Learning From Your Patients

Some of my best learning moments as a clinician came when a patient left me.  They liked me enough, and respected my trying to meet their needs, to let me know personally why they were leaving me.  Early on, one patient listed my faults (which were many!), including not washing my hands before I examined their child.  Another one, later on, told me I was ineffective in dealing with her troublesome child, and had me read "The Difficult Child" by Henry Turecki, which is a great book that I have recommended to all my patients ever since.  It was painful, but I learned.

And then there was the patient I had with repeated bouts of acute abdominal pain.  I had them come into the office, against their will since they thought I should be able to do it over the phone for free.  I looked at the kid, I thought about it, I walked around the room, and I said, "Does he chew sugarless gum?" 

"Why, yes, he does!" they said. 

"It could be the sorbitol," I said. 

They cut out the sugarless gum and no more stomach aches!  One of my best diagnoses.  I had been studiously reading my newsletters in pediatrics, and it paid off.

The next thing I heard from them was a notice requesting that their records be transferred to a doctor nearer their house.  So I called them up to ask why they were transferring.  They said something about the distance.

I said, "What about that diagnosis that cured the abdominal pain?"

They said, "We expect that!"

What a world.  

Budd Shenkin

Ta-Nehisi Coates: Between The World And Me

I just read another book I wouldn't have read except for my book club, Norm's Bookies, having assigned it. In a close vote we chose the widely acclaimed Between the World and Me, by Ta-Nehisi Coates. http://www.amazon.com/Between-World-Me-Ta-Nehisi-Coates/dp/0812993543/ref=sr_1_1?s=books&ie=UTF8&qid=1450188646&sr=1-1&keywords=ta-nehisi+coates+between+the+world+and+me.

The last two years have been filled with evidence of the pervasiveness of police terrorism towards African-Americans. It's incontrovertible – Baltimore, Staten Island, Ferguson, Cleveland, Chicago. All together, the picture is of police terrorism toward African-Americans.

What we have seen in these killings is the outside view. What Coates presents us with is the inside view, what terror lurks in the heart of the oppressed. He, and other African-Americans, need constantly to be on the alert, not at the wrong place at the wrong time, not pissing off the wrong cop, staying under the radar. His friend from Howard, Prince, didn't do that. He wasn't offensive, but he probably was obvious and true to his name, princely. An off-duty Maryland cop stalked him into Virginia and killed him and got away with it. That's not an aberrance, that's the standard, there are many like him, this was just the case closest to Ta-Nehisi.

Stay alert, keep your head down, know where you are. That's really no way to live. He looks at the carefree suburbanites and is irritated. Why do they get to live like that, when Ta-Nehisi has to keep his head down? He's right.

He is on less solid ground, I think, when he talks about his body and relates it to history. It's not just in his mind, they can actually kill him, get to his physical self. In slavery, bodies were captured and ruled. Well, yes, it isn't just mind control, that's true. But that is just history, and it isn't just African-Americans, it's everyone in the world. People didn't just assemble and reason together, after all. Gangs got together, ruled the unorganized and fought the other gangs until finally one gang ruled everything. That's the way states began. The treaties came later, within countries and among countries. The Magna Carta was a treaty between the royal gang and the aristocrat gang. In political theory, the sine qua non for a government that works is having a monopoly on violence.

So, yes, it was a brutal world for slaves and a brutal world still for many. But at least now we have regular ways of negotiating differences, and overall, law is a wonderful thing. Perverted in the case of cops and African-Americans, yes, but better than it was, and it will be better still. Not to say that African-Americans need to be patient. Patience is frequently not a virtue, and this is one such place.

But objectivity isn't the strength of the book; the heart of it is Ta-Nehisi's subjectivity. What he remembers so vividly is that his father had a belt up on the mantlepiece, and he lived in fear of that belt. His father used it frequently, saying “better me than the police.” He made sure by stark physical means that his son would not die at the hands of the police by not showing respect, by mouthing off, by not being aware. Ta-Nehisi accepts the explanation of the father he reveres. He gets beaten for his own good.

I hear this with the ears of a pediatrician. And what I hear is, child abuse. When I hear the alert and watchful adult story, I hear in addition to the reality of police abuse, a certain amount of PTSD from child abuse. Maybe it is functional PTSD; maybe it keeps him out of trouble. But it seems all too reminiscent of scars of child abuse.

I am reminded of the sad case of Adrian Peterson, suspended for a year from the NFL for beating his little son. Charles Barkley objected to the league's view, saying they “They don't understand the South.” Maybe it is necessary; maybe it is. It doesn't sound like it's identifying with the oppressor, man kicks boy and boy kicks dog. It might be one way of dealing with police terrorism. But in any case, it leaves a scar.

It is not just a rhetorical device, then, that the book is written as a letter to his son. We serious people take our parenting seriously. We look at our parents, and we look at ourselves as children. We think, how can I do what I need to do with this most important job of my life?

Our parenting has three major influences. Our default is to replicate our own experience; we can't help but do a lot of that. Our major conditioner is our own personalities. We can only do so much, based on who we are. But then the third influence is what we choose to concentrate on, the things that we want to change. We might have to think about it constantly, because it doesn't come automatically. We might make lots of mistakes, and suspect ourselves of not doing it well enough, or constantly enough. But there are things we think we had better do for the good of the child, things we need to correct in our own upbringing, things in which the clay has hardened in ourselves but not yet in our children.

What Ta-Nehisi has decided to do differently is not to beat his son. And he's trying to tell him, look, I'm not beating you, but you still have to be careful, you hear? They are still out there waiting for you. You hear? I don't want you winding up on a slab like Prince, that magnificent presence at Howard. You can excel, I want you to excel, but you be careful. You hear? You hear?

And now in publishing this book, the rest of America – you hear?

Budd Shenkin

Is It Politically Correct To Be Smart?

I had lunch today with a good friend who takes pride in not being politically correct. I always enjoy it.

He told me about a discussion he had with a younger colleague at the University. My friend Bruce was discussing an issue that had come up on constructing a website for a Departmental project. I think it was on a governmental contract. The problem was this: the staff had constructed the website directory and placed the files in a way that a visitor would have trouble finding what he or she wanted. They had divided up the files according to how they had divided them among themselves as they created them, but that didn't accord with the logic of a visitor. No matter the titles they made up for the sections, It's as though one folder could be called “Mindy's files,” another one “Janet's files,” etc. The path to relevant files was impenetrable.

Bruce said to his friend, “The staff just isn't smart enough to do that job. You need the professors to do it.”

His friend replied, “The staff just doesn't have enough experience in the field.”

“No,” said Bruce, “they're just not smart enough. Don't be politically correct. They're staff, not professors.”

His friend couldn't bring himself to agree. For him, it had to be a question of experience. Apparently, under the current rules of political correctness, calling one group “smarter” than another is a no-no.

Well, I could agree with Bruce! Love to be politically incorrect, of course, love being a shit-kicker, but also, like to call a spade a spade.

I told Bruce about my experience when I was a two-year doc in the US Public Health Service in the later 60's. Each year a bunch of us came in as commissioned USPHS officers, Lieutenant Commanders we were, for two years not spent in Vietnam. We did bureaucratic staff work, we worked hard, and in my case it was a high point of my life. We worked side by side with the bureaucracy. We weren't seeing patients, we weren't wearing uniforms, we were doing paper work mostly, looking at the medical stuff that came through Health, Education, and Welfare. It was an eyeopener that gave me knowledge of the ordinary that I have used the rest of my life.

In my experience, the top governmental administrators are pretty smart. They have hard jobs. Imagine trying to get meaningful work out of thousands of employees who are GS-9s or 10s or 12s, who chose government work; that's who you have.

So what would sometimes happen is that a problem would come up that the staff couldn't solve. It would be technical, perhaps, it would be involved, but it wasn't at the level that the administrator him or herself could work on personally. But it had to be solved.

So here is what the savvy administrators would do. They would say, “Get a two-year officer on it!”

“But this isn't medical,” the staff would say. “A two-year guy won't know anything about it!”

“Doesn't matter,” the administrator would reply. “They'll figure it out.”

And they would. It was a selection issue. Doctors are smart. Some are jerks, some are smug, some are whatever people generally are. But they are smart. They had passed the tests. And they would inevitably solve the problems that the career staff couldn't solve. Because they were smart.

And so are professors. Sure, it's nice to say we're all equal. Just doesn't happen to be true. You could explain to the staff what kind of organization you wanted in the website, you could give examples maybe, but at the end, the professors might as well do it themselves. Incredibly enough, some people are just smarter than some others.

Hope that doesn't constitute a micro-aggression.

Budd Shenkin

The Obamacare 2014 California Report Card

A couple of years ago I made a bet with my friend Herschel Lessin, a skeptical Republican pediatrician of Poughkeepsie, NY, a graduate of Stanford Medical School and Yale pediatrics residency, and no dummy. Obamacare (otherwise known as the ACA) was just starting, and Herschel believed that the health plans would fail, and that insurance rates would rise significantly the second year.

I didn't think so. I thought that insurance companies would be cautious, since their main lines of business would continue to be non-Obamacare policies, and that they would probably make their rates on the higher side to be safer and not lose money out of the gate, figuring they could gain market share later on when the risks were more knowable.

Herschel won. I don't remember if I have yet ponied up the ten bucks, but still, he won. Rates rose the second year. I supposed that companies had gone for market share after all.

But an article in today's LA Times makes me wonder if the actual culprit for rising rates lies elsewhere. Even though Herschel won (and I will pay up!), I think his win might be tainted.

http://www.latimes.com/business/la-fi-obamacare-profits-20151209-story.html?utm_campaign=KHN%3A+Daily+Health+Policy+Report&utm_source=hs_email&utm_medium=email&utm_content=24476793&_hsenc=p2ANqtz--15WpcLPv3R2iH0_DaJ2yQySzgQvXpvG3f_866710fo2UOR-drAbT4FFEYE_e6Oh4BSmhn89NtAUqdB62kvI__k-4mLg&_hsmi=24476793

It turns out that three of California's big four health insurance companies made significant amounts of money last year selling individual policies on the ACA California marketplace. Blue Shield was number one in the country, Kaiser number two, and Blue Cross number seven. So there must be something special about California.

It turns out there is. California mandated that the insurance companies terminate their existing individual policies. According to the article:

Amid a national uproar, Covered California defied the Obama administration and required participating insurers to cancel existing individual policies at the end of 2013.
That move created a healthier, more diverse mix of old and new policyholders at the start of the exchange. About 35 other states allowed consumers to stay longer on health plans that didn't comply fully with the new law.
That decision left many states with a smaller and sicker population signing up for Obamacare. Many new enrollees had been denied coverage previously because of pre-existing conditions.

So that's the story. The problem with the other states is that they didn't really adopt the full ACA as a program; they waffled. As a result it looks like the ACA is a failure, with all those companies losing money, and half the Coop plans going out of business. But in fact, their decisions to let people keep their old policies made the ACA plans victims of adverse selection.

But that's not all there is to the story. In the area of health insurance, it's bound to be complicated. Remember, the biggest wager of the ACA was that insurance companies would reform their sharp practices and compete on quality and price rather than aggressive underwriting and policy denials, that old dogs would find new tricks. Did California health insurance companies learn new tricks?

Well, it seems not. Blue Shield – a chronic offender of sharp practices, according to those of us in the field – benefited by the fact that

consumers had difficulty finding a doctor or getting care during 2014. That could have reduced medical claims, boosting the bottom line for companies.

In fact,

Michael Johnson, a former Blue Shield official and now a company critic, said the San Francisco insurer should issue more refunds to customers. "Blue Shield made this huge profit because they hindered access to care."

And in addition, both BS and BC had inaccurate provider directories, which means that when patients went to sign up and they checked to see if their doctors were in the plan they were signing up for, and they saw that they were indeed on the plan, that information was frequently inaccurate, and after they signed up, they had to switch doctors.

And why were the doctors not on the plan? That's because of the infamous “narrow networks.”

The insurance companies would have us believe that the new plan selected superior clinicians who were most economical in the use of resources, the best and smartest doctors. In fact, however, what happened on the ground was, they circulated a rate schedule to the doctors and said to them, will you take these horrible rates for our new plan? Those that said yes were then christened by the insurance companies as the best of the best.

And meanwhile, let's add one more observation about the insurance companies. There was a ballot initiative last year in California to allow the state Insurance Commissioner to negotiate rates with health insurance companies, as most other states allow their IC to do. It lost with huge insurance company (and organized medicine) advertising campaigns against it. But part of the success of the California ACA state plan is that

Unlike most other states, California negotiates premiums with health plans and doesn't allow every insurer into its exchange.

So in summary, it looks like the ACA looks worse nationally than it should because of the adverse selection problem – too high a proportion of the new policyholders represent people who couldn't get insurance before because of preexisting conditions, probably. And in California, it looks like Covered California is a go, although it could do better with regulating the insurance companies and their practices and narrow networks. And it looks like the old dog insurance companies are continuing with their old tricks.

Stupid insurance companies.

Budd Shenkin

Climate Change, The Nuclear Option, And Organizations

With the Paris conference on climate change beginning in two days, and with many thinking that this is the world's last realistic chance to plot a path toward survival, a venture capitalist named Peter Thiel makes a case for nuclear energy in the NYT. http://www.nytimes.com/2015/11/28/opinion/the-new-atomic-age-we-need.html?action=click&pgtype=Homepage&clickSource=story-heading&module=opinion-c-col-left-region&region=opinion-c-col-left-region&WT.nav=opinion-c-col-left-region&_r=0

He is not wrong. The overwhelming issue of our time is, will mankind survive? In my early lifetime the threat was the Nazis – yes, mankind would have survived, but the history would be troubled. Then the threat was nuclear weapons, and truth be told, it still is. On The Beach was not unreasonable fiction, except how beautiful Ava Gardner was, and I guess Gregory Peck. But the threats are accelerating. nClimate change, né global warming, is arguably the most serious of all. James Lovelock sees disaster but not total annihilation. There will still be “mating pairs in the Arctic,” he says, which is less than totally reassuring.

What is behind it all is the exponential expansion of the anthropocene age. (https://en.wikipedia.org/wiki/Anthropocene). I have used the image of the beehive before, and it comes to mind again. When humans crawl all over the world and all over each other, they stay alive by an interconnectedness that works for a limited time. But nothing stays the same for long, and if you are precarious you eventually fall, and that's inevitable with our exponential-ness. The only alternative is planning, and restraint, and a sense of all being into it together. Good luck with that.

Nonetheless, we keep trying, and nuclear is an important option, as Thiel says. Years ago, when it became apparent that we had a problem and my Dad had not yet died, he and I discussed it in a couple of words, which was all we needed since we tended to think alike. All of his professional life as a neurosurgeon, my Dad had looked at dangerous operations and unpalatable choices, delayed decisions and followed cases assiduously until a choice became clear and sometimes inevitable. And when we talked, even in his decline, he faced the problems of the earth with the same coldly reasonable calculations that he used in judging the advisability to operate. So when I asked him, “Dad, what do you think about climate change and energy?” he responded, “I think we have to go nuclear.” Which was just what I thought, too. I figured, you just have to be careful, find the right way to do it, and put the radioactive debris in the right spot – I figured, send it to outer space, but then, I tend to be a risk taker.

The problem was, however, that we were both thinking like doctors, like Lone Rangers, which is what old fashioned doctors tend to do. We were thinking, get your best doc and go on in and be careful to do it right, concentrate, do it right.

But that way of thinking is a mistake. Nuclear power can't be operated by a Lone Ranger. Nuclear power has to be run by a large organization; as a matter of fact, since the world is a big place, it has to be run by many large organizations. So it's not an individual challenge, it's an organizational challenge, which is a horse of a different color.

Earlier this year we visited Japan and, as is my custom when traveling, I read the local English language press. There was an article about the Fukushima accident of 2011. I remembered that it was clear early on that Tepco, the utility company that ran it, had disingenuously reported about and dealt with the accident, not to mention having made mistakes with the initial design. It seemed to be a poorly run organization with strong political support charged with what could be a dangerous mission. Now the Japan Times reported that no significant changes in administration have been made. I read that a citizens' committee – a citizens committee! What a sign of entrenched bureaucracy! -- had twice (twice!) recommended that the top officials of Tepco should be tried for ineptitude and negligence. They reasoned that punishment would have a deterrent effect in the future, and thus perhaps change organizational behavior. But the article reported that twice had this recommendation has been dismissed by the establishment prosecutors. http://www.japantimes.co.jp/news/2015/10/03/national/media-national/whos-responsible-fukushima-disaster/#.VhDhz6KiahQ.

It reminded me of the investigation of Chernobyl, which found that political appointments had so infested the organization that it was non-functional. To the Russians' credit, they made the investigation, just as the Japanese did. But the consequences for personnel were few; after all, these were favored apparatchiks who had been placed there in the first place.

Here's the point: you can build organizations for a purpose and get impressive success. You can win World War II, go to the moon, build the 50's Yankees. But then, over time, organizations decline. They just do. Guardians of nuclear missiles in North Dakota get lazy and drunk and no checks are made on the missiles. NASA leaders dismiss warnings from their intimidated scientists that the O-rings might not work at low temperatures. CDC forgets to safeguard the smallpox vials. Achievement organizations become blame organizations, as incentives shift from high accomplishment to avoiding blame, where personnel shift from dream-seekers to get-a-job-and-get-promoted seekers. It's just the natural history of organizations.

So as the VC Peter Thiel touts nuclear as the answer, he thinks technically, not organizationally. VC's think about starting a company and selling it, usually, not operating it into perpetuity. Could you build nuclear plants all over the world that would never fail, or if they failed, would have damage contained? Maybe. Computers have become very powerful. But there are still operators all over to oversee the plants, and if they are not unqualified apparatchiks, or Tepco bureaucrats, they can still be Homer Simpsons. 

Thiel thinks that the downsides of accidents have been exaggerated, and that side effects can be contained. Maybe he's right. Maybe my father and I were right. Or maybe we need nuclear not as a permanent solution, but as a bridge to a future technology that would truly work automatically. And maybe running the risk is better than simply continuing on as we are on the road to mating pairs in the Arctic. And maybe Space X can take our nuclear debris on a quest to find dark matter.

But in the meantime, if nuclear turns out to be the necessary risk we take, let's not just concentrate on the technology. Let's pay as much attention to advance organizational theory as to engineering theory. That could be the biggest challenge.

Budd Shenkin

United Health Care Might Exit The Exchanges

There is some consternation today over United Health Care's considering exiting the field of the Health Insurance Exchanges – the Affordable Care Act's policies for individuals. Does this mean that the ACA is not working?

Well, it's a complicated situation. I am indeed afraid that the ACA is not working in a very significant way: the ACA has incorporated High Deductible Health Plans into its midst, and they suck, as both the NYT and the Boston Globe (below – quoting me!) have pointed out graphically this week:

http://www.bostonglobe.com/news/politics/2015/11/16/high-deductible-health-plans-make-affordable-care-act-unaffordable-critics-say/eaWZZJNrFhm6vVPDBcdZ0I/story.html

The worse the plans are for people the more enrollment will fall, and I have to think that the high deductibles make people feel they are not getting much for their money, so some don't enroll or reenroll.

But I think the UHC issue is different, and doesn't indicate ACA failure as such. UHC is very big and the exchange programs are a relatively small part to their business. They can probably make a profit on them, even though they say they can't, but the profit might not be big enough for them to want to concentrate on it. GE's strategy under Jack Welch was to make sure that every GE unit was #1 or #2 in the industry, and if they weren't, they either had to be built up or sold. From a corporation's point of view, you need to have some focus. And as we appreciate that point of view, I guess it's not such a bad thing to see them exit from this business segment. It's just a decision that there are more profits to be had elsewhere, and a corporation can't do everything. Is it such a bad thing for us that UHC can't find that much profit in Exchange programs? I think it's fine.

Looking back, the idea of the ACA was to make insurance companies make money a different way from the way they did it before, which was largely by excluding subscribers by underwriting, and writing tricky policies. Instead, insurers would have to make money by efficiency and service. That was a big gamble for both sides -- can insurance companies reform themselves? Can corporate cultures change? If not, then better to exit the field, concentrate on traditional markets, and other health-related fields like Optum.

Here is the way I put it six (!!!) years ago:

http://buddshenkin.blogspot.com/2009/09/understanding-health-insurance-exchange.html

There will have to be a period of time where old companies try to adapt, and where new companies could even come into being to meet the new standard. The new companies might emerge from health care delivery models themselves, I would think. We'll just have to see.

Here's that NYT article today: http://www.nytimes.com/2015/11/20/business/unitedhealth-lowers-profit-estimates-citing-losses-in-policy-sales.html?hpw&rref=business&action=click&pgtype=Homepage&module=well-region&region=bottom-well&WT.nav=bottom-well&_r=0

Budd Shenkin

EMRs, Government, and Capitalism

I wrote in my last post how the government screwed the pooch on Electronic Medical Records by not requiring interoperability as it invested $30 billion in the enterprise. With that kind of money going to by EMRs and equipment, surely the proviso that they be interoperable could be included. Was it corruption or incompetence that omitted that proviso? I couldn't be sure. Maybe a mixture

So here's a follow up from JAMA, September 22/29, pages 1213-1215, a medical news article: “On the Road to Interoperability, Public and Private Organizations Work to Connect Health Care Data.” The reporter, Julie Jacob, interviews the Office of the National Coordinator for Health Information Technology (ONC) spokesperson, Erica Galvez MA. The article states:

Although the ONC road map presents the movement toward interoperability as a smooth, straight road, in reality it's more like fitting together the pieces of a giant jigsaw puzzle. Several public and private organizations are working on different pieces, including organizations creating technical standards, establishing health information exchange (HIE) networks, connecting those HIEs, and developing principles of governance and usage. The hope (emphasis added), according to health care information technology experts, is that all the pieces eventually will interlock.

Because the Feds have basically opted out of direct action and laws requiring interoperability, several organizations have formed to try to fill the breach, one from the AMA called Healtheway, another called CommonWell Health Alliance which was spawned by the EMR industry sans Epic, and which requires a fee from participating institutions. Another older one is the Indiana HIE. Epic has their own system called Care Everywhere, available for a fee when you buy Epic and which was charging for each chart searched when Epic was presented to me, which links together Epic systems and some others who choose to join (for a fee which has been waived for five years, I guess under some pressure.)

Why all the flailing around? The JAMA reporter:

The highest barriers are financial and policy ones, not technical ones, noted those with expertise in health care technology.

“Technology is almost never the obstacle,“ noted Indiana HIE's (John) Kansky. “It is really the governance of the data and getting organizations with different agendas to agree on what you are going to do.”

In other words, it is precisely the role of government that is not being well filled here. Government has taken a hike. Amazingly, this is the ONC goal:

...electronic exchange of health information among clinicians, health facilities,and patients should be widely available within 10 years.

Holy moley – 10 YEARS!! Let's see: Kennedy's speech, 1961; moon landing, 1969. ONC is not what we would call, let's say, overambitious.

I was interested that the spokesperson from ONC JAMA interviewed had only an MA degree, so I googled her, and got a hit from four days ago. From Healthcare IT News:

“Former ONC Interoperability Manager Erica Galvez joins Aledade.”

What is Aledade?

Aledade was founded in 2014 by Mostashari with a focus on supporting independent, primary care physicians creating and or running ACOs. They provide healthcare technology, business transformation services and upfront capital.

More from Forbes:

Farzad Mostashari, who was formerly national coordinator for health information technology, raised $30 million in series B funding for Aledade. ARCH Ventures Partners led the round, with participation from return investor Venrock, bringing total funding to $35 million.
Mostashari, an internist, oversaw the nationwide implementation of electronic health records in the initial stages between 2011 and 2013. Last June, he founded Aledade to help doctor practices, as small as one, band together in so-called accountable care organizations (ACOs).
...By the end of the year, Aledade expects to have more than 100 physician practices in its ACOs, managing 75,000 Medicare patients. Practices pay a membership fee of $500 per general practitioner per month. They keep 60% of savings, with 40% going to Aledade.

In other words, the former head of ONC left to raise money for a private venture and hired a former staffer for him at ONC to come to the private venture. Let me note, however, that Aledade actually is interesting in that it focuses on private practices and has software that is designed to keep them independent of large hospital networks. Still, as they used to say, is this any way to run a railroad? But I have to say that I myself was in government early in my career, and looking around at what took place there, I decided that it was not a good place for me in the long run, much as I learned and loved some of my years there. I can't criticize others for making the same decision.

So, here is the picture. There are so many loose ends in the current non-system, it's not at all clear that this puzzle can be put together. To my mind, the Federal government has never looked so bad. They fail to look forward to see where private enterprise – here, EMR development – needs some help, some regulation if you please, to pave a road ahead so that companies can innovate and compete, but still develop a system that works together for the public's benefit. Companies themselves put a low priority on working together, as would be expected; that's why government is needed, as a convenor. Even when the Feds have a $30 billion windfall from ARRA, which would ensure they had the clout to enforce standards, they fail to exercise it. ONC continues to be meek and silly, setting a 10 year horizon for something that has governance and political impediments rather than technical ones. Government continues to fail to see, or at least talk about, the implications for the system as a whole, where some large capitalistic systems will benefit from lack of interoperability to the detriment of true competition and progress. Government accepts the role of bystander and beggar. Private companies seek to fill the government void of data coordination and interoperability. The problem of rotation of personnel from government to private business continues in health care as with other fields. Given the toothlessness and fecklessness of government, one can hardly blame them, although I'm sure there is much connivance from the private world. In fact, perhaps I am blaming the victim as I blame government. Who knows?

What I do know is, this really sucks.

Budd Shenkin