The devil is in the definition, as least when it comes to getting financial incentive payments for the adoption of electronic health records (EHR). The American Hospital Association (AHA) recently asked the White House Office of Health Reform, the Department of Health and Human Services, and the Centers for Medicare & Medicaid Services to revise the definition of "hospital-based" so that physicians working in hospital outpatient clinics or hospital-based facilities can receive incentive payments from Medicare and Medicaid under the American Reinvestment and Recovery Act (ARRA).

In many ways, AHA’s request makes sense. If ARRA is to incentivize "meaningful use" of EHR, it should not exclude physician users practicing in off-site clinic or outpatient locations — these are often the very physicians whose implementation and use of EHR is key to the creation of a community-wide EHR infrastructure. In other ways, though, AHA’s request is a vexing reminder of the mental contortions required to maintain the old meanings and purposes of terms while introducing new ones.

Whether an outpatient or "provider-based" clinic qualifies as part of the hospital for reimbursement purposes varies from state to state and from payer to payer. AHA’s request to expand the definition for purposes of ARRA incentive payments seems to make sense from an EHR-policy implementation perspective, but folding in yet another "hospital-based" definition for ARRA purposes challenges the conceptual integrity of the word — and starts to make my head spin.

The AHA letter is available at