By Jane Sarasohn-Kahn. Over 85% of the world’s population is covered by wireless phone signals. The global proliferation of wireless phones provides a technology platform to move health services to people — broadly referred to as ”mobile health” or “mhealth.” mHealth: New Horizons for health through mobile technologies, the World Health Organization’s (WHO’s) second report on mobile health, summarizes a survey of mobile health developments around the world, published in June 2011 based on survey data from 2009 collected in 114 nations.

WHO learned that mHealth is most easily deployed into health applications where voice communication via traditional phone networks has been used. Thus, in important applications like surveillance and decision support, mHealth is less likely to be established because these functions require more advanced capabilities and technology infrastructure.

The survey evaluated mHealth services in 14 categories, as shown in the chart. These include health call centres, emergency toll-free phone services, emergencies and disasters, mobile telemedicine, appointment reminders, community mobilization and health promotion, treatment compliance, mobile patient records, information access, patient monitoring, health surveys and data collection, surveillance, health awareness raising, and decision support.

The most prevalent of these services are toll-free emergency applications, mobile health call centres and emergency services, and mobile telemedicine, all available in over 50% of WHO member states. In addition, mHealth-based appointment reminders are available in a plurality of nations.

The most popularly piloted mHealth programs include patient monitoring, treatment compliance, mobile telemedicine, and patient records.

Health Populi’s Hot Points:  Most of the mHealth deployments around the world tend to be small-scale pilots that deal with single issues. The largest scale mHealth programs are usually supported via public/private partnerships. (more…)

By Jane Sarasohn-Kahn. “Ward and June Cleaver have left the building,” observe analysts at Nielsen. “The white, two-parent, ‘Leave it to Beaver’ family unit of the 1950s has evolved into a multi-layered, multi-cultural construct dominated by older, childless households,” starts a report from The Nielsen Company, The New Digital American Family.

Whatever ethnic flavor this Digital Family may represent, there’s one equalizer across all of them: the smartphone, which is owned by households across cultures and income levels.

First, the socio-demographics paint a picture of increasingly multi-cultural households. Recent immigrants to the U.S. accounted for 90% of population growth from 2000-2010, over-indexing for Hispanic and Asian communities. Hispanics are the fastest-growing segment of the multi-cultural nation, now numbering 50 million people in the U.S. Marriage seems to be going out of fashion, with only 52% of adults being married in 2008 compared with 72% in 1960. In the next decade, households with young children will grow more slowly than in the past; the greatest growth will be among multi-cultural, lower/middle income families. Nielsen forecasts that most families with kids in the U.S. will be multi-cultural before the end of this decade. (more…)

By Casey Quinlan. In my daily business life, I have lots of conversations about healthcare IT (HIT), electronic medical records (EMR), personal health records (PHR), and the rest of the alphabet soup of acronyms used in health care’s march into the 21^st century. Each of those conversations always winds up leading to the same question, “what’s the ROI?” Meaning what’s the expected financial benefit to the provider deploying the technology.

This is most definitely a valid question – any enterprise looking at a technology product or service needs to have a solid understanding of what the business results of that technology can be, and what the cost of those results will be. Also, the likelihood of those results actually showing up is important: what’s the track record of the system or service on offer?

Here’s where the ROI question falls short of the mark in the current health care landscape: results become all about revenue. This is a particularly sticky question in health care, given that, outside of large health systems like Kaiser Permanente or the Veterans Administration, health care IT has been more about managing information and data flow within a closed system than about sharing information with patients, other providers, or payers.

The Patient Protection and Affordable Care Act (PPACA, or as it’s known in arguments across the US, “health care reform”) is the best attempt yet to get everybody in health care – from major hospitals to urgent care centers, from Park Avenue ob/gyns to free clinics – into the EMR pool. The carrots driving adoption are meaningful use incentive payments. The sticks are lower reimbursement schedules for failing to adopt EMR or to achieve that meaningful use.

Looking for strictly financial ROI in this landscape is almost impossible – there isn’t enough data yet to make any accurate statements about what the return, in dollars, might be. Vendors make promises, but anyone who’s been involved in a large-scale IT implementation knows that projects take a big commitment in time and treasure, and can often stretch far beyond the original scope of the project.

The ROI on EMR won’t be visible until EMR systems have been in wide use for at least two years within a provider organization. It will take another two years to see how the creation of state, regional and national health information exchanges (HIEs) return results in time or money.

A better question for HIT in its current state is, “what will it cost to do nothing?” I don’t just mean not getting the meaningful use stimulus payments – I mean the cost to health care providers who don’t adopt EMRs, or who don’t join up with state and regional HIEs as they come online.

The push to repeal PPACA that started when the balance of power in Congress shifted after the 2010 election risks making health care worse, not better, if repeal leads us back to Square 1. Health care – all parts of the process: providers, patients, and payers – has a stake in creating a better system. From Square 1, looking for the ROI on technology that can create that better system is only half the question.

What will it cost to do nothing? The answer to that question shows the way forward.

By Halle Tecco. It was beautiful in San Francisco last week, the perfect weather to welcome 1,000 health geeks to the fourth Health 2.0 conference.

Two themes seemed to anchor the demos and conversations at the conference: data and consumer empowerment.  

On day 1, Aneesh Chopra, CTO of the United States and Todd Park, CTO of US Health & Human Services set the tone with their enthusiasm for data.gov and what this means for healthcare.  They also announced the ‘Blue Button’, a program being piloted by the Department of Veterans Affairs to give veterans the ability to download their claims or medical information.

Private sector innovation was demonstrated by companies like FirstLife Research.  FirstLife is mapping and analyzing user-generated medical data that’s already on the web.  Then they use semantic algorithms and medical ontologies to convert these reports to actionable insights about medications.  Similarly, PatientsLikeMe combs through data on 19 conditions through their army of 45,000 patients that regularly track their health.  

With consumer technology comes the ability for patients to be more informed and connected.  There was lots of buzz for Castlight, a new site that provides employees with individual-level views of their health care benefits and costs. Such granular detail enables employees to become informed consumers and better shop for health care services.

Wellness apps were abundant, and a team of students from Stanford won the Move Your App! Developer Challenge, sponsored by Catch and HopeLabs.  They created an app, called Happy Feet, that encourages physical activity through a game-like activity tracker.  Another team built an augmented-reality mobile app that displays Health Rankings information based on a GPS reading, for home-shoppers or just the curious.

It was great to see a combination of large players like Google Health and Microsoft HealthVault, alongside garage hackers and health geeks.  Everyone agreed– technology is quickly making its mark on healthcare.

By Jane Sarasohn-Kahn. Electronic health records (EHRs) broaden access to patient data and provide the platform for pushing evidence-based decision support to clinicians at the point-of-care. This promotes optimal care for patients, reduces medical errors, optimizes the use of labor, reduces duplication of tests, and by the way, improves patient outcomes. When done in aggregate across all health providers, a team from McKinsey estimates that $40 billion of costs could be saved in the U.S. health system.

Reforming hospitals with IT investment in the McKinsey Quarterly talks about the American Reinvestment and Recovery Act’s (ARRA) $20+ billion worth of stimulus funding under the HITECH Act and estimates that 80% of existing hospital IT applications will be affected by the regulation. Hospitals will be spending about $120 billion to meet the adoption and meaningful use provisions of the Act. This equates to $80,000 to $100,000 per hospital bed. ARRA incentive payments will cover roughly 20% of this cash outlay, meaning that $60-80K won’t to covered.

But McKinsey says, “Hold on!” There are ways to recoup the spending gap between HITECH incentives and cash-out-of-the-hospitals-budget. McKinsey’s research calculates that optimizing labor, reducing adverse drug events and duplicate tests, and adopting revenue cycle management can help the average hospital save $25,000 to $44,000 per bed each year. That gets to the $40 billion in annual savings when multiplied across all hospital beds in the U.S.

In operational terms, the savings accrue through:

• Managing inpatient beds more efficiently using equipment-scheduling software
• Optimizing the use of clinical equipment
• Determining optimal staffing
• Reducing administrative waste
• Reducing adverse drug reactions through computerized-physician-order-entry (CPOE) which cost $8,000 to $15,000 per bed each year (up to $3 million for a 200 bed hospital)
• Managing the revenue cycle by billing unbilled services, equivalent to 0.4% of hospital services, or $4,000 per bed.

Jane’s Hot Points: The McKinsey team rightly points to three critical success factors for maximzing health IT investments that the most wired, effective hospital-adopters have learned: get critical buy-in among clinicians and hospital execs early in the HIT adoption process; ‘radically’ simplify health IT architecture; and, elegantly plan and execute.

It’s the implementation phase in health IT adoption that so often gets short-shrift. McKinsey notes that Canada’s hospital system devoted 30% of its entire budget to change management. That’s a big number, but it’s also where rubber meets road: a capital outlay of $N million is the easy part of HIT adoption. The follow-on implementation resources, both in terms of sheer dollar volume and labor/staffing, along with disruption of clinical workflow, is the hard part. But getting to meaningful use will require no small amount of implementation effort in the form of evangelism, education and training, and ongoing assistance and support.

Originally posted on The Health Care Blog on August 18th.

Did you miss Disruptive Women bloggers Indu Subaiya, Jane Sarasohn-Kahn, Trisha Torrey, and Regina Holliday this week on the Real Women on Health! Radio series? Or did you hear them, but want to listen again? If so, you can listen to the podcasts now available.

By Pamela Cipriano. On July 13, 2010, the clock started running for eligible providers, hospitals, and critical access hospitals, to become meaningful users of certified electronic health records (EHR). Under the direction of the Secretary of Health and Human Services, the Centers for Medicare and Medicaid, together with the Office of the National Coordinator for Health Information Technology (ONC) released the final rules that lay out the first two years of requirements for eligible professionals to qualify for incentive payments included in provisions of the American Recovery and Reinvestment Act of 2009 through the HITECH act (Health Information Technology for Economic and Clinical Health).  View the press conference led by Secretary Sebelius.   (Disruptive Woman Regina Holliday, spoke at the press conference)

Seven months and 2000+ professional and public comments later, the final rules lay out a three phase graduated approach of requirements for demonstrating meaningful use of certified EHRs.  Since not one stakeholder group is wholly enamored with the rules, they are more than likely equitable and balanced.  Listening to the feedback, the ONC made a number of changes from the proposed to the final rules, taking into account concerns about the speed and scope of implementation of criteria to qualify as a meaningful user.  Groups across the industry gave faint praise as they acknowledged the greater flexibility in the final rules and an easing of some of the requirements.  The phased approach lays out the goal for Stage 1 as capture of data in coded format, Stage 2 exchange of information with emphasis on guiding and supporting care processes and coordination, and Stage 3 improving outcomes by focusing on decision support with improved access to comprehensive patient data.

With quality at stake, the meaningful use incentives tie payments to achieving advances in health care processes and outcomes.  The payments are intended to help accelerate use of HIT. Fortunately there is already broad agreement that populating data into EHRs, using electronic prescribing, reviewing and sharing data across providers and settings, and reporting on quality measures has a positive effect on care.  Dr. Don Berwick, newly appointed Administrator of the Centers for Medicare and Medicaid, emphasized that the new rules define the use of EHRs that is “meaningful to care and to people,” emphasizing the direct improvement in patient safety, transparency, and access to data resulting in better, safer, and more reliable care for everyone.  Certified EHRs help providers know more about their patients, make better informed decisions, and reduce costs of care.  Electronic systems can reduce potential for errors, and enable consumers to work with their providers to coordinate and manage their care.     (more…)

By Robin Strongin. It didn’t receive much attention in the context of oil wells being capped and financial services legislation being passed, but the Federal Communications Commission (FCC) took a step last week that could make a profound difference for Americans who live in rural parts of the country.

The FCC voted unanimously to have the federal government pay a greater share of broadband Internet costs for rural health care providers, and the commission also expressed its intent to subsidize the construction of broadband networks.

Why is this important?  Over the past 25 years, according to the Center for Health Transformation, over 500 rural hospitals have shuttered their facilities.  And, while 25 percent of the U.S. population lives in rural areas, only about one in ten doctors base their practices in sparsely populated areas, creating a serious physician shortage.  For many, it’s an economic hardship to drive a few hundred miles to see a specialist.  Broadband access can bridge those distances and help physicians and rural patients share vital information.

The FCC has a $400 million annual spending cap for rural health care telecommunications programs, but it wasn’t spending all of that money.  So, now it will pay 50 percent of monthly broadband charges for eligible health providers, instead of 25 percent.

It’s not a lot of dollars in the grand scheme of federal outlays, but if it can help bring quality health care closer to those living in America’s wide open spaces, it’s one of our nation’s better investments.

By Mary Grealy.  An organization of health industry chief executives today applauded federal regulators for being responsive to the concerns of hospitals and physicians in constructing the final “meaningful use” regulations that will determine the allocation of health information technology (HIT) incentive funds.  But, said the president of the Healthcare Leadership Council (HLC), the newly-released rules leave some critical issues still unaddressed.

HLC president Mary R. Grealy said that, even though her organization was still analyzing the regulations, “it’s clear that federal regulators paid close attention to the more than 2,000 comments they received on the proposed rule, and that they have been responsive to concerns that the initial regulations placed the “meaningful use” bar so unrealistically high that the health technology revolution would have been slowed instead of accelerated.”

The “meaningful use” regulations establish standards that health providers must meet in order to qualify for a share of the more than $27 billion authorized by Congress in last year’s economic stimulus legislation.

The Healthcare Leadership Council is a coalition of chief executives from all sectors of American healthcare.

Ms. Grealy said, “An example of this responsiveness is seen in the fact that the rules no longer require that, in the initial stage of implementation, all of a health provider’s administrative transactions must be included in an electronic health record.  That simply wasn’t realistic.  Those requirements are now in Phase 2 of implementation, which is achievable.”

She said, though, that legitimate concerns remain.  For example, the regulations should consider each campus of a multi-campus hospital system as a separate entity in qualifying for HIT incentive payments.  And, she said, health providers who have built and succeeded with their own information technology systems should be grandfathered into the universe of successful “meaningful use” qualifiers, but that doesn’t appear to be the case based on an initial review of the rules released today.

Nonetheless, Ms. Grealy said, “we’re seeing important progress with these regulations.  Clearly, the administration saw there was a gap between the theoretical standards they initially wanted to apply and the real-world challenges that physicians and hospitals face in achieving HIT advancement.   We all want the benefits that come from information technology – enhanced patient safety, more cost-efficient operations, greater use of evidence-based medicine – but to make strides forward, regulators and providers need to be moving at a coordinated pace.”

Orignially posted on Prognosis: A Healthcare Blog on July 13th

On June 8th, in conjunction with Health 2.0 Goes to Washington, we held a Disruptive Women breakfast on the topic of Health 2.0. For highlights, read our summary and watch the video below.

By Sheryl Flynn.  Earlier this week, the American Heart Association (AHA) announced a new partnership with Nintendo of America.  According to their website (www.activeplaynow.com), the AHA and Nintendo are working together to promote physically active play as a part of a healthy lifestyle. This is the first time that the AHA has partnered with the video game industry to help consumers discover how video games that incorporate movement can be beneficial to health.  According to their “Healthy Lifestyle Tips” they encourage everyone in the house to enjoy active-play video games together and when the weather prevents outdoor activities- they encourage hosting an active-play video game tournament in your living room. 

 Today, according to AHA’s press release- They are not supporting playing all video games in an effort to promote a healthy lifestyle- only the Nintendo games such as WiiFit™ Plus and Wii Sports Resort™ software for the Wii are supported by the AHA.  The AHA’s logo will be found on these products beginning this summer. 

 The AHA is “trying to reach people where they are.”  They suggest that if you don’t move at all- move some.  If you move a little, move a little more.  In essence, if you go outside and play sports or are already active- they are not suggesting that you come inside and play video games- rather, they are trying to get those people who play video games (or are otherwise) mostly inactive- to start doing something active.  They figure, if you like playing video games and typically play video games with your thumbs while surfing the couch- perhaps you could get a little exercise by playing active video games. They are targeting the “no physical activity” group and trying to get them to move!

So, as one would expect- there is controversy over the two companies working together.  Some people believe that both Nintendo and the AHA see a significant return on their partnership investment.  But the AHA has suggested that this is not the case.  Nintendo has contributed $1.5million to AHA to fund a prevention platform aimed at informing Americans about heart disease and stroke prevention.  Another important consideration to keep in mind is that Nintendo is not the only “active-play” video game company out there.  Sony PlayStation released the “EyeToy” years before the Wii and it offers many hours of fun, active gaming as well.  The EyeToy is fun because you can see a video projection of yourself in the game, rather than controlling an avatar as with the Wii games. Microsoft plans to release Project Natal later this year- these games will also offer hours of active gaming fun! There are a number of other off-the-shelf gaming devices that promote active gaming- the consumer should be encouraged to seek the game that would be most fun for them. 

Perhaps most exciting, however, is the Innovation Summit that the AHA intends to host.  With $350,000 support from Nintendo, the AHA will bring together “Thought Leaders” in the area of health care, research, physical activity, fitness and video gaming to look at the synergies and potential benefits of active-play video games and physically active lifestyles.  Now that is exciting!  Finally!  The game industry, researchers and health care industry all together in one room to envision the future!  Wow!

The World Health Report 2008, from WHO, entitled “Primary Health Care Now More Than Ever” acknowledges the need to improve health systems for all through a Primary Health Care (PHC) reform. The report cites Brazil among other countries as good example of successful implementation of PHC policies and emphasizes the role of integrated health information systems as instrumental to achieving this reform.

It is impossible to deliver high quality health services to hundreds of thousands or millions of people without robust processes. That doesn’t mean taking away the human nature of health care. It means that it is possible to put methods in place that can, with the strong support of technology, organize health care delivery, support promotion and prevention, improve services quality and extend its reach. That IS eHealth.

In general, eHealth only makes sense if it supports a Health System. An example I’ve been closely involved with is SIGA SAUDE system in Sao Paulo city. SIGA SAUDE is São Paulo city’s integrated health information system. It is in operation since 2003, and today is present in all 700 health care facilities, with 14 million people in its database, processing 45 thousand scheduling requests a day. SIGA SAUDE implements all the business rules of the Brazilian National Health System, from family and community care, to surveillance and patient flow management.  The system reflects our country’s experience of using a national health system heavily focused on PHC and its long tradition of developing health information systems, now in the move to an integrated architecture.  Thirty years ago, we started developing several health information systems to deal with specific health issues, leading to 200 different systems that did not talk to each other. From 1999 on, we made the decision to move to an integrated health system to support the nation health system comprehensively. The basic premise is that information should be collected only once at the point whre it is generated and from that shared in the network.

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The following guest post on the subject of drug adherence is written by Julie Murchinson, Founder, Health 2.0 Accelerator and Managing Director with Manatt Health Solutions.

The tools are coming! The tools are coming! For a while now, tools to manage drug adherence have been developed, many designed to enable the patient to self-manage in the context of and in collaboration with the health care system from a specifically designed device or heavy application. Patient adoption, however, has been slow and the vision for self-management of drug adherence not yet reality. But recently from the budding Health 2.0 space, we are seeing tools built on more accessible web and mobile platforms that allow patients to manage when and where they want to with their mobile device (e.g. iPhone, Blackberry, cell phone). So, in much the same way many people’s lives have changed as a result of being able to use Facebook or Twitter, or read the Washington Post from their phones on the bus or out at lunch, patients who have previously required proximity to their home device or desktop to log medications taken can now not only track on their phone what they take from their pill box, but also take advantage of glow cap or smart label technologies that can technically interact with a phone-based mobile application.

It was one thing when the Brazilian government was sending text messages to remind women to take their birth control pills (which, by the way, has been highly effective), but we are in a new age of both passive and active patient engagement with mobile platforms. There are iPhone accessible apps like Polka and TheCarrot.com that enable patients to schedule and track their medications taken along with a number of other health topics including sleep, exercise and mood, among others. Medic8Manager provides an iPhone solution that goes a few steps deeper on drug adherence for managing scheduled medications with reminder functionality, refill tracking, missed dose alerts, as-needed meds and discontinued medications. A similar application in development from Informediq even uses the tagline, “enabling healthcare anywhere”. While some products are typically used solely by patients without involvement required from a physician or other caregiver, we are starting to see more user-friendly tools that originate from the physician-patient care process, while allowing for more consumer-friendly adherence tracking, a good example of which we are seeing from the new AdhereTx product. The next step in innovation can be seen from eMedMobile which facilitates a phone working with “smart labels” on prescription medication bottles that store drug data and send alerts to caregivers when a drug is missed.

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I’ve always been someone who (pretty much) does what I’m told. When my parents or a doctor told me “Take your medicine”, I complied. However, I remember a number of years ago when I was taking an antibiotic for a bad kidney infection; I started to feel better and I wondered why I should continue to take the drug. It wasn’t until someone explained to me that by not taking all the medication, or even skipping a few pills, the bacteria-causing infection could become resistant to future antibiotic treatment – they’d be bigger, “badder”, bacteria. This tidbit of information made perfect sense to me and I’m pleased to report that today, I take all my medications as prescribed, even when I might not have any symptoms.

Based on my personal experiences, I was very surprised to learn what an extreme problem drug adherence is to the health care system. It appears that many, many people are not listening to their health care professionals about taking their medicine as they should.

Before looking at possible solutions to this national epidemic, let’s identify a few reasons patients don’t take, or sometimes, even fill, their prescriptions. One common reason is a lack of understanding about the disease or diagnosis for which the prescription was written. Other reasons may be concerns about the drug’s effectiveness, fears related to medical side-effects, lack of belief that they can control the disease, or like me with the antibiotic, they stop taking the medication because they are feeling better and don’t realize the side effects of not taking all of the prescription. It seems to me that many of these reasons for non-adherence can be addressed if people were provided with more information about both their medical conditions and how their medications can be of benefit.

One possible emerging solution to this information/education problem is the application of healthy games – multimedia experiences that are fun and deliver health benefits. Healthy games hold the potential for many benefits, including improving health literacy, physical fitness, cognitive fitness, condition management and motivating behavior change (like increasing the likelihood of drug adherence).

iConecto, a company working to empower personal health and organizational performance though healthy games, gaming technologies and social media, has collected the largest database of healthy games for consumers and professionals. In addition, iConecto is tracking the evidence and experience of the benefits of these games. Currently, there are over 35 documented studies which show that well-designed games can help engage and empower consumers health behaviors leading to higher treatment regime adherence, better overall health, and more clarity in communication with others about their conditions. These clinical studies have focused on a variety of areas, including cancer, asthma, diabetes, cystic fibrosis, exercise/weight loss and brain games. This blog post will focus on a few examples related to improving drug adherence through the use of healthy games.

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As the President and CEO of the American Academy of Nursing, I am very interested in the direction and potential of HIT. Of course, the issue of meaningful use is at the center and of tremendous importance. But the definition as it currently stands does not go far enough.

What follows are recommendations put together by a working group of the Academy’s technology and informatics experts for The Department of Health and Human Services.

To Meet the Needs of Patients, the American Academy of Nursing
Says we need to go Beyond Meaningful Use

The American Academy of Nursing (AAN) is an advocate for improved patient safety, cost-effective care management of acute and chronic conditions, and the effectiveness of nursing and interdisciplinary care. The Academy strongly supports health care reform that goes beyond the prevention, diagnosis, and treatment of disease to include assisting persons to manage their own and their family’s health as well as possible. Such reform must capitalize on the contributions of all health care disciplines. This aggressive approach to broad health care reform will only be achieved and sustained if information systems are collaboratively designed by the “meaningful users” to address data elements that reflect the work of all health care disciplines.

The AAN recommends that future electronic health records (both EHR’s and PHR’s) not only provide for documentation of the services provided by all disciplines but also address the shifting of care from acute and ambulatory care settings to home and community-based settings. To achieve its intended role in health care reform, comparative effectiveness research (CER) must include accurate data collection and data exchange, address health as well as illness content, and be interdisciplinary versus physician-centric.

To assure meaningful use of health care information and information systems by all health care disciplines, the AAN therefore respectfully requests the following:

1. The “Meaningful User” Definition should specifically include advanced practice registered nurses (APRNs), registered nurses (RNs), and other interdisciplinary health care clinicians as providers, particularly in hospital settings, but also in most ambulatory and home care [or community-based] settings where the nurse may collect key demographic data, conduct the initial screening, and support implementation of the medical regimen, and whose documentation will largely determine if the overall encounter meets the various mandatory guidelines for effective and efficient patient care. In creating the definition of “meaningful user”, CMS must include all essential contributors to the care episode documentation if those contributions provide critical evidence of the effectiveness of care.  (See Sample Definition Matrix at end)

2. The “Meaningful Use” definition should include inpatient documentation by nurses and other patient care providers. Likewise, ambulatory care including community and home based settings where nurses and other key patient care providers deliver services that will impact the quality and outcomes the care should be included in the definition. The use of the EHR by nurses and other key providers is essential in supplementing and expanding the meaningful use by physicians. In the majority of situations, especially in the inpatient sector, physician design of the EHR and the population of the information fields will be incomplete and the data collection not comprehensive without the meaningful involvement and contributions of nurses and other key providers.

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