In February, President Obama signed The American Recovery and Reinvestment Act of 2009 into law. The stimulus plan (as it's often called) contains numerous provisions regarding healthcare. One of the more widely known provisions calls for physicians and hospitals to receive $19 billion to adopt Electronic Health Records (EHR). This seems like a smart, potentially viable measure, but to understand the nature of the governmental push for EHR requires close examination of the plan's details.

For physicians considering EHR or who currently use one, several provisions in the law are worth noting. For example, incentives begin in 2011 and end in 2015. At the end of this period, the incentives go to zero and the disincentives begin (see Table 1). The plan reflects the Obama administration's high ambition for digitizing medicine, as it leaves open a four-year window for incentives that dwindle over that time.

Physicians who adopt EHR into practice by 2011 or 2012 are eligible to receive up to $44,000 through Medicare. It's also worth noting that physicians practicing in health professional shortage areas can receive a 10 percent additional payment, for a total of $48,400. This applies to all physicians who can prove use of a qualified EHR, regardless of purchase date. Physicians would receive an incentive payment equal to 75 percent of the amount they collected from Medicare during a calendar year in which they qualified as a user of an EHR system, up to the annual cap. If your first qualifying year is 2011, in order to receive the maximum bonus of $18,000, you would have to have Medicare revenue equal to at least $24,000 for that year. If your Medicare revenue is $12,000 in 2011, you would be eligible for a $9,000 bonus payment.

"Meaningful" EHR. Importantly, there is one significant caveat potentially making the incentive structure much more complicated for EHR users. Simply having an EHR system is not sufficient to qualify for the incentives; several important provisos were written into this law.

The language states that to qualify for incentives, a qualified provider must be a "meaningful user" of EHR. This stipulation can result in doctors being penalized an increasing percentage of Medicare pay up to five percent if they aren't meaningful users of EHR. However, the definition of "meaningful user" is extremely vague at this time, perhaps due to the controversy surrounding the Secretary of Health and Human Services post vacated by Tom Daschle. But now that the position is occupied by Kathleen Sibelius, physicians hope that the verbiage in the legislation is made clear sooner rather than later.

As it is currently defined "meaningful" use of EHR includes using a certified EMR, demonstrating information exchange, and reporting clinical quality measures. All three components are to be further defined by the Secretary of HHS. These provisions were likely developed to enable the HHS secretary to adjust goals and meanings based on need (i.e., higher disincentives if CMS spending went too high) without going to Congress for approval.

For physicians, however, vague language in Federal legislation might only add to current frustrations and pressures regarding the use of an EHR. While most medical students and residents will be familiar with EHR when they begin practicing, established physicians understandably lack the patience to learn a whole new system. But the stimulus plan makes very clear that the direction of EHR in the US is a primary concern. It is, in fact, inevitable.

Perhaps the greatest difficulty for physicians who are just setting out to adopt EHR will be not to fall behind the curve of EHR normalization in medical practice. But physicians also should not be too far ahead, either, since the free market has not determined which EHR companies will emerge as leaders in innovation in dermatology and general medicine. Physicians are therefore in a difficult position; They must remain on a curve that has yet to be defined by the government, even though it has dictated the curve's incentive/disincentive structure.

Although we cannot know what "meaningful" use of EHR is until it is defined by the HHS, all physicians would be wise to observe trends in Health Information Technology on a broad scale as well as in dermatology. EHR is going to play a larger role in healthcare with each passing year, which is why education should be a foremost priority of physicians and medical organizations.