During orientation, new graduate nurses learn that no documentation translates to "not done." Many experienced nurses feel that only nursing colleagues should review their documentation and many believe that documentation is used as a legal defense maneuver. These beliefs are about to undergo a truly fundamental change with the American Recovery and Reinvestment Act (ARRA) and the concept of meaningful use. (See ARRA HITECH Act overview.)
Dr. David Blumenthal, director of the Office of the National Coordinator, states that "by focusing on meaningful use we recognize that better healthcare does not come solely from the adoption of technology itself, but through the exchange and use of health information to best inform clinical decisions at the point of care."1 Every healthcare provider will quickly need to become familiar with the Meaningful Use Matrix, the ARRA, and their impact on patients, hospitals, primary care practices, and public health. These new U.S. health policies contain key practice implications for nurses; let's examine the five health policy priorities as they relates to practice.
Improve quality, reduce disparities
A primary goal includes access to comprehensive patient health data for the healthcare team. Nursing will need to become diligent in capturing key patient clinical information in order to meet the goal of providing safer and more efficient delivery of care. If data elements aren't captured, information won't be available to maintain up-to-date advance directives, health problems, medications, allergies, vital signs, and patient-specific care plans. In addition, this information won't be available to share with healthcare providers within and among the organization, outside healthcare providers, and the community. By 2013, the meaningful use expectation is that organizations will utilize evidence-based orders sets, closed-loop medication management (electronic medication administration records [eMARs] and bar coding), and clinical decision support such as real-time reminders and alerts. All tools will improve quality, safety, and efficiency, and reduce health disparities. Clinical system use will be the mainstream in daily practice.
Engage patients and families
Another major priority is to provide patients and families with timely access to data, knowledge, and tools to make informed decisions and manage their own healthcare. As personal health records become more available to consumers, nursing will have the opportunity to use the individual's information in processes such as assessments and medication reconciliation. Because chronic disease care management and prevention are essential to the success of positive health outcomes, information technology (IT) capabilities centered around patient-specific education resources, tracking patient preferences, and self-management tools will become prevalent. Patients will be offered secured messaging with a provider via electronic means such as e-mail. Given this objective, nursing will be heavily involved in providing health information and education to patients and their families via the use of technology.
Enhance care coordination
Yet another core priority is the ability to exchange key clinical information in order to facilitate safe and effective care at relevant encounters and transitions of care. Three key areas will be the electronic summary care record for clinical hand-offs, electronic prescribing, and electronic medication reconciliation. This will mean the sharing of comprehensive patient data, prescriptions, and clinical summaries from multiple sources to those with proper authorization. Additionally, the development of health information exchanges across the United States will provide the national framework to electronically share patient information across organizations, communities, regions, and states. As coordinators of care, there's an increased accountability and responsibility for nurses to share key clinical data with other healthcare professionals in order to maintain continuity of care and improve patient outcomes. The ultimate goal is to access and retrieve key clinical information to provide continuous, safe, timely, and efficient patient care via interoperability (data standards) between providers and pharmacies, labs, primary care offices, hospitals, and patients.
Target public health
The documentation and communication of key data such as immunization status and lab results will be paramount in meeting this priority. Such communication is vital for nursing to adapt and deliver healthcare services to meet specific community needs. The ultimate goal is managing population health. Providers will need to receive alerts and provide surveillance data for adverse events, near misses, disease outbreaks.
A major concern with sharing clinical and health information is privacy and security, which is the last of the five priorities. Although trust is closely associated by patients with our roles as nurses, there will be very strict policies and close monitoring to ensure and prevent breaches of confidentiality. This also means that organizations will need to provide patients on request with a timely accounting of disclosures for treatment, payment, and healthcare operations in compliance with applicable law. As technology becomes mainstream in healthcare, the nursing profession is in the midst of this journey, which ultimately affects workflow processes and creates a change in culture.
The nurse manager's role
It isn't a revelation to realize that access to information became easier with the use of electronic medical records (EMRs). For example, nurses are no longer searching for manual patient charts because the information can be easily retrieved and is readily accessible with the use of computers at the patient bedside or in nursing units. However, based on a 2009 Healthcare Information and Management Systems Society Analytics study of all U.S. hospitals, only 69% of organizations have adopted nursing documentation; 60% have adopted eMAR capabilities; 35% have implemented complete multidisciplinary clinician documentation, including clinical decision support, protocols, and guidelines; and a mere 2.5% have adopted computer-based provider order entry (CPOE) as part of their health IT strategy.2 Such low adoption demonstrates that a shift in thinking must occur for all healthcare professionals, including nursing, regarding the delivery and transformation of patient care using IT. The overall adoption of EMRs hasn't been easy for clinicians, especially nurses. This is especially true for the baby boomer generation, as compared with generation X and millennial nurses.
Effectively managing staff requires different education and mechanisms to support the change process in order to create an easier transition for nurses. Two timely recommendations should be in the forefront of nursing management:
* Review your electronic clinical documentation to ensure that all data elements for the required outcome measurements are captured. As part of this recommendation, in order to achieve meaningful use, nursing must also address the continual layering of technology on top of existing care processes.
* If you have clinical application gaps in your readiness to achieve meaningful use, strongly encourage clinical and IT leadership to make clinical systems an immediate priority.
By integrating health IT into our daily workflow, we can practice safe care by utilizing real-time systems and not circumventing safeguards. The challenge will be assimilating clinical knowledge into workflow by applying patient-relevant lookups, alerts, reminders, and interruptions in a way that preserves patient safety without creating a nuisance.
All about outcomes
Meaningful use is all about outcomes that focus broadly across quality, CPOE use, high-risk medications, preventative care, results reporting, patients' access to their health records, clinical summaries, medication reconciliation, and privacy and security compliance, among other topics. Meaningful use is also about the way we collect, analyze, and use information to facilitate nursing participation in achieving healthcare transformation through positive patient-care outcomes. Nursing's involvement with quality patient outcomes will result in a better understanding of clinical knowledge and a closer linking of IT to nursing practice.
ARRA HITECH Act overview
President Obama signed the ARRA of 2009, a critical measure to stimulate the economy and improve the nation's healthcare through health IT by promoting the meaningful use of electronic health records (EHRs) via incentives. As part of the ARRA, the Health Information Technology for Economic and Clinical Health (HITECH) Act allocates 19 billion dollars as incentives through Medicare and Medicaid reimbursement to assist providers in adopting EHRs and EMRs. Within the next 5 years, goals have been set to accomplish levels of use aimed at the required health IT capabilities. Although the initial focus is data capture and sharing (2011), goals progress to achieving advanced clinical processes with decision support (2013) toward the ultimate goal of improving health system outcomes (2015).
This progression toward outcomes is centered on five health policy priorities, along with their objectives as defined by the Health IT Policy Committee, within the Office of the National Coordinator for Health and Human Services, in a document called the Meaningful Use Matrix.1 These are: improve quality, safety, and efficiency and reduce health disparities; engage patients and families; improve care coordination; improve population and public health; and ensure privacy and security protection for health information.
Per the legislation, incentive payments will be distributed through Medicare and Medicaid to hospitals and eligible professionals (physicians, nurse practitioners, and others) who are meaningful users. Users must demonstrate the meaningful use of a certified EHR/EMR, demonstrate the exchange of health information to improve the quality of healthcare, and report on clinical quality and other measures using certified systems and technology. Ultimately, if not addressed by 2015, providers and hospitals will then experience penalties in their reimbursements.
Currently, the Centers for Medicare and Medicaid Services (CMS) is in the process of developing rules for how proof of outcomes will be submitted and guidelines on meeting criteria in order to achieve incentive payments. Final CMS rules are anticipated in the spring of 2010.2
1. Office of the National Coordinator for Health and Human Services. Meaningful Use Matrix. http://healthit.hhs.gov/portal/server.pt/gateway/PTARGS_0_10741_872719_0_0_18/Meaningful%20Use%20Matrix.pdf.
2. Centers for Medicare and Medicaid Services. Medicare and Medicaid health information technology: Title IV of the American Recovery and Reinvestment Act. http://www.cms.hhs.gov/apps/media/press/factsheet.asp?Counter=3466&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=6&intPage=&showAll=&pYear=&year=&desc=false&cboOrder=date.
1. Blumenthal D. "Meaningful" progress toward electronic health information exchange. http://healthit.hhs.gov/portal/server.pt?open=512&objID=1350&parentname=CommunityPage&parentid=5&mode=2&in_hi_userid=11113&cached=true#. [Context Link]
2. Davis MW. The state of U.S hospitals relative to achieving meaningful use measurements. http://www.himssanalytics.org/docs/HA_ARRA_100509.pdf. [Context Link]