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Running head: MEANINGFUL USE OF ELECTRONIC HEALTH RECORDS
Meaningful Use of Electronic Health Records
Eric C. Jean
Ferris State University
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Abstract
President Barack Obama signed the American Recovery and Reinvestment Act of 2009 (ARRA)
on February 17, 2009 (McCartney, 2011). The Health Information Technology for Economic
and Clinical Health Act of the ARRA authorizes the Centers for Medicare and Medicaid Services
to provide reimbursement incentives to hospitals and providers to become meaningful users of
electronic health records (Murphy, 2010). The purpose of this paper is to provide a synopsis of
meaningful use and the significance of this government initiative. An overview of the
legislation and the resulting meaningful use initiative is provided. The legislation is identified
and a position of support for meaningful use is included. An analysis of meaningful use shows
many of the implications associated with the initiative as they pertain to hospitals, nurses,
physicians and the public. Interviews with key stakeholders provide insight to the significance
of meaningful use as well as positions of support for the initiative. Additional stakeholders are
identified and their positions regarding meaningful use are put forth. Finally, political strategies
are identified which could impact the legislation.
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Meaningful Use of Electronic Health Records
The use of technology in health care is not new, however, recent government actions
have significantly stimulated the acceleration of health information technology (HIT) adoption.
President Barack Obama signed the American Recovery and Reinvestment Act of 2009 (ARRA)
on February 17, 2009 (McCartney, 2011). The ARRA includes three immediate goals. First, it
intends to stimulate economic activity by providing $228 billion in tax cuts and financial
benefits. Next, the ARRA provides $224 billion to government entitlement programs and $275
billion to stimulate the economy via loans, contracts, and grants (RAB, 2012). Of these funds,
$147 billion is allocated to reform the nation’s health care system (Murphy, 2010).
The Health Information Technology for Economic and Clinical Health Act (HITECH) is
a component of the ARRA which has allocated $19.2 billion in incentives to enhance the
adoption of health information technology (McCartney, 2011). According to Murphy (2010) the
HITECH provision of the ARRA authorizes the Centers for Medicare and Medicaid Services
(CMS) to provide reimbursement incentives to hospitals and eligible providers to become
meaningful users of electronic health records (EHR). The goals of these incentives are to
improve the quality of care and decrease health care costs. The funding for HITECH incentives
began in 2011 and continues until 2015 (Murphy, 2011). These government rules and incentives
regarding EHR adoption are collectively referred to as meaningful use, and have created a flurry
of activity regarding HIT.
The definition for EHR provided by HITECH is as follows: “an electronic record of
health-related information on an individual that is created, gathered, managed, and consulted by
authorized health care clinicians and staff” (Tomes, 2010, p. 91). The relevance of meaningful
use to health care and nursing cannot be overstated. The transformation from a paper based
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system to one that is fully electronic will result in interconnected and interoperable systems
nationwide resulting in significant benefits to the patient (Murphy, 2010). The adaptation of
nurses to these technological changes offers enhanced information access and ultimately may
lead to improved patient care (Ozbolt & Saba, 2008). As the largest group of health care workers
to interact with the EHR, nurses are well positioned to impact the quality, efficiency, and cost of
health care (Murphy, 2010).
The purpose of this paper is to provide a synopsis of meaningful use and the significance
of this government initiative to health care. A clear overview of the legislation including
analysis of the implications to health care and the field of nursing is provided. Interviews with
key stakeholders provide insight to the significance of meaningful use. Additional stakeholders
are identified and their positions regarding meaningful use are put forth. Finally, political
strategies are identified which could impact the legislation.
Description & Relevance
The HITECH provision of the ARRA has allocated $19.2 billion in incentives to enhance
the adoption of health information technology (McCartney, 2011). This provision is the
legislative source for the meaningful use initiative. The HITECH provision of the ARRA
authorizes the CMS to provide reimbursement incentives to hospitals and providers to become
meaningful users of EHRs (Murphy, 2010). Many hospitals and providers are scrambling to
meet the criteria of meaningful use in attempt to capture incentive funds and avoid future
financial penalties.
According to Murphy (2010) President George W. Bush addressed the need for further
development of health information technology in his 2004 State of the Union address. In this
speech President Bush set the goal of 2014 for every American to have an EHR. This timeline
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has been largely adhered to by meaningful use. In 2009 approximately 44% of U.S. hospitals
operated completely without any electronic component of the medical record (Sensmeier, 2009).
In a survey conducted by the American Hospital Association and reported by the United States
Department of Health and Human Services (DHHS) Office of the National Coordinator for
Health IT (ONC), shows that these numbers are rapidly increasing (DHHS, 2012). The
percentage of hospitals which had adopted certified EHRs between 2009 and 2011 has more than
doubled from 16% to 35% (DHHS, 2012).
The deadline set by meaningful use determines that all hospitals and eligible providers
must meet the criteria for meaningful EHR use by 2015 to receive incentive funds and to avoid
financial penalties in Medicare and Medicaid reimbursement (Tomes, 2010). Approximately
85% of hospitals report that they intend to meet meaningful use guidelines by the 2015 deadline
(DHHS, 2012). Although criteria for exemption from this deadline exist, there is much work to
be done related to HIT.
To understand the potential impact of meaningful use it may be helpful to first consider
some past and current practices associated with health care information practices. In the hospital
setting patient information previously existed only in paper format. Basic patient information
such as allergies or health history would have to be gathered from the patient or family on
admission or retrieved from paper files. Accessing the appropriate paper files could take much
longer than accessing an electronic record. These paper files often included hand written
information which may be difficult to interpret. In addition, patients or family often presented
information on hand written papers as no standardized electronic format for this information was
available. No format has previously existed to allow seamless transfer of patient data from the
outpatient setting to the inpatient setting or between patients and providers. Physician orders
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were historically hand written in a paper chart. These orders were often transcribed by a clerk or
secretary and then signed or reviewed by the nurse. This process is known to potentially result in
errors. If a patient were to be transferred to another facility, elements of the paper chart would
be copied and sent to the receiving facility.
Murphy (2010) described the previous system to manage health information as
disconnected and inefficient with the potential of HIT today to become interconnected and
interoperable. Today, most providers continue to use paper based health records (DHHS, 2011).
However, certified EHR adoption has more than doubled since the ARRA became law (DHHS,
2012). Basic patient information is often captured in the electronic record from previous hospital
visits or from the patient’s primary care provider’s information system. Patients are beginning to
use patient portals to access and update their health information. The inpatient “chart” no longer
exists in a completely paper form in many institutions. Certified provider order entry (CPOE)
implementation in many institutions has changed the format of physician orders to become
electronic based. Providers are increasingly documenting care in an electronic format as well.
To provide the details of meaningful use are beyond the scope of this paper. The
following is an overview of the program. According to Murphy (2010) HITECH authorizes the
CMS to provide financial incentives and penalties to hospitals and providers based on
meaningful use of certified EHRs. Certification requirements for EHR are set by the Office of
the National Coordinator for HIT (ONC) as appointed by the secretary of the DHHS (Murphy,
2010). Hospitals and providers may use one product or a combination of products to meet the
EHR certification requirements (Tomes, 2010). These certified EHRs must provide for exchange
of health information but also improve the quality of care (McCullough, Casey, Moscovice, &
Burlew, 2011). Elements of the certified EHR include: a) patient demographic and clinical
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information, b) support clinical decision making, c) physician order entry, d) capture quality
information, and e) exchange electronic information (McCullough et al., 2011).
There are currently three proposed stages for meaningful use (Murphy, 2010,
McCullough et al., 2011). According to Murphy (2010) the HIT Policy and Standards
Committees as well as the ONC provide input to the details of meaningful use rule development
to CMS. After publishing a proposed rule and allowing for a 60-day public comment period,
CMS released the final rule for stage 1 of meaningful use July 13, 2010 (Murphy, 2010).
According to McCullough et al. (2011) stage 1 of meaningful use focuses on capturing patient
information to facilitate patient care management and report public health quality measures.
Stage 1 meaningful use began in 2011, although hospitals and eligible providers may begin to
participate at any time (DHHS, 2011). To achieve stage 1 meaningful use hospitals must meet
fourteen core objectives and five items of a ten item menu set within the CMS rule (McCullough
et al., 2011). The core objectives for stage 1 meaningful use include but are not limited to: a) use
of physician order entry, b) demographics capture, c) reporting clinical quality measures, d)
provide patients electronic discharge instructions, and e) protect electronic health information. A
complete list of stage 1 and proposed stage 2 requirements may be found in the appendix.
A proposed rule for stage 2 meaningful use has been made available for public comment.
This proposed rule as well as possible stage 3 objectives may be found on the DHHS website
(DHHS, 2011). This proposed stage 2 rule goes into effect in 2013. Stage 2 meaningful use
focuses on continuous quality improvement via HIT and the exchange of health information
(McCullough et al., 2011). Some elements of meaningful use which were menu items in stage 1
are now core objectives in stage 2. For example, the electronic reporting of immunization status
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to registries was a menu item in stage 1 and is a proposed required objective in stage 2
meaningful use (DHHS, 2011).
Stage 3 meaningful use begins in 2015 with the focus of this stage set to include: a)
improvements in quality, safety, and efficiency, b) support decision making for high priority
conditions, c) improved patient access and self-management, and d) access to comprehensive
patient data to improve population health (McCullough et al., 2011). Since the previous two
stages have undergone changes, it seems likely that stage 3 will as well. Although only three
stages of meaningful use have been outlined to this point, there are those within health care that
suspect more will follow (personal communication, March 8, 2012).
The potential impacts of meaningful use may result in a more interconnected national
health care system which empowers patients, decreases costs and improves quality. Patients will
be empowered to take a larger role in the management of their health care via meaningful use
(DHHS, 2011). Where access to medical records and information was previously difficult,
patients will have greatly improved access for themselves and possibly family members via the
internet. The electronic format of the EHR will facilitate portability among institutions and
providers while also enhancing information security (DHHS, 2011). The electronic format of the
EHR facilitates the capture of patient information which may be analyzed and applied to
evidence based practice as a means of improving quality.
Although the potential impacts of meaningful use are significant there are those who may
not support the legislation behind meaningful use. The ARRA results in over $700 billion in
government expenditures (RAB, 2012). This represents a significant financial burden to the
American taxpayers. In addition, the U.S. Government is spending this money while operating
with trillions of dollars in debt. As mentioned, over $147 billion of these funds go towards
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health care reform (Murphy, 2010). Yet, as the government is spending billions of dollars to
reform health care, some may question whether these actions are appropriate for the government
or not. There are those within politics who advocate for less government involvement in the
private sector and for smaller government in general.
Identification of Legislation
The ARRA, also known as “the stimulus bill” was introduced to the U.S. Congress as
H.R. 1 by Wisconsin Representative David Obey of the Democratic Party, January 5, 2009
(Open Congress, n.d.). The bill went on to be passed by the United States Senate February 9,
2009. The ARRA was signed into law by President Barack Obama on February 17, 2009
(McCartney, 2011) as one of the first major acts of his presidency. At this time the bill became
officially known as Public Law 111-5 (AHIM, 2012). The stimulus bill allocates over $700
billion to facilitate recovery in the U.S. economy (RAB, 2012). The ARRA includes $147
billion towards health care reform (Murphy, 2010).
Title XIII of the ARRA is known as the Health Information Technology for Economic
and Clinical Health Act or the HITECH Act (AHIM, 2012). HITECH has allocated $19.2 billion
in incentives to enhance the adoption of health information technology (McCartney, 2011). This
legislation authorizes the CMS to provide financial incentives and penalties to hospitals and
eligible providers based on meaningful use of certified EHRs. The criteria for EHR certification
and the rules of meaningful use are determined by the ONC as appointed by the secretary of the
DHHS (Murphy, 2010).
Meaningful use is not the only focus of the HITECH Act. According to Murphy (2010),
HITECH addresses quality measures which hospitals and providers must report either to the state
for Medicaid or to CMS for Medicare. Research is supported via HITECH funding with over $1
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billion going to the Agency for Healthcare Research and Quality and National Institute of
Health. An additional $200 million is allocated for research grant awards (Murphy, 2010). In
addition to these funds the ONC has made available $60 million to support Health IT Advance
Research Projects to evaluate meaningful use. Finally $250 million are allocated via HITECH
for the establishment of 17 beacon communities to demonstrate the effectiveness of HIT
(Murphy, 2010).
This author is in full support of the meaningful use initiative which resulted from the
HITECH Act of the ARRA. Meaningful use presents significant opportunities for patients and
health care. If the goals of the initiative are met, patients will have improved access to health
information, improved quality and lower costs in the future. Although these benefits present
significant financial cost to the government and challenge the health care system, the potential
outcome is worth the risk.
Implications of meaningful use
While the potential benefits of meaningful use have been demonstrated, the initiative may
present challenges within health care. For hospitals there is a very large financial incentive to
meet the requirements of meaningful use in the appropriate timeline, yet, according to Mihalko
(2011) as many as 50% of EHR implementations fail. Many hospitals do not have the personnel
or systems in place to meet meaningful use (Bahensky, Ward, Nyarko, & Li, 2011). While many
larger hospitals have the necessary elements for meaningful use in place, many smaller hospitals
do not. Basic information technology activities such as websites, internet, and help desks are
often outsourced by smaller hospitals. In addition, some hospitals have no IT personnel at all
(Bahensky et al., 2011). In 2009, Sensmeier said that an additional 40,000 additional IT
professionals may be needed as health care becomes paperless. Independent hospitals and
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providers with inadequate resources may be forced to join with larger organizations to avoid
future penalties associated with meaningful use.
Computer use is a significant part of providing care for nurses today. Yet, studies have
shown that many nurses voice concern related to the introduction of new technologies (Zuzelo,
Gettis, Hansell, & Thomas, 2008) such as the ones being implemented to meet meaningful use
requirements. Nurses have cited dissatisfaction with computer use related to change in work
flow, decreased charting quality, and negative impact on interpersonal relations (Lee, 2008).
Nurses have said that they do not feel like real nurses due to increased interaction with computer
technologies (Zuzelo et al., 2008). Since nurses are the largest group of electronic medical
record users (Murphy, 2010) meaningful use is sure to have a significant impact on the
profession.
Many nurses lack the basic informatics competencies necessary to perform the necessary
functions of the role (Zuzelo et al., 2008). As technologies continue to increase, nurses must be
able to access information and apply the information to improve patient care (Ozbolt & Saba,
2008). Inadequate education regarding technologies is often a significant concern for nurses
(Zuzelo, et al., 2008). As meaningful use is sure to increase the use of computer technologies
this lack of education presents a significant problem for the profession. Meaningful use not only
presents challenges to nursing, it also presents opportunity. Over 8,000 nurses work as nurse
informaticists (Sensmeier, 2009). Many more may be needed in the future. Nurses today must
be competent in both computer technologies and nursing skills alike.
Physicians have also voiced concerns related to EHR adoption including dissatisfaction
with software applications and disruption of workflow (Tomes, 2010). Despite these
frustrations, eligible providers are rapidly implementing EHRs in attempt to meet the deadlines
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set by meaningful use. For physicians the potential impact of meaningful use is similar to that of
nurses, improved access to information at the point of care may lead to improved outcomes for
patients (Sensmeier, 2009). According to the DHHS, the potential benefits of meaningful use to
health care providers are more complete and accurate information as well as improved access to
information (DHHS, 2011). In addition physicians have the added benefit to receive incentive
dollars and avoid future reimbursement penalties.
Hoffman and Podgurski (2011) suggest that meaningful use does not adequately address
patient safety and must take further steps to meet the needs of consumers in the digital age.
While supporters of meaningful use suggest that improved quality and outcomes will result some
studies have shown an increase in errors with components such as CPOE. Meaningful use
regulations may also fall short in evaluating software vendors which may result in breaches in
general system safety (Hoffman & Podgurski, 2011). Sittig and Classen (2010) point out that no
organization or entity exists for providers to report safety hazards which result from EHR
implementation.
Vendors may attempt to rush new products to market to meet the time constraints of
meaningful use. Additionally, testing systems in adequate environments requires partnership
with clinical settings which may be difficult for vendors to come by (Hoffman & Podgurski,
2011). Sittig and Classen (2010) recommend a comprehensive EHR monitoring and evaluation
framework to be implemented by the ONC or another federally appointed agency to ensure EHR
safety resulting in lower cost and improved outcomes.
Stakeholder Interviews
The following interviews represent the viewpoints of two director level executives at
Munson Medical Center in Traverse City, Michigan. The strategy associated with choosing
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these individuals is to gain both an upper level information systems perspective and an upper
level nursing administration perspective regarding meaningful use. Although both interview
subjects represent management perspectives, their specific focuses and backgrounds provide a
view of meaningful use through different lenses.
Interview A
Randi Terry is the Director of Information Services at Munson Medical Center (personal
communication, March 8, 2012). Randi is the leader of the meaningful use initiative for the
organization. Randi is formally educated in computers and received a bachelor’s degree in
computers and a master’s degree in health care administration from the University of Toledo.
Randi’s career began as an analyst and quickly moved to supervision, then management. Randi
has been a director for 27 years.
To establish the relevance of meaningful use to healthcare Randi discussed the three
stages of the initiative (personal communication, March 8, 2012). Stage 1 meaningful use is all
about data capture or getting the data into an EHR. Stage 2 meaningful use is where the
relevance begins. This stage involves getting the right data to the right people so that they can
make decisions and getting the patient engaged in their care via increasing access to information.
Stage 3 focuses on improving outcomes. The data is going to the right people, duplications, and
redundancies are reduced now outcomes and safety may be improved while costs are decreased.
The literature currently shows that performance of the EHR depends how it is installed
(personal communication, March 8, 2012). If the original process which is to be automated was
poorly designed and not improved upon, then the EHR will not deliver. Physicians must be
engaged and work processes must be streamlined prior to EHR installation. Poor design and lack
of engagement may result in failure and removal of the EHR. “I believe the single largest barrier
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to meaningful use is workflow redesign”. Processes must be evaluated and streamlined prior to
automation or deficiencies may be magnified. Meaningful use is redesigning the way we do
business and doing so in a better more efficient way.
According to Randi the potential benefits of the meaningful use initiative include: a)
quality, b) safety, c) efficiency, and d) reduced costs (personal communication, March 8, 2012).
While meaningful use has potential benefits, there are negatives associated with the initiative.
However, any potential negative may be a benefit depending on one’s perspective. For example,
some physicians do not care to meet the criteria for financial reasons. As a result, physicians are
no longer going to be in small practices. This may be beneficial to patients as efficiency is
increased or negative to the physician wishing to have an independent practice. Hospitals are
joining larger systems for IS support and EHR implementation. Again, efficiency may be
increased resulting in cost savings, yet many communities may wish for the local hospital to
remain locally based to ensure community involvement. According to Randi, 50,000 jobs have
been created to meet the requirements of meaningful use. This may benefit the economy, yet
hospitals and vendors must hire these individuals.
Randi Terry’s position regarding meaningful use is one of overwhelming support
(personal communication, March 8, 2012). Although Randi supports the initiative this includes
an acknowledgment of disappointment in the necessity for the government to mandate the
initiative. “It would have been nice if we (health care) could have come together as an industry
and done this on our own for the good of the patient”.
Interview B
Jennifer Standfest is the Director of Nursing Practice and Professional Development at
Munson Medical Center (personal communication, March 8, 2012). Jennifer obtained a
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bachelor’s science of nursing degree from Calvin College and a master’s science of nursing from
Grand Valley State University. Jennifer has worked primarily in cardiac care, including critical
care and telemetry settings and also as a nurse educator. Jennifer provides a viewpoint of a high
ranking nurse within the organization with knowledge regarding the overall impact of
meaningful use on the organization.
The relevance of meaningful use includes significant financial incentives for participation
and disincentives for not participating (personal communication, March 8, 2012). All facilities
are in the midst of dealing with populations which have less private insurance and increasing
reliance on public insurance, making the capture of these funds critical. Although meaningful
use is highly relevant to the patient, the initiative may cause other highly relevant projects within
organizations to be temporarily delayed. “This is a very difficult time for health care
administrators”.
The potential benefits of meaningful use will begin to be realized when the parts of the
EHR work together (personal communication, March 8, 2012). This will allow providers to be
more proactive in providing care to patients. Information will follow the patient and outcomes
will be directly measured providing an opportunity for enhanced quality improvement. “I don’t
think we even know how meaningful use will impact nurses yet”. Many of the impacts of stage
1 meaningful use are behind the scenes for nursing. As information becomes more available the
implications could be massive. One significant potential benefit of meaningful use it to validate
what nursing has been saying and doing all along. It will place an emphasis on documentation of
the care that nurses provide.
The barriers to meaningful use include the nebulous nature of the regulations (personal
communication, March 8, 2012). The regulations put forth by CMS often get modified. “Who is
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to say that this project does not change or go away in the future”? If organizations are
participating in meaningful use just to capture funds and for the potential the system to benefit
patients, things may not work as well as possible. If the EHR can be a successful clinical tool
and meet the requirements of the initiative, that is where the greatest potential exists.
Jennifer’s position on meaningful use is also one of overwhelming support yet it comes
with reflection on the implications of the initiative (personal communication, March 8, 2012).
Meaningful use is causing health care administrators to make difficult choices. Meaningful use
is a project that must be done for various reasons; however, there are many other projects which
could also benefit patients that will be delayed. Meaningful use will take the top space on the
priority list for the organization for the next three years.
Stakeholders and Positions
There are many millions of individuals and groups which stand to benefit or suffer from
meaningful use. Meaningful use is a predominant issue in health care, yet few groups or
individual stakeholders have produced position statements for or against the initiative. One
stakeholder group which has voiced concerns with meaningful use is the American Hospital
Association (Manos, 2010). The AHA has indicated that many of the requirements of
meaningful use may be unattainable by many hospitals. The barriers to widespread HIT
adoption listed as concerns by the AHA include: a) incentive exclusion of hospitals in multicampus settings, b) adverse impact on rural hospitals, c) penalization of early adopters, and d)
rules limit the pace of EHR adoption (Manos, 2010).
The American Medical Informatics Association (AMIA) is a stakeholder group which
publicly supports meaningful use (AMIA, 2012). The focus of AMIA is to advance biomedical
informatics and to influence the field in the legislative arena. AMIA supports the meaningful use
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initiative and the pace set forth for CMS incentives. The AMIA proposed three essential
principles necessary for EHR adoption, these are: a) investment in both people and technology,
b) EHR systems must support decision making and evidence based practice, and c) EHR
adoption requires a balance of both burdens and benefits (AMIA, 2012).
The American Medical Association (AMA) is a group which represents the interests of
physicians and influences health care related policy. The AMA has produced a statement of
support for meaningful use (Stack, 2012); however, the statement has a cautionary tone
regarding the initiative. The AMA supports EHR adoption which supports high quality care and
allows for the streamlining of practice. The AMA also cautions that stage 1 meaningful use
should be completely evaluated prior to the implementation of stage 2. In addition, the AMA
stresses that flexibility should be included in the meaningful use initiative (Stack, 2012).
Physicians stand to benefit financially from meaningful use but also may be penalized if
incentive requirements are not met.
Within the United States Government there are many individual stakeholders which may
impact or be impacted by meaningful use, however, none may be more closely associated with
the initiative than Farzad Mostashari, MD. Dr. Mostashari is the National Coordinator for
Health Information Technology within the DHHS and chair of the HIT Policy and Standards
Committee (DHHS, 2011). Dr. Mostashari is at the forefront of the meaningful use initiative.
He directs the principle entity in charge of developing the process of nationwide EHR adoption
(DHHS, 2011). The position of support for the initiative is not explicitly stated by Dr.
Mostashari but displayed in the actions of the ONC.
The American Nurses Association (ANA) attempts to advance the nursing profession
through: a) supporting high practice standards, b) promoting the rights of nurses, c) supporting a
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positive view of nurses and d) by lobbying regarding nursing and public health issues (ANA,
2012). The ANA has produced a public statement which strongly supports the goals of the
meaningful use initiative. In this position statement the ANA repeatedly refers to the potential
benefit to the patient via improved safety, outcomes, privacy and portability. Additionally, the
ANA recognizes the need for all stakeholders including nurses and patients to play a role in the
development of the EHR (ANA, 2012).
Perhaps the most significant group of stakeholders regarding meaningful use is the
patient. “The patient stands to benefit from meaningful use more than any other group of
stakeholders” (R. Terri, personal communication, March 8, 2012). Patients have shown support
for meaningful use by electing government officials who support health care reform and the
advancement of HIT. According to the DHHS (2011) patients stand to benefit from having more
complete and accurate health information made available to the provider at the point of care.
Patients and families will have the opportunity for increased access to secure information to
more greatly participate in care. Patient information will support providers in decision making
resulting in better outcomes and decreased healthcare costs (DHHS, 2011). If these potential
benefits of meaningful use are realized, patients will undoubtedly continue to support meaningful
use.
Political Strategies
Meaningful use originated with the HITECH provision of the ARRA, this legislation has
been made into law. Whether legislation is being proposed or has been made into law, political
strategies to support or thwart the bill may be the same. One strategy to impact health related
politics is to join an organization which is politically active and supports the desired special
interest group. Groups such as the ANA (ANA, 2011) or the National League for Nurses (NLN)
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(NLN, 2012) are groups which have political components and act in the interests of nursing. The
NLN objective regarding public policy is to impact policies which influence the nursing
workforce. The NLN website encourages nurses to take an active role in impacting policy and
includes links and tips to facilitate this. Among this information are an annual public policy
agenda for the organization, policy news releases, information on key political figures and
leading issues which impact the nursing workforce (NLN, 2012).
Communicating with legislators is a political strategy which is supported by Abood
(2007). Political officials must act on a large volume of legislation making it impossible for
them to be experts on all of them. Nurses have the opportunity to provide an expert point of
view regarding many pieces of legislation (Abood, 2007). Letter writing is a communication
strategy which is supported by the ANA (ANA, 2011). The ANA website includes tips on
writing letters to political figures and editors. Political officials maintain personal websites
which contain contact information including email addresses. In addition, both the U.S. Senate
and the House of Representatives websites include contact information for public officials.
Voting for or supporting the political campaigns of public officials with known positions
on various subjects is yet another strategy to impact legislation. For example, the ARRA was
introduced to the U.S. House of Representatives by a democratic member of congress and later
signed by a Democrat, President Barack Obama (Open Congress, n.d.). To support this
legislation a voter could support Democratic candidates known to support health care reform.
Conversely if a voter does not favor the ARRA, a Libertarian candidate may be more likely to
repeal measures of the ARRA as a means of decreasing government involvement in the private
sector.
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Nurses may also enter the political arena themselves and become candidates. Nurses
represent the largest number of health care providers in the U.S. and thus represent a significant
political force (Abood, 2007). If a nurse were to run for office and was able to mobilize the
nursing workforce for support this would represent significant political power. Taking political
action directly into one’s hands may be the ultimate political strategy.
Finally, a political strategy which has only become possible in recent years is the use of
social media to support political action. Social media includes texting, and the use of Facebook
and Twitter or other similar communication tools. Major political actions across the globe have
recently benefited from the coordination offered by social media (Grabowicz, Ramasco, Moro,
Pujol, & Eguiluz, 2012). Coordinated public political action has resulted in the overthrow of
entire political regimes. The use of social media allows for people with similar concerns to come
together to have a unified voice (WHO, 2011).
Conclusion
This paper provides a synopsis of meaningful use and demonstrates the significance of
this government initiative which originates from the HITECH provision of the American
Recovery and Reinvestment Act of 2009. An overview of the legislation and the resulting
meaningful use initiative shows the scope and relevance of the three stage government action.
The original legislation is identified and a position of support for meaningful is included. An
analysis of meaningful use shows many of the challenges associated with implementing EHRs as
they pertain to hospitals, nurses, physicians, and the public. Interviews with key stakeholders
provide insight to the significance of meaningful use as well as positions of support. Additional
stakeholders are identified and their positions regarding meaningful use are put forth. Finally,
political strategies are identified which could impact the legislation.
MEANINGFUL USE OF ELECTRONIC HEALTH RECORDS
21
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MEANINGFUL USE OF ELECTRONIC HEALTH RECORDS
Appendix
Meaningful Use Objectives and Menu Set
Eligible hospital stage 1 meaningful use core objectives (DHHS, 2011)
a. Implement CPOE to meet state and local guidelines.
b. Implement drug-allergy and interaction checks.
c. Maintain up to date problem list.
d. Document active medications.
e. Maintain medication allergy list.
f. Record demographics.
g. Document changes in vital signs.
h. Record smoking status.
i. Report quality measures to CMS or state.
j. Implement a decision support rule and track associated quality.
k. Provide patients with electronic health information.
l. Provide electronic discharge instructions upon request.
m. Key clinical information is in a format capable of exchange.
n. Maintain safety of electronic health information.
Eligible hospital stage 1 meaningful use menu set (DHHS, 2011)
a. Conduct drug formulary checks.
b. Record advanced directives for patients < 65 years old.
c. Clinical lab tests are incorporated into EHR.
d. Create patient lists categorized by condition.
e. Use EHR to identify and provide education materials.
f. Implement medication reconciliation.
g. Provide patient care summaries upon transfer.
h. Immunizations are in electronic transferable format.
i. Maintain capability to submit electronic data to public agencies.
j. Syndrome surveillance data is in format to be submitted to public health agencies.
Eligible hospital stage 2 meaningful use core objectives (Advani, Raiford,
Panjamapirom, & Copoulos, 2012)
a. Implement CPOE to meet state and local guidelines.
b. Record demographics.
c. Document changes in vital signs.
d. Record smoking status.
e. Implement drug-allergy and interaction checks.
f. Clinical lab tests are incorporated into EHR.
g. Create patient lists categorized by condition.
h. Implement electronic medication administration.
i. Provide online access to health information.
25
MEANINGFUL USE OF ELECTRONIC HEALTH RECORDS
j. Use EHR to identify and provide education materials.
k. Implement medication reconciliation.
l. Provide patient care summaries upon transfer.
m. Immunizations are in electronic transferable format.
n. Maintain capability to submit electronic data to public agencies.
o. Syndrome surveillance data is in format to be submitted to public health agencies.
p. Conduct security risk analysis.
Eligible hospital stage 2 meaningful use menu set (Advani, Raiford, Panjamapirom, &
Copoulos, 2012)
a. Record advanced directives for patients < 65 years old.
b. Electronic prescription capability.
c. Family health history is in electronic format.
d. Maintain capability of electronic imaging.
26