The IT community is one step closer to a definition of "meaningful use" of electronic health records since the HIT Policy Committee made its recommendations today to the Office of the National Coordinator for Health Information Technology.

I spoke with a number of executives to get their predictions and strategies regarding "The Meaning of Meaningful Use" for the June issue of HealthLeaders magazine. Since then, I've spoken to even more industry executives to get their thoughts on the phrase that has caused confusion, criticism, and alarm. Here are some excerpts from those conversations.

Will the bar on "meaningful use" be set too high or too low to improve quality?
That is a real risk, says Lynn Vogel, MD, vice president and chief information officer at The University of Texas M. D. Anderson Cancer Center. "Since these are 'stimulus' funds and likely a one time opportunity, I am concerned that there will be a temptation to expect that they will fix all that ails our healthcare system and that is completely unrealistic." It's not IT's burden alone to improve the quality of care, says Vogel, who is also the associate professor of bioinformatics and computational biology. "Hospitals should not be penalized if all they have done is to improve the caregiver's access to clinical data through electronic capabilities. That is valuable and 'meaningful' by almost any standard," he says.

The government will not hold organizations "hostage" to high standards, says Mark D. Crockett, MD, an attending physician at Morris (IL) Hospital and the president of the emergency care division for Picis, an Wakefield, MA-based IT software vendor. "It will be more of a carrot than a stick," he says. "They are looking to reward hospitals that are making moves—reporting quality and using some type of CPOE. They are also looking for information exchange."

Are the stimulus funds a big enough 'carrot' to spur quick adoption, or will most organizations just try to avoid penalties?
The answer is different for hospitals and physicians, says J. Marc Overhage, MD, PhD director of medical informatics and research scientist at Regenstrief Institute, Inc. and president and CEO of the Indiana Health Information Exchange. "For hospitals it is probably enough," he says. "For physician practices, by and large, it is not enough."

The combination of incentives from the Centers for Medicare & Medicaid Services and the American Recovery and Reinvestment Act removes any doubt that physician practices must adopt an electronic health record in the next five years, says Phyllis Schuck, CIO at Pinehurst Surgical Center. "The financial aspects are designed to encourage rapid adoption." But they don't "significantly offset" the capital outlays that an EHR requires, she says.

Overhage predicts there will be a large number of organizations in jeopardy of being penalized under the guidelines.

What will the impact be if a large number of organizations rush to purchase HIT in the hopes of securing stimulus dollars without putting in enough planning time?
Organizations could be wasting their money in the long run, if they buy IT just because there is stimulus money, but they are not ready or purchase a system that isn't what the caregivers need, says Vogel. "That's the challenge—and the risk—of the stimulus funding," he says. "Some number of these purchases will not be successful because the organizational context within which the system will be implemented will not be ready to make the changes necessary to be successful."

"Our biggest risk, is will we effectively use these dollars to deliver better care for patients," says Overhage. "If I can send and receive healthcare data, but no one else is out there to do it—the patients won't get any benefit." There is a critical mass that needs to be achieved for widespread adoption to occur, Overhage says. And while he's not sure what that figure is exactly, it is probably in the neighborhood of 60% to 70% of healthcare data that needs to be exchanged, he says.

Will there be a better approach to achieving meaningful use—enterprise path or best of breed?
Crockett is not convinced it will make a difference over the long haul. "Everyone wants to see an integrated system where all documents are visible and useful to everyone in the hospital," he says. Historically, that has only been achieved with enterprise systems, but organizations often have to sacrifice some level usability and effectiveness for clinicians with those systems. One system can't do everything well, says Vogel. For some organizations having a single system is worth avoiding the hassles associated with a best-of-breed approach. Then again, for other organizations like academic medical centers where state-of-the-art capabilities are expected in every area, the only way to accomplish that is through best of breed, says Vogel. "Just like in cars, a high performance racing vehicle is not the best vehicle for commuting to work every day, and the best car for your daily commute would run far back in the pack on the race track."

Crockett believes the solution is in interoperability standards. "If I needed to achieve meaningful use in one year, I have no choice but use one vendor," he says. "But if I can do this over time as standards are put in place, then I can buy a system from anyone and have it work."

The HIT Policy Committee will offer some additional direction with its recommendation to ONCHIT, but the industry will still be in a holding pattern until it receives the official definition. Then, it will be a race for "meaningful use" status and cold hard cash. Will most organizations take the time for planning to ensure they get the value out of the IT being implemented—improved outcomes and cost savings—even if that means forgoing some stimulus money? Or will they speed up the decision-making and planning process in order to go for the cash and hope to sort it out on the backend? I must admit, I think there will be some definite redo's from organizations that didn't quite find a system that fits their clinicians' needs.

At about the same time President Barack Obama was telling the American Medical Association in Chicago about making spending cuts through targeting inefficiencies in the Medicare program, the Medicare Payment Advisory Commission (MedPAC) officially was releasing its report to Congress on "Improving Incentives in the Medicare Program" that addresses similar spending issues.

MedPAC, with its 17-commissioner board, has provided advice to Congress since 1997. But this small organization has attracted more than its share of attention recently after the president suggested in early June that it should have new power as an executive-level agency to determine Medicare reimbursements.

On top of MedPAC's discussion list was overpayment to Medicare Advantage programs. According to MedPAC Executive Director Mark Miller, Medicare—under the current payment system—will pay as much as $12 billion more for beneficiaries enrolled in Medicare Advantage plans this year than it would spend if they were in traditional fee-for-service Medicare plans.

Those high payments have resulted in some plans offering no innovation to the Medicare program: instead plans were mimicking FFS programs—at a much higher cost to the program. MedPAC proposed four different solutions to turn this around, including setting benchmarks through competitive bidding.

MedPAC also examined the feasibility of accountable care organizations, which it defines as a set of providers held responsible for the quality and cost of healthcare. An ACO could consist of a group of primary care physicians, specialists, and at least one hospital.

The report describes two variations of the ACO model: mandatory or voluntary. With a mandatory ACO, participation by providers would be required. With a voluntary ACO, providers who reorganize care and change practice patterns could receive financial bonuses.

Providers in a successful ACO would need some type of mechanism to jointly decide on care protocols, according to MedPAC. However, this level of decision-making would be difficult in a mandatory model in which providers were placed together—without first agreeing on a system of common governance.

Other highlights of the report:

Biologics. Current Medicare spending on biologics was about $13 billion in 2007. While they account for a small part of the Medicare market now, their growth is expected to skyrocket soon. MedPAC is calling for establishment of a process to approve follow-on biologics.

Self-referral of imaging services. The use and spending of imaging has grown without a clear link to higher quality. MedPAC said it intends to explore policies "to encourage more prudent use of imaging services."

When David Priver, MD, once an American Medical Association delegate, read last week that the group opposed President Barack Obama's public insurance plan option for adults under age 65, he blasted an angry e-mail to his colleagues:

". . . If nothing is done to reverse this ill-advised AMA policy, we can expect (AMA) membership to drop like a stone," wrote the San Diego obstetrician-gynecologist.

Even when learning the AMA backed off from that stance the next day, clarifying that it merely opposed any plan that forces physicians to participate or which pays Medicare rates which are too low, Priver was not appeased.

"Why make a statement like that and backtrack a day later?" Priver rhetorically asked in an interview Monday, saying he thought the move was disingenuous. "I think they really shot themselves in the foot this time."

For many physicians across the country, the AMA's initial stance severed any allegiance doctors have for the nation's largest and most powerful physicians group.

"The AMA has badly misread the sentiments of not only its members, but of physicians across the country," says Priver, former president of the San Diego County Medical Society and delegate to the California Medical Association. "Most of us don't want to be seen as obstructionists for reform. And the AMA, if they did a better job of keeping in touch with the grassroots, would have known that," Priver says.

Priver joins an increasingly vocal group of doctors who say they are defecting from the AMA.

In an article last week entitled "Dear AMA, I Quit!" in the Huffington Post, a Maryland physician said he was "disgusted" that the organization seems pre-occupied with physician reimbursement at the expense of patient care. Instead of working for patients, it seems to be "supporting the private insurance industry, which has been a driving force in creating the dysfunction(al) health care system we have today," wrote Chris McCoy, MD.

McCoy said he was reacting not just to the Thursday article in the New York Times, but also to the AMA's 12 pages of comments on health reform submitted May 11 to the Senate Finance Committee. Such a plan "threatens to restrict patient choice by driving out private insurers, which currently provide coverage for nearly 70% of Americans," the AMA wrote.

"A crowd-out of private insurers and the corresponding surge in public plan participation would likely lead to an explosion of costs that would need to be absorbed by taxpayers," according to the AMA.

McCoy said those comments indicate the AMA's position "is driven by out-dated political ideology that blindly supports private industry."

A volley of letters to the New York Times on Sunday questioned why the AMA would make such a statement before details of a public plan are understood. For some, it seems the latest AMA stance was consistent with its policies in the 1960s when it opposed the creation of Medicare and Medicaid.

"The AMA is considered by many in the medical community as out of touch and only caring about medical malpractice costs and reimbursement," said Bryan Liang, MD, of the California Western School of Law. AMA doctors, he said, tend to be older, male, more conservative, and used to "the good old days" before managed care, a time when they had more autonomy, he said.

Last week, the AMA's position on a public plan option crystallized opposition against the organization for many younger doctors who may have been sitting on the fence.

Mandy Krauthamer, MD, a primary care physician in Washington D.C., and spokeswoman for Doctors for America, a coalition of 13,000 physicians across the country who are upset with the AMA, says the organization "no longer speaks for physicians."

"We took a survey and in the first 48 hours, 2,000 of our members said they would like a public plan considered," she says. "There's healthy debate within the House of Medicine. And taking the AMA's voice as ‘the voice of all physicians' is not the way to go anymore," she said.

In reality, many doctors are not happy with Medicare or Medicaid and bridle at the obstacles put in front of them by private health insurance. But they also see their ability to do their jobs threatened by paperwork, insurance, government bureaucracy, and rising healthcare costs that all too often prompt patients to seek care too late. They are willing to give something else a try, and feel that this may be their last real chance.

The California Medical Association, which represents about one-third of California's doctors, has not yet taken a position on a public plan option, says spokesman Ned Wigglesworth. But Wigglesworth says a key concern on the West Coast is that "people in Washington should focus less on expanding coverage, which has often been a false promise, and more on expanding meaningful access to healthcare."

"Many doctors don't fully embrace either private insurance or public programs as the foundation for health system reform because they and their patients have had such problems with both," he says.

For Priver, it's important for doctors to "think over carefully the option for a public plan" and keep their place in the discussion. "We need to decide what will be the legacy we leave behind. We don't want to follow in the footsteps of the AMA. Some of us may not be happy about what's being talked about, but if you stamp your feet and walk away, you'll like the situation even less."

General Electric Co. said its GE Capital division will make no-interest loans to hospitals and healthcare providers that purchase GE's healthcare information technology. GE said it expects to offer $100 million in interim financing to hospitals and healthcare providers for projects that are expected to qualify for funds from the economic-stimulus package.