I’ll start this segment with something that sounds like a sure-fire soporific, guaranteed to put you to sleep. Just hold your eyelids up while you read through the next paragraph – I promise that there is a very important point coming up shortly. While reading some of Nicolas Terry’s more recent work on the effectiveness and safety of EHRs, in particular a 2013 article in the Journal of Legal Medicine, I came across part of a paragraph that, although sterile in the academic fashion, startled me.  As backdrop, Terry was discussing a 2009 paper by Michael Christensen and Dahlia Remler in the Journal of Health Politics, Policy and Law. In that paper, the authors were discussing market failures as responsible for impeding IT development and adoption. Their primary point is that market failure is due to misaligned incentives, observing that providers (doctors) are the ones who pay for EHRs, although insurers and payers welcome EHRs. Although the point is absolutely correct and astute, the writing did not make my pulse race in the same way that it does when reading F Scott Fitzgerald’s The Great Gatsby, for instance. However, then I read:

`Christensen and Remler identify several failures common to general IT adoption, … However, they argue: “[F]antastic gains of [IT] have outweighed those barriers in most industries and aspects of both public and private life. Why does health care [IT] lag so far behind?” One answer is patient heterogeneity. Going down that imperfect information road also implicates provider heterogeneity.`

These couple of lines hit me like a ton of bricks. As in, “Mommy, aren’t all doctors the same? They’re not?”  Yet, once I started to think about it in the context of the Affordable Care Act (ACA), I realized that an implicit presumption of `physician homogeneity` underpins and pervades most, if not all aspects of any associated planning, logistical or economics analysis. This covers costs, competency level, experience, and degree of availability, and a few other criteria that might cause one to differentiate among possible choices. We have been reduced to utterly generic commodities in the business model of the ACA. Thus the first year doc who eked into a mediocre medical school and barely completed his residency program last June is viewed (economically and logistically) as equivalent to a section head or chair at Harvard or Johns Hopkins with 40 years of experience, or to a similarly eminent private practitioner. Sadly, much of the present treatment of physicians within today’s hospital environment accurately reflects this viewpoint, as described in the previous essay.

I can only wonder what the response by a hospital president would be when informed that his lunch engagement at Per Se (Thomas Keller’s Michelin 3-star gastronomic restaurant in Manhattan) was changed to a meeting at McDonald’s, to achieve cost savings based on chef homogeneity.

Along similar lines, and also very important, is the implicit (business) presumption that there is no consequence to a patient’s medical care if one switches insurers, and as a result, switches treating physicians on a yearly basis. During the past two years, the ACA has initiated new markets for health insurance, as well as new ways of buying it, via online exchanges. But these new markets have also seen dramatic price variations, or changes in policies, that cause many consumers to switch plans each year. The present administration is actively encouraging comparison shopping and switching as a way to avoid steep increases in premiums, and to promote competition among insurers. Indeed, among states that use HealthCare.gov, about 60% of enrollees had switched to a different plan for 2016. This extent of switching is being trumpeted as a success, validating the economic model and incentives in play here. And I agree, from a perspective focused exclusively on near-term cost control, budgetary objectives may be fulfilled. In a system of identical robot physicians all seamlessly sharing complete information about a patient, this logic would be impeccable.

Unfortunately, in the human world, I believe that this model will most likely lead to greater long-term system costs, particularly for patients with complex medical regimens. Sadly, for these patients, without the continuity of care from a familiar doctor, I would often expect to see a substantial relative decline in their long-term health, and greater complications from medical or surgical interventions. I fear that this would likely be accompanied by a concomitant increase in medical costs that would be significantly larger than the projected systems savings achieved by controlling insurance rates. Why would that be? There are a number of reasons, but the following few points should already voice my concerns.  Many doctors will feel less invested in the long-term health of patients if they believe that the patients will be with them only for a short while. There will be fewer incentives for a doctor to develop a master long-term personal health plan for the patient, to push for diet and exercise management and balance, to indicate timely screenings, or to `pull strings` in extenuating circumstances, each of which would be beneficial to both the patient and to the system. And many patients will not have developed the trust in a physician to adopt an `unusual` change in their habits that could be very helpful, and will not feel free to discuss `something minor` or confidential that if properly addressed, could make a world of difference to their health. Moreover, the bottom line change here, I fear, will also often come with a quality of life drop, as well, in addition to the added financial pain.

So we need to be very careful with our budget exercises. If we presume or seek genericity, we may yet achieve mediocrity.

In the essay `Throw Dr. Kildare from the Train`, I wrote that there has been an acceleration in retirements and in retirement planning among local New Haven-area physicians, including both senior members of the Yale Medical school faculty and doctors from the private community. I know from friends and colleagues across the U.S. that this dynamic is playing out in many academic medical centers nationally. Unfortunately, the collateral damage will be severe, with the loss of irreplaceable expertise and experience. The departing muses generally shared a viewpoint of medicine as a calling, and an art, not a corporate infrastructure to be climbed. They also included many of our absolutely best minds and most compelled individuals. Yes, many had alpha-type egos and matching social behavior, but they brought innovation, depths of understanding, fire, and panache to their profession. Who will be left to advise the hard, out-of-the-box, non-formulaic cases that no template protocol can accommodate, once these physicians have left the scene? I do not know. Within modern corporate America, it has become an increasingly common business practice to force out older, often high-functioning senior employees to be replaced by less costly new hires. But this strategy has primary appeal only for short-term accounting. Within medicine, this de facto strategy looks to be a recipe for disaster long-term.

When I was young, medicine was considered to be the top career choice by many, and a very significant percentage of our smartest and most driven students became `pre-meds`. At present, the job of doctor is still generally well regarded, but the profession no longer seems to attract nearly as many star students, particularly compared to finance, consulting or entrepreneurial ventures. The following data, all obtained from published university sources, tell an interesting tale. I would expect that data from many other colleges and universities would tell a similar story. (1) Yale University. Percentage of graduates who entered Medical School: in 1975, 17%; in 2010, 4% (a remarkable decrease, again consonant with similar observations at other `top` schools). In contrast, going into Business & Finance: in 1975, 8%; in 2014, 21%. (2) Brown University. In 2014, 5% of the graduating class went to medical school. In 2011, of graduates entering the work force, 20% went into consulting or finance, and another 10% went to Silicon Valley or technology companies. (3) MIT. In 2014, 6% of graduates went into health or medicine; 50% went into finance/banking, consulting & computer technologies. (4) Harvard University. In 2014, 5% of grads went into health-related fields; 31% went into finance/consulting (and 70% of the graduating class sent resumes to Wall Street and consulting firms). (5) Princeton University. In 2010, about 3% of graduates went to medical school; 36% of graduates with full time jobs went into finance; if you add management consulting, the figure exceeds 60%.

Even a decade ago, we already perceived a profound shift in the medical talent pool. In a 2004 Medical Economics survey, when asked “Do you think the brightest young people are going into medicine today?” 72% of the 7,700 physician responders said No. In my specialty ob/gyn, the percentage was even worse, 82%. Major complaints were a recitative of excessive bureaucracy, not enough reimbursement, medical education debt, and liability. In agreement with the data from the previous paragraph, already by 2004, much of the attrition was due to top students heading to either Silicon Valley or to Wall St, although not yet quite at today’s rates. Why? In a nutshell, they seemed to be following Sutton’s Law for robbing banks, “That’s where the money is.” Charles Lockwood, then chairman of ob/gyn at Yale, felt that nationwide, the quality of candidates had fallen precipitously and that our specialty was “in dire straits.” Lockwood noted that applications and acceptances to ob/gyn training programs by US medical students have dropped to the lowest level in years, a point subsequently echoed by many chairs and program directors across diverse medical specialties. Based on local evidence, this trend appears to be continuing, if not accelerating.

There is a lot of unhappiness with electronic health records (EHRs) among nearly all my medical friends and colleagues, and I have heard all flavors of complaints about them. Many of the anecdotes are compelling, in fact at times bordering on the absurd, and given time and license, I can share many horror stories. But here I want to go beyond the anecdotes, in two different directions. First, many recent surveys on EHRs all point to a similar conclusion, from related yet distinct perspectives. I discuss these below as Sad Numbers. Second, I found a published 2014 research report by RAND Corporation, Redirecting Innovation in U.S. Health Care: Options to decrease spending and increase value (RR-308), to be very much on point here. As part of the analysis in this report, RAND undertook several case studies, which included an up-to-date analysis of the role of EHRs in health care. The report provides essential background, some executive level conclusions, and policy suggestions. In fact, there are two published `versions` of this report, each of which basically bears the same title. The more executive and slightly glossier version is denoted by RR-308; the second has a subtitle `Case Studies`, and goes into each of the eight studies in somewhat more depth than does the executive version. Nonetheless, they are very similar, and complementary. I found the content of both reports to be illuminating, confirmatory, infuriating, and saddening. Without question, the report is spot on the topic. I will simply refer to RAND or the RAND report below to indicate that the source is one (or both) of these versions. The link to the more executive version is:

http://www.rand.org/content/dam/rand/pubs/research_reports/RR300/RR308/RAND_RR308.pdf ,

while the link to the more detailed Case Studies version is

http://www.rand.org/content/dam/rand/pubs/research_reports/RR300/RR308/RAND_RR308.casestudies.pdf.

I’ll discuss the RAND report (in context) below by focusing on their contrast between two major EHR vendors, Epic and VistA, along with their conclusions. One point in RAND’s methodology does need to be clarified up top, since their analysis bridges several directions. They synthesized information from peer-reviewed and other literature, from a panel of technical advisors that was convened for the project, and from 50 one-on-one extended expert interviews. These interview subjects included health care industry and/or policy experts, drug and device inventors, regulators, providers, payers and insurers, venture capitalists, and researchers. A few of these interviews provided poignant quotes that pack a powerful, decisive wallop, and I wanted to share them here. So below, when I am quoting from the reports, to clarify who said what, I will indicate RAND commentary by [RAND]:, and commentary or quotations from one of the experts by [EXP]:, along with italicized text.

Sad Numbers As Melinda Beck reported in September 2014 in the Wall Street Journal, the depth of doctors’ dissatisfaction has been confirmed by several recent large-scale studies, with widespread complaints about poor design and usability, incessant needless alerts and poor work flows. 47% of physicians say that EHRs detract from patient care, according to a 2014 survey of 20,000 physicians by the nonprofit Physicians Foundation. In the same study, 46% of respondents indicated that they would give a D or F grade to the Affordable Care Act (ACA); 39% of physicians indicated that they will accelerate their retirement plans due to changes in the healthcare system; and 50% of physicians indicated that implementation of ICD-10 (the new system of narrowly defined and finely detailed medical coding) would cause severe administrative problems in their practices. A 2014 survey by the industry group Medical Economics discovered that 67% of doctors are “dissatisfied with [EHR] functionality.” In a 2013 AMA/RAND survey, 43% of physicians said that EHRs slowed them down, requiring them to spend too much extra time on data-entry, leaving less time for patients. Moreover, according to the results of a study published by the American Medical Association and the American College of Physicians’ American EHR division, physicians have become increasingly dissatisfied with EHRs during the last five years. The survey, “Physician Use of EHR Systems 2014,” found that only 22% indicated they were satisfied, and 12% “very satisfied” with EHRs, a sharp drop from the parallel study conducted five years earlier. An Accenture study in 2012 found that of the eight developed countries surveyed, the U.S. had significantly lower percentages of doctors who believed HIT improves diagnoses, health outcomes or quality of treatment decisions.

An October 2014 survey from the executive suite buttressed these findings. The study from Frost and Sullivan, “EHR Usability-CIOs Weigh in on What’s Needed to Improve Information Retrieval,” surveyed about 60 Chief Information Officers (CIOs), primarily from mid to large community hospitals. The CIOs themselves concluded that EHRs are falling down on the job when it comes to finding the information that they hold. The respondents reported that the EHRs were too slow and lacked precision when it came to information retrieval. These problems, as well as the difficulty in finding and reviewing the data, created `significant` productivity losses and increased potential risks to patient safety. Respondents also indicated that rudimentary search functionality and poor usability are more important causes of search problems than lack of end-user training or clinician dislike of technology. Moreover, the principal analyst Nancy Fabozzi predicted that as EHR data expand, the retrieval problem will worsen, and that regulatory response will be forthcoming. So if the experts, who presumably are hardly Luddites, determine that the EHR problems are with the systems and not with the users, there really is a major problem here.

Epic and VistA RAND chose to contrast two of the largest and most influential EHRs in the United States today, Epic Systems and VistA, to illustrate how market forces and public policy actually shape adoption of EHRs by hospital systems and medical practices.

Epic: As RAND describes, Epic is a privately held company that owns its proprietary technology. Among its clients are the vast majority of the United States’ elite academic medical centers, including the Cleveland Clinic, Johns Hopkins, Dartmouth-Hitchcock Medical Center, Kaiser Permanente, nearly the entire University of California system, and Yale-New Haven Health System. Epic has won several awards for both inpatient and outpatient EHRs, as well as for software used in scheduling, billing, and collections. It has been named “The Top EHR Vendor by Number of Meaningful Use Attestations.” Epic has been led by its founding CEO, Judith Faulkner, into a global company with approximately $1.5 billion in revenue in 2012. As RAND discreetly states it, “Epic does customized installations for each client, allowing health care systems to tailor Epic’s applications and functionality to meet their own needs.” The RAND report quotes from a article in Forbes, `In addition to the software, [Epic] customers pay dearly for hardware, and for an army of Epic-certified technicians that needs to be deployed to get the system up and running.` On point, this past June, Boston-based Partners HealthCare (the Harvard system) launched its Epic system, Partners’ single biggest investment ever, three years in the making at a cost of $1.2 billion. That’s correct – billion, with a B.  The RAND report then continues, “Although Epic is expensive, it works, and in the conservative world of health IT, that’s all that matters.”

This is perhaps more easily understood by distilling some information from the essay `Cheat Sheet`. First, the Health Information Technology (HITECH) Act of 2009 put many billions of dollars in federal incentive payments on the table for medical centers and private practices to adopt certified EHRs that demonstrated `Meaningful Use` (MU). Second, Epic’s CEO, Judith Faulkner was the only head of a health IT company to serve on the Obama administration’s Federal Health IT Policy Committee, when the HITECH Act was being formulated. This gave Faulkner and Epic a critical edge, as Faulkner was then able to advise federal officials as they crafted policy framework, including criteria ultimately adopted to satisfy MU in the HITECH Act. Naturally these official criteria would mesh well with Epic’s existing systems, or with relatively turnkey modifications and additions to their systems. Since the business decision of which EHR vendor to choose almost always reduced to the question of which vendor would max out Meaningful Use revenue, Epic had a very advantageous market position. And indeed, as of mid-2014, more than half of the $24 billion spent to date by the Meaningful Use program had gone to customers of Epic.

Let’s think about new pressures within the Harvard system, for instance, now that they just invested $1.2 billion for their spanking new Epic EHR. The business side of the house, which has acquired outsized power within most major academic medical centers, will surely want to recoup this sum `in an expedited fashion`.  In an age in which 78% of CEO’s say that they will mortgage the future (sell out) to meet the next quarterly earnings report estimate, I am fearful that physicians in the system will feel both implicit and explicit pressures to generate substantial (new) revenue streams. A permanent position versus being let go, tenure, a promotion, a named chair, a piece of the action – all of these incentives seem more tied to new dollars than ever before, entirely apart from the chronic pursuit of NIH grant money. So in the vast numbers of medical settings in which there are a justifiable range of possible actions, given the choice between further testing and procedures rather than `let’s just sit tight and keep a close eye on this for the moment`, or first trying lifestyle changes (in diet and exercise), I see a heavily tilted see-saw.

There are a couple of other important issues with EHRs as now in place that also require some serious attention. First, although Epic (and many other) EHRs are espoused as powerful tools to advance patient safety, they have inadvertently spawned new types of medical errors. For example, many EHRs impose severe alert fatigue, with very frequent alerts that numb the attending doctors and nurses to the point of tuning them out. In The Digital Doctor, Robert Wachter tells a frightening story about a 39-fold overdose of a common antibiotic given to a teenager, to a large extent the result of this fatigue. The protocol systems for alerts must undergo serious revision, and any revised models should be required to be rigorously field-tested by doctors, nurses and pharmacists for approval.

In addition, I experienced several instances of Epic crashes when I was regularly using the EHR, in which the system would be down for hours, paralyzing doctors, staff, and thus indirectly, patient care. In principle, there is a Help Desk, but responses would also be long in coming, and often nonconstructive. To be fair, this problem hardly seems unique to Epic – many friends and colleagues who use other large scale EHR systems have also experienced similar episodes, both in private practice and in hospital-based settings. Apparently this issue still persists today, perhaps with a little less frequency. But in a medical environment, this can be extremely dangerous. More back-up (redundancy) is imperative, in the name of patient safety. We have back-up generators to handle power failures. And some systems, such as mechanical ventilators, are classified as life-critical, requiring a very high degree of reliability. In an age in which we are becoming exclusively dependent on our electronic records system to function, we must likewise develop (and in fact, require) analogous highly reliable `solutions`.

VistA: As counterpoint to Epic, the RAND report then goes on to describe VistA, from which the following is excerpted. The EHR for the Veterans Health Administration (VA), denoted VistA, provides a sharp contrast to the Epic EHR. Developed in its present form in the mid- to late 1990s, it is very well regarded within the VA health care system for its user-friendliness, interoperability, and impact. VistA has received many accolades for reducing costs, improving both outpatient and inpatient care, and enhancing clinical outcomes in the VA health care system. VistA incorporated, and in some instances pioneered, computerized order entry, electronic prescribing, and bar code medication administration. VistA’s success has been attributed in large part to the collaborative nature of its development. Clinicians and information technology (IT) experts worked together to design its user interfaces and patient record system. Equally important, because VistA is built on a standard code, it is fully interoperable within the entire VA.  Today, VistA and derivative EHRs, are installed in every Veterans Health Administration (VA) facility in the country. Several recent major independent surveys, including ones by the American Academy of Family Physicians (AAFP) and by Medscape, indicated that physicians are broadly satisfied with VistA, which ranked as one of the very highest systems overall. Notably, VistA significantly outscored nearly all EHRs offered by large vendors, including those by Epic and McKesson. In particular, when the AAFP survey asked respondents to express their level of agreement with the statement, “This EHR enables me to practice higher quality medicine than I could with paper charts,” VistA received the top score.

`Higher quality medicine` – now there’s a concept worth holding on to.

Yet, as RAND concludes, “despite its known strengths and many favorable reviews by physicians, VistA has not been enthusiastically embraced by the private market. Medsphere, a company created to market a commercial version of VistA, has a modest share in the market, but most hospitals and providers have purchased commercial products that they believe are better designed to meet their needs, particularly billing.”

Or perhaps I would prefer to slightly edit the above to read “… , particularly billing.”  This is hardly surprising, since VistA was not developed with billing (of veterans) as a primary focus. Nonetheless, many doctors, including myself, would very much like to see many of VistA’s attributes incorporated into the EHRs that they are required to use. VistA clearly demonstrates that EHRs can be quite beneficial to medicine overall, not only in principle but in practice, at no expense to caregiver morale. However, the ruthlessly `business and billing-centric, all else is extraneous` model of EHRs that has emerged as a natural response to HITECH’s financial incentives throw us all under the bus in the name of near-term profit.

The $hort-term is Winning: Furthermore, the present reimbursement model (via HITECH) does more than `merely` bias towards procedures, as opposed to discussion and watchful waiting. Of at least as much concern to me, it is also accelerating the trend to favor short-term rewards over long-term benefits. Several quotations from the RAND reports strongly reinforce this observation. As one expert reported, [EXP]: “Payers tend to have a short-term perspective. A life saved in the future provides no financial value. Payers do not benefit from cancer prevention through screening.” [RAND]: “In the context of preventive services, some of which could decrease [long-term] spending,” another expert reported [EXP]: “when you look at preventive services, the reason that developers are deterred or discouraged from creating high-value technology that lowers overall spending revolves around reimbursement . . . we can’t set future value to justify the price of preventive services. There’s no market incentive.” [RAND]: “In addition, when a health system is siloed [compartmentalized] — few, if any, decisionmakers account for benefits or costs that accrue outside of their silos.” Then yet a third expert said [EXP]: “There’s little ability to do longitudinal holistic decisionmaking and evaluation of cost-benefit.” The RAND authors then conclude that “Limited time horizons and fragmented decision-making have played substantial roles in the development, adoption, and use of HIT.”

The RAND report notes that “EHRs’ principal economic impact to date has been facilitating clinical documentation to support timely and complete billing. … Viewed in hindsight, it is not surprising that introducing IT to health care did not immediately generate substantial gains in productivity. …  When other U.S. industries adopted IT in the 1970s and 1980s, productivity growth initially fell, often significantly. However, when these industries redesigned their IT systems to make them more usable by employees and customers and redesigned work processes to take advantage of IT’s capabilities, productivity soared.” In the present setting, the theoretical argument that EHRs will improve American health care and (probably) the economy is quite sound. However, academic studies have shown that the technology’s promised impact on patient care has been blunted, in likelihood by elective limitations in EHR design, usability, and the extent of its interoperability, in the overarching aim to maximize MU receipts. If and when suitable substantive changes are made to EHR design to better serve doctors and patients as well, there remains a strong possibility that EHRs will realize its promise. But that `If` must come from the top, not solely based on free market forces, and it must come shortly.

RAND has the last word here. They conclude that “it is not known how use of EHRs in the United States will evolve, but two points are clear: (1) EHRs are here to stay, and (2) how they are designed and employed will profoundly influence the quality, efficiency, and cost of American health care for decades to come.”

Indeed – profoundly. This is crucial. Let’s right the ship straight away.

The ability to review and transfer EHRs from one doctor or hospital to another is one of the major selling points for the adoption of EHRs, and until told otherwise, most patients presume that `of course` this capability is already fully in place. In fact, full interconnectivity and interoperability of EHRs is essential to the smooth functioning of the health care system, needs to be a highest priority requirement, yet as we saw in the essay `Worse than Russian Roulette`, is very far from the present reality. So what is the current State of the Union on EHRs? And what were and are some of the critical `behind the scenes` issues and dynamics that frame the present state?

The following excerpts from the RAND report RR-308 featured in the previous essay highlight the trade-offs that were made to ensure cooperation from the business world. (Recall from the `Cheat Sheet` that the HITECH Act injected billions of dollars into the health care system to spur adoption and Meaningful Use of EHRs.) [RAND]: “HITECH’s language clearly indicated that Congress wanted HIT systems to be interconnected and interoperable so that they can readily share data between providers. … Unfortunately, the rules that the U.S. Department of Health and Human Services (HHS) issued to guide implementation of HITECH watered down the requirement for connectivity.” Then we have the following, directly from the horse’s mouth, in a document just released this past October by The Office of the National Coordinator for Health Information Technology, entitled Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap. Final version 1.0. “Industry response to ONC’s request for information on the topic indicated a general desire for ONC to refrain from formal governance activity at that time and to allow nascent and emerging governance efforts in industry to take shape.” In other words, as the RAND report puts it, “The practical effect of this policy change was to promote adoption of existing EHR platforms, rather than to encourage the development of interconnected systems.” I appreciate that some compromise was initially required to entice various segments of the health care industry, particularly large vendors and many health care systems, to come to the dance. But now, we must evolve. As the RAND report goes on to say, “Provisions in the ACA [the Affordable care Act] will enhance interoperability … and should substantially increase the value of EHRs to health care providers and their patients. The shift will be less welcome to large legacy vendors because it will blur the competitive edge they currently enjoy. … Irrespective of industry ambivalence, the Office of the National Coordinator for Health IT is determined to press ahead.”

This issue has reached a critical threshold. Congress has begun to address the problem of information blocking (interoperability) in a bill denoted the `21<sup>st</sup> Century Cures Act` (HR 6), that was passed last July in the House of Representatives with robust bipartisan support (344 Y, 77 N). One key provision in this bill is that if determined to be noncompliant with interoperability criteria and standards, vendors of EHRs, hospitals and healthcare providers may be found to be `out of compliance`. Then, if bad behavior persists, they can subsequently be decertified (with a minimum exemption of one-year from the Meaningful Use Program, i.e., billing) and possibly subject to a monetary penalty.

As indicated earlier, Epic has been seen as the poster child of information blocking, and has been seen as unwilling to engage in the development of industry-wide communications standards. On the healthcare blog healthcareit.me, Colin Rhodes, a prominent expert in health care IT and a Chief Information Officer, wrote an interesting entry last May, entitled `Why Fines for Information Blocking Won’t Work` that sheds some light on this topic.  Rhodes indicates that “The reality is a bit more complicated. Epic products can interoperate with other systems. Epic offers the features and functions that are needed to work with most of the other prominent EHR providers. More importantly, the integrations use standards based protocols.”  Rhodes suggests that what’s missing from the equation are powerful enough business incentives that go beyond the `cost of doing business.`

Last March, Niam Yarhagi, a research fellow at the Brookings Institute’s Center for Technology Innovation, wrote an article for the authoritative web-based forum, The Health Care Blog, entitled `Congress Can’t Solve the EHR Interoperability Problem`. Yarhagi wrote that “Decertification is not good policy. … The threat of decertification is a bluff.” He argues that ONC cannot decertify an EHR vendor that has the largest market share [to which I’d like to add, especially at the top academic center hospitals]. At best, if the bill passed unchanged through the Senate and were signed into law, Yarhagi stated that even “in the best case scenario, after Congressional pressure, such vendors may enable data exchange, but will demand very high fees [from competitors] to overcome a plethora of technical barriers, especially if the EHR vendor has a monopoly in the market.” He concludes that “this is a complicated situation which I believe cannot be resolved through regulation.”

Also, the timeline and lack of real urgency here greatly worries me. Although the 21^st Century Cures Act was passed in the House last July, nothing firm has emerged from the Senate. There seemed to be definite interest within this chamber — last April, Senate Health Committee (HELP) chairman Lamar Alexander (R-Tenn) and Ranking member Patty Murray (D-Wash) announced a bipartisan working group specifically to address ways to improve EHRs, also notably flagging interoperability as a central focus. “It’s a great idea, it holds promise, but it’s not working the way it is supposed to,” Alexander said of EHRs. So ostensibly we have bipartisan enthusiasm to ensure interoperability, from both houses of Congress. But quite evidently, the issue was not sufficiently `burning` to rapidly progress ahead to a vote, suggesting that the usual jockeying for political credit and primacy between the House and potential Senate versions is very much in play. In this upcoming and especially volatile Presidential election year, I fear that little substantive new legislation will be passed. Further complicating matters, I am concerned that any bipartisan cooperation may be severely compromised by the politics surrounding the filling of the late Antonin Scalia’s seat on the Supreme Court. Thus I will be pleasantly surprised if anything firm on interoperability were to be ready for a Presidential signature before 18 months, at the earliest, and to be clear, I am a bit dubious that any bill will have suitable muscle to change Epic’s present business model of blocking electronic records exchange. Finally, and this is incredibly important, the aforementioned ONC document Connecting Health and Care for the Nation is a 10 year plan, and full interoperability would not be required until the 2021-2024 time-period. This length delay would cripple the emerging network utility for electronic patient care at a distance for much too long. It would continue to accelerate the attrition of many senior physicians from the core system. And it would also castrate free market competition among EHR vendors, since only a very few competitors to Epic could afford to financially survive this extended time period. Yet, barring a disruption to the present course, it would appear that the Epic’s apparent corporate model to encourage the `slow-walking` of any system-wide changes to EHR protocols will be a decisive and winning business model for them. But at what cost? And with what recourse, what anti-monopolistic protections for patients and doctors?

Several recent government and industry initiatives have been initiated, ostensibly to facilitate interoperability. Among these the CommonWell Health Alliance, which includes Cerner Corporation, McKesson and Athenahealth; Carequality, with whom Epic has aligned, along with some of its existing partners; the Argonaut Project, which is `defining and testing the next generation of interoperability standards`; and the eHealth Initiative, which has released a 2020 Roadmap to broad interoperability. Although in principle these are promising, the evident business conflicts of interests and incentives persist, and more notably, fully realized interoperability outside of any major vendor still lies primarily well into the future.

You Can’t Always Get What You Want The saga of the United Kingdom’s Connecting for Health EHR program, formally called the National Programme for IT or NPfIT, presents an important cautionary tale for the U.S. Within the U.K., major National Health Service (NHS) IT projects have a history that dates to the late 1960’s, with a number of individual NHS Trusts and hospitals introducing their own smaller scale information systems in the 1970s and 1980s. The 1992 NHS Information Management and Technology (IM&T) strategy was the first truly nationwide NHS IT effort. Ultimately this initiative failed, in part due to political battles, in part due to a lack of specificity and sufficient overall objectives and evaluation, plus a need for `better stakeholder communication`, although there were some significant regional successes. This led to a more centralized IM&T strategy, which became known as NPfIT, and launched in 2002 with an expected total cost of about $3.4 billion. We fast forward, skipping a few nasty bits in the process. In 2011, the U.K. “urgently” dismantled this futile (now) $20 billion attempt to connect patients’ records electronically, following years of well-publicized problems from a system that couldn’t even track immunization side effects. A “death knell” for the system began in 2009 because “costs were escalating without evidence of benefits, despite the programme having run for seven years already,” as per the Public Accounts Committee. A very interesting 2014 case history report by University of Cambridge researchers provides many further `juicy` details, and can be found online:

https://www.cl.cam.ac.uk/~rja14/Papers/npfit-mpp-2014-case-history.pdf.

Although the U.K. setting is hardly identical to our own, there is much to learn from this report, since several major conclusions are broad-stroked and thematic. The authors document a whole series of IT failures, including `no time to engage with users`, `failure to check progress against expectations`, `failure to test systems`, `not providing training`, and `a lack of concern for privacy issues`. We ignore the evident commonalities, and the lessons of history, at our own peril.

Epic Failure In a report very recently published (September, 2015), the United Kingdom’s Care Quality Commission (CQC) recommended that the Cambridge University Hospitals NHS Foundation Trust (CUHFT) be put on “special measures,” to a large extent because of problems the Trust had in implementing its new Epic EHR, which was implemented in October 2014. (The report is available at www.cqc.org.uk/sites/default/files/new_reports/AAAD0111.pdf). The report related that the Commission inspected the Trust, which operates Addenbrooke’s and the Rosie Hospitals, in April and May 2015, and found its performance rating “inadequate” overall, with five elevated risks and four risks on its Intelligent Monitoring system. Just five months prior, the Trust had only two elevated risks and one risk on the same scoring system. The inspection found, among other things, that: (i, p. 16) EPIC was the “root cause” of the problems with data collection within maternity and gynaecology (and inferentially, within many other specialties, as well); (ii, p. 70) the system was time consuming to use and limited engagement with patients; (iii, p. 17) EPIC created significant numbers of delayed discharges that impacted on patients receiving end-of-life care; (iv, p. 152) since the implementation of EPIC the trust had seen a serious decline in its referral-to-treatment performance, with 14 of 18 specialties not meeting the required target of 92% of patients waiting no more than 18 weeks from referral; (v, p. 152) the system did not produce accurate data; (vi, pp. 4, 118) the system generated prescription errors; (vii, p. 15) since the introduction of the EHR system, outcomes of patient care and treatment were not robustly collected or monitored; (viii, p. 124) some information seemed to disappear from patient records.

As collateral damage, the trust’s chief executive Dr Keith McNeil `unexpectedly` quit just prior to the release of the CQC report, as did the chief finance officer, Paul James.

A related article from the BBC noted that the Epic system cost £200m and illustrated one of the Trust’s `mistakes.` As the BBC News Analysis team reported, “Perhaps the most worrying aspect of the Addenbrooke’s story is not that such a world-renowned hospital has ended up in a predicament like this, but rather that it happened so quickly. A year ago, the trust which runs the hospital – CUHFT- wasn’t even on the Care Quality Commission’s radar in terms of being a failing centre. In fact, two years ago, [ …] it was among the band of hospitals considered to be the safest, according to the risk-rating system at the time. But now a hospital which can boast to being a centre of excellence for major trauma, transplants, cancer, neurosurgery, genetics and paediatrics, has been judged to be a basket case and will join the 12 other failing hospitals already placed in special measures.”

In fact, problems with Epic’s Cambridge launch were acknowledged long before this CQC report. In December 2014, just 2 months post-launch, John Naughton reported on this in The Guardian, in an article titled `The NHS’s chaotic IT systems show no sign of recovery: Paperless patient records are a necessity, but a new, US-made system at Addenbrooke’s in Cambridge is a chronic misreading of patient needs`. Naughton noted that the official hospital announcement of the switch onto EPIC on October 26 trumpeted the new system as being “on bespoke software that has been designed by and for clinicians.” He then went on to provide stark contrast given in an email one week post-launch, from a friend who had broken her foot and gone to Addenbrooke’s. “From the patients’ point of view,” she wrote, “it [the new system] is quite dehumanising. Staff now approach [while] gazing at a mobile device and trying to find you on it; then they check you in with a wrist barcode. There is no time for conversation or even often for eye contact. Some of this might improve as they get more confident with the system but they are deeply unhappy with the change in culture and they say all the real nurses will leave.”

In the essays above, I have attempted to identify and discuss a number of primary issues that have accompanied the recent major changes within health care, with a view to the long-term. Here, I would like to propose a few suggestions that could potentially help to resolve several of these concerns, at least in part. It is my sincere hope that these thoughts trigger productive discussions that either lead to or catalyze some changes in course.

Patient Histories: In the essay `Life Begins at 60`, I raised a concern that would still greatly compromise the utility of EHRs, even if we achieved full interconnectivity among the major hospital electronic systems. Namely, currently the vast majority of Americans have either no or minimal long-term electronic medical histories in any large hospital EHR system. This is a major limitation, one that I believe must be addressed very shortly as a top priority item. But what can be done? I would propose a WPA type of effort to collect histories on all Americans. This could come from a one-time collection process, done in a similar manner to the collection of census data, with mandatory participation by all, with significant non-compliance penalties. We could recruit and train a small army of recruits to do structured interviews in a systematic way, to obtain standardized `personal history` entries. The training of interviewers could be done in a similar mode to the training presented in many present coding courses. The interviews would (as best as possible) identify which hospitals, private practice doctors and other medical personnel have records about each individual, either recent or well into the past, and then these sources would then be tapped for the appropriate data entry. As well, the interviews would allow one to indicate recent changes, and/or particular health issues or data of special importance. All these data would be aggregated and entered into a centralized secure, single repository. Routine access to these records would be allowed to individuals or organizations specifically named by each interviewee, such as physicians, hospitals, family members; in emergencies, more flexibility of access would be allowed, on an acute need-to-know basis. The records would be maintained both as a spreadsheet format, as well as a converted file, for instance as a searchable pdf file (so that a doctor could quickly search throughout the history for a key term or attribute).  This model would still be imperfect, but much closer to the mark, and in particular, could provide a rich and crucial source of data on the many Americans at highest risk for interventions, yet with modest and very incomplete EHRs at present. At the very least, such a repository would buy time until a universal, totally integrated and updated database were developed (if ever).  Of course, the ideal remains a patient with whose records and history are with a single physician, practice or system records, where records could in general be readily accessed, but in a more fractionated and discontinuous world of care, I believe that this could help to fulfill many of the needs for true universality. Finally, it should be easy to recruit and train the requisite army of interviewers — at 62.5% participation rate, the proportion of Americans in the labor force remains near historic lows, with many white collar workers out of job, and very eager to work.

Patient Privacy: I agree in principle with the mission, that long-term, a well-constructed EHR system that balanced privacy and accessibility needs could significantly improve the overall quality of our healthcare. However, the actual roll-out of the Affordable Care Act, particularly of EHRs, to date has primarily facilitated the needs of hospitals, administrators, billing and insurance companies, rather than physicians and patients.

In a 2007 article in the University of Illinois Law Review entitled `Ensuring the Privacy and Confidentiality of Electronic Health Records`, Nicolas Terry and Leslie Francis wrote that what is required is a government-funded independent and apolitical regulatory body and commissioner that will have the power to mediate disputes and publish codes of conduct. (I also referred to this article, with some brief background on both Professors Terry and Francis, in the essay entitled `Legal Recourse: Slim and None`). Australia, Canada, New Zealand, and the United Kingdom have all adopted such regulatory review and dispute resolution models as part of their data protection regimes, and most have been particularly active in the health domain.

Frequently, some portions of a patient’s records are very sensitive. Many of my patients would strongly prefer that these portions be considered to be `highly confidential` contents, and then classified as unreadable by providers with routine access to the EHR system. Such contents could be accessed only (i) by explicitly named providers; (ii) with a specific additional consent from the patient; or (iii) in the case of an emergency. Obvious examples of sensitive information that might be secured in this way include mental health history; sexual and reproductive history, including abortion, STDs, birth control, pregnancy and sexual dysfunction; and HIV/AIDS history. Other categories should be identified that a patient could routinely wish to tag as highly confidential, such as colorectal cancer. It would be extremely timely to address this in the very near future, even if the only categories identified as eligible for high confidentiality classification were the obvious examples just named. There is plenty of precedent for restricting data access based on `need to know` and trustworthiness criteria – the FBI, CIA and NSA have well-established protocols for security clearance, and notably, multiple layers or levels that are commensurate with the degree of sensitivity and the vulnerability if a breach occurs. Indeed, following this theme, there must be meaningful penalties for violations of confidentiality, more than modest fines that amount to `the cost of doing business` that seem so prevalent today. Breaches to NSA or CIA records come with serious consequences, and even disclosures of IRS return information may be subject to felony charges and five years in prison. I feel confident that many of my patients would be less upset by a leak of the their taxes than of their sexual history.

Additionally, and perhaps less obviously, some related data must also be protected. For example if I see a prescription for a patient of 250 mg ceftriaxone plus 1g azithromycin, I can infer with virtual certainty that this is for the treatment of gonorrhea. In the paper record world, standard forms for a transfer of a patient`s medical records allow for the exclusion of STD, HIV/AIDS and psychiatric histories, including any pertinent drug and prescription information; these same protections must also carry over to the EHR world. It goes without saying that such information could be used for darker purposes such as extortion or other forms of blackmail. Given the extent of data vulnerability and theft that abounds in online databases, in conjunction with the value of and interest in medical–related data, we need to pay special attention to this issue.

Also, we should recognize that much of Western Europe has strict data protection rules that have enshrined an individual’s privacy as a fundamental right on a par with freedom of expression. Even Google and Facebook have run into this head on during the past few years. I believe that we should consider some of these protections in rebalancing our own present domestic privacy policies, both for EHRs and well beyond. For instance, a new European data privacy rule finalized just several months ago will have major repercussions for U.S. tech companies that do business there. Among the most prominent aspects of the new directive are fines of up to 4% of a company’s global gross revenue if it misuses people’s online data, including obtaining information without people’s consent. While companies are unlikely to be hit with the full fine amount except for egregious privacy breaches, the numbers are still staggering. For Google’s parent company, for example, the fines could reach $2.4 billion; for Apple, $9.3 billion. These kinds of penalties for privacy violations, even if only approached in the U.S., would definitely raise the awareness and responsibility of businesses and agencies that either analyze or pass along our data. Otherwise, the status quo within the U.S. seems quite inadequate. Even when record-setting penalties to major corporations (or banks) for misbehavior are announced with much hoopla, the beat goes on. The penalties are almost always effectively a slap on the wrist, the cost of doing business, and much smaller than the profits gained by pursuing the illegal activities.

Treatment of Docs: In several of the essays, I have tried to point out the degree to which many physicians, especially senior members, are feeling both disheartened and beaten down by systemic changes to medicine within the last 5 years.  But what should we make of this, and what can we do to try to ease the pain while moving forward in an electronic world? The bottom line from my perspective has entries in two columns. In the economics column, we must re-align the presently perverse financial incentives, with much more emphasis on long-term health, outcomes and costs. In the personnel column, we must impose some regulations so that physicians are not increasingly treated as `commoditized revenue-generating units to be squeezed`. At a minimum, this should include some mutually agreeable cap on patient volume, with some sane flexibility built in to accommodate unusually complicated cases, emergencies, or atypical patient cohorts. Secondly, significant changes to existing health care software should be mandated towards more doctor- and nurse-centered design, including a very sharp reduction in the number of incessant alerts, with more clearly flagged emphasis on events that require urgent action. Better-tailored order sets to individual specialties would also be a welcome and productive change, and should facilitate improved work-flow. Finally, more reliability and redundancy, that is, system back-up resources should be required of the EHR providers, to significantly reduce the frequency and duration of system down-times, which can paralyze the entire system and endanger patient care.

Regulation of EHRs: In an earlier essay, I mentioned an article by Niam Yarhagi in The Health Care Blog entitled `Congress Can’t Solve the EHR Interoperability Problem`. In April 2015, Ross Koppel, an adjunct professor of Sociology at the University of Pennsylvania (and a leading scholar of healthcare IT and EHRs), and Stephen Soumerai, a Professor of Population Medicine at Harvard Medical School, wrote a response piece. They agreed with Dr. Yarhagi’s core points, although they did disagree with his solution. However, my interest here goes beyond their (convincing yet somewhat technical) disagreement, but rather to what they next wrote, which frames the broader issue beautifully: “The more salient question is: why should any HIT vendor be permitted to charge a penny to help share data that is needed to make medical care safer, more efficient, more informed, better? A key feature of HIT is that it allows exchanging information on patients.  The government is giving $30 billion to subsidize purchase and use of these technologies; hospitals and other providers are spending trillions of dollars buying and installing them. It is unconscionable that a vendor would even think about charging clinicians to share data on patients’ health. The government need not threaten vendors who don’t allow sharing of data. There should be no choice. Data exchange must be required through regulation. We don’t negotiate with car drivers about stopping at red lights, and we don’t compromise on truck weight limits on certain bridges. Some rules are simply necessary for public safety.”

Koppel and Soumerai lead right up to the door of regulating EHRs, at least in part, and I believe that a very strong case can be made here to complete this thought, both on the basis of precedent and of parallelism.  Recall the old Bell System telephone network during the 1960’s. Prior to divestiture, it was regulated as a public utility, an indispensable part of the national infrastructure, on which we relied constantly. The Bell System gave outstanding service, and established the precedent that identifying a business category as a utility need not compromise the associated product in the slightest. The Federal Communications Commission (FCC) ruled last year to regulate broadband Internet as a public utility, on the basis that it is a public good. This ensured `net-neutrality`, which means that no content is blocked and that the Internet cannot be divided into pay-to-play fast lanes for some users, and slow lanes for everyone else. Given that universal health care is the signature policy initiative of the last 8 years, we should likewise regulate EHRs as a public utility, on the basis of Common Good, and specifically mandate universal interconnectivity without favoritism. If Comcast and its competitors could work it out, so can EHRs. A public-utility commission (PUC) can ensure that a company neither disadvantages competitors, nor abuses its market power. Every state has a PUC regulating electricity, gas, water, railroads, and telephone service, providing essential consumer protections. PUCs have the power to hold public hearings in response to customer complaints, and critically, have suitable authority to fix problems as they arise, that is, to hold providers` feet to the fire until satisfactory resolution is achieved. Their commissions usually assert their mission is to provide safe, reliable service at reasonable rates.  Reasonable rates can be interpreted many ways. Utilities are allowed a fair return, usually calculated as a percentage return to their investments, for example 8%. Indeed, 8% seems a generous incentive, given the present rate of inflation, and should produce a nice profit for the regulated companies. The public benefit would be the assurance of quality service to and treatment of all constituents, here including both the patients and the physician providers. Finally, quality service must include ready access and user-friendliness to all!

Some recent testimony in the context of telephone service provides compelling arguments for the necessity of (existing) regulation in a more familiar, yet in many ways parallel, setting. In 2013, Harold Feld, senior VP of the nonprofit public interest organization Public Knowledge, testified to Congress on `The Evolution of Wired Communications Networks`. (The testimony can be found online at

https://www.publicknowledge.org/files/Feld%20Testimony%20FINAL%2010.23.13.pdf).

Feld identifies five “fundamental values” that define our telecommunications network: “service to all Americans (universal access), interconnection and competition, consumer protection, reliability (the system must keep working), and public safety.” I believe that these same fundamental values should equally well apply to our EHR network. Feld persuasively argues that free-market incentives cannot and will not ensure that these values are satisfied, but rather, that government oversight is imperative, both on the basis of several convincing case studies, as well as on more conceptual grounds. As one example, in the case study `The “Market” v. Real People`, Feld referred to Superstorm Sandy’s impact on Fire Island in New York, in which much of the existing copper network infrastructure was destroyed. The local carrier Verizon faced a choice: rebuild its copper network, deploy the fiber-optic network FIOS, or deploy its fixed wireless product called Voice Link. Verizon made the entirely rational business decision that deploying either a copper or fiber network for the Island’s small permanent population was simply not cost effective. Instead, they announced that they would deploy Voice Link, which was much less costly to them, with some well-wrung talking points on the market embrace of wireless, away from traditional copper. This decision created a firestorm of customer complaints and negative news stories that, combined with regulatory scrutiny from the New York Public Service Commission and the FCC, ultimately forced Verizon to commit to deploying FIOS on Fire Island. Reliability and quality of service (and reception) were concerns about the proposed wireless service. As Feld noted earlier in his testimony, “Given the importance of communications infrastructure to our lives, particularly in an emergency, we will hopefully continue to maintain reliability as a core value and acknowledge that government at all levels have both a keen interest in the safety of their citizens and an important role in ensuring that safety.” A simple substitution of `health care` for `communications` in the previous sentence should highlight the parallelism here.

And notice that regulation hardly means the end of competition or profit – it just mandates reasonable minimum floor levels of service and responsibility by the vendors, in a few essential categories.

Finally, on the crucial line item of interoperability, let’s borrow Mr. Peabody and Sherman’s Wayback time machine, and head backwards in time nearly 50 years, to 1969 and the birth of the Internet. The Internet was actually born as the ARPANET during the 1960s, at the height of the Cold War between the United States and the USSR. Indeed, universality or full interoperability was its initial raison d’être, not only during routine operation, but even or especially under severe disruption. US authorities considered ways to communicate without interruption in the aftermath of a nuclear attack, if centralized telecommunications switching facilities were destroyed by enemy weapons. This led to the development of a decentralized (distributed) network architecture by Paul Baran with colleagues at RAND, implemented as the ARPANET in 1969 (and renamed the Internet in the late 1980s). The most salient point here, though, is that given enough political will, protocols could be readily established (50 years ago) to establish full interoperability, even among a network of ostensibly very different components. Leonard Kleinrock, a Professor of Computer Science at UCLA and a seminal contributor to both the mathematical theory and early implementation of the ARPANET, succinctly stated the case in his 1976 textbook on Queueing Systems, in which he describes the collection of 100 computers geographically distributed across the United States that were to be connected. “The (HOST) computers are in many ways incompatible with each other, coming from different manufacturers and containing specialized software, data bases, and so on; this in fact presented the challenge of the original network experiment, namely, to provide effective communication among, and utilization of, this collection of incompatible machines.”

And of course, in addition to the Internet, telecommunications and banking, which are likewise essential networks, have been fully interconnected via standardized protocols for many decades.

So for all the reasons stated earlier, a fully realized and interoperable EHR network should be made a topmost, URGENT priority, to be completed shortly. The stars align — there is an acute need; significant historical precedent; bipartisan support; readily available engineering expertise; and existing software infrastructure either already in place or nearly so. Let’s move!

Nearly all of my physician friends and colleagues have entered the EHR world in the past few years, only to report that they just feel as if they are on the short-end of an escalating beat-down. The joy of patient care is being ripped away by increasing administrative demands that are often counterproductive and superficial. Many of my contemporaries who have incorporated their practices into a local academic hospital complex are being treated like titled grocery store clerks, forced to see significantly increased numbers of patients and/or generate specified levels of revenue, regardless of acute patient needs. Doctoring is being forced to become increasingly programmatic and color by number, dehumanizing the doctor-patient dynamic. Non-revenue generating counsel to patients, for example, important discussions of potential side effects or the impact to one’s quality of life, are de facto being badly punished. Most of my colleagues who are at least 60 years old are actively thinking of getting off of this treadmill in the near future, either by retiring altogether, or at least by leaving the practice or teaching of medicine. Who is winning? The hospitals (as a business); the insurance companies; the associated electronic software and Information Technology industry; and legions of administrative intermediates. Who is losing? Short term, doctors; longer-term, patients, because of the loss of continuity of care, of a doctor truly vested in them for an extended period, and because the incentives play against the doctor getting the care right, so long as the care is administratively plausible or justifiable. Unchecked, I foresee an acceleration towards two-tier medicine, and I do not believe that such a resolution was the intended goal, or in society’s best interests.

I certainly recognize the Realpolitik compromises needed on the part of the administration to get the insurers and IT companies (that created the EHRs) to the dance.  The very fate of this administration’s signature policy initiative rested on this crucial pivot point, with huge political as well as societal ramifications. But although the basic structure of the Affordable Care Act brings both promise and humanity, the initial implementations, if continued for any extended timeframe, will destroy much more of lasting health care worthiness than it will create. There still is time, if we act expeditiously and decisively, to significantly change yet preserve the system while creating much better long-term outcomes for patients and doctors. And we can do this in a way that will still allow quite reasonable profits to be made by the business side of the model. How? Change electronic health records to incorporate the best features of both the VA’s VistA and the private EHRs. In particular, mandate a high level of user-friendliness for both doctors and patients, as VistA presently has, as well as significant functionality to broad health care as embodied by the Meaningful Use requirements. Impose a public utility structure on the EHRs, on the basis of Common Good, to ensure that these mandates be met, and also to ensure full interoperability, ASAP. Facilitate long-term continuity of care, rather than emasculating it by encouraging frequent or yearly changes of insurers (and docs).  Impose sensible privacy policies that protect patients, with serious penalties for violations, not the cost of doing business. Record and centralize personal histories on all Americans. And recognize that doctors are not commodities, and that there is much more at stake than a budgetary exercise.

Is this achievable? I believe, or at least hope so, if there is enough political will, plus some cross-the-aisle recognition that both sides have much to gain (and much to claim) if the system is extensively altered for the better. So the opportunity still remains open, but the time is now, not in ten years. Bon courage!