Brian Keaton, past president of ACEP recently posted about this on the ACEP Informatics Section ListServ, here's some of his post that I think will shed light on this subject: 
 
 
 
I was the primary voice for ACEP during the discussions that led to this decision and feel it was the best outcome we could hope for. All discussions were based on the assumption that the federal government was going to be successful in enacting legislation and drafting regulation that would require adoption and meaningful use of electronic health records. These discussions took place under the shadow of the Patient Centered Medical Home (PCMH)where the ER was being cast as the inefficient and ineffective “bad guy.” There were not a lot of sympathetic faces around the table. We also never dreamed that the feds would make the financial commitment that they subsequently made. As Todd Taylor has pointed out, however, even with this unprecedented federal investment, they won’t come close to covering the cost of connecting all of healthcare and there is no guarantee that their bet is going to be successful. My goal was to limit the bleeding and minimize the risk and the pain for the docs that I represented.  
 
 
 
The biggest question was who was going to pay for purchasing, implementing, maintaining, securing, and updating the systems and who was going to be penalized for failed implementations. My answer to all of these questions was, not me! I realize that the emergency physician will incur unreimbursed cost related to the inefficiencies inherent to operating the EDIS, but that was going to happen anyway. I did not want to saddle the emergency physician with the upfront cost and ongoing financial risks associated with the hardware, software, etc. If emergency physicians were paid incentives to implement and operate the systems, the emergency physician would become responsible for purchasing, implementing, and operating what is essentially an enterprise system and the hospital would have significantly less incentive to choose a system that enables the ER docs to become “meaningful users”. An even more onerous solution that was proposed was to pay incentives to hospital-based physicians who would be responsible for the cost of systems that supported their practices and then to have the hospital-based physicians pass these payments through to the hospital who would actually purchase, implement, operate and support the systems. Under this scenario, the hospital-based physician would be the “owner” of the hospital-based IT system and would be responsible for cost over runs and failed implementations. Having all the responsibility, all of the risk, and very little control did not strike me as a very good deal either.  
 
 
 
I believe the proposed rule represents the best solution for aligning the interests of the hospital with the interests of the emergency physician and our patients. In previous comments to the draft meaningful use definition, ACEP argued that the needs of our patients would be best met if the hospital’s requirements for meaningful use optimally supported the information needs of emergency patients and care givers. This is reflected in the current proposed rule. For example, one of our biggest issues has been ED crowding and the boarding of admitted patients in ED hallways. We’ve made little progress because this was seen by the hospital as an ER problem. By including ED Throughput measures (Table 20: Proposed Clinical Quality Measures for Electronic Submission by Eligible Hospitals for Payment Year 2011-2012 - page 153) as clinical quality measures that the hospital needed to report, ED boarding and throughput become a problem that is shared by both the hospital and the ED and the hospital bears a financial risk. We all know that you never fix what you do not measure, and you are less likely to fix problems that are not associated with a financial penalty.  
 
 
 
I could write a book about the work that ACEP and the members of its informatics and quality sections have done and continue to do to improve the health of our nation. While I know that “meaningful use” will be painful, I believe the current proposed rule presents us with a chance to make a significant step forward. It is incredibly important that we engage our hospital leadership and work closely with the hospital IT and quality staff to take advantage of the opportunity that is “meaningful.” I hope my comments help address some of the questions that have been raised and shed some light on what the College has been doing behind the scenes to support the practice of emergency medicine.