* 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.

* 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 information 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 systems, and the HITECH Act also stipulated clear penalties 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.

IN 2004, THOSE OF US IN nursing informatics or who follow health information technology (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) systems (Certification Commission for HIT). In 2006, the 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 prototypes. 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 number 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 hospitals 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 background and details surrounding the federal incentives.

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 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 quality standards. It includes broad provisions for improving 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 growing recognition advanced HIT is and will be essential to support the massive amounts of electronic 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 critically 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 legislation 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 displaying clinical information when and where it is needed to improve individual patient care and to provide aggregated, cross-patient data analysis.

EHRs will manage health care data and information 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 materials.

ARRA and its HITECH Act Provision

ARRA and its important HITECH Act provision were passed into 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. 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 systems, and the HITECH Act also stipulated clear penalties 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 "meaningful use" are divided into five initiatives:

1. Improve quality, safety, and efficiency, and reduce 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 hospitals or providers will receive the incentive payment. 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 standards being published in 2011, 2013, and 2015.

Quality measures. One of the "meaningful use" criteria for both hospitals and providers is the requirement 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.

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 clinical 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 beginning in 2012.

The quality measurement is considered one of the most important components of the incentive program under ARRA/HITECH, since the purpose 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. Improving 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 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 specific scientific and health research challenges in biomedical and behavioral research.

In addition, the National Library of Medicine (NLM) offers applied informatics grants to health-related and scientific organizations that wish to optimize 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-performing, continuously learning health care system.

Beacon communities. Also funded by HITECH, the Beacon Community Program includes $250 million in grants to build and strengthen the HIT infrastructure and HIT capabilities within 17 communities. These communities will demonstrate the future where hospitals, clinicians, and patients are meaningful users of HIT, and together the community achieves measurable improvements in health care quality, safety, 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 communities are expected to generate lessons learned on how other communities can achieve similar goals enabled by HIT.

Workforce training. Finally, ARRA funding has also been designated to educate the workforce 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 certificate and advanced degree HIT training programs, 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 community colleges in all 50 states to help address the demand for skilled HIT specialists.

* $10 million to support HIT education curriculum development.

* $6 million to develop an HIT competency examination program.

Nursing Informatics Empowering Meaningful Use

In this massive transformation from disconnected, inefficient, paper-based islands of care delivery to a nationwide, interconnected, and interoperable system 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 development, 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 interoperability initiatives focused on policy, standards and terminology development, standards harmonization, and EHR adoption. In their front-line roles, nurses 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 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. In addition, as drivers in organizational planning and process reengineering to improve the health care delivery system, 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.

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 project managers, consultants, educators, researchers, product developers, decision support and outcomes 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 information 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 understanding of effectiveness research, evidence-based practice, innovation and technology to optimize patient care and health outcomes. The future of nursing will rely on this transformation, as well as on the important role of nurses in enabling this digital revolution" (ANI, 2009, p. 9).

For no professional group does the future hold more excitement and promise from so many perspectives than it does for nursing.