THCB

Missive from the DMZ

Not everything about improving health care is breathlessly hanging on one high stakes decision.

The Supreme Court will rule soon enough on the constitutional challenges to the Affordable Care Act. Meanwhile, even amid the drama and bitter struggles, progress can occur in health care improvement—like the ever increasing adoption of health information technology. Believe it or not, there is broad agreement about using this technology in health care. Scott Gottlieb and J.D. Kleinke in a recent Wall Street Journal opinion said it well, “. . . promotion of health information technology is one of the only demilitarized zones in Washington—consistently attracting bipartisan support . . . .”

So, this rare consensus seems real and durable, but what is actually happening in the hallowed HIT ground where both sides have somewhat oddly come to a policy truce?

Since May of 2004 when President George W. Bush established the Office of the National Coordinator for Health Information Technology (ONC) we’ve witnessed a slow but relentless upturn in adoption. That progress dramatically accelerated with attention and funding in the American Reinvestment and Recovery Act in 2009. Since 2006, the Robert Wood Johnson Foundation (RWJF) in collaboration with ONC has supported an ongoing, independent effort to monitor the national adoption of the electronic health record.

RWJF recently released the latest edition of that report, “Health Information in the United States: Driving Toward Delivery System Change 2012”. Both Health Affairs and JAMAalso simultaneously published articles based on chapters in that report, and Health Affairs hosted a briefing at the National Press Club regarding that release. Much of the information in this report comes from two important national surveys—one on ambulatory care conducted by the CDC/NCHS and the other on inpatient care by the American Hospital Association. The RWJF project in collaboration with ONC developed the key definitions for both the “basic” and the “advanced” electronic health record. All of the legitimate assessments of the national rate of electronic health record adoption in the U.S. since 2006 have used these gold standard definitions.

From the most recent NCHS and AHA surveys included in the 2012 report—there is both good and sobering news. First the good—the rates of adoption at both the physician and hospital level are increasing significantly. For example, the rate of physician adoption of at least a “basic” electronic record rose from 12 percent in 2007 to 34 percent in 2011. Similarly, for hospitals—the adoption of at least a “basic” system has risen from about 9 percent in 2008 to about 26 percent in 2011. The sobering news comes with the next step.

Unfortunately, these same surveys highlight both increasing physician intention to apply for meaningful use incentives but also an extremely limited ability to use the technology meaningfully. For example, a little over one half of physicians reported an intention to apply for incentive payments while only 10.5 percent of those actually had an electronic record with functionalities to support meaningful use. For hospitals, over 80 percent at the time of this survey could not meet meaningful use standards.

What about exchanging the information? That step remains a major challenge. In this year’s report immediate past national coordinator, David Blumenthal notes, “The exchange of information is going to be one of the most ambitious health care social projects that we have ever undertaken. The mapping of the human genome will look simple in comparison. The reason is that it’s a human-ware problem, not a software problem.”

RWJF has had its own experience with health information exchange challenges. Central Indiana Alliance for Health started as one of 17 communities in RWJF’s long term effort to help communities improve care, Aligning Forces for Quality. In Aligning Forces, regional leaders work together on a variety of activities—including publicly reporting quality and cost information, engaging consumers, changing payment and supporting clinical improvement. Central Indiana with its nation leading Indiana Health Information Exchange (IHIE) should have been ideal for such an effort. Unfortunately, they weren’t. As noted in this report, these leaders were simply not able to use the information exchange resource for Aligning Forces—especially for public reporting of quality measures for their community. IHIE’s problems were not technical ones—but cultural—or human-ware problems. The community leaders could not overcome longstanding resistance to using their information exchange for publicly available information.

We have many tough health and health care challenges facing our nation—and we have just a few areas of consensus where we’re working together. As this RWJF report shows, we are making some progress in the HIT sweet spot—but just having consensus is not going to be enough. If we are to meet our massive challenges, we will need all hands and minds working together to meet them—and even then, there are no guarantees. Time is ticking, friends—let’s stay focused—and look hard for more DMZs. We’re going to need them.

Michael W. Painter, JD, MD is the senior program officer at the Robert Wood Johnson Foundation.

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65 replies »

  1. Thanks, Michael. Agree with you completely-the country is making progress getting this technology into health care. That alone, though, will not transform care. That seems to be the very wise consensus in this discussion.

  2. Bravo, Mike, for being reality based and focusing on the important goals health IT is designed to help us reach. Even if it’s not going to be as magically easy as some proponents promised.

  3. The authors conclude:

    “invest in creating new measures of productivity that can reveal the quality and cost gains that arise from health IT”

    I.E., start with your pre-determined result, and try to design some sort of measure that leads to it. Love it.

  4. That NEJM perspective above was defective in its failure to consider the human rights violations of the patients serving as subjects in this experiment, that so far, has only enriched the vendors, while doing nothing for outcomes or cost reductions.

  5. Let’s get back to the issue. Both sides of the aisle have been deceived by the HIT vendors and their trade group to hand out boatloads of cash for meaningfully useless workflow altering devices and billing machines.

  6. I do not see paper money disappearing in outlr lifetime. I do see more sophisticated forms of paper money being developed. On the other hand the metal forms of money are endangered. If the civilized world were to opt out of paper money, describe for us this brave new world of transactions at the street level . Perhaps you have the currency model of the future all mapped out… I doubt that. Not with all your Bernackies, Volkers, Greenspans together with the basket of EHR PhDs from ONC will you be able to do this. If you have it , then publish it or cut it.

  7. southern doc-on your point about payment…Exactly. You’re singing my song now. I also think I’m understanding you now-and that we probably do agree. Very interesting. And ditto on your replies–thank you.

  8. “Change.The.Payment. Paradigm”

    And THEN design a functional EHR system. Rather than building one now that reinforces the current paradigm.

  9. It would be SO EASY to design and use an EHR that was solely about better patient care. Sadly, that’s not what we’re getting and not what we’re being forced to us.

    Many of us are becoming increasingly hostile to EHRs because we see that they are ALREADY being aggressively used to preserve, not fix, the dysfunctions in the system: corporatization, obsession with profits, unequal access to care, and so on.

    Thanks for the replies. We probably agree on much of this (though I still think that NEJM article was really lousy).

  10. southern doc-Your observations about care dysfunction are spot on. You’re also right to say that if folks are just using EHRs within the dysfunction to optimize within that dysfunction rather than as part of efforts to correct it, then EHRs will likely just be another part of the problem. I agree with that.

  11. Rob-very thoughtful post-agree with you that there is a big difference between regulatory meaningful use–and meaningfully using the technology-nice.

  12. A more plausible statement, RN Russel, is that paper will be around as long as there is paper money. Which is disappearing in our lifetimes.

  13. Don’t deny that EHRs have the potential to be a great improvement, and have demonstrated that in other countries. However, here they’re being implemented in a system that is so dysfunctional from top to bottom that they tend to make things worse rather than better. They’re just a bandaid being applied to a gaping wound, and they are diverting resources and attention from addressing the really serious problems we have. To continue with your analogy, using EMRs in our health care system is like being given a car to drive up 90 degree rock wall. I’d rather have a good pair of shoes and a strong rope.

  14. I just want to know who would go to a bank that didn’t use a computer to keep track of their financial transactions, instead using paper ledgers. Again, the problem with EMR is its use and implementation. When it is used poorly, it makes care worse. When used well, care is much, much better. Doing a study of paper charts vs. EMR is like doing a study to see if cars are faster than walking. The problem with many implementations of EMR is that they are akin to giving the doc a car but telling them they have to push it. Of course walking will be faster than having to push a car. Put gas in the car, however, and it goes better.

    Any assertion otherwise is beyond absurd.

  15. Speaking of $ee$hit and lightbulbs at its Chi office on So Wackers (lights are on but no one is ever home), perhaps the WSJ authors will retract their statement in their op-ed about how certification equates to assurance of safety?

  16. That study is a disaster. The demographic differences between the practices involved are so enormous that it is impossible to adjust for them.

  17. “If a physician in 2012 tells you that his or her memory and handwriting are better for you than an EMR, you should run, not walk, to a physician who practices in the current century.”

    Even though the studies show again and again that standards of care are met at a greater rate by docs using paper charts than those using EHRs (most recently in last month’s Family Practice Journal)?

    Interesting.

  18. How many CCHIT guys does it take to change the light bulb?
    Answer: TOO many & they will have to hire some that will fit in their shoe box office on Wacker Dr.

  19. So what constitutes realistic expectations? Data integrity issues, data privacy issues, endangered patients and failed EMR installations? And don’t come back with the typical crapola about “improved quality, better care, yada, yada…” You can’t prove it; you can’t even come close.

  20. EMRs are tools used in the treatment of patients. They do not themselves directly affect the patient, and they do not qualify as “medical devices.” If you want to make a serious problem much, much worse, throw another government agency into the mix. We need FDA approval of EMRs like Holland needs seawater. Better to have ANSI or UL do the certifying; at least they have a history of writing clear, intelligible standards into their testing processes.

    Better yet, require vendors to remove their “release from liability” clauses from the contracts they impose upon hospitals. They’ll then have the proper incentives to ensure their products do what they claim, the way they claim.

  21. It behooves JD MD Painter and JD Kreinky to read the editorials in the current issue of the NEJM about the crappy tools being put out there without any accountability to transform medical care in a sham on the American people.

  22. The data in the reply is just as strong as the data in the original article – in both cases, there is no real supporting data; just differing conclusions.

  23. My “crappy doctors” comment obviously hit a nerve.

    The real issue with EMRs and their celebrated imperfections is a displacement of resentment over accountability and transparency. Such “intrusions” of technology into the realm of a previously impervious guild always infuriates some of its members, usually the more economically vulnerable and/or technically incompetent.

    If a physician in 2012 tells you that his or her memory and handwriting are better for you than an EMR, you should run, not walk, to a physician who practices in the current century.

    In the meanwhile, I’ll continue to indulge in my “Jobsian fantasy” – right here on my iPhone.

  24. I don’t beleive that Health IT is either a problem or a solution. With respect to EMRs, I think that they will always be torn by conflict as long as payment is dominated by 3rd parties. Neither payers nor providers want clean claims. In a well functioning insurance system, claims have friction. That is why insurance is for events that are unforeseen, rare, and catastrophic.

  25. “Can’t we all just get on with the computerization of health care and stop bitching about the roughness of the ride out of the darkness?”

    Considering that HIT doesn’t solve any of the problems you identify (and has been shown to make some of them worse), I wouldn’t consider you a reliable guide to get us out of “the darkness.”

  26. There is a sort of an ironic aspect to our discussion here–since the post strikes a sober yet hopeful policy truce note.

    Again, we all acknowledge the major safety and quality problems in health care–and many, many people are working hard to improve the safety, quality and cost of care. The IOM and the good people here in this discussion are helping to remind us that HIT comes with its on set of safety concerns.

    Technology of all kinds can help us improve care–but each time we introduce a new technology there are risks. A stethoscope helps the health professional examine the patient-it can also, though, be a fomite carrying disease from one patient to another. Same with our important communication devices like smartphones, iPads–even back in the day–pagers. CT scanners can help heal–they can also kill and cause harm. Nobody is suggesting that our health professionals stop using new tools and technologies that help them examine and treat–or communicate with each other. And remember, paper record keeping causes horrendous harm and safety breaches–from lost records, redundant tests, illegible record keeping–lack of key information at the point of care.

    HIT is simply another necessary technology that must come to health care. The onus is on all of us to make sure we minimize the risk to our patients and families–and maximize the benefits.

    Meanwhile–at least in this instance–it seems that our policymakers–in spite of everything–get that.

  27. JD Keinke is flat out wrong.

    The analogy is naive.

    The better analogy is in the form of a question: Does anyone know if a 40 watt light bulb that emits highly concentrated cyanide gas when lit better than darkness?

  28. A 40-watt light bulb is better than the darkness. There will never be a perfect HIT anything. Vendors are indeed in the business to make money. But the simple fact of the matter – central to the now landmark IOM report “Crossing the Quality Chasm” – is that paper charts kill.

    Paper charts also allow providers to waste money and endanger patients on redundant testing, and they allow crappy physicians to hide in the shadows. Can’t we all just get on with the computerization of health care and stop bitching about the roughness of the ride out of the darkness?

  29. The patient killing, injuring, and endangering complaints about CPOE systems are extensive, but they are denied and systematically covered up by both vendors and their hospital financial bedmates.

    No organization is serving as a protected, secure, deinsentified repository of such complaints, thus there is little data in the public domain.

    The FDA is the logical place for such data and scrutiny of CPOE medical devices.

    This HIT experiment must stop. Human rights are being violated, especially those of the dead babies in places like Pittsburgh as published in the Pediatrics journal.

  30. Paper will be around as long as there is money… Not everyone is buying into the monkey wagging the elephant by its tail, and those that do buy in; will by design, continue to buy in , upgrade, renew or change entire platforms just to keep their systems running.

    It should not be the taxpayer footing the bill. This expense should be considered sunk costs to the practitioner. Those who want it, buy it. Those who don’t want it, can give it thumbs down.
    Bobby G said it all.

  31. Great comment, Rob. You said it well–the technology can be wonderful or terrible–we need to make sure we’re using it well to improve care–but one thing is for sure, as you say–we’re not going back to paper.

  32. So, are people really suggesting that health care doesn’t need IT to improve care, or are they just complaining about the current application of IT via EHR products, CCHIT, or meaningful use? I don’t want to commit a straw-man fallacy by pointing out how incredibly stupid it would be to think that health care does not benefit from organized data used efficiently, but many people sound like they believe we are better off without EHR.

    My perspective is that of a PCP being deluged with information and requests for it, and there is no way this could be done without some sort of organized database. Having watched the evolution of EHR over the past 16 years from the inside, I will say that it hasn’t gone that well. The government’s involvement, which I thought would be a positive by encouraging adoption and standardizing data structure, has been a real bad thing. Combine that with EHR vendors who know little about clinical workflow and hospitals/health systems that pretend they know it, and most EHR installations are terrible for actual patient care. But that doesn’t mean the premise of EHR is flawed, it just means the way it’s going in for most doctors is harmful.

    I do think the enthusiasm should be tempered, as implementation is far more important than product when it comes to clinical care, but implementation is largely ignored or completely misunderstood by the people putting these systems in. I’ve seen both sides. EHR can be wonderful or it can be terrible. But please do not imply we’d be better off with paper.

  33. Things work well in the lab so lets deploy them wrapped in an IPO.
    When mistakes happen we spin the news and promo the stock.
    So really there is nothing new here… My broker keeps calling me to buy stock in companies still making “Pintos” with exploding gas tanks. I’m not buying it and hopefully Spain is not buying into it with fresh bailout money either. I believe the IOM knew about the problems long ago- actually I remember sending them my resume in 2005 about this ; marked Attn: Harvey Fineberg .

  34. BobbyG says:

    “Well, I never claimed that the problematic circumstance of the lack of scientific evidence of the safety of HIT “proves” that HIT is “safe,” so don’t put words in my mouth.”

    Was not trying to; my response was directed to all, not at you.

    I should ahve also linked to this post that shows the risk levels might be very high: http://hcrenewal.blogspot.com/2011/01/maude-and-hit-risk-mother-mary-what-in.html

    And this that debunks the ignoring of what some call “anecdotes”: http://hcrenewal.blogspot.com/2011/08/from-senior-clinician-down-under.html

  35. Sharing private information occurs everyday. Online access to banking information has grown exponentially in the past decade, and all of this information is private and secured. Mint.com allows people to aggregate information from different institutions and organize their financial information in one place. Why can’t this be done in health care?

    I see three barriers. 1) Someone has to design a system that is compatible across several EMR platforms (something that many HIEs have already accomplished). 2) Hospitals need to use the system. 3) Probably the most important aspect is that the patient must be educated about accessing the system and better managing their health care.

    I welcome other people’s comments and appreciate this engaging post.

  36. @Fran – “I am troubled that someone of your stature and intellect is willing to carry on a national experiment that has already failed in the UK”

    The problem here is one of unrealistic expectations. The UK programme was wildly ambitious, largely because legislators expected too much from their system (no surprises there) and because vendors were more than happy to say yes (sure we can do that). Where is the big surprise?

    Lawmakers promise big things. Vendors say yes. Lawmakers promise more big things. Vendors say yes.

    This is how government and technology play together.

    The real question should be: how do we make the process smarter?

  37. I am troubled that someone of your stature and intellect is willing to carry on a national experiment that has already failed in the UK.

    The privacy and security of the patients are being compromised in the same experiment.

  38. “[A] recently published Doctor Patient Medical Association survey from physicians asked about the current healthcare system:

    • 90% responded that the US medical system is on the wrong track

    • 83% indicated that recent changes in the medical system make them want to quit practicing

    • 67% believed electronic health records (EHRs) compromised privacy and confidentiality

    • 65% said government is to blame for the current situation

    • 48% won’t consider joining accountable care organizations (ACOs), 26% would only if required

    While patients and providers were responding to different questions for different surveys, the general response is still the same. At what point will the healthcare system change for the betterment of the providers and patients, the stakeholders whose interests are higher than all other sponsors?

    In some circles, health information technology (IT) is seen as a panacea that will cure all the ills of expensive and inconvenient medical services. In others, meaningful use is viewed as a necessary driving force to improve care while reducing cost. What’s common among everyone is that healthcare as is doesn’t work. Whether health IT and meaningful use is capable of ameliorating the situation, time will tell. The question is, how long will we have to wait?

    http://ehrintelligence.com/2012/06/08/can-ehrs-improve-healthcare-in-the-us/

  39. Well, I never claimed that the problematic circumstance of the lack of scientific evidence of the safety of HIT “proves” that HIT is “safe,” so don’t put words in my mouth.

  40. Your comment mentions the “tool” philosophy of HIT and how it may “improve care”.

    Your key word is “hopefully”. How many guinea pigs have to die while you hope?

    Have you read the Federal Food and Drug and Cosmetic Act’s defintion of a medical device? Well, EHRs and CPOEs ARE!!!! medical devices. Where is the FDA approval, may I ask?

    Are all of the patients whose care is run by these devices unconsented guinea pigs for the HIT vendors so that they can, after 5 years of complaints, improve their devices and kill and injure a few less and enrich themselves more?

    Are the doctors and nurses who are forced to use these workflow devices that are toxic to safe and efficacious care also guinea pigs, offering suggestions for workaroounds so as to not kill more patients?

    Who is recording the crashes and their durations? Are the delays in care and deaths from that being investigated?? Not at my place, and probably not at any other. No one wants to know how bad these things are.

  41. BobbyG writes:

    “Data?”

    —–

    IOM says:

    … While some studies suggest improvements in patient safety can be made, others have found no effect. Instances of health IT–associated harm have been reported. However, little published evidence could be found quantifying the magnitude of the risk.

    Several reasons health IT–related safety data are lacking include the absence of measures and a central repository (or linkages among decentralized repositories) to collect, analyze, and act on information related to safety of this technology. Another impediment to gathering safety data is contractual barriers (e.g., nondisclosure, confidentiality clauses) that can prevent users from sharing information about health IT–related adverse events. These barriers limit users’ abilities to share knowledge of risk-prone user interfaces, for instance through screenshots and descriptions of potentially unsafe processes. In addition, some vendors include language in their sales contracts and escape responsibility for errors or defects in their software (i.e., “hold harmless clauses”). The committee believes these types of contractual restrictions limit transparency, which significantly contributes to the gaps in knowledge of health IT–related patient safety risks. These barriers to generating evidence pose unacceptable risks to safety.

    [IOM (Institute of Medicine). 2012. Health IT and Patient Safety: Building Safer Systems for Better Care (PDF). Washington, DC: The National Academies Press, pg. S-2.]

    —–

    FDA lists similar impediments to information diffusion in its 2010 internal memo on H-IT risks, as does JC in its 2009 Sentinel Events Alert on HIT. FDA says what they know is likely the “tip of the iceberg” (quoting Jeff Shuren MD JD, CDRH, FDA).

    —–

    Proof of safety by lack of evidence is cavalier at best by people who don’t know better, and possibly criminal by those who do.

  42. Great comments—please keep them coming.

    I did say in this post that there seems to be a durable political consensus about promoting health information technology. I also noted that HIT adoption is accelerating. Those are simply facts.

    I did not say that this technology—or any for that matter—is by itself an unmitigated good. This tool is simply a tool. Hopefully, if we begin to use it well it will help us improve care—but we should understand that like any tool or technology, if we use it poorly, it might not help—and it could worsen things. Clearly, adding a dollop of HIT here and there—or even a lot of HIT everywhere—will not improve the quality or cost of health care. Obviously, we are still learning about how we might use this technology for that improvement.
    We also know, for a fact, that our health care—even without this new potentially powerful technology—has major, intractable quality and cost problems. Included in those major problems are significant safety risks—as the seminal IOM report, To Err is Human, noted over 10 years ago. We don’t need HIT in order to have safety problems in health care—we already have the safety issues. Given that, if we assume anything, we should assume that bringing a new technology, like HIT, into that difficult mix will also raise safety concerns. ONC was exactly right to request that the IOM study the potential safety concerns around HIT adoption and use. The IOM HIT patient safety report is a sober call for careful monitoring as the use of this technology accelerates—and rightly so. Kudos to those of you who keep reminding us all about that risk and sounding that alarm.

    What we are seeing—and what this post highlighted—is ongoing significant increases in HIT adoption—and some increases in its use—though not as much or as speedy as policymakers might like. We also should understand that information exchange remains a vision rather than a reality. And as several of you have noted—all of this technology churn is difficult on those adopting—and again comes with its own set of safety and other problems.

    Still, the consensus (notwithstanding some of the concerned comments here) is real—and the progression of the technology is happening. The horse has probably left the barn—we probably need to work hard to try to ensure that this technology help us do what we need it to do—improve the quality, cost and safety of care—and do everything we can to make sure it doesn’t make things worse.

  43. Bush said that these systems save lives at this time in his Executive Order: “Since May of 2004 when President George W. Bush established the Office of the National Coordinator for Health Information Technology (ONC) we’ve witnessed a slow but relentless upturn in adoption. ”

    What was his proof, exactly? Was it the education he and his staff got from HIMSS, the HIT industry’s trade group?

    The government is wasting $ billions on these systems, just as the UK did. The US does not learn from history.

    All this does is shift funds from the patients and their care into the coffers of the vendors, their executives, and their shareholders. Sick, isn’t it?

  44. CPOE and EHR documentation start for me in two days. Near as I can tell, the throughput time per patient for our ED will double. That means a lot of people waiting a long time for care. That means a direct hit on productivity and income. And that means no one in there right mind should be a physician.

  45. I have a lot of sympathy with Dr. Harrison’s comments. I don’t know why anyone would assume that bipartisan legislation is good. HIPAA was massively bipartisan and it did not achieve its goals (at least according to President Obama, whose health-insurance reforms address the same problems that President Clinton assured us were solved by HIPAA).

  46. “They have caused premature death and injury with countless near misses, at a high $$$ cost. There are countless crashes of these EHR and CPOE devices in which care is delayed and no records kept of the adverse events.”
    __

    Data?

  47. As a former Deputy FDA Commissioner, the author of the WSJ Op-Ed should know better than to claim that CCHIT offers assurance of safety and efficacy.

    $$$$Scott Gottlieb and J.D. Kleinke in a recent Wall Street Journal opinion said it well, “. . . promotion of health information technology is one of the only demilitarized zones in Washington—consistently attracting bipartisan support . . . .”$$$$

    The reason for this this, my friends, and JD MD Painter, has to do with the financial largesse of the HIT vendors via EHRA and HIM$$ that greased the campaigns of and deceptively educated both sides of the aisle of Congress and POTUS that CCHIT Certification meant that these devices were safe and efficacious.

    These are experimental work flow directing devices that are not ready for prime time. They have caused premature death and injury with countless near misses, at a high $$$ cost. There are countless crashes of these EHR and CPOE devices in which care is delayed and no records kept of the adverse events. Overall, there is not any evidence that outcomes are better or costs reduced.

    Th IOM begs to differ with you JD MD Painter, with its recent report on the state of HIT.

    Why have these devices received a pass from regulation as required by the Federal Food Drug and Cosmetic Act?

    Doctors will be ahead financially with improved patient care by NOT purchasing these disruptors and by taking the penalty.

  48. The challenge with any new technology or plan is threefold. First, establish agreement or the DMZ. Remarkably, as the article references, this has happened despite the highly political environment. Second, develop the technology that can support the workflow processes to augment, rather than hinder, existing needs. This is happening but not as well as one would hope. Even well developed HIT systems like Kaiser and the VA struggle, and they are closed systems without the complexities of exchanging information. Lastly, and importantly, is the issue of adoption. This is the slowest and most challenging step. The key will be a combination of giving real value, rather than just forcing a poor product, and combining buy-in with some measure of regulation. Mass change always takes time, but it can happen.

  49. Interesting post. Lots of good points. Agree that HIT is less at risk than many of the more controversial pieces of the administrations reform package. (exchanges, mandate, center for innovation) . Does this mean that we give the Bush admin a (little) more credit in retrospect? I suspect it does.

    / j

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