By Jared Sinclair, an ICU nurse in Nashville who has a blog about health care and technology
If you follow health care news regularly, and yet you still feel unsure what “meaningful use” means and how it will affect your job as a nurse, then you have something in common with even the most knowledgeable people on the subject. Despite the fact that discussion of meaningful use among health care IT and informatics folks has reached a fever pitch since the HITECH (Health Information Technology for Economic and Clinical Health) Act was passed last February, in many ways we are no closer to understanding how it will change health care than when discussion first began.
What do we know for sure? The HITECH Act promises incentive payments to providers and hospitals that use electronic health records in ways that meet a minimum set of requirements called “meaningful use.” That sounds simple enough; however, there isn’t just one set of requirements. The criteria for meaningful use will come in three stages, and the requirements for stages two and three have yet to be determined. This is why your local hospital’s nurse informaticists may be less than enthusiastic about the next five years of their jobs. They bear the responsibility for preparing their hospitals for huge changes—without the luxury of knowing what those changes will be.
We can get a glimpse of stages two and three by taking a closer look at the requirements for stage one. There are dozens of requirements, ranging from the use of computerized physician order entry (CPOE) to providing an electronic copy of a health record to a patient upon their request. To qualify for the incentive payments, hospitals must meet all of the requirements, but only to a specified degree. In the case of CPOE, for example, the Final Rule (see PDF link here) states:
More than 30% of unique patients with at least one medication in their medication list
[must] have at least one medication order entered using CPOE.In plain English, that means that a physician must order at least one drug for one third of his patients directly via a computer, and not with a handwritten order entered into a computer by a clerk.
The really worrisome issue. All of the meaningful use criteria merit discussion, but CPOE in particular stands out above the rest. According to a comment made in the Final Rule (see PDF link above), CMS has received more concerned responses about CPOE than any of the other criteria. Stage one only requires a fraction of orders to be entered via CPOE, but the general opinion among industry leaders is that either stage two or three will require as much as 100% CPOE adoption. Consider what it would mean for a hospital to permanently do away with paper charts:
1. How would the transition be accomplished: all at once, or by one group of physicians at a time?
2. If a hospital physician can write an order via his office computer, how will the bedside nurse be alerted that an order has been written?
3. What if two physicians, one of whom has not been transitioned to CPOE, unknowingly order the same stat drug, one on paper and the other by the computer? Will the bedside nurse be able to manage keeping track of orders on two systems?
There have been some eyebrow-raising studies on the impact of CPOE on patient outcomes in the past several years, with stunning contrasts between their conclusions. An article prepared for the July 2009 issue of Pediatrics found that overall mortality rates for inpatients of a California hospital decreased by 20% after implementation of a commercially available CPOE system. A similar study in 2009, also published in Pediatrics, found the opposite result. The latter study found that overall mortality of ICU patients at the Children’s Hospital of Pittsburgh increased after CPOE was introduced. As yet there have been no definitive studies establishing why some CPOE implementations fail when others succeed.
Another thing we know for sure about meaningful use is that it is going to be a hot-button topic for at least the next decade. The timeline for incentive payments extends through 2021, with intermediate steps along the way. One notable year will be 2015, when Medicare reimbursement penalties will be imposed on providers and hospitals that are not “meaningful users.” In other words, what begins next fall as a bonus system for forward-thinking, technology-loving hospitals will eventually become a necessary burden on all hospitals just to break even.
According to current data published by HIMSS Analytics, less than 1% of U.S. hospitals have gone completely electronic when it comes to medical records. Half of them are halfway electronic. More than 10% have virtually no computerization at all. Most of the latter are rural and community hospitals with tight budgets. CMS promises additional financial support to get these hospitals ready for meaningful use, but the specifics have yet to be determined.
What’s it mean for nurses? The HIMSS Analytics data shows us just how far we have to go before we are ready for meaningful use. Implementing new or upgraded electronic medical records will likely be a messy process. Bedside nurses in particular may find themselves frustrated by the workflow effects of implementation decisions in which they had no say. They might consider getting involved with their hospitals’ nursing informatics teams as a way to influence these decisions. At the very least, nurses should recognize that huge changes are coming and expect the unexpected.
You make an excellent point with your observations about the potential confusion that this initiative will cause. The timeline for this program is rather aggressive when you consider the EHR status of the current system. There will obviously be administrative confusion as it appears that the guidelines are being developed “on the fly”. As you point out, however, there may even be a greater potential for confusion from a clinical standpoint, and this will need to be monitored very closely.