It is a rare healthcare professional who hasn't heard about electronic health records (EHR).
And yet as often as it is addressed, adoption of this technology is not moving as quickly as anticipated, said a federal information technology expert.
"There was a belief the market itself would drive implementation of EHRs; after all we saw industry and retail embrace technology quickly," explained Judy Murphy, RN, FHIMSS, FACMI, FAAN, deputy national coordinator for Programs and Policies in the Office of the National Coordinator (ONC) for Health IT in the U.S. Department of Health and Human Services.
"But technology uptake was not taking place in hospitals," she said, "so the government decided to offer incentives for adopting it."
That incentive is called Meaningful Use, an umbrella term for rules and regulations that, among other things, involve electronic record keeping and e-documentation of care that hospitals and physicians must meet to qualify for federal incentive funding under the American Recovery and Reinvestment Act of 2009 (ARRA).
It is meant to encourage providers to embrace technology and thoroughly document patient information that can travel with the patient anywhere in the healthcare continuum, encourage patients to get involved in maintaining their own health, and enabling providers to benchmark their care using evidence-based practice.
Linked to Incentives
According to provisions of the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, a component of ARRA, organizations that achieve meaningful use of EHRs by 2014 will be eligible for incentive payments.
Those incentives also are linked to reimbursement for the care of Medicare and Medicaid patients. Conversely, organizations that fail to achieve the standard by 2015 will be penalized.
Meaningful use was designed to occur in three stages:
• Stage 1 began in 2011 and involved adoption of computerized physician order entry (CPOE).
• Stage 2, which impacts nursing, brings greater emphasis, among other things, on disease management, clinical decision support, transition of care, documentation of care plans and patient access to health information. In the original proposal for stage 2, healthcare providers must record care plan fields, including goals and discharge instructions within 36 hours of being released from the hospital, for more than 10 percent of patients. Although stage 2 begins next year, final regulations have not been publicized. The federal government solicited public comment on proposed stage 2 regulations until May 7 and are reviewing those comments. Final regulations will be published in August or September, according to Murphy.
• Little has been explained about stage 3, which begins in 2015, and is expected to continue building on the goals of stage 1 and 2.
The Nitty Gritty
Although stage 2 isn't finalized many of the goals within the original version are expected to remain intact and nurses will need to gear up for practice changes, several sources commented.
"The proposed stage 2 includes criteria requiring more consumer involvement. The ONC has been working on consumer e-health with a program that revolves around three A's: access, action and attitude," Murphy explained.
"Stage 2 proposes encouraging patients to access their health records and get involved in their own health and healthcare, so it encourages patients to get a copy upon discharge of what happened to them while they were in the clinic or the hospital.
"Action involves them taking charge of their health; looking at their diet, activity, etc.," she continued.
"If they are diabetic, are they tracking their blood sugars? If they have high BP, are they doing activities that would promote keeping their BP down.
"Attitude involves changing how healthcare providers think," Murphy said. "Many thought this was our information, not the patient's.
"Patients don't understand their own power; and they do understand what their health records say, despite prevailing views," she continued. "There are plenty of good resources out there to help them."
Some help may come from accountable care organizations (ACOs), a network of doctors and hospitals sharing responsibility for providing care to patients, whether on Medicare or privately insured.
Other aid is coming from the technology industry in the form of mobile apps that help track chronic conditions.
"We're seeing a number of new computer applications that track activity, diet, etc. that demystifies the complexities of care," a government source said.
Stage 2 & Nurses
Murphy believes nurses are the professionals best positioned to help patients with all three A's. Joyce Sensmeier, MS, RN-BC, CPHIMS, FHIMSS, FAAN, vice president of Informatics at HIMSS (Healthcare Information and Management Systems Society), agrees.
"In general, this program is moving in the direction of nurses focused on improving patient outcomes," Sensmeier told ADVANCE. She sees that resulting in "much better research and evidence-based practices. As we identify key data elements and fully incorporate quality measures, nurses are better able to see the impact of their care," she said.
"If the hospital has an EHR with clinical decision support in place, they can see that impact right away," she continued. "They can see if the patient had a previous episode of high BP and can proactively do something about it."
Sensmeier, who said some of HIMSS's 44,000 members participated in the public comment on stage 2, believes "nurses will be fine with stage 2 requirements if the organization they work for does it well.
"What we don't want to see are duplicate sets of nursing documentation particularly on the quality measures," she told ADVANCE. "We want measures built into the system, so the system can show what the end results are. We want the system to do that calculation."
This refers to one stage 2 requirement that providers must give more than half of their patients e-access to their health information and provide more than 10 percent with EHR-generated patient education resources.
It is not clear if providers can charge patients for releasing these health records; Murphy said the federal government is "silent on this one."
How Can Nurses Prepare
With all that nurses do today in patient care, what impact will meaningful use stage 2 have on their practice?
Pat Button, EdD, RN, chief nursing officer at Zynx Health, a developer of clinical decision support tools headquartered in Los Angeles, said "many of the proposed requirements have, to some degree, been professional requirements for a long time
"The difference now is that nurses will be required to systematically and reliably apply those requirements under stage 2," Button said.
"Two components will be necessary, having an EHR with functionality that supports the regulations and having clinical decision support content that includes goals and interventions in plans of care to guide clinicians.
"The idea of variations and standards of care changing by geographic regions is not considered adhering to evidence-based practice," Button continued.
"What one wants is to provide the same evidence-based standard of care across the board, taking into consideration the needs of the patient and the family."
Gail O. Guterl is a frequent contributor to ADVANCE.