Meaningful Use of Electronic Health Records
Meaningful Use of Electronic Health RecordsEric C. JeanFerris State UniversityAbstractPresident 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.Meaningful Use of Electronic Health RecordsThe 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 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 & RelevanceThe 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 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 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 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 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 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 LegislationThe 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 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 useWhile 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 providers with inadequate resources may be forced to join with larger organizations to avoid future penalties associated with meaningful puter 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 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 InterviewsThe following interviews represent the viewpoints of two director level executives at Munson Medical Center in Traverse City, Michigan. The strategy associated with choosing 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 ARandi 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 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 BJennifer Standfest is the Director of Nursing Practice and Professional Development at Munson Medical Center (personal communication, March 8, 2012). Jennifer obtained a 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 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 PositionsThere 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 multi-campus 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 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 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 StrategiesMeaningful 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) (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. 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).ConclusionThis 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. 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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.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. ................
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