study in Sweden that assessed nurses' attitudes toward EHRs approximately four years after they'd begun to be implemented.5 The increased use of standardized care plans and quality standards that resulted from the implementation of EHRs was seen by the Swedish nurses as a positive change, and one that would enable them to continue to provide high-quality patient care. Factors that appear to affect nurses' opinions are the EHR's usability and perceived usefulness, as well as the length of time since implementation. Nurses had a more positive opinion of EHRs one year after implementation than they did three months afterward, according to one study.6

In its 2010 report, The Future of Nursing: Leading Change, Advancing Health, the Institute of Medicine emphasizes the importance of nurses being a part of the selection, implementation, and execution of technology solutions for patient care.7 The report describes the way technology is creating a "new practice milieu" that features a "digital commons" in which all care providers will be able to access electronic and personal health records and shared support systems. One goal of such a system is to enhance the way multidisciplinary team members interact with each other and their patients.

Nurses represent the largest workforce within the health care delivery system and must be at the forefront of any care redesign based on the meaningful use of these new technologies.8-10 It's important that, as we rethink the way we record data and deliver care using HIT, we create patient-centered processes. The goal is not to institute technology for the sake of technology alone, but to create a more efficient and safe health care system that allows nurses to spend more time at the bedside.

FEDERAL INITIATIVES

In the spring of 2004, President Bush signed an executive order directing the Department of Health and Human Services to create the position of National Health Information Technology Coordinator (now called the National Coordinator for Health Information Technology). This appointment was part of a larger movement to establish EHRs for most Americans within 10 years to allow providers immediate access to accurate and secure information about patients, regardless of place of treatment.

The creation of a national, interoperable HIT framework is a daunting task, given the initially slow adoption of this technology by providers and hospitals. A 2009 study found that only 1.5% of U.S. hospitals had a comprehensive EHR system (present in all clinical units), 7.6% had a basic system (present in at least one clinical unit), and 17% had computerized provider order entry (CPOE) systems in place for medication orders.11 These percentages, however, have been rising significantly in recent years. Data obtained from the American Hospital Association's annual surveys and compiled by the Department of Health and Human Services show that, as of 2010, 15.1% of acute care nonfederal hospitals had instituted at least a basic EHR, compared with just 8.7% in 2008-a nearly 75% increase.12

The Obama administration, convinced like its predecessor of the potential benefits of this technology, has pushed ahead, appropriating billions of dollars in the Health Information Technology for Economic and Clinical Health (HITECH) Act-passed as part of the American Recovery and Reinvestment Act of 2009-to promote and accelerate the implementation and adoption of EHRs in hospitals and ambulatory care clinics by 2015. The legislation authorizes the Centers for Medicare and Medicaid Services (CMS) to give out to eligible providers approximately $19 billion over five years-financial incentives meant to offset the cost of purchasing and implementing EHR systems and to encourage the full adoption of these systems.

These EHR incentive programs require that eligible providers and hospitals adopt and implement electronic health systems and modules certified by the CMS; they must then demonstrate the meaningful use of this technology before receiving a monetary incentive. The Medicare incentive program is administered by the CMS, whereas the Medicaid incentive program is administered by each state and territory. Both programs launched in early 2011, but not all states and territories have programs up and running yet (to find out the status of a specific state program, go to http://www.cms.gov/apps/files/statecontacts.pdf). Medicare's program runs through 2016, whereas the Medicaid program goes until 2021 (although providers must begin participating by 2016). As the CMS Web site puts it, requiring the use of standardized technology is intended to ensure that providers are implementing systems with the "technological capability, functionality, and security to help them meet the meaningful use criteria" and to effectively "work with other systems to share information."

Are nurses 'eligible providers'? It's important to note that the federal government's definition of an "eligible" provider-the provider or facility qualified to receive these incentive payments-is different in the Medicare and Medicaid incentive programs. Doctors of medicine, osteopathy, dental surgery or medicine, podiatric medicine, and optometry as well as chiropractors are considered to be eligible Medicare providers, whereas Medicaid's definition includes physicians, dentists, certified nurse midwives, NPs, and physician assistants practicing in federally qualified health centers or rural health clinics led by a physician assistant. This means that NPs, for example, are eligible to apply for as much as $63,750 in incentives (over five years) from Medicaid when they meet the definition of and can demonstrate meaningful use. For more information on the financial incentives available to NPs and other Medicaid-eligible providers, go to http://go.cms.gov/LRgC2g.

A NATIONAL NETWORK

Since 2004 the Office of the National Coordinator for Health Information Technology has been supporting the development of a national network of providers and facilities that shares standards, policies, and services. While it presently comprises only a relatively small group of providers and facilities, the Nationwide Health Information Network Exchange (previously the National Health Information Network) is expected to grow significantly in the next few years-in part because of the Medicare and Medicaid EHR incentive programs-ultimately covering the care of most Americans.

Meaningful use. This endeavor recognizes that EHRs can only deliver on their potential when health care information and the EHR are standardized. One challenge is that many EHRs are not yet truly interoperable. For instance, a lack of standard terminology may prevent a clinical document created on one system's EHR from being read on another system.

In addition to certifying which electronic health systems and modules can be used, the federal government has defined what constitutes "meaningful use" of this technology. The American Recovery and Reinvestment Act details three components or stages of meaningful use (see http://go.cms.gov/LmRCj7 for more):

* using the technology in a meaningful manner (for example, the use of electronic prescriptions)

* using it to exchange health care information electronically, with the goal of improved quality of care

* using it to gather clinical quality measures

Thus providers and hospitals will initially use the technology to support the capture and sharing of point-of-care clinical data (stage I), followed by the use of electronic information systems that support more advanced clinical processes and the exchange of information (stage II), and finally, the use of a system that has the ability to effectively and efficiently utilize data to improve population health and quality of care outcomes (stage III) (see Figure 1). Those participating in the Medicare and Medicaid EHR incentive programs are asked to work toward achieving meaningful use over time (this can take several years), since the stages are progressively more technically challenging.

Figure 1 - Click to enlarge in new window

Figure 1. The Three Stages of Meaningful Use

Under the HITECH Act, key programs to support the growth of a national HIT infrastructure have been created, including (but not limited to) the State Health Information Exchange Cooperative Agreement Program and the Regional Extension Center Program, which has $677 million in funding from HITECH and aims to help educate and support at least 100,000 providers as they implement HIT. Sixty-two Regional Extension Centers are spread across the United States and its territories, providing training and support, technical assistance, and other guidance in an effort to speed and ease the adoption, implementation, and meaningful use of EHRs.

NURSING IMPLICATIONS

The Medicare and Medicaid EHR incentive programs detail objectives and measures that outline precisely how providers must use EHRs to improve the safety and quality of care.13 To be recognized as using technology meaningfully in stage I, for example, a provider must ensure that all 14 core measures are met and then choose to fulfill five of the 10 "menu set" measures (see Table 1).

Table 1 - Click to enlarge in new window

Table 1. EHR Meaningful Use Objectives and Their Likely Effect on Nursing

Based on our years of experience implementing EHR systems, we've noted in this table what we believe is the likely effect-low, medium, or high-of the meaningful use measures on day-to-day nursing practice. We believe, for instance, that the measures will have a high impact on nursing practice associated with CPOE, medication management, and patient education, but a low impact on documenting demographics and providing patients with a summary of their visit. When physicians use CPOE, nurses will now check the EHR for new orders instead of looking in a paper chart. By contrast, gathering additional demographic information-asking about the patient's ethnicity, for instance-shouldn't affect nurses much, because this information is most often collected during registration. In our experience, onerous electronic charting requirements are beginning to be offset by the time nurses save using biomedical device interfaces, which can electronically transfer data from medical devices such as ventilators and monitors into the EHR.

By focusing on the measures we believe will have the most significant impact on nursing practice, nurses may better prepare for the implementation of EHR systems in their facilities. In fact, nurses should expect to see EHR technology adopted at a much faster pace throughout the United States in the next couple of years, since according to American Hospital Association data, nearly 81% of acute care nonfederal hospitals plan to apply for payments through the Medicare and Medicaid incentive programs by 2012 (Medicare will impose penalties on those that don't apply by 2015).12

CPOE and electronic medication administration records are gradually replacing labor-intensive transcription tasks normally conducted by nurses. CPOE can improve quality of care and patient safety by preventing common prescribing errors 14 and eliminate nurses' frustration in the face of illegible written orders-which can, for instance, require a nurse to make extra phone calls to clarify what's written.

Bar code medication administration technology can help in the prevention of medication errors by allowing nurses to double-check medications by scanning them before administration. Patient wristbands and medications are verified by the system, which checks for the accuracy of the "rights of medication administration," such as right patient, right medication, and right dose, among others.

Work-arounds. Some have voiced concerns about the work-arounds in these systems, which may allow nurses or others to circumvent medication review and patient safety measures. While work-arounds may exist, bar codes add an additional layer of safety to the medication administration process not available prior to the emergence of EHRs.

Electronic documentation systems offer nurses the ability to document the care they provide, creating efficiencies with the use of templates and bedside medical device interfaces, such as a wall-mounted computer or laptop or tablet. Technologies are available today that allow for the import of bedside monitoring device data into the EHR through nurse verification instead of nurse transcription.15

Clinical decision support rules are a part of many HIT systems and can be customized to create warnings and reminders that assist nurses in keeping track of important tasks. For example, the system can automatically order follow-up tests based on the results of previous tests.

The introduction of EHRs will present nurses with specific challenges. Anecdotal reports show conflicting evidence regarding efficiencies and improved quality relating to EHRs,16-20 and although EHRs are expected to streamline certain processes for nurses, there is the possibility that switching to this new technology could compromise patient safety if users aren't properly educated on its use. In one ICU, physicians and nurses described how they were unable to simultaneously view the various types of information-order and problem lists, a vital signs graph, the medication list-they typically write on one large sheet of paper.21 The EHR contained this information, but accessing it required switching among several screens.

Nurses must be aware of the new types of errors EHRs can introduce, which may differ from those encountered in a paper chart system. Preparation for EHR implementation, therefore, requires at a minimum educational support for electronic documentation.

THE IMPORTANCE OF NURSE ENGAGEMENT

Nurses spend more time with patients than any other health care provider and thus have the opportunity to play crucial roles in implementing and achieving meaningful use of EHRs.22 It's important that nurses identify how they can make a difference in ensuring that this technology is used meaningfully. For example, nurses can utilize the data captured in the EHR to research care and inform the nursing community of their findings. Nursing informatics offers a new career path for those inclined to become involved in this rapidly expanding field. Other key roles include that of nurse executives with roles in decision making, advisors to a facility's committee on HIT, and those who act as "super users"-that is, the key HIT resource person on a unit. Specifics of how this can be accomplished will be provided in the third article in this series.

For its part, the American Nurses Association (ANA) has been urging the CMS, as it continues to develop its regulations on meaningful use, to ensure that patients and their caregivers have access to their EHRs.23 The ANA has also called for funding of team-based development and evaluation of clinical quality measures for EHRs, and recommended that Medicare and Medicaid incentive payments be extended to facilities and providers in other settings (long-term care facilities, for instance), citing an "urgent need" for advanced practice nurses to be eligible for the Medicare incentive payments in addition to those available through the state Medicaid programs.

If HIT systems are going to truly improve care, nurses need a voice in their planning and development to ensure patient safety and system usability. The success of this technology depends on nurses informing the industry-at all levels, from influencing federal policy to providing feedback to their department and facility leaders-about what works best for the patient and the clinician. If wisely implemented, HIT may eventually free up more time for nurses to spend at the bedside-caring for, assessing, and educating patients, and providing them with emotional support.