Why are doctors so slow in implementing electronic health records (EHRs)?

The government has been trying to get doctors to use these systems for some time, but many physicians remain skeptical. In 2004, the Bush administration issued an executive order calling for a universal “interoperable health information” infrastructure and electronic health records for all Americans within 10 years.

And yet, in 2011, only a fraction of doctors use electronic patient records.

In an effort to change that, the Obama economic stimulus plan promised $27 billion in subsidies for health IT, including payments to doctors of $44,000 to $64,000 over five years if only they would use EHRs. The health IT industry has gathered at this multibillion-dollar trough, but it hasn’t had much more luck getting physicians to change their ways.

What is wrong with doctors that they cannot be persuaded to adopt these wondrous information systems? Everybody knows, after all, that the Internet and mobile apps, powered by Microsoft, Google, and Apple and spread by Facebook, Twitter, YouTube, and the iPhone and iPod, will improve care and cut costs by connecting everybody in real time and empowering health-care consumers.

I suspect the answer may lie partly in something essayist E. B. White said about humor. “Humor,” said White, “can be dissected as a frog can, but the thing dies in the process, and its innards are discouraging to any but the pure scientific mind.” Similarly, humanity withers when it is dissected and typed into an EHR. As Jerome Groopman, a Harvard internist, wrote in How Doctors Think, “Clinical algorithms can be useful for run-of-the-mill diagnosis and treatment … but they quickly fall apart when doctors need to think outside their boxes, when symptoms are vague, or multiple and confusing, or when test results are inexact.”

The computer is oversold as a tool to improve health care, implement reform, cut costs, and empower patients. The reasons are obvious to anyone who treats patients. You cannot look a computer in the eye. You cannot read its body language. You cannot talk to an algorithm. You cannot sympathize or empathize with it.

We physicians are not Luddites or troglodytes. We are savvy about using the Internet, technology applications, and social media. For us, medicine mixes art and science. What we seek from patients are clues, constellations of signs and symptoms, and stories. We choose not to be reduced to data-entry clerks sorting through undigested computer bytes.

A string of numbers containing demographic, laboratory, and other patient information, no matter how systematically assembled or gathered, is not narrative. It does not tell a story. It contains “just the facts,” as Sergeant Joe Friday used to say.

That is why an ophthalmologist told me that when he gets an EHR summary, he ignores it: “It does not tell me the patient’s story. It does not tell me why the patient is here, what troubles the patient, and what the referring doctor wants me to do.”

There are also more mundane reasons why physicians, particularly in small practices, do not cater to EHRs or to their private enthusiasts and government backers. EHRs, you may hear physicians argue:

· are sold by so many companies—more than 100 at present—that no one knows how to separate the good from the bad and survivors from non-survivors.
· slow productivity.
· show negative investment returns.
· don’t speak to one another.
· distract from patient time.
· require total reorganization of practices.
· conceal a strategy for monitoring, controlling, and dictating practice activities.
· can be misused or hacked to invade privacy, reveal sensitive information, and threaten the security of patient and doctor alike.
· raise practice costs.

A word on the final point. It is not only the $40,000 that software vendors charge to install an electronic records system and the $10,000 to $15,000 for annual maintenance. It is the hassle factor and the often prohibitive cost of hiring staff to enter the data and to comply with new rules and regulations. When added to the time and effort already required to deal with Medicare, Medicaid, and health insurance plans, EHR requirements are the final straw.

Many doctors are seeking refuge from bureaucratic demands by retiring, closing practices to new Medicare and Medicaid patients, or seeking hospital employment.

This is ironic, since many physicians believe that new apps, such as better speech recognition or systems that translate data into narrative, will make EHRs easier to use. “Free,” government-subsidized, or cheaper models will enter the market; clinical algorithms, based on demographic and patient-entered historical information, will make diagnosis, treatment, and management faster and better.

But these features must evolve from below rather than being imposed from above. EHRs won’t be useful and physician-friendly until physicians themselves have more input into their design.

The digital revolution, and all the improvements in health care that are promised, will remain promises until the EHR is more useful—in medical and economic terms—for doctors.

Richard L. Reece is a retired pathologist and the author of The Health Reform Maze: A Blueprint for Physician Practices. He blogs about health reform, medical innovation, and physician practices at medinnovationblog.

This post first appeared at Technology Review, published by MIT.

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72 Responses for “Why Doctors Don’t Like Electronic Health Records”

  1. Some of the underlying presumptions are changing, and with it the adoption curve is shifting. There are now free web-based EHRs with self-service sign-on, which has been a significantly popular model (especially for smaller ambulatory practices). Good, clean and simple UI design is also emerging (many of the products at Health 2.0 this year illustrate that). I remain hopeful that the “promises” of EHRs will become commonplace over the course of this next year.

  2. Craig "Quack" Vickstrom, M.D. says:

    Why don’t doctors like EMRs? B/c they suck. You spend less time diagnosing and treating patients. They aren’t fun. They suck much of the enjoyment out of practicing medicine. I use one b/c I have to, not b/c I want to. I spend more time interacting with the computer than my patient. They weren’t ready for prime time, so the industry went around us and got Clinton to mandate them. Of course, they could have improved EMRs until we actually wanted to pay for them and use them, but that would be too much work.

    • WonderDoc says:

      EHR’s that is automated, responsive, and integrated, can make clinical documentation more efficent, more accurate, and comprehensive. I believe when this happens, the doctor will spend more time on patients and less time on charting.

    • Ava George, MBA, CHDS, AHDI-F says:

      I totally agree. I have spoken to legislators in DC about this issue. Clinical end users were never consulted about what it is that they require to communicate critical patient information from clinician to clinician with respect to an EHR. Tech companies have code writers building a product with no idea about how physicians work. These programs usually disrupt a physician’s clinical workflow to such an extent that it lengthens the time a physician or other clinician has to spend on administrative work rather than seeing patients. They absolutely were not ready for prime time. BTW….It wasn’t President Clinton who mandated EHRs…..It was President Bush in 2004 as part of his push to make all clinical records electronic and transferable.

  3. MD as HELL says:

    Bingo!!

    And they suck, too.

  4. BobbyG says:

    I saw Dr. Reece’s post on his “Medinnovaton” blog earlier today. I’ll respond in some detail on my REC blog this weekend, but for now, this is and observation I contributed to our REC updated ONC Ops Plan this afternoon, under staff

    “Challenges Requiring Support and/or Assistance”
    ___

    “Vendor delays in rollouts of ONC CHPL certified upgrades, along with ‘bugs” (non-conformances) we find in various products, wherein MU criteria data destination/workflows do not function as advertised. Such events precipitate repeated vendor support “ticket” requests, the satisfactory upshot of which varies.

    Example: we recently interacted with an REC client office (10/04/11) that had just gotten upgraded to their ‘MU Certified” EHR release. Two criteria templates were out of compliance. The vendor informed the provider that they would not modify the templates unless she could provide them with certification source documentation.

    We provided the NIST test specs and OMB 15 documentation to this client, but this is NOT the responsibility of the end-users nor the RECs.

    Moreover, beyond the foregoing, we find a general inadequacy of EHR MU reporting functionality and a glaring inadequacy of MU workflow documentation (with a few notable exceptions).

    While we have a good aggregate grip on the MU criteria, again, consistent vendor implementation (w/respect to the numerator/denominator measures) of the requisite structured data captures remains inconsistent. HealthInsight, being “vendor-neutral,” has a particular challenge here owing to the dozens of EHR platforms we must support.”
    ___

    I am sensitive ongoing to the criticisms expressed by doctors such as “Quack,” and, I am no unreflective cheerleader for HIT. My own Primary, a long-time EHR user (up since 2004) makes some of the same complaints.

    ” You spend less time diagnosing and treating patients…I spend more time interacting with the computer than my patient.”

    That is to a great degree a function of the evolved reimbursement paradigm (which may be about to get even worse).

    It is very complicated, all of it. I swore I would never go back to credit risk modeling,

    (http://bgladd.blogspot.com/2008/12/tranche-warfare.html)

    but, when I see those job openings paying base salary) 3x what I make now (to take shit in health care related blog comments about how I’m a “Socialist bent on enslaving doctors” who has no right to an opinion because I’m not an MD), it gives me pause.

  5. steve says:

    EHRs do not work very well. When they do, we will want to use them. At present, they are designed with administrative needs as a priority. I think some standardization would help, but we need some good ones before it happens.

    Steve

  6. Dr. Mike says:

    “Meaningful use” has been an unwelcome brake on the progressive improvements we were seeing in EHRs. As a user of Dr. Rowley’s Practice Fusion, I know this to be true. The tens of thousands of hours they collectively must have spent making their product meet Meaningful Use guidelines could have been better spent on further improvements to the user interface and data entry. I have yet to see a product that intelligently guides the user in a way that makes data entry intuitive and seemless with the patient encounter. You should really think about hiring some computer game programers Dr. Rowley.

    • Dr. Henry says:

      Amen:
      All of the good programmers work for Google Facebook and Apple. The hacks in Bangalore are not up to the task of building a decent EMR engine.

      • The level of ignorance that this and that several other comments here reveals is astonishing. Whoever is behind the Dr. Henry moniker is no physician and appears to even lack a functioning brain.

  7. Technologist Eric says:

    As a patient I enjoy having access to a medical record I can refer to, one that is based not on repurposed claims data (data smoothed for compensation) but one based on clinically accurate attestations made by the clinician at the point of care. I like seeing this data aggregated with data taken from a lab panel, or a pharmacy order fulfillment. Before EHRs I could not access any of my medical history w/o a medical record release request, a fee, and a 30 day delay. Then I had insurer hosted web based EHRs, where I could get inaccurate data based on charge codes. These diverge enough from my actual procedures and test that I notice the inaccuracies. The EHR is not just a diagnostic chat room between provider. It helps empower the patient to research their care and communicate their history more accurately. The best of breed EHRs also allow patients to report self-care in between routine follow up visits. A tech savvy medical practice could implement a free, open source, MU certified EHR (llook at SAMHSA’s as an example). It is not a chargeable service, but electronic health records reduce the inaccuracies in patient’s pre-registration paperwork, as well as empowering them to research their care outside the walls of the practice.

  8. Prof. Ferrer says:

    Please think about. Most of those problems will not appear if medical students, now medical doctor, will have in their own medical training: Telemedicine and Medical Informatics. This will assure enough knowledge to drive the change, avoid engineers designing EHR and medical application, assure medical people enough trained to direct what to use, what to select, what to merge IT application.

    • DeterminedMD says:

      “Most of those problems will not appear if medical students, now medical doctor, will have in their own medical training”

      What does this mean? You are advocating that education becomes self driven? Learn how to treat people from computers?

      If that is the gist of the comment, thank you for reinforcing my fears that human contact is destined to be obsolete by those who have no vision!!!

      • Prof. Ferrer says:

        “their own medical training”. This means his-her training in the school of Medicine. Sorry if it was not clear enough
        They need to be trained in Telemedicine and Medical Informatics

  9. EHRs do not work very well. When they do, we will want to use them. At present, they are designed with administrative needs as a priority. I think some standardization would help, but we need some good ones before it happens.

  10. DeterminedMD says:

    Sorry, Dr Jaded and Cynical here to once again remind you in times of selfishness, laziness, and lack of investment in the community, those who want to enforce implementation of this process have an agenda that is not wholesome and pure in the end.

    Putting everyone’s health information into one system is as much dangerous as allegedly beneficial. Just ask those who had loans called in by bankers back in the later 1990′s because the customers had diagnoses of possible terminal nature. And that did not even involve full computer involvement.

    Computers are tools, not the end product. The generation that composes 15-30 year olds, their social and tolerance skills are eroding fast. Much in part to the complete reliance on computers, cell phones, and other technological products that allegedly minimize time and effort.

    Hmmm, seems to echo the cheap and lazy comment recently, eh?

  11. pcp says:

    The problem is data entry.

    Until entering accurate, relevant free-form data into an EHR becomes time and cost efficient, they’re no good.

    • BobbyG says:

      Praxis EMR claims to do just this. And, it’s ONC Certified for the Meaningful Use incentives.

    • There are a couple of terms here that need definition:

      “relevant” – To whom? Towards what purpose?

      “cost-efficient” – To calculate cost efficiency, we must quantify the created value. What is that value?

      • pcp says:

        Relevant to the patient-doctor interaction, leading to better health care.

        Cost-efficient from the point of view of the doc who pays for the EHR. Unfortunately, created value for the doc is quite small.

        Isn’t meaningful use moving these measures in the wrong direction?

        • I believe that the narrow patient-doctor interaction and its importance to better health care is currently being redefined downwards.

          I also believe that cost-efficiency is being evaluated from a different perspective than the one you mention.

          I think meaningful use, and the various regulations it is intended to support, are moving us in a different direction than the one you (and I) would consider right.

  12. DeterminedMD says:

    This may not be the best post to link this comment, but I found it amongst my files recently in a discussion with a colleague about issues like these at this site per physician autonomy and how PPACA will take a giant dump on it, so I will leave it here for now and see who can understand it, much less appreciate it and understand the perpspective people like me have in hearing and reading the endless garbage of basically “screw doctors, you have no place in the health care debate as of now”:

    http://www.uoworks.com/pdfs/remarks/remaMA00.pdf

    It’s a good read for any and all who appreciate individuality, autonomy, and concern for the people you call patients.

    Can’t wait to who actually does take the time to read it and twist it into another faux cause to cheapen medical care.

    • BobbyG says:

      Question for you:

      Do your believe in the rule of law?

      • DeterminedMD says:

        Gee, I can free associate too. When a tree falls in the forest and you are there but deaf, does it make a sound?

        If you are alluding I have no respect for the law, which of course is a generic term when there are assorted different laws for different arenas of our culture, you wonder why I have little respect for your retorts and lame efforts at rebuttals, but I am glad you like to annoy people and then act so holier than thou because you have alleged legitimacy as a blog author at another site. It is a shame others do not call you on your behaviors, but, they must have equal vested interests in promoting an agenda that does not really help health care, at least the providers in it.

        I’ll answer this generic question per the role I have as a physician: I have never been sued as of this writing, never had disciplinary action against me by any governing body or health care institution, and strongly believe in the boundaries that are in place for patient-physician interactions.

        Is my being intolerant of this process at hand called PPACA inappropriate? Perhaps to someone just coming into this site and reading my writings for the past couple of months, sure, I come across as harsh and unyielding. But, when a system that is even moreso harsh and unyielding like the bastards who concocted this BS legislation back in 09, you can’t negotiate much less even be heard being a gentleman and respectful. Good luck trying to be the mensch with the turds that are entrenched incumbents in DC.

        Oh, by the way, that wonderful gentleman from Nevada who is the biggest hypocrite of his group of Senator colleagues, what a genuine moment this past Thursday evening of how to manipulate the system for his party’s own good. Read up on why it is called a nuclear option, and how this asshole was so vocal how wrong it was when Republicans threatened to try it back in 2005. People like him can’t die fast enough for me, because he has no humility or grace when to know to retire. At least Steve Jobs had the decency to step down and name a successor before he died, because he had some sense to the adage “the needs of the few outweigh the needs of the many”.

        Which is why I forward outside comments like the above link. Not for you, Mr G to understand nor appreciate, but my colleagues who’s collective silence is similar to that of the above tree falling . Asking politicians to take the proverbial lead in health care decisions from those of us who actually embrace the terms and expectations of being providers is like asking thieves to design the security systems of banks and other financial systems. Wow, after writing that last sentence, a true analogy for me!

        Maybe if the tree fell on the collective heads of the AMA members who agreed to support this moron in the White House, maybe those of us far away might hear their screams. Not that I would rush to their aid though.

        Memo to those of you, watch the original version of “Logan’s Run” from the late 1970′s, that will be the overall example of Health Care for the US circa the later 2020′s. Because the elderly will have been effectively ignored and allowed to die off overall, and then those who have any chronic illness will be encouraged to die for the greater good of the healthy.

        Sounds ludicrous? Why is it art imitates life, and silly movies or Sci Fi books from decades ago end up being blueprints for the current times? Maybe some people sense the nature of humans. Especially anticipating that of those in power and control. We are a corrupt species until proven otherwise. But, naivete has a strength. Yeah, but being blind to have stronger hearing is not an advantage to me!

        Just watch out for those proverbial branches falling before the trunk!

        • BobbyG says:

          Y’know maybe you oughta see that Jonathan Rosman psychiatrist guy you cited. You have some blaring issues.

          It was a simple question.

          Give me 5 minutes of Socratic with you (or any Randianista), and I will leave you in deductive and inferential rubble. For someone who has such repeated little regard for my views, you sure keep taking the bait.

          :)

          • DeterminedMD says:

            Wow, you tell me I should seek out psychiatric help and then finish with “Give me 5 minutes of Socratic with you (or any Randianista), and I will leave you in deductive and inferential rubble.”

            I would suggest you consider a session or two yourself, but, narcissism on the scale you write is not treatable. At least no drugs will have any effective impact. Well, maybe Thorazine, as some levels of Narcissism do reach grandiose scales of psychosis.

            Umm, we are waiting for your “OK, stayed tuned, this is gonna be a doozy. I’m no only gonna read it (I found an editable copy, even though he tried to “copy protect” it; took me all of 5 seconds), I’m gonna flowchart the “logic” so there’s nothing to “twist.” ” Personally, I do sincerely hope after you read it, you did realize that the author did have legitimate points about autonomy that were fair and reasonable.

            Besides, if you attack it as mercilessly as you allude to try, would this alienate your physician buddies? Me hopes your silence is one of responsible reconsideration.

            By the way, did I answer your question about my respect for the rule of law as you first inquired?

          • BobbyG says:

            “Personally, I do sincerely hope after you read it, you did realize that the author did have legitimate points about autonomy that were fair and reasonable.”
            ___

            All I see thus far is the std Rand Rant.

            “realize that the author did have legitimate points about autonomy that were fair and reasonable.”
            ___

            Yeah, of course. It’s called “Even A Broken Clock Is Right Twice A Day.”

            BTW, this is interesting:

            http://www.bgladd.com/PDF/AynRandBioReview.pdf

            You’re waiting, ‘eh? I thought you didn’t give my assertions any credence?

            Keep waiting. It takes a bit of time. This one took me about 40 hours:

            http://www.bgladd.com/PDF/JAMA1994SinglePayerProposalAssessment.pdf

            “By the way, did I answer your question about my respect for the rule of law as you first inquired?”

            No. It was a trick question anyway, given who you cited.

            BTW, thanks for the precise psych dx (I guess I’m a 298.8, psychotic NOS). At least YOU may be able to bill for it (let’s call it a “portal based TeleMed e-Visit”. e-Rx me some Ativan along with teh Thorazine while you’re at it, OK? Generic would be fine).

            :)

        • BobbyG says:

          “It is a shame others do not call you on your behaviors”
          ___

          It couldn’t be much easier to do. I don’t see how I could be any more public. Would my long-form Birff Certificate help?

        • DeterminedMD says:

          Oops, two mistakes in my above rant:

          1. It should be “the needs of the many outweigh the needs of the few” and
          2. the Logan’s Run comment issue of example where it may be a reality of our culture is probably moreso likely in the 2030′s, gotta give it a full generation to have the impact, as well as let the current generation that is over 65 to be eradicated, per the Logan’s Run premise.

          Re-reading this today, I still stand by it. Politicians continue to reveal their true intent since PPACA was passed. It is either their way, or no way. At least people who are passionate about their concerns and philosophy who equally respect people who differ should have a choice by offering the highway.

          We have alleged leadership from both sides of the aisle who only want to crush and destroy any opposition. Really, this is what you folks want and appreciate in this type of leadership? I mean, really, do you readers here not see what is the agenda?!

          Blind faith really is that, blindness of strict dogma or naivete is a dangerous weakness. Leadership is earned and constantly reappraised as ongoing. Sometime, terms of an elected position are not limited to a time frame. Isn’t impeachment applicable to all posts of government?

          Oh yeah, that requires insight and judgment of alleged colleagues. Scrap that!

          • Dr. D., I’ve been reading your comments here since the days you were Exhausted and I don’t see how you can support the views expressed in that article. The person who wrote that article is all about money, openly and explicitly.
            I understand how many docs are concerned with government’s (and insurers’) intrusion in the way they provide care, and I understand the concerns that politicians today are largely bought by big interests, and to a large degree I do agree with both concerns. What I don’t understand is the cold blooded disregard for people that don’t bring in revenues.
            Do you really consider your profession to be morally and ethically equivalent to selling cars or fixing toilets?

        • Chronicallyill says:

          Determined MD. Thank you for caring for your patients. BobbyG sounds like an employee of the government or lobbyist for some health insurance company. I just pray more doctors still care about the oath they took. I am working hard to find my local congressman to protect my patients bill of rights (puke). God help us all especially the sick ones.

    • BobbyG says:

      Quoting you earlier”

      “Sorry, Dr Jaded and Cynical here to once again remind you in times of selfishness, laziness, and lack of investment in the community…”
      __

      OK, stayed tuned, this is gonna be a doozy. I’m no only gonna read it (I found an editable copy, even though he tried to “copy protect” it; took me all of 5 seconds), I’m gonna flowchart the “logic” so there’s nothing to “twist.”

      :)

  13. Technologist Eric says:

    Free-form text can be entered in a number of EHRs (GE Centricity is an example). If yours does not support it out of the box, ask how much it costs to add a field for the entry and reviewing of free-form text. It is not going to meet the long term requirements for quality of care reporting to CMS. Free-form clinical documents are extremely expensive and error prone to parse into something you can measure against quality of care metrics.

    • BobbyG says:

      Praxis EMR claims to be able to parse and save structured data elements from free-text progress notes into SQL tables. I’ve only seen it in the clinic once (one of my REC clients).

      They got ONC certified, insofar as that says anything.

  14. It is very helpful fort me and this is a good article that I saw,thanks for sharing!

  15. BobbyG says:

    “The person who wrote that article is all about money, openly and explicitly.”
    ___

    Well, Margalit, that’s what the Cult of Randianism is all about. It is pretty much unreflective beyond that nominal point — hence all of the bely-laugh internal inconsistencies and endless maze of non sequitur potholes (shovel-ready?) along its Road to Reason.

    And, we may be about to yet enter one of those eras where the “money” will once again be severely debased, perhaps violently so. Read Michael Lewis’ new book “Boomerang.”

    From the Rand bio I cited (which looks to now be in Moderation purgatory):

    “…[Rand's] work may be easy to ridicule, but it has appealed to gen- erations of readers precisely because it seems to articulate something true about a society in which there is little sense of common purpose or regard. Should there be any lingering shame or sadness at our modern Gilded Age, at the material gaps that place some in luxury skyscrapers and others out on the streets, she encourages her readers to renounce that discomfort as the true immorality. Her work offers a way of making sense of a profoundly unequal society, of making it tolerable, even virtuous. Is the arid world she describes, in which all common creativity and sense of intellectual tradition has been reduced to individuals acting alone, not reflected in the empty nature of our public life? Do we not live in a world divided between winners and losers, between people who seem to live as Supermen and those who are treated as though their lives have no value at all? If societies get the thinkers they deserve, it is troubling to think that Rand is ours…”

    To the committed Randian, there IS no concept of a “commonweal.” Humanity consists merely of the aggregation of molecular, autonomous, darwinian socioeconomic You’re-Not-The-Boss-Of-Me transactional dyads.

    It’s just silly. An epistemological hairball.

    BTW, she had me at “Altruisim is the greatest Evil. It requires the sacrifice of the competent to the incompetent.”

    Well, I guess that rules out parenting.

  16. Very interesting, I had no knowledge of the topic until this article. Thanks!

  17. DeterminedMD says:

    Interpretation is individual specific, and I read the article as saying doctors have the right to practice as trained and as long as staying in the boundaries of appropriate care and expectation of reimbursement, per the author’s quote at the end, “It’s my life–hands off”. If someone wants to bill $1000 for a procedure or intervention that most others charge $500, who will be practicing in the next 2 years? Certainly insurers will set limits, and let’s be honest, anyone who pays out of pocket will too.

    I think what needs to be answered by the general masses of our society is why are you all accepting of your liberties and choices being nicked away to eventual full servitude by a government and the real leaders, the financial oligarchy that is Wall Street and major corporations, and then telling those who responsibly reject this agenda to shut up and accept servitude. Being a doctor is about providing care that is what is the standard of care, or if going outside the box at least being honest and direct with the patient in noting this is uncharted territory in care but respecting the patient is the one receiving the care, and while cost is an element to the boundaries, it is not the ONLY one,

    Face it, people have forgotten the basic premise that you often have to spend money to make money, if not at least see results that give satisfaction and a sense of sound resolution. Insurers are clueless to this now. All they see is an expense today, irregardless if it will save money 6 months to a year down the road. And politicians are the opposite, because it is not their money and often the consequences of irresponsible spending will not be felt until after they have left office. But, in this case of PPACA, the ones who are covering costs and have profit agendas have the ears and actions of the politicians.

    I’ll leave readers with this comment in the latter third of the link if some of you aren’t interested in reading it:
    “And it is the best doctors, the most dedicated and those least ready to relinquish their independent judgment, who have been the first to leave the practice of medicine when doctors’ rights were trampled on.”

    I’ve quoted the Ayn Rand line that Dr Rosman also notes, and you all better think about it very closely should PPACA stay in place and dictate care by people NOT in the treatment process. “”It is not safe if he is the sort of man who resents it [whose life has been throttled by inappropriate intrusions into care], and still less safe if he is the sort who doesn’t.”

    Do you all want to be treated by people who just blindly agree to health care interventions set by politicians, irregardless if it does not allow access to the best treatment intervention the illness requires, or, what if the doctor does not care and is only focused on that paycheck at the end of the week, even if it is less than it was before PPACA?

    That is the reality coming. And, psychiatrists are not the big money makers in medicine, Ms G-A, although there are some who are really trying to be the king of the hill.

    By the way, you think Dr R was off base in this sentence:: “They [intellectuals outside the treatment process] have taught doctors that the consumers of medical services (patients) are morally superior to the providers of medical services (doctors), just because the consumers are in need.” When providers stupidly allowed people to be called consumers or customers instead of patients, guess what, that opened the door to the absurd and extremist attitude of business, that the customer is always right.

    No, the customer, even the patient, has the right to speak out and challenge the process, but, simply speaking does no infer correctness. That is one of the big nails that is cramming medicine into the coffin it now finds itself in.

    Hey, don’t believe me, just pay attention to which doctors are staying in practice by 2014, and who is leaving. Betcha it is not the respected and committed people you see or hope to see now. Think about it!!!

    And remember, this article by Dr R was written in 2000. Way before PPACA became the nightmare it is intending to offer!

    • BobbyG says:

      Recommended reading: “American Mania: When More Is Not Enough”

      http://www.amazon.com/American-Mania-When-More-Enough/dp/0393059944

      “…Although [Dr.] Whybrow believes that the “American Experiment” is genetic as well as social, his book is not another simplistic approach to genetic determinism handcuffed to socio-biology. As a practicing doctor, trained in endocrinology and neuropsychiatry, he knows that genes, though a contributing factor, are not the blame, as some other reviewers presuppose. In fact, he is not placing blame; he is attempting to help us understand and urging each of us as individuals to take back control of our lives from the merchants and an economic system whose goal is not to make us healthy and happy but to sell us more.

      What he does so well throughout the book is try to help us unravel and question how our insatiable drives for security, betterment, material affluence and positive affirmation- fueled by the reward system of our uniquely affluent society-have reached a level that is making us perpetually anxious and fearsome as individuals and confused as a nation. An interesting review by Peder Zane thinks that the book, “speaks to an unease with American Life that can be heard on the left and the right.”

      This is not a happy book. The author presents some hard facts that some might find a bitter pill to swallow. We Americans tend to have pretty thin skins when it comes to serious social commentary and criticism…”
      ___

      Came to that via Michael Lewis. The “lizard brain” stuff is Nassim Nicholas Taleb 101 (though he can’t lay exclusive claim to it; it’s also Kahneman & Tversky et al 101 — “Behavioral Econ”).

      • BobbyG says:

        “…The road out of Vallejo passes directly through the office of Dr. Peter Whybrow, a British neuroscientist at U.C.L.A. with a theory about American life. He thinks the dysfunction in America’s society is a by-product of America’s success. In academic papers and a popular book, American Mania, Whybrow argues, in effect, that human beings are neurologically ill-designed to be modern Americans. The human brain evolved over hundreds of thousands of years in an environment defined by scarcity. It was not designed, at least originally, for an environment of extreme abundance. “Human beings are wandering around with brains that are fabulously limited,” he says cheerfully. “We’ve got the core of the average lizard.” Wrapped around this reptilian core, he explains, is a mammalian layer (associated with maternal concern and social interaction), and around that is wrapped a third layer, which enables feats of memory and the capacity for abstract thought. “The only problem,” he says, “is our passions are still driven by the lizard core. We are set up to acquire as much as we can of things we perceive as scarce, particularly sex, safety, and food.” Even a person on a diet who sensibly avoids coming face-to-face with a piece of chocolate cake will find it hard to control himself if the chocolate cake somehow finds him. Every pastry chef in America understands this, and now neuroscience does, too. “When faced with abundance, the brain’s ancient reward pathways are difficult to suppress,” says Whybrow. “In that moment the value of eating the chocolate cake exceeds the value of the diet. We cannot think down the road when we are faced with the chocolate cake…”

        http://www.vanityfair.com/business/features/2011/11/michael-lewis-201111.print

        Indeed.

    • Dr. D., I think you may be aligning yourself with a philosophy that you don’t necessarily support in its entirety, just because part of its argument resonates with you.
      I understand and sympathize with your outrage at having outside interests attempting to dictate how medicine is practiced, with little more than lip service to both patients and doctors interests. This in my mind has little to do with payment rates and more to do with professional judgement. I think I would have shared the article’s outrage on payment levels if the medical profession was largely comprised of paupers, but it is not. Somehow, particularly during this economic downturn, demanding “freedom” to extract more money from the already impoverished 99%, and suggesting that those who cannot come up with the cash should have the “freedom” to pretty much go to hell, seems a bit in bad taste for a doctor.

      I would suspect Dr. D, that the author of that article (I cannot force myself to call him a doctor), has absolutely no problem with the Wall Street oligarchy, or the blatant corruption in government, as long as it coincides with his financial interests. He is not standing up for freedom. He is standing up for his “right” to make as much money as possible, without having to consider the consequences of his actions to anybody but himself. I wish people like him would be barred from laying hands on patients.

      • nate ogden says:

        “He is not standing up for freedom. He is standing up for his “right” to make as much money as possible,”

        Wouldn’t any limit on the right to make as much as possible be anti-freedom? Sounds like you support freedom as long as you can limit it to your ideology, sort of like how you apparetnly want to decide who and who is not a doctor?

        “without having to consider the consequences of his actions”

        Sort of like how the left passed PPACA and eliminated the individual market for kids and drove up the cost of insurance?

      • DeterminedMD says:

        I have issues with some of your comments per the 12:44 posting:

        1. “I think I would have shared the article’s outrage on payment levels if the medical profession was largely comprised of paupers, but it is not.” Seems you are basically saying we as physicians are rich, overpaid people. Umm, how about you spend twelve or more years after HIGH SCHOOL and learn a professional training that makes you responsible for people’s lives, literally. And per your specialty training, carry a phone or pager around for at least a few days a week and risk being called to handle medical matters at whatever time of the day. Gee, when you hear it that way, yeah, we should get paid $30 an hour, because, hey, same thing like being a tow truck operator.

        2. “Somehow, particularly during this economic downturn, demanding “freedom” to extract more money from the already impoverished 99%, and suggesting that those who cannot come up with the cash should have the “freedom” to pretty much go to hell, seems a bit in bad taste for a doctor.” Extract more money from people. Man, I must have missed the muzzle prints on patients’ heads when they come to see me. Last I checked, treatment is about choice, unless you are in an acute trauma or medical emergency like an MI or stroke. Even cancer is not an acute care issue, yet the way you wrote this sentence, every one who walks into a doctor’s office has us forcing them to come to us and then we stick our hands in their wallets/purses and rip the cash out. How freakin’ insensitive this comment was by you!

        3. “He is standing up for his “right” to make as much money as possible, without having to consider the consequences of his actions to anybody but himself.” Wow, that is quite the interpretation of what Dr Rosman wrote, and by the way, another shot at physicians by saying you can’t call him a doctor. Sure, there are statements about making an income, but, why is it a lot of you here think that doctors should just be stripped of income while other professions that literally do not impact on peoples’ lives at a moment’s notice can still pursue sheer capitalism and have no accountability?

        Face it, your comment can be easily interpreted we should take a vow of poverty and be thankful we are still allowed to provide care. I thought you to be a bit of an ally, but after today’s comment, forget that!

        Nate below was on the mark, PPACA can be passed without anyone in the halls of Congress having to consider the consequences of their actions, and we should all genuflect and pray for our leaders’ well being and ongoing ideology. Wow, another example of hear the lie enough it becomes the truth.

        Are you out on the streets near Wall Street now? Sorry, I was raised to be a fiercely independent person, and found the profession of medicine to work for my type of philosophy and desire. And guess what, a good portion of my patients seem to appreciate my attitudes and expectations.

        Good luck finding doctors embracing the desire to work honestly and earnestly should PPACA survive the Supreme Court. You all will get the care you deserve should politicians keep lowering the bar!!!

        • Dr. D.,
          You are reading things that are not there. There is no need to look for interpretations in what I write. I usually call it as I see it explicitly.

          1) Statement: Physicians as a group are not living in poverty. Does this statement imply that they should live in poverty? Not at all. Does it even imply that they should be making less money? Nope, and neither does it imply that they should make more. It is a plain statement of fact.
          My opinion, as strange as it may seem to you, is that with the exception of primary care, which should be paid a lot more, most docs are adequately compensated.

          2) Yes treatment is a matter of choice, and in the cancer example the choice is get treatment and maybe live, or don’t get treatment and die. I guess you can call it a choice, but it is very different than most choices people have to make in the course of normal life, and it is definitely different than fixing one’s toilet, or not. And IF and WHEN a patient makes that choice and comes in for help, it seems unfair to reserve the right to charge as much as possible just because life, or excruciating pain, may be in the balance. And this is exactly what the author is demanding as his right. Those who have the cash, will get the treatment. Those who don’t….oh well, who cares….
          You can’t possibly agree with this, right?

          3) Doctors should not be stripped of income. This goes to point #1 above. There is a huge difference between stripped of income, vow of poverty and the simple requirement that a few greedy individuals with a peculiar attitude should not be allowed to gauge prices.

          I would like to keep the PPACA out of this. I have my own problems with the Act but that is irrelevant here because the article was written way before that, so the only rage the author could have had would have been against the sheer existence of insurance. Of course nobody was forcing him to accept any insurance, but I guess that idea didn’t seem lucrative enough.

          And by the way, not calling the author a doctor, is not a shot at doctors. It is a sign of respect.

        • BobbyG says:

          “yeah, we should get paid $30 an hour, because,”
          ___

          No, to me, more like $300/hr base, I would say.

          “Umm, how about you spend twelve or more years after HIGH SCHOOL and learn a professional training that makes you responsible for people’s lives, literally. And per your specialty training, carry a phone or pager around for at least a few days a week and risk being called to handle medical matters at whatever time of the day.”

          How poignant.

          http://www.bgladd.com/NoCryingInHealthCare.jpg

          Yeah, I know; you’re pissed (justifiably) and confused. You are not alone.

  18. steve says:

    ““And it is the best doctors, the most dedicated and those least ready to relinquish their independent judgment, who have been the first to leave the practice of medicine when doctors’ rights were trampled on.”

    That is most certainly not what I have seen. First, not that many leave. Secondly, those who leave over perceived rights issues have all been fruitcakes. Almost always a really crappy doc also. Every one.

    Steve

    • BobbyG says:

      Interesting.

      From my late daughter’s story:
      ___

      “Money-grubbing, egotistical docs”

      Late one quiet evening on the 4th floor at Brotman, a double-shift weary Dr. Mittleman and I leaned on the counter at the nurses’ station and mused at length upon some of the more absurd alternative therapy allegations. Responding to the notion that his profession was raking it in while suppressing the “competition,” he quietly countered “right; I’m getting rich on the sixteen dollars a day I get from Medi-Cal for seeing your daughter.”

      Here was a man repeatedly to be found perched on the edge of Sissy’s bed at odd hours, talking with her for 30-40 minutes at a time– a temporal generosity he shared time and again with me in the halls as we discussed the more technical aspects of her situation. This is a man who continues to field and return her calls, sees her on a moment’s notice, and jawbones the Medi-Cal bureaucracy on her behalf, even though she is technically no longer his patient.

      I recently emailed Dr. Mittleman to express my gratitude, joking that “should they ever decide to start cloning the best doctors, I’ll be by your office to pick up a DNA/tissue sample.”

      Likewise for Dr. Sherry Wren, the swaggering, 5’3″ supremely confident surgical wizard who saved Sissy’s life in April of 1996, and who continues to stay in touch with us. Likewise also the innumerable doctors, nurses, therapists, and support personnel who have rarely failed to accord my daughter the utmost respect and compassionate, knowledgeable care throughout the past year and a half– many of whom will earn less in a lifetime than Dennis Rodman was debited by the NBA last season for unsportsmanlike buffoonery.

      Every discipline has its share of the “arrogant and narrow-minded,” but I have mostly found mainstream health care professionals to be a dedicated, unpretentious, and self-deprecating lot quite aware of the limits of their knowledge and the risks of presumption. Once, during a series of health care quality improvement seminars I attended at Intermountain Health Care in Salt Lake City during my Peer Review tenure, a speaker– himself a noted pediatric surgeon– wryly observed that “the best place to hide a hundred dollar bill from a doctor is inside a book.” The Director of the seminar series, Dr. Brent James of IHC (and a Fellow of the Harvard School of Public Health), noted in our opening session that physicians would probably admit– off the record, of course– that perhaps only 10% of their clinical decisions made during daily practice could be traced to the peer-reviewed scientific literature. Dr. James also made the droll observation that, were you to walk into the typical medical adminstrator’s office, “you’d be much more likely to see copies of the Wall Street Journal rather than the New England Journal strewn about.”

      What can one take away from such remarks? First, the many physicians I have come to know in the past few years are in the main acutely sensitive to the problems of clinical conceit and “paradigm blinders.” Indeed, the Utah pediatrician’s”$100 bill” wisecrack was offered to an audience of doctors and their allied health personnel during quality improvement training. Second, the body of peer-reviewed medical literature does not constitute a clinical cookbook; even “proven” therapies– particularly those employed against cancers– are generally incremental in effect and sometimes maddeningly transitory in nature. The sheer numbers of often fleeting causal variables to be accounted for in bioscience make the applied Newtonian physics that safely lifts and lands the 747 and the space shuttle seem child’s play by comparison. Astute clinical intuition is a necessary component of a medical art that must, after all, act and act quickly– so often in the face of indeterminate, inapplicable, or contradictory research findings.

      Finally, with respect to Dr. James’ Wall Street Journal quip, the capitalist imperatives within which health care clinicians must operate are, in the aggregate, neither of their making nor under their control. Moreover, blanket indictment of the profit motive as necessarily inimical to optimum medical care and research is a rather simplistic notion. Strategies aimed at maximizing investors’ net returns probably spur at least as many medical advances as they inhibit…”

      http://www.bgladd.com/1in3/
      ___

      But, to JohnGaltMD — uh, “DeterminedMD”, I’m an anti-physician ignoramus out out enslave doctors.

  19. Julie, NP says:

    I am a nurse practitioner in private practice and I have a web based EMR for notes, billing and e-prescribing. It is more time consuming to use an EMR as far as having to go to different screens and enter data. It was much faster writing in a chart, but charts get lost, and they take up too much space. I started my practice with paper for two years and then transitioned to an EMR which entailed scanning in all the records. I was just starting a part time practice at the time so I only had a few hundred records that had to be scanned in. For providers with huge practices, it would take a lot of time and money to transfer over all records. Its best to start out that way. I do think that EMR’s cause you to do better more thorough documentation and can prevent medical errors and are more efficient.

    I have heard the concerns about privacy and safety when using web based EMRs which are less expensive and require no equipment but I dont have that concern and it is the wave of the future. I believe that in 2014 the government will start taking a small amount of money away from providers who do not use EMR’s who take medicare. That has causes some of my colleagues to not want to accept medicare patients. Many doctors now have quit taking medicare patients let alone medicaid patients because they do not believe they are adequately reimbursed for this. I dont agree with that but that is their prerogative.

    I do believe that the medical field has become more of a business than a helping profession and is money driven and also corrupt in many ways. I consider myself a conservative but I am in favor of health care reform because I believe that change needs to occur due to rampant abuse. I do not agree with doctors or any other health care providers being opposed to “being told what to do” when what they are being told to do is for the best of their patients, their profession, the health care system, and their country.

    Another example of this is prescription drug monitoring programs. Health care providers seem reluctant to check these databases to see if their patients have been getting controlled drugs from other providers, known as doctor shopping. Only seven states require providers to check the databases. Many doctors are against regulations requiring them to check the database event though doing so is proven to reduce prescription drug abuse. Sometimes we have to do things that are time consuming or inconvenient if its in the best interest of others.

    • BobbyG says:

      “Health care providers seem reluctant to check these databases to see if their patients have been getting controlled drugs from other providers, known as doctor shopping.”
      ___

      See

      http://regionalextensioncenter.blogspot.com/2010/11/first-do-no-hold-harmless.html

      In particular my citation of the Broulliard paper “Emerging Trends in Electronic Health Record Liability”

      Moreover,

      “Sometimes we have to do things that are time consuming or inconvenient if its in the best interest of others.”

      Too often there is a compartmentalization of the FTE time burden, confusing the nominal with the aggregate. Clarifying this is part of the work with which I am charged.

    • DeterminedMD says:

      “I do not agree with doctors or any other health care providers being opposed to “being told what to do” when what they are being told to do is for the best of their patients, their profession, the health care system, and their country. ”

      Really? Based on who’s supervisory experience and accountablility? Politicians? Insurers? Patients?

      People who write these kinds of positions better watch out, because I don’t know what physicians Steve hangs out with, but I know several colleagues who are at least a dozen or more years from retirement who are contemplating it now, and others who are just going to go to a cash only practice and see how it plays out.

      You all think doctors should answer to non-clinician demands? Good luck with that, but, the antiphysician mentality that comes out here sure explains why such ignorant and dismissive rhetoric gets traction. After all, we are sure seeing a mob mentality up in New York, and how easy it is for those who are predators to get the menials to do their bidding.

      • DeterminedMD says:

        By the way, a Nurse Practitioner telling doctors to answer to others. What, your specialty? I can’t wait to find out when malpractice insurers catch up with your demands for more intervention skills, and then the premiums shock you all into what real accountability costs!!!

  20. BobbyG says:

    “DeterminedMD says:” October 10, 2011 at 6:12 am
    “Is this a genuine supportive statement or usual sarcasm without the fonts?”
    ___

    I meant it.

    • DeterminedMD says:

      Well, thank you, but no one deserves $300 an hour unless one can guarantee a cure or is exceptional at saving lives in trauma/acute care settings.

      some people have the work ethic and focus on patient care that may well justify a reimbursement rate that is extraordinary. Most doctors who do so more often aren’t looking for the dough though, they really like seeing people survive and get better.

      There is no one easy tip to define what a physician is like instinctively, but one I note more often is a hint of attitude: what kind of car they drive. People who do care for the sake of doing care drive a realistic, prudent vehicle. People who are superficial and vain, well, you know what type of vehicle they own. Me, I bought my most expensive car this past year, a Hyundai Santa Fe. Will never pay more than $20 K for a car the rest of my life, per inflationary adjustments. You think about how you conduct yourself in the community, it shows in the office too.

      Just my opinion.

      • BobbyG says:

        When I had to set up guardianship on my late Dad in 2008, the lawyer’s rate was $300 per hour (she was a highly recommended geriatrics law specialist). The whole ball of wax ended up costing about $4,300.

        More later; gotta run.

  21. smiths ryan says:

    really a very nice article….Want to get a FREE Health Newsletter or find articles for your good health….

  22. Julie, NP says:

    Our health care system does not work. Our system costs more and produces less results than most industrialized countries. Our system is consistently rated at the bottom. Our morbidity and mortality rates are high and we rate very low in treating illnesses. If the system were not broken, there would be no need for a fix. Unfortunately the government is having to step in and enforce changes and controls. I would prefer to see our current system fixed and reformed prior to expanding coverage to more Americans but the fix we got was the Affordable Care Act.

    Insurance companies are making record profits, healthcare corporations such as for profit companies that own hospitals are making profits and in some cases, physician incomes are extraordinarily high. Something has to give. If the main powerful players, the doctors, hospitals, and insurance companies would have been playing fair and managing the system with positive outcomes, then reform would not be necessary.

    I dont understand any provider, doctor, physician assistant, nurse practitioner, dentist, optomotrist, etc, being against reform that leads to positive patient outcomes. The government is providing a lot of money for providers to transfer to EMR systems. We have to put the patient first and what is best for them and set aside some power and control and possibly some income in order to do that. We simply cannot afford to continue in the current direction with healthcare. The results of our health care system are terrible and an embarrassment and this is a known fact despite the huge cost. There is rampant abuse and corruption from upcoding to changing diagnosis to unnecessary procedures and admissions for profit. If physician autonomy and income goes down and this leads to people leaving the profession it will make way for a new group of providers going into the profession because they want to provide quality care and are willing to do what that takes, even if they dont have 100% autonomy or mega incomes.

    • MD as HELL says:

      What a crock!!

      Typical regimented nurse=speak.

      • DeterminedMD says:

        Really, NPs just want their alleged piece of the pie, and should they get more than they bargained for, they will find out the adage, “power corrupts, and absolute power corrupts absolutely.”

        I just love the looks of astonishment and incredulity, when I remind the ones who want my job responsibilities, that there will be changes in malpractice coverage once the insurer finds out what they want to do in clinical care interventions. Ooooh, what did you all miss, NPs, when the adage “with great power comes great responsibility”? Every body who is not an MD wants all the perks and none of the accountability.

        It’s like what a supervisor in residency told me: everyone wants to be the doctor until the crap hits the fan, and then who is out of the room first to avoid the trajectories? Not the doctor or patient!!!

  23. Jimmy1920 says:

    Let me offer a patient perspective. Not necessarily an experienced patient, fortunately, but an occasional patient, who has seen a variety of doctors over the years.
    I have two bad knees. Not severely bad, but only because I work to keep them functioning. I had my most recent surgery about eight years ago. Every time I have had some knee ‘difficulty” – maybe three or four episodes since that surgery, i have returned to the same practice, based in a respected university teaching hospital,
    Each time they always have my demographic information correct, even my insurance information, yet absolutely no evidence whatsoever that they ever did anything with my knees. I have learned to bring my own images, which baffles me. and to have to start from scratch describing a medical history of 30+ years of ACL-less knees.
    Likewise, my wife use to think it was important to return to the same imaging center for her periodically required diagnostic images – until she discovered they don’t keep the images either.
    I would like to go to a doctor and know that he or she knows, or can find out, when I had my last tetanus shot, or what immunizations my children have had and still need even when I move to a different town. i don’t have to want to wait five+ minutes while they fumble through a ream of paper trying to figure out what prescription they gave me the last time I visited. And without e-prescribing, how do they expect to know whether I filled or took the prescription.
    I picked my most recent doctor, in part, because the practice uses computers. i cannot speak to its ease of use from the docs perspective. She hasn’t complained to me. But she walks into the examining room with a small laptop and can quickly lookup anything she needs to know about my previous visits.
    I yearn for the day when all my doctors have access to the same medical history.
    i administer a large benefit plan and we hire a disease management firm. Why should an employer sponsored plan be purchasing “disease management”? Because physicians don’t seem to operate in an environment where they have access to all of the information needed about patient care. so disease management firms have learned to mine claims data – hardly perfect – to find out when members are doctor shopping for certain prescription drugs, when they are seeing different doctors for multiple conditions with no care coordination whatsoever.
    I don’t think we should be in that business, but docs aren’t, and as long as I am getting positive feedback from our employees and a return on our investment, we will continue.

    • nate ogden says:

      Great example of why people shouldn’t be so quick to get rid of employer sponsored coverage. Right now employers are the only ones looking to hold down cost and improve employee health on a consistant basis.

      Yes some employers will just buy the cheapest plan or not offer coverage at all but the vast majority of employers are trying to do whats best for their employees and help them. Not that they get any credit or appreaciation for it.

  24. MediPro says:

    I agree, adopting an EHR comes with a lot of training, implementation, long grusome hours of inputting new data, etc. However, what many doctors don’t realize is finding the proper vendor is a major part of EHR adoption. Once the vendor helps you transition from your paper records to the EHR, there is definitely a quick ROI. You will free up more time for your staff because all of your patient records will be one click away. And even more so, you will be able to put a better focus on patient care. Finding all of the patient’s useful information on the screen directly in front of you in a quick easy manor will be able to help you better diagnose that patient. It is up to the doctor to ensure that they still make direct eye contact with their patient, make them feel comfortable in the room, etc. EHRs are a GREAT tool for more efficient pratices in the future. EHRs are the future and they will continue to grow with your practice for years to come. Again, adopting an EHR can be a struggle and seem overwhelming but many people fail to realize is the importance of finding the right vendor. The vendor and the EHR should be offered as a package deal and they should both be able to meet your needs and put your fears and hesitations to rest.

  25. Thanks for sharing your thoughts on aol.
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