The document discusses the evolution of health information technology (HIT) and the establishment of electronic health records (EHRs) in the U.S., highlighting key legislative milestones such as President Bush's 2004 goal for EHRs and President Obama's subsequent initiatives in 2009 through the American Recovery and Reinvestment Act. It details the allocation of funding and incentives aimed at encouraging the meaningful use of EHRs within the healthcare system, emphasizing the essential role of nurses in implementing these technologies effectively. The text outlines the importance of nursing informatics as a critical component in transforming healthcare delivery and improving patient outcomes through advanced technology and data management.

1. 283NURSING ECONOMIC$/July-August 2010/Vol. 28/No. 4
I
N 2004, THOSE OF US IN nurs-
ing informatics or who fol-
low health information tech-
nology (HIT) trends were
thrilled when President George
W. Bush said in his 2004 State of
the Union address “…an
Electronic Health Record for
every American by the year
2014…by computerizing health
records, we can avoid dangerous
medical mistakes, reduce costs,
and improve care” (Bush, 2004). This was the first
time a president formally recognized the value of HIT
and set a deadline to do something about it! President
Bush went on to establish the Office of the National
Coordinator for HIT (ONC), and Dr. David Brailer was
appointed as the first coordinator by Tommy
Thompson, then Secretary of the Department of
Health and Human Services (HHS).
The support continued. In 2005, funding from
HHS was earmarked to establish organizations for
standards harmonization (HIT Standards Panel) and
for certification of electronic health record (EHR) sys-
tems (Certification Commission for HIT). In 2006, the

2. Agency for Healthcare Research and Quality (AHRQ)
launched its National Resource Center for HIT.
Government attention persisted in 2007 with the
funding of National Health Information Network pro-
totypes. Momentum was building and there was
much attention on HIT from the federal government.
Fast forward to 2009. President-Elect Barack
Obama says he wants the federal government to
invest in EHRs so all medical records are digitized
within 5 years and vows to continue to push for the
2014 deadline established by Bush. “This will cut
waste, eliminate red tape, and reduce the need to
repeat expensive medical tests,” he said, adding that
the switch also will save lives by reducing the num-
ber of errors in medicine (Obama, 2009).
President Obama then does more than talk about
HIT. He works with Congress to pass the American
Recovery and Reinvestment Act (ARRA), providing
unprecedented funding to promote health care reform
through the use of HIT. Incentives totaling $19 billion
are allocated for “meaningful use” of EHRs in hospi-
tals and ambulatory settings beginning in 2011. This
sets the stage for today’s focus on the use of HIT, and
the proliferation of EHR implementation projects in
our clinical settings. Let’s explore the legislative back-
ground and details surrounding the federal incen-
tives.
Legislative Background
On March 23, 2010, President Obama signed into
law the landmark Patient Protection and Affordable
Care Act (PPACA), a federal statute that represents the
most recent legislation in a sweeping health care

3. reform agenda driven into law by the Democratic
111th Congress and the Obama Administration. The
new law is dedicated to replacing a broken system
with one that ensures all Americans have access to
health care that is both affordable and driven by qual-
ity standards. It includes broad provisions for improv-
ing health care delivery that will take affect from the
moment of enactment through 2018.
For the Obama Administration, the hard-fought
legislative success of PPACA turns the spotlight on
The Journey to Meaningful Use of Electronic Health Records
JUDY MURPHY, RN, FACMI, FHIMSS, is Vice President,
Information Services, Aurora Health Care in Milwaukee, WI; a
HIMSS Board Member; and a member of the federal HIT
Standards Committee. Comments and suggestions can be sent to
[email protected]
NOTE: Hear Judy speak on “The Economic$ for Meaningful
Use
of Health Information Technology” at the 4th Annual Nurse
Faculty/Nurse Executive Summit, December 13-15, 2010, in
Scottsdale, AZ. Visit www.nursingeconomics.net for Summit
program and registration information.
EXECUTIVE SUMMARY
The American Recovery and Reinvestment Act and its
important Health Information Technology Act provision
became law on February 17, 2009.
Commonly referred to as “The Stimulus Bill” or “The
Recovery Act,” the landmark legislation allocated $787
billion to stimulate the economy, including $147 billion
to rescue and reform the nation’s seriously ailing health
care industry.

4. Of these funds, $19 billion in financial incentives were
earmarked for the relatively short period of 5 years to
drive reform through the use of advanced health infor-
mation technology (HIT) and the adoption of electronic
health records (EHRs).
The incentives were intended to help health care
providers purchase and implement HIT and EHR sys-
tems, and the HITECH Act also stipulated clear penal-
ties would be imposed beyond 2015 for both hospitals
and physician providers who failed to adopt use of
EHRs in a meaningful way.
Nurses will be integral to achieving a vision that will
require a nationwide effort to adopt and implement
EHR systems in a meaningful way.
Nursing Informatics
Judy Murphy
Judy Murphy
NURSING ECONOMIC$/July-August 2010/Vol. 28/No. 4284
the growing recognition advanced HIT is and will be
essential to support the massive amounts of electron-
ic information exchange foundational to reform. In
fact, the universal agreement that meaningful health
care reform cannot be separated from the national,
and arguably global, integration of HIT based on
accepted, standardized, and interoperable methods of
data exchange provided the linchpin for other criti-

5. cally important legislation that created the glide path
for PPACA.
This consensus resulted in the broad support and
passage into law of the ARRA and its key Health
Information Technology Act (HITECH) provision in
the early weeks of Mr. Obama’s presidency in 2009.
Backed with an allocation of over $19 billion, this leg-
islation authorized the Centers for Medicare and
Medicaid Services (CMS) to provide reimbursement
incentives for hospitals and eligible providers that
take steps to become “meaningful users” of certified
EHR technology to improve care quality and better
manage care costs.
At the core of the new reform initiatives, the
incentivized adoption of EHRs will improve care
quality and better manage care costs, meeting clinical
and business needs by capturing, storing, and dis-
playing clinical information when and where it is
needed to improve individual patient care and to pro-
vide aggregated, cross-patient data analysis.
EHRs will manage health care data and informa-
tion in ways that are patient centered and information
rich. Improved information access and availability
will increasingly enable both the provider and the
patient to better manage each patient’s health by
using capabilities provided by enhanced clinical
decision support and customized education materi-
als.
ARRA and its HITECH Act Provision
ARRA and its important HITECH Act provision
were passed into law on February 17, 2009.

6. Commonly referred to as “The Stimulus Bill” or “The
Recovery Act,” the landmark legislation allocated
$787 billion to stimulate the economy, including $147
billion to rescue and reform the nation’s seriously ail-
ing health care industry. Of these funds, $19 billion in
financial incentives were earmarked for the relatively
short period of 5 years to drive reform through the use
of advanced HIT and the adoption of EHRs. The
incentives were intended to help health care
providers purchase and implement HIT and EHR sys-
tems, and the HITECH Act also stipulated clear penal-
ties would be imposed beyond 2015 for both hospitals
and physician providers who failed to adopt use of
EHRs in a meaningful way. Here are some of the key
components of ARRA (Murphy, 2010) and HITECH
(Blumenthal, 2010; HITFHC, 2009a).
Meaningful use. The majority of the HITECH
funding will be used to reward hospitals and eligible
providers for “meaningful use” of certified EHRs by
“meaningful users” with increased Medicare and
Medicaid payments (HITFHC, 2009b; Murphy, 2009).
Both programs have start dates of fiscal year 2011
(October 1, 2010) for hospitals and calendar year 2011
(January 1, 2011) for eligible providers. On December
31, 2009, the Centers for Medicare and Medicaid
Services (CMS), with input from ONC and the HIT
Policy and Standards Committees, published a
Proposed Rule on Meaningful Use of EHRs and began
a 60-day public comment period. After reviewing
more than 2,000 comments, HHS issued the final rule
on July 13, 2010. The final criteria for meeting “mean-
ingful use” are divided into five initiatives:
1. Improve quality, safety, and efficiency, and reduce

7. health disparities.
2. Engage patients and families.
3. Improve care coordination.
4. Improve population and public health.
5. Ensure adequate privacy and security protections
for personal health information.
Specific objectives were written to demonstrate
that EHR use has a “meaningful” impact on one of the
five initiatives. Under the final rule, there are 14
“core” (required) objectives for hospitals and 15 for
providers. Both hospitals and providers have 10 other
objectives in a “menu set” from which they must
choose and comply with five. If the objectives are met
during the specified year and the hospital or provider
submits the appropriate measurements, then the hos-
pitals or providers will receive the incentive pay-
ment. The hospital incentive amount is based on the
Medicare and Medicaid patient volumes; the provider
incentives are fixed per provider. The incentives are
paid over 5 years, and the hospital or provider must
submit measurement results annually during each of
the years to continue to qualify. The objectives will
mature every other year, with new criteria and stan-
dards being published in 2011, 2013, and 2015.
Quality measures. One of the “meaningful use”
criteria for both hospitals and providers is the require-
ment to report quality measures to either CMS (for
Medicare) or to the state (for Medicaid). For
providers, the final rule lists 44 measures, with a
requirement to comply with six. For hospitals, the
rule lists 15 measures, with a requirement to comply
with them all.

8. Because HHS will not be ready to electronically
accept quality measure reporting in 2011, the
Proposed Rule specifies that hospitals and eligible
providers will submit summary information on clini-
cal quality measures to CMS through attestation in
2011. HHS expects to be ready to electronically
accept quality measure reporting in 2012, so hospitals
and providers will be expected to submit their results
on the clinical quality measures electronically begin-
ning in 2012.
285NURSING ECONOMIC$/July-August 2010/Vol. 28/No. 4
The quality measurement
is considered one of the most
important components of the
incentive program under
ARRA/HITECH, since the pur-
pose of the HIT incentives is
to promote reform in the
delivery, cost, and quality of
health care in the United
States. Dr. David Blumenthal,
current national coordinator
of HIT, emphasized this point when he said “HIT is
the means, but not the end. Getting an EHR up and
running in health care is not the main objective behind
the incentives provided by the federal government
under ARRA. Im proving health is. Promoting health
care reform is” (Blumenthal, 2009; Manos, 2009).
Research support. ARRA and HITECH increased
funding by more than $1 billion for comparative
effectiveness research through AHRQ and the

9. National Institutes of Health (NIH). In addition, NIH
designated over $200 million for a new initiative
called the NIH Challenge Grants in Health and
Science Research. NIH anticipates funding 200 or
more grants, each up to $1 million, addressing specif-
ic scientific and health research challenges in bio-
medical and behavioral research.
In addition, the National Library of Medicine
(NLM) offers applied informatics grants to health-
related and scientific organizations that wish to opti-
mize use of clinical and research information. These
grants help organizations exploit the capabilities of
HIT to bring usable, useful biomedical knowledge to
end users by translating the findings of informatics
and information science research into practice
through novel or enhanced systems, incorporating
them into real-life systems and service settings.
SHARP grants. Alongside the NIH and NLM focus
on incentivizing research, ONC also made available
$60 million to support the development of Strategic
Health IT Advanced Research Projects (SHARP). The
SHARP Program funds research focused on achieving
breakthrough advances to address well-documented
problems that have impeded adoption of HIT and
accelerating progress toward achieving nationwide
meaningful use of HIT in support of a high-perform-
ing, continuously learning health care system.
Beacon communities. Also funded by HITECH,
the Beacon Community Program includes $250 mil-
lion in grants to build and strengthen the HIT infra-
structure and HIT capabilities within 17 communi-
ties. These communities will demonstrate the future
where hospitals, clinicians, and patients are meaning-

10. ful users of HIT, and together the community achieves
measurable improvements in health care quality, safe-
ty, efficiency, and population health. The funding was
awarded to communities already at the cutting edge
of EHR adoption and health information exchange to
push them to a new level of
sustainable health care quality
and efficiency. The communi-
ties are expected to generate
lessons learned on how other
communities can achieve sim-
ilar goals enabled by HIT.
Workforce training. Finally,
ARRA funding has also been
designated to educate the work-
force required to modernize the
health care system by promoting and expanding the
adoption of HIT by 2014. Four grant programs support
the training and development of the necessary skilled
workforce:
• $32 million to establish nine university-based cer-
tificate and advanced degree HIT training pro-
grams, including one sponsored by the University
of Colorado-Denver School of Nursing.
• $360 million to create five regional community
college consortia of more than 80 member com-
munity colleges in all 50 states to help address the
demand for skilled HIT specialists.
• $10 million to support HIT education curriculum
development.

11. • $6 million to develop an HIT competency exami-
nation program.
Nursing Informatics Empowering Meaningful Use
In this massive transformation from disconnect-
ed, inefficient, paper-based islands of care delivery to
a nationwide, interconnected, and interoperable sys-
tem driven by EHRs and advancing HIT innovation,
the importance of nurses and nursing informatics will
be difficult to overstate. For decades, nurses have
proactively contributed resources to the develop-
ment, use, and evaluation of information systems.
Today, they constitute the largest single group of
health care professionals, including experts who
serve on national committees and participate in inter-
operability initiatives focused on policy, standards
and terminology development, standards harmoniza-
tion, and EHR adoption. In their front-line roles, nurs-
es continue to have a profound impact on the quality
and cost of health care and are emerging as leaders in
the effective use of HIT to improve the safety, quality,
and efficiency of health care services.
Informatics nurses are key contributors to a work-
ing knowledge about how evidence-based practices
designed in information systems can support and
enhance clinical processes and decision making to
improve patient safety and outcomes. In addition, as
drivers in organizational planning and process re-
engineering to improve the health care delivery sys-
tem, informatics nurses are increasingly sought out by
nurses and nurse managers for leadership as their
profession works to bring IT applications into the
mainstream health care environment.

12. Informatics nurses are keycontributors to a working
knowledge about how
evidence-based practices
designed in information
systems can support and
enhance clinical processes and
decision making to improve
patient safety and outcomes.
NURSING ECONOMIC$/July-August 2010/Vol. 28/No. 4286
Therefore, it will be increasingly essential to the
success of today’s health care reform movement that
informatics nurses are involved in every aspect of
selecting, designing, testing, implementing, and
developing health information systems. Further, the
growing adoption of EHRs must incorporate nursing’s
unique body of knowledge with the nursing process
at its core.
The Future
Many nursing and health care leaders agree that
the future of nursing depends on a profession that
will continue to innovate using HIT and informatics
to play an instrumental role in patient safety, change
management, and quality improvement, as evidenced
by quality outcomes, enhanced workflow, and user
acceptance. In an environment where the roles of all
health care providers are diversifying, nurses will
guide the profession from their positions as HIT proj-
ect managers, consultants, educators, researchers,
product developers, decision support and outcomes

13. managers, chief clinical information officers, chief
information officers, advocates, policy developers,
entrepreneurs, and business owners. To achieve our
nation’s health care reform goals, health care leaders
must leverage the patient care technologies and infor-
mation management competencies that informatics
nurses provide to insure their investment in HIT and
EHRs is implemented properly and effectively over
coming years.
In fact, in its October 2009 recommendations to
the Robert Wood Johnson Foundation on the future of
nursing, the Alliance for Nursing Informatics (ANI)
argued nurses will be integral to achieving a vision
that will require a nationwide effort to adopt and
implement EHR systems in a meaningful way. “This
is an incredible opportunity to build upon our under-
standing of effectiveness research, evidence-based
practice, innovation and technology to optimize
patient care and health outcomes. The future of nurs-
ing will rely on this transformation, as well as on the
important role of nurses in enabling this digital revo-
lution” (ANI, 2009, p. 9).
For no professional group does the future hold
more excitement and promise from so many perspec-
tives than it does for nursing. $
REFERENCES
Alliance for Nursing Informatics (ANI). (2009). Statement to
the
Robert Wood Johnson Foundation Initiative Future of
Nursing: Acute care, focusing on the area of technology.
Retrieved from http://www.himss.org/handouts/ANI
ResponsetoRWJ_IOMonTheFutureofNursing.pdf?src=winew

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Blumenthal, D. (2009). National HIPAA Summit in Washington,
DC. Retrieved from http://www.healthcareitnews.com/news/
healthcare-it-means-not-end-says-blumenthal
Blumenthal, D. (2010). Launching HITECH. New England
Journal
of Medicine, 362(5), 382-385.
Bush, G.W. (2004). State of the Union Address. (2004, January
20). Retrieved from http://whitehouse.georgebush.org/news/
2004/012004-SOTU.asp
Health Information Technology for the Future of Health and
Care
(HITFHC). (2009a). HITECH programs. Retrieved from
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87&parentname=CommunityPage&parentid=1&mode=2&in_
hi_userid=10741&cached=true
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Care
(HITFHC). (2009b). Meaningful use. Retrieved from
http://healthit.hhs.gov/portal/server.pt?open=512&objID=
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Obama, B. (2009). President-elect speaks on the need for urgent
action on an American Recovery and Reinvestment Plan.
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urgent_action_on_an_american_r
Manos, D. (2009). Healthcare IT is the means, but not the end,
says Blumenthal. Healthcare IT News. Retrieved from

15. http://www.healthcareitnews.com/news/healthcare-it-
means-not-end-says-blumenthal
Murphy, J. (2010). This is our time: How ARRA changed the
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regard-
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