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Putting the “AI” in “Legal” (and “Health Care”)

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By KIM BELLARD

I once again have to thank The New York Times for introducing me to a new concept. Sarah Kessler wrote about the rise of “legal engineering” – for which, it turns out, one doesn’t have to be either a lawyer or an engineer.

Their role is to help integrate A.I. into the practice of law, whether at law firms or companies. That sure sounds like a prudent, if possibly belated, idea – and one suspects we’re going to see such “engineers” in other fields. I certainly hope that healthcare is one of them, sooner rather than later.

Irene Liu, the executive director of the A.I. initiative at Stanford Law School, explained the job to Ms. Kessler thusly: “If you were to just put it into an equation, it’s law plus technology plus business process.” That Venn diagram gets pretty small very quickly.

Mary O’Carroll, the C.E.O. of LegalEng Consulting Group, also explained the role to Ms. Kessler: “You don’t necessarily need a giant pyramid of lawyers anymore. People who have this kind of skill set don’t have to have a J.D., and they don’t have to be software engineers, but there’s business process re-engineering, or this M.B.A. type skill, that I think is really necessary.”

Ms. Kessler notes that they are sometimes referred to as “knowledge and innovation counsels,” “innovation attorneys,” or “legal applications engineers,” which may illustrate that the role is both new and evolving.

If you’re considering why this role is important, note that the 2026 Legal Industry Report from 8am™ found that 69% of legal professionals report personally using Generative AI (GenAI) tools such as ChatGPT, Gemini, or Claude for work-related purposes, up from 31% a year earlier.

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2026 Mid-terms: Voting for the Future

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By MIKE MAGEE

This week, New York Times political columnist, Linda Kindler reflected on “How Silicon Valley Stole the Future.” Signaling that this wasn’t simply another article on the binary choices of an AI world – or as she put it “either a world in which A.I. has eliminated all jobs, unleashed bioengineered viruses and enabled catastrophic warfare or a utopia in which the technology gives people ‘greater power to live life as they choose.’”

Instead, the AI discussion steered away from Fellow Times columnist, Thomas Friedman’s scary Halloween AI piece the day before (“We Just Set Off the Second Big Bang”) and focused instead on the work of Jonathan White, the Professor of Politics at the London School of Economics and Political Science where he teaches on democracy, political thought and political theory.

Professor White’s message was a clear warning not to abdicate control over AI to the Tech bro’s, in that “the capacity to imagine alternatives that may be improbable and to pursue them against the odds” is a “democratic resource.” In Kindler’s words, White argues, “When the future increasingly seems like something to avoid rather than something to look forward to, the very foundations of democracy are weakened. The future has been the primary terrain upon which all politics are practiced since the French Revolution challenged the divine right of kings.”

And Americans have made it pretty clear over the past two years that they reject Kings in the White House. Last week’s “No Kings” rally at thousands of sites across the nation were in fact a recurring event. Back in June 19, 2025, the Guardian took notice commenting that “The scale of last weekend’s “No Kings” protests is now becoming clearer, with one estimate suggesting that Saturday was among the biggest ever single-day protests in US history.”

Americans apparently want control of their own future destinies, AI and otherwise. With 5 days remaining before the 2026 Mid-Term elections, the levels of participation by the electorate are projected to set a record nationwide at 54% (past record was 49% in 2022) with a projected 135 million of the eligible 250+ million casting votes.

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I’d Like Some Choices, Please

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By KIM BELLARD

Let’s say your favorite social media platform is bought by a right wing trillionaire, who espouses free speech, but only when it echoes his. You can switch to, say, Threads, but – whoops – that’s owned by Mark Zuckerberg, another of the super-rich who have turned to the right. There’s always Facebook but – damn! – Zucked again! So you migrate to Bluesky, where the discourse is more civil but the audiences admittedly smaller. At least you have some choices.

Not so much if, say, you are the President of Ukraine. Ukraine has unexpectedly held off the much bigger Russia for over four years now, in the process reinventing modern warfare by turning it from the traditional men, tanks, and artillery to a technology-powered war, especially with drones. To do so, it relied heavily on Starlink and its Pentagon-version Starshield. Unfortunately, Ukraine was blindsided a couple weeks ago when Starlink speeds were drastically lowered. Drones were literally falling out of the sky.

President Zelensky raised the alarm. Secretary of State Rubio said he thought software “glitches” were to blame, but most people suspected either Starlink’s owner Elon Musk and/or President Trump. Mr. Musk pointed fingers at the Pentagon, President Trump blamed Mr. Musk, and for several days Ukraine was hampered. Finally Mr. Musk admitted he’d ordered the slowdown, saying Ukraine had violated the “terms of service” of the service, using it “for offensive drone strikes to kill people.”

Note that Serhii Beskrestnov, a Ukrainian presidential adviser on military technology, wrote on social media “we are PHYSICALLY UNABLE TO USE COMMERCIAL STARLINK for deep strikes or medium-range strikes.”

The “loophole was closed last week,” according to both Mr. Musk and President Zelensky, with normal speeds resumed, but if you were President Zelensky you’d sure have to be looking for alternatives, as you’d never know when the equally mercurial Mr. Musk or President Trump might pull another Lucy on you (Gen Z: check your “Peanuts” references).

Unfortunately, there really aren’t any, and that’s a problem.

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HCAHPS 2.0 Is Not a Survey Update. It’s a Strategic Shift for Healthcare

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By XAVIER WARTELLE

The Metric Healthcare Could Never Move

One statistic should capture the attention of every hospital executive. A peer-reviewed analysis published in Medical Care examined HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) performance across nearly 4,000 U.S. hospitals over an eleven-year period. Nearly every measured category improved meaningfully except one. Overall hospital ratings improved. Nurse communication improved. Discharge information improved.

Physician communication barely moved.

After more than a decade of public reporting, value-based purchasing incentives, star ratings, communication training, and patient experience initiatives, physician communication improved by just 0.8 percentage points, the smallest gain of any major HCAHPS domain. That finding should force healthcare leaders to ask an uncomfortable question: What if the industry’s approach to physician communication has reached its limits?

Many health systems have invested heavily in communication training, service excellence programs, scripting initiatives, and patient experience workshops. These efforts have value. But they largely focus on behavior. HCAHPS 2.0 suggests that behavior alone may no longer be enough. What if the real challenge was the antiquated tools provided to physicians that haven’t changed in nearly 50 years?

And HCAHPS 2.0 will put an even greater emphasis on this. For years, patient experience metrics largely focused on satisfaction. Did patients feel respected? Were they treated courteously? Did they have a positive overall impression of their hospital stay? Those questions remain important, but the updated framework moves beyond satisfaction and toward something far more consequential – understanding.

The new methodology places greater emphasis on care coordination, communication across care teams, family involvement, and post-discharge planning. At the same time, CMS is moving away from a scoring model that rewards only top-performing responses and toward one that recognizes incremental improvement across the entire patient population. Every improvement now matters. Every patient interaction counts. Every conversation has measurable value.

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Enough of Asshole Capitalism

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By KIM BELLARD

I recently read both Plastic, Inc. (Beth Gardiner) and These Are the Plunderers (Gretchen Morgenson and Joshua Rosner), and, boy, am I mad. Nothing in either book really came as a surprise, but the degree to which some people are willing to be greedy at the expense of others is still daunting. The latter introduced me to the phrase “Asshole Capitalism,” a phrase that comes from the work of Aaron James, a philosophy professor at University of California, Irvine. It can be summed up as a system where “citizens feel entitled to unlimited personal enrichment even at social cost.”

In other words, capitalism. No wonder a recent survey found that 43% of U.S, adults view socialism favorably (although Vice President J.D. Vance finds it a hard term to define and seems to think it has to do with foreign workers and transgender athletes).

Plastic, Inc. tells the story of how, over the course of several decades, the petrochemical industry has worked to have us consume ever more plastic while not only absolving themselves of the responsibility for what happens to all that plastic but also boldly attempting to make consumers feel guilty about not doing a better job of recycling it. Those of us of a certain age might remember the “Crying Indian” littering ad. Well, that ad was sponsored and paid for by the industries that were producing the litter.

These Are the Plunderers shows how private equity firms blithely take companies and strip them of valuable assets, enriching themselves while often essentially destroying the companies. The authors focus much attention on healthcare, such as nursing homes or emergency room staffing, in which private equity ownership leads to demonstrably higher costs, job cuts, and worse care, while making boatloads of money for the private equity owners. Manufacturing, retailing, and other industries have also had victims.

Capitalism is replete with disregard for the common good. E.G., the fossil fuel industry giving us cheap gas without being responsibly for the ensuing climate change, mining companies that strip the earth while wrecking ecological damage on the environment, or manufacturers that pollute their local communities then close the factories when asked to clean up their waste. Capitalism has a very bad habit of not recognizing either costs imposed on others or costs to clean up their actions. It’s someone else’s problem, and that someone else usually ends up being those of us who pay taxes, or whose health is deemed unimportant.

Cancer alley is no secret, nor are the health risks of the fracking craze that has supercharged the profits of oil & gas companies. We’re becoming more aware of how pervasive microplastics are, and just starting to realize how bad that is for us.

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What Good Is Health Coverage If You Cannot Get to the Doctor

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By JOE MKHITARYAN

We spend a lot of time talking about who has health insurance. I think we need to spend more time asking who can actually use it.

You can approve an appointment, find a specialist and cover the treatment. But if the patient cannot get out of the house and into the right vehicle, none of that gets them to the doctor.

I have been in the medical transportation business since 2010. I built my businesses in Southern California, where a few miles on a map can turn into a long trip in traffic. Running these operations has taught me to ask questions that are easy to miss when you are looking at a transportation budget.

Can the patient walk? Can they sit upright? Are there stairs outside the home? Do they need a wheelchair vehicle or a gurney? Who is bringing them back?

Those answers determine whether the ride will work. They need to be settled before a vehicle arrives.

Non-emergency medical transportation, or NEMT, is how many patients reach appointments when they cannot get there on their own. It is easy to describe it as a ride. Providing it is more involved.

Take a gurney trip. In our operation, that means sending two staff members. They have to help the patient safely, load and secure the gurney, make the trip and complete the handoff. Then there is the return. That crew is working well before the vehicle starts moving and after it stops.

If you price that trip mainly by the miles driven, you leave a lot of the work out of the calculation.

I pay attention to this because I am the one paying wages, insurance and vehicle expenses. I have a business interest in the rates. But anyone responsible for patient access should care whether those rates can support the service they expect. You cannot keep asking for trained staff and dependable vehicles without considering what it costs to provide them.

Of course, paying more does not automatically produce better service. Providers should have to show that they are safe, reliable and doing the work they bill for. The question is whether the payment and the expectations make sense together.

The need is real.

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Have doctors given up on doctoring?

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By MIKE MAGEE MD

I read with interest, Dr. Rachael Bedard’s September 25, 2026 New York Times article titled “Being a Doctor Will Never Be the Same After A.I.” In her second paragraph she writes “Amid our recent doom cycle about whether A.I. will lead to extreme societal harms, a parallel anxiety has taken hold in medicine about whether A.I. will one day replace physicians.”

Dr. Bedard self-identifies as a primary care physician trained in internal medicine, geriatrics and palliative care. Her practice focuses on the special challenges of homeless and incarcerated elders. She is also heavily involved in political advocacy for pro-choice health policy.

But her Opinion piece mainly considered the impact of AI on current medical students and residents in training.

In her view, “It’s impractical and counterproductive to train physicians in 2026 without exposure to A.I. Doctoring . . .”

Her words seem to reinforce my own bias that physicians are increasingly distancing themselves from the human side of health care, finding it easier (and less messy physically and emotionally) to focus on diagnosis, treatment options, and chronic care team management within the confines of a work week closer to 40 hours than 80 hours as in the past.

Internet connectivity and AI efficiency certainly make this migration more realistic. But even before AI, patient empowerment and ready data access encouraged patients to self-manage many of their own health care decisions. In addition, urgent care and pharmacy based clinics filled the gap left by uneven access to care that occurred as more and more physicians became employees of merging corporate health care organizations and the numbers of primary care physicians necessary for ready patient access lagged behind demand.

Physicians salaries have risen to $280,000 a year as numbers of primary care physicians declined with projected shortages by 2038 of 24% for Family Medicine and 17% for Internal Medicine. Their work hours are more reasonable, but over 1/2 reported “burnout”, complaining of excessive paperwork, medical school debt, being hostage to patient satisfaction scores, and work/life balance issues (women 56%, men 44%). Too many bureaucratic tasks topped the list of complaints at 62%, while lack of respect from patients was near the bottom of their concerns at 22%.

As for solutions, what would bring them psychic relief? Increased compensation (48%), more support staff (47%), more flexible work schedules (46%), increased physician autonomy (41%), more respect from administrators (35%), lighter patient loads (33%).

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Medicine Gave Itself a Code for Diabetes Remission. A Year Later, the Payment System Still Can’t See It.

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By HANA KAHLEOVA

“Will this only get worse?”

Patients with type 2 diabetes have asked me some version of that question for my entire career. For most of it, the honest answer was “probably.” We treated diabetes as a one-way street: glucose climbs, medications pile up, complications follow. Good care slowed the slope. It didn’t reverse it.

A year ago today, that assumption stopped being true, at least on paper. On October 1, 2025, CMS added E11.A, “type 2 diabetes mellitus in remission,” to the ICD-10-CM code set. To use it, a clinician has to document an HbA1c below 6.5% for at least three months after a patient has stopped all glucose-lowering medication. That’s the definition the American Diabetes Association, the Endocrine Society, the European Association for the Study of Diabetes, and Diabetes UK agreed on in 2021. “Well controlled” doesn’t count. The code exists to separate remission from management.

That’s a real concession. When CMS creates a code for an outcome, it is saying the outcome is real, measurable, and common enough to track.

The evidence behind it isn’t new. In DiRECT, a cluster-randomized trial run through ordinary UK primary care practices, 46% of participants in a structured weight-management program were in remission after a year, compared with 4% on usual care. About a third were still in remission at two years. These weren’t patients at an elite research center. They came from routine general practices. That’s what makes the result a policy question, not a curiosity.

So here’s the policy question. One year in, what has the code changed?

As far as payment and quality measurement go, almost nothing.

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Big Bucks, No Whammies, Part 2: So You Won. Now What?

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By STEPHEN FARBER

Part one argued that patient access was never the finish line; it was the foundation. This is about what we build now that we are standing on it.

Every good game show has a second round, and the second round is always harder. The first round was about getting health information out of the buildings that held it. Regulation, standards, and a decade of unglamorous plumbing have brought us to an important threshold. Individuals can increasingly pull records from multiple institutions into one place. The board paid out. The audience cheered.

Then a quieter and stranger question arrives. You are holding years of visits, laboratory results, medications, and discharge summaries, and you realize that having your history in one place is not the same as understanding it. Assembly was the first hard problem, but it was not the last.

The record is finally readable

This is where artificial intelligence walks onto the stage, and the promise is real. Few clinicians have time to read a patient’s entire history every time a decision must be made. Appropriately safeguarded AI can summarize years of encounters, support medication reconciliation, explain a laboratory trend in ordinary language, and surface a pattern buried across multiple providers. Large consumer platforms have already begun connecting AI assistants to medical records; Amazon’s Health AI, for example, draws on a person’s One Medical history to provide personalized explanations and guidance. Once the record can be assembled, a capable assistant can finally make more of it legible.

Legibility, however, is not reliability. The farther AI moves from explaining a record toward acting on it, the thinner the evidence becomes. A 2026 scoping review of agentic AI in healthcare found that most of the available studies were exploratory and lacked robust clinical validation, and that only one trial involved patients. An assistant working from an incomplete, duplicated, or subtly wrong record can produce a fluent and plausible conclusion that is still wrong. AI does not make data quality less important. It makes the consequences of poor data quality harder to ignore.

AI cannot read what was never written

There is a more fundamental limitation, and it has less to do with the model than with the record itself. A longitudinal record can tell us what happened, but it rarely tells us enough about why. It preserves the encounter, the diagnosis, the result, and the prescription while losing much of the reasoning that surrounded them. Why was one treatment chosen over another? What was the person hoping to preserve at that point in life? Who else was helping? What changed after the visit, and what did a family member notice before anyone thought to schedule another one?

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A Regulatory Blind Spot Hiding in Plain Sight

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By JUSTIN MCKAY

When I’m brought back into the diagnostic area, one of the first things I see is a lead apron, well-worn and folded into itself, about ready to slide off the table where it was absentmindedly placed. For many people, this sight would not be startling, but I know firsthand the life-threatening dangers associated with garments that are not cleaned, stored, and maintained properly.

It is time that patients and staff understand this danger, and regulators take action.

My co-founder and I contracted ringworm in two different hospital networks from wearing unclean garments just like these, handled by hardworking, decent individuals in the imaging and surgery departments we routinely visited.

Healthcare professionals should be more mindful of the cleanliness and the condition of these garments, but those efforts alone are not enough to prevent hospital acquired infections. What my experience and the experiences of so many others indicate is that what is not measured, is not managed. To protect patients and medical professionals alike, there needs to be a clear regulatory protocol for cleaning and maintaining high utilization equipment and garments.

Study after study shows the need for this structure. Research shows that when regimented cleaning and maintenance protocols don’t exist, bacteria grows. In fact, Association of periOperative Registered Nurses (AORN) 2025 guidelines spell out this danger pretty clearly: aprons, vests, skirts, and thyroid shields have contamination rates between 62.5% and 100%. This finding is especially worrisome since, as the National Institutes of Health has found, 80% of chronic infections and 65% of microbial infections are associated with biofilms (thin, sticky layers of microorganisms that form on surfaces).

The question I keep coming back to is: why don’t the standards reflect what we already know? And, trust me, on this issue we know a lot about the danger.

A 2014 study found 84% of tested interventional radiology aprons were colonized with S. aureus and Tinea, and 12% with MRSA while a 2019 report detected bacteria on 80% of operating room apron swabs, with an 80% recurrence rate within six hours of disinfectant wipe-down (wipes alone are ineffective). The dearth of effective cleaning practices are also well-documented. A study released in 2025 found 51.7% positivity across 120 swabs from 20 aprons, only dropping to 41.7% after cleaning while another report issued the same year documented 80.7% contamination across 88 garments. Despite these threats, only two-thirds of departments had any cleaning protocol, or internal compliance records, none had a defined frequency for cleaning.

Clearly these garments are pathogen reservoirs.

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