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In this series, a clinician extemporaneously discusses a diagnostic approach (regular text) to sequentially presented clinical information (bold). Additional commentary on the diagnostic reasoning process by a clinician educator (italics) is integrated throughout the discussion.

The past decade has seen ongoing debate regarding federal support of graduate medical education, with numerous proposals for reform. Several critical problems with the current mechanism are evident on reviewing graduate medical education (GME) funding issues from the perspectives of key stakeholders. These problems include the following: substantial interinstitutional and interspecialty variations in per-resident payment amounts; teaching costs that have not been recalibrated since 1983; no consistent control by physician educators over direct medical education (DME) funds; and institutional DME payments unrelated to actual expenditures for resident education or to program outcomes. None of the current GME reform proposals adequately address all of these issues. Accordingly, we recommend several fundamental changes in Medicare GME support. We propose a re-analysis of the true direct costs of resident training (with appropriate adjustment for local market factors) to rectify the myriad problems with per-resident payments. We propose that Medicare DME funds go to the physician organization providing resident instruction, keeping DME payments separate from the operating revenues of teaching hospitals. To ensure financial accountability, we propose that institutions must maintain budgets and report expenditures for each GME program. To establish educational accountability, Residency Review Committees should establish objective, annually measurable standards for GME program performance; programs that consistently fail to meet these minimum standards should lose discretion over GME funds. These reforms will solve several long-standing, vexing problems in Medicare GME funding, but will also uncover the extent of undersupport of GME by most other health care payers. Ultimately, successful reform of GME financing will require “all-payer” support.

What do we mean by innovation in health care? Clay Christensen’s seminal work, “The Innovator’s Prescription” expands upon his ideas of disruptive innovations that transform industries. In these new models, no organization is too big to fail, and organizations without the ability to adapt will find their missions compromised. In medicine, these discussions often leave the expert practitioner with a great sense of unease. Stepping outside of medicine may aide the uneasy expert in responding to the inexorable sweep of transformations occurring in the health care industry. Disruptive innovations require three characteristics: technology enablers, business model innovations and value networks. Using a Christensen example, in the 1970s and 1980s, mainframe computers took deep technical engineering expertise to develop and operate, commanded high prices and were accessible to just a few privileged companies and individuals. The technology enabler, the microprocessor, allowed Steve Jobs and Michael Dell to put together desktop computers in their garages, but alone did not transform computing. The business model innovation of mass production at new processing sites allowed for low-cost, low-margin products to be developed (outside of prior large-margin sales incentive models), now affordable by the general public. Finally, the value network of mutually reinforcing innovative companies created an entirely new suite of products available to a great swathe of society. By creating products that removed the need for deep technical expertise, the technology literate can now create and edit movies at home, design their own websites, and hold teleconferences with friends and family across the world. Mainframe businesses that did not adapt or innovate were devoured by the changing technology markets which naturally adopted lower cost, similar quality, and scalable technology products. In healthcare, new disruptive business models are exploding. Single procedure shops have dropped the cost of eye surgery or colonoscopy, shortening procedural time and increasing volumes. In hospitals, nurses perform procedures previously done only by physicians (for instance, peripherally inserted central catheter (PICC) line teams). In shopping malls and grocery chains, midlevel providers have increased access to basic and moderately complex medical care for patients. Yet medicine is not a true free market, and adoption of innovation has been tempered. Medicine’s heavily regulated environment pits quality and safety concerns against process and product innovation. As Zimlichman1 points out in a recent JGIM editorial, reimbursement changes will foster creative ways of providing patient/population care, adapting to pressures surrounding bundled payments and price sensitivity from higher patient cost-sharing. This month in JGIM, Ohl2 explores a new business model—telemedicine—that brings medical care directly to patients’ hometowns by geographically disparate expert medical practitioners. For the cognitive fields, this methodology reduces expert physician overhead and increases accessibility to high quality care for internet-enabled patients and primary care providers. Ohl’s small but powerful mixed-methods study demonstrates that veterans with HIV in rural Midwestern towns overwhelmingly chose telehealth care from their primary care physician offices, rather than travelling several hours to see a specialist in person for ongoing care. The telehealth technology is scalable and efficient, and a future of having routine appointments conducted from a living room, or a screening appointment from one’s sickbed is a near reality. Yet, who gets left behind? Many medically complex patients are vulnerable to poor health outcomes, especially when they cannot participate fully in their medical care. Wu3 and Bauer4 separately explore the effects of health literacy on patient outcomes. Wu’s study of almost 600 CHF patients at four academic medical centers illustrates that those with low health literacy had a higher rate of re-hospitalization and all-cause mortality (incidence rate ratio, 1.46). Bauer finds that amongst Kaiser patients with diabetes and depression, low health literacy rates (about 75 % of their patients) had subsequently worse early/late medication persistence or had increased medication gaps. As accountable care organizations expand (accepting “full risk” for a patient’s care outcomes), innovative care delivery models will likely find new ways of engaging patients and their social networks in self-care. The lure of the disruptive innovation is compelling. Is there a counterpoint? Perhaps, less celebrated is the value of the deliberate innovation. These innovations expand the scope and reach of existing organizational care delivery, aligning mission, scope and finance. For example, initiatives around the patient-centered medical home (PCMH) seek to bring into alignment the needs of the patients with the processes of medical care. This transformation from “solution shops” (every problem has a unique solution) to “process shops” (most problems have a common method of approach) should increase efficiency, if supported by infrastructural and technologic innovation. Yoon5 and Cronholm6 explore this area from a PCMH standpoint. In studying over 2 million patient encounters at 814 VA hospitals, Yoon found that for every 10 % increase in adoption of a PCMH model, hospitalizations were reduced by 3 % for ambulatory care sensitive conditions, demonstrating the value of aligning mission and care on patient outcomes. Cronholm’s qualitative PCMH study illustrated the changes in mental models—especially around role redistribution and new role adoption—that need to be addressed as future internal institutional transformation occurs away from clinician-centered care. Expertise may no longer be the limiting factor in high quality health care delivery. This month, JGIM holds lessons for those who seek to create both disruptive and deliberate innovations. As synthesized information increases, and the general public becomes more informed, deep expertise may no longer be required to provide the highest quality of care. Non-experts, in conjunction with decision support, may be able to provide increasingly complex care. Technology enabled patients may take more control over their own care, while others are cared for in a more traditional manner. Fostering dissemination of cogent useful innovations, both disruptive and deliberate, is part of the Journal’s charge as we look forward to the future of healthcare.

I n November 2013, USAToday, 1 WebMD and other news outlets reported the results of a study presented at an American Heart Association annual meeting in Dallas. The study highlighted common symptoms that preceded heart attacks in 567 men aged 35 to 65 years, based on retrospective chart review. The results, though not unexpected, seemed to gain traction because of the recent death of a well-known actor (James Gandolfini, The Sopranos) from a sudden myocardial infarction. To quote the USAToday synopsis of the study

Over the past several months, the Affordable Care Act (ACA) has endured a painful population roll-out to try to expand health insurance for the nation, plagued by governmental shut downs, software malfunction, and mistake-laden information shuttled between enrollment websites and insurers. Critics have pointed out the potential for ballooning health care costs, the inability of the current American health system to absorb the flux of the newly insured, and increased costs borne by healthy individuals to offset the cost of catastrophic care and care for the sick. This massive attempt to tame the unruly American health care system is impressive in both ambition and scope. Despite the pain of the initial ACA rollout, this attempt at non-socialized universal health insurance is likely to spur hosts of innovative care delivery models. Jeff Dyer’s book, “The Innovator’s DNA,” describes the characteristics of individuals and teams who successfully innovate. Dyer posits that five major traits of innovators can be both understood and acquired. These traits will be familiar to JGIM readers, who, through their research and clinical activities, have acquired these traits to enhance the impact of their work. In medicine, associating disparate ideas through experience and culture may take the form of combining urgent care and retail best practices to create Minute Clinics in grocery stores, or combining social media, broad band connections and health care to create telemedicine companies. This month in JGIM, Weeks et al.1 bring together principles of care coordination, organizational management, and quality improvement to develop a framework to aide primary care clinics prepare for improving caring for their diabetic patients. As Shi and Khurshid2 comment, this self-assessment tool provides clinical organizations insight into actionable areas for improving diabetic care quality. Thoughtfully questioning why a current process works or doesn’t work generates new insights, much like the old Hewlitt Packert commercials asking “what if…” (and its extension, “why not?”). In an era where bending the health care cost curve downward is critical, Danis et al.3 question the willingness of patients to discuss both their out-of-pocket costs and insurer costs with their doctors—pointing the way for physicians to have a greater role in reducing costs for their ill patients, especially by establishing more trusting relationships. Duru et al.4 ask, “what if physicians made medication substitutions for patients enrolled in Medicare Part D plans,” comparing therapeutic and generic substitution schemes to understand potential cost savings to patients and their country—finding annual savings of $452 per beneficiary in the therapeutic substitution analysis. The process of intensive observing allows individuals to understand why a process or culture works, why it does not work, and how to better meet customer needs. For instance, Benzer et al.5 examined the effects of removal of pay-for-performance incentives on seven quality measures at 128 VA hospitals, finding sustained improved performance levels after incentive removal. Their study points to individual and organizational issues that facilitate organizational transformation after initial performance investment. Dyer posits that innovators are networking not to sell their services, but rather to bring new ideas together. Meeting people with different educational backgrounds, in different industries, within different cultures foments cross-pollination leading to consistently better ideas. Dyer breaks his fifth and final trait, experimenting, into three dimensions: learning new skills (for instance, Steve Jobs took a calligraphy class that became the basis for Apple’s font collection), taking apart existing ideas (Einstein took apart Newton’s time/space framework), and testing through prototypes. By observing why cancer screening rates are poor for safety net patients, Hendren and colleagues6 developed an intervention that brought colon screening tests to low income patients’ homes and provided reminders/support to participate in care, increasing colon cancer screening rates by 20 % in this at risk population. Dyer’s framework illustrates the way in which implementation science researchers are trained innovators, poised to take a leadership role in the accelerating national health reform efforts. As the country turns its attention to more systematically improve health care access and quality, these innovators (including those highlighted in this issue) will play a greater part in shaping the national dialogue, hopefully cutting through political rhetoric with new care models, supported by data.

Evidence-based Medicine (EBM) has been increasingly integrated into medical education curricula. Using an observational research design, we evaluated the feasibility of introducing a 1-month problem-based EBM course for 139 first-year medical students at a large university center. We assessed program performance through the use of a web-based curricular component and practice exam, final examination scores, student satisfaction surveys, and a faculty questionnaire. Students demonstrated active involvement in learning EBM and ability to use EBM principles. Facilitators felt that students performed well and compared favorably with residents whom they had supervised in the past year. Both faculty and students were satisfied with the EBM course. To our knowledge, this is the first report to demonstrate that early introduction of EBM principles as a short course to preclinical medical students is feasible and practical.

A healthy 28 year-old man with isolated oral candidiasis at 17 and 26 years, on no medications, and having a recent URI 1 week before, presented with acute-onset progressive, painful oral mucositis and odynophagia (Fig. 1). His temperature was 101.6°F. The white blood cell count was 19.5, with 4.4% lymphocytes, 226CD4. Oral nystatin and IV caspofungin were started. Subsequently, the patient developed injected sclera with bilateral subconjunctival hemorrhages (Fig. 2) and marginated, erythematous, targetoid genital papules with vesicular centers (Fig. 3). His oral, ocular and genital lesions corresponded to the classic distribution of Behcet’s syndrome, initially placing this at the top of the differential diagnosis, followed by erythema multiforme (EM) and herpes simplex. However, generalized oral mucositis, conjunctivitis and, most importantly, targetoid lesions are not common in Behcet’s syndrome. Behcet’s syndrome frequently presents with aphthous ulcers sparing the outer lips, genital ulcers and uveitis. Subsequent biopsy of the targetoid lesions demonstrated EM, with vacuolizing keratinocytes and tagging lymphocytes. Skin lesions and pain resolved after 1 week of high-dose methylprednisolone without complications. Repeat complete blood count (CBC) showed resolution of the lymphocytopenia. EM is a self-limited hypersensitivity reaction to external triggers, most notably HSV, Mycoplasma pneumoniae and medications1,2. In this patient, HIV, HSV, M.pneumonia and Legionella studies were negative. Traditionally, EM has been placed within the hypersensitivity reaction spectrum, which includes Stevens-Johnson syndrome and toxic epidermal necrolysis3. However, there is suggestive evidence that EM may be a distinct entity. Treatment targets underlying infection and removing offending agents. Currently, systemic steroids are frequently used, but remain controversial. Figure 1 Oral ulcerations. Figure 2 Subconjunctival hemorrhages and ocular ulcerations. Figure 3 Scrotal and penile shaft ulcerations.

Erudite readers of JGIM may not naturally pick up David McRaney’s book, You Are Not So Smart, wrapped in a bright orange cover with an image of an ostrich standing with its head buried in the sand. Yet, McRaney’s accessible description of cognitive biases, heuristic errors and logical fallacies reinforces the idea that oftentimes our decision-making is influenced by thought patterns of which we are unaware. Some appellations of cognitive errors, such as “priming” or “normalcy bias,” may be more common in our lexicon than others, such as “The Dunning Kruger Effect,” which explains why we have difficulty accurately predicting our performance in any given situation. JGIM readers are often on the forefront of studying these cognitive errors and their consequences in health care, even when those studies are described through the lexicon and lens of health services or quality improvement. This month in JGIM, several articles explore how cognitive processing errors play out in health care and examine methods to overcome those errors. First, in their article, “The Body Gets Used to Them,” Brook-Howell and colleagues describe how patients think about antibiotic resistance. While this article has important implications for infection control, their findings fit with two common cognitive errors—“confabulation” and “embodied cognition.” Confabulation represents the false narratives we construct to explain our actions, history or beliefs. Embodied cognition expresses the idea that we believe that our opinions are based on objective evaluation; yet as we translate our physical world into words, we believe in those words and their associations. Ma and colleagues, in their article “Racial Disparities in Medical Expenditures within Body Weight Categories,” explore reasons why medical expenditures of black and white patients differ, including issues related to their health beliefs. Individuals with a “positive illusion bias” (or illusion of control, overconfidence bias or self-denial) view themselves in unrealistically positive terms. When this healthy adaptive defense is taken too far, individuals believe that they have a high degree of control over events and the future—more than population based data would indicate—negatively affecting their decisions. In their study, Ma et al. found that patients with positive health beliefs were less likely to utilize medical care, regardless of weight or ethnicity. A similar underlying bias may strike the reader when reading Krien and colleagues careful study of rates of hospital acquired infections, which have decreased since the CMS and other groups have ceased paying for the additional incurred costs of these infections. Many of these infections (especially line infections) are preventable, begging the question of why infection control measures are not more widely adopted. Perhaps the lack of action is due to competing clinical demands, inadequate monitoring systems, or a positive illusion bias on the part of providers and hospital administrators. Other cognitive errors contribute to disparities in health care. For instance, “ad hominem fallacies” occur when a person does not trust another individual, and therefore discounts his or her message, regardless of the underlying validity of the message. This fallacy appears in health care as distrust of physicians and their messages, when individuals are convinced that the physicians are profit driven or rationing care. When interpreting a clinical study or encountering a challenging patient, “attribution bias” results in incorrect conclusions about the individual or population. When attribution errors occur, we ascribe specific behaviors to the personal character of an individual or group, when in reality, the behaviors are situational (not dispositional). The lens with which we choose to examine a clinical question profoundly shapes the solution that we apply in addressing that question. As JGIM readers, developing greater awareness of common cognitive errors may allow investigators to develop targeted interventions to change the way individuals think, thus improving the chances of adopting better health behaviors and quality measures.

In June 2011, James Verone walked into a bank in North Carolina and attempted to rob it for a single dollar. Three years previously, he had been laid off from his 17-year job as a Coca-Cola deliveryman and, unable to find permanent alternative employment, had depleted his life savings. Unlike most bank robbers in this predicament, his goal was not pecuniary, though he certainly could use more money. Instead, his objective was to be apprehended and eventually imprisoned for robbery in order to obtain free health care from within the prison system. Unarmed, he was taken into custody. Sadly, Mr. Verone felt that the prison health care system was his best option for having access to medical care for his chronic medical conditions. Mr. Verone’s actions, while extreme, highlight the continuing problem of access to health care faced by over 50 million people in the US. The 2010 Patient Protection and Affordable Care Act health reform bill is poised to decrease that number dramatically, by increasing health care access through taxes, offsets, and negotiated deals—for an estimated $900B invested over 10 years. Among other measures, the PPACA enacted provisions to mandate most legal US residents to buy or continue health insurance (through subsidies, health insurance exchanges, penalties and employer mandates), and prohibits discrimination by insurance companies based on pre-existing conditions. Additionally, the provisions of the 2009 American Recovery and Reinvestment Act (ARRA) provided $90B to states to strengthen Medicaid, $2B for community health care centers, and more. These progressive acts of legislation have an underlying assumption—that increased demand for medical care can be accommodated by our current system of medical care. However, as most patients know, primary care practices are full. The 350,000 US primary care physicians are unlikely to have the capacity to provide care for the PPACA-subsidized newly insured. The AAMC estimates a 150,000 physician shortfall within 15 years. In this issue of JGIM, several papers explore the value of primary care access and patient empowerment. DeVoe addresses the need for insured patients to obtain access to a usual source of care. In her cohort of 62,000 Medical Expenditure Panel Survey (MEPS) adults, insured patients without a usual source of care were significantly more likely to have problems obtaining primary care. Using a nationally representative sample of 1,000 US primary care physicians, Carrier studied the relationship between quality of care delivered and socio-economic characteristics of their Medicare patients. Her findings of a significant but inconsistent relationship between lower quality of care and lower income and education, black race and Medicaid eligibility are important to consider as we re-consider methods to provide equitable care using ARRA stimulus funds. In addition to measures used to improve access to care, innovative solutions must be found to help patients maintain or improve their health. For instance, in this issue of JGIM, Hill-Briggs and colleagues randomized 56 urban African-Americans with poorly controlled diabetes and hypercholesterolemia to an intensive and condensed literacy-adapted self-management course. Her patients underwent health problem-solving training. While all patients had an improvement in knowledge, at 3 months the intensive education group decreased their HbA1c by 0.71%. James Verone took extreme and unusual measures to gain access to medical care. While access to primary care is a necessary first step to improve health outcomes, access alone will not ensure high quality medical care. As we confront the urgent need for health care reform in the US, we must consider new models to engage our patients in their own health care for chronic disease management—keeping in mind current variations in health care outcomes across education, income and race.

In his book “The Clustered World,” Michael J. Weiss describes how socio-demographically, the American population can be seen as 62 clusters, defined by specific characteristics across geographic regions. Weiss notes increasing fragmentation at all levels of society, as our insular communities live separate, non-overlapping lives. Whether Blue Blood Estates, Gray Power, Young Influentials, Hard Scrabble, or Mines and Mills, our lives intersect regularly only in public venues or in health care. This issue of JGIM highlights the health challenges faced by these insular, vulnerable clusters of American society—and the need for more evidence to guide their care. One of our most vulnerable clusters is the poor elderly, whose complex medical disorders are heightened by lack of physiologic and financial reserve. Zulman and colleagues examine the lack of evidence to guide appropriate medical care in the elderly. In their systematic review, they examine all randomized therapeutic trials published in 2007 in five major medical journals assessing morbidity and mortality outcomes. Of the 109 studies reviewed, 20% of randomized clinical trials (RCTs) excluded elderly patients at the outset, almost half excluded patients based on criteria which would effectively exclude the elderly, and only a quarter included quality of life or health status outcomes important to elderly patients. These exclusions are understandable, as RCTs focus on answering a specific question, and prefer homogeneity to complexity. Can observational studies of natural cohorts provide the evidence needed to improve vulnerable patient care? Perhaps. In this issue, Shrank explores the biases and limitations of major observational studies, including biases implicit in sampling healthy adult users of and adherers to medical care. While methodologically more challenging than enrolling and following nurses (e.g. the Nurses Health Study) or health conscious individuals using supplements, sampling complex older patients for both RCTs and observational studies may help us utilize health care resources more appropriately. As we contemplate providing better care to the complex older adult, Lindquist explores the ability of paid non-family caregivers to provide appropriate care to their elderly charges. In this study, one- third of caregivers had poor health literacy, while 60% made errors with pillbox text medication. (See editorial by Sudore and Covinsky in this issue). General internists are well aware that lack of time, resources and evidence can serve as barriers to providing the best care for our complex elderly, many of whom have often outlived their cohorts. Whether caring for a 78-year-old woman with advanced COPD, CHF, and OA whose family has died, or a 92-year-old active man with cognitive decline and a severe anxiety disorder, we struggle with important questions about their care. How do we reach across our American clusters to gather the resources to help them improve (or maintain) their health? How much benefit will accrue to our patients, if we prescribe one course of action in comparison with another—not just for longevity, but for quality of life? We need more evidence and better system-wide approaches to provide comprehensive care to our complicated, vulnerable elderly, clustered in sight but often out of reach.

A 50-year-old athletic man presented with two weeks of debilitating “sinus” headache, continuous left nostril drainage, persistent cough, with no history of head trauma. His nasal discharge was unilateral, worse with coughing or leaning forward (Fig. 1), with one clear drop every 2–3 seconds. Analysis demonstrated beta-2 transferrin, a transferrin isoform found almost exclusively in cerebrospinal fluid (CSF). Brain MRI showed no cribriform or ethmoid sinus fractures. Endoscopy revealed a small bony defect in his left nasal cribriform plate (Fig. 2), with active CSF drainage, causing his rhinorrhea. After endoscopic meningocele repair, his symptoms completely resolved. Further review revealed that our patient was a former US Marine who exercised aggressively, bench-pressing 200-300lbs daily, but with poor technique—holding his breath while lifting. Normal intracranial pressures (ICPs) range from 5–15cmH20 when laterally recumbent1. Patients with CSF leaks, regardless of etiology, have ICPs of 26–33cmH20, suggesting correlations between intracranial hypertension and CSF leak2. When fifteen patients were placed in left lateral recumbent positions and asked to bear-down against a closed glottis (Valsalva), every patient achieved ICPs of 25cmH20 or greater, with one reaching 47cmH203. People performing frequent Valsalva maneuvers, including weightlifting without exhaling, elevate their ICPs to pressures associated with spontaneous CSF leaks. Smaller leaks may spontaneously heal. Large, symptomatic or continuous leaks should be repaired to prevent meningitis. Large or rapidly draining defects may be visualized during endoscopy. Smaller defects are localized with dyes injected into CSF. We presume that our patient’s Valsalva maneuvers during weightlifting elevated his ICP, eroded his meninges, eventually causing an meningocele and spontaneous CSF rhinorrhea. Figure 1 His nasal discharge was unilateral, worse with coughing or leaning forward. Figure 2 Endoscopy revealed a small bony defect in his left nasal cribriform plate.

From the Editor’s Desk: Legislating Change Malathi Srinivasan, MD 1 and Mitchell D. Feldman, MD, MPhil 2 Department of Medicine, University of California, Davis School of Medicine, Sacramento, CA, USA; 2 Department of Medicine, University of California, San Francisco, San Francisco, CA, USA. J Gen Intern Med 25(3):173 DOI: 10.1007/s11606-010-1261-9 © Society of General Internal Medicine 2010 Seismic changes in medical practice typically have come from discovery (such as DNA or penicillin) or new innovation (for example, new imaging devices such as MRI scanners), but rarely as the result of legislation. However, the American Reinvestment and Renew Act (ARRA), passed by Congress in February 2009, may do just that. The ARRA, which allocates $19 billion specifically to incentivize the use of electronic health records (EHR), is poised to dramatically change medical practice in the US. This money would be paid directly to physician’s practices, with early non-hospital-based adopters of EHRs receiving up to $63,000 per physician ($42,500 for pediatricians) over 6 years through add-ons to Medicare payments. The majority of US physicians still practice in solo, small (2– 10) or medium (11–50) size group practices. Currently, these physicians face serious financial obstacles to implementing even limited (non-enterprise) EHRs. Behavioral change can be fueled by financial incentives/disincentives that are over 10– 20% of base salary, when the downsides of the change are just moderately onerous. Under ARRA, the adoption incentive is quite high, while the non-adoption disincentive is quite low (1– 5% Medicare cuts starting 2015), especially for mid-sized group practices. While non-adopters would eventually be penalized, the incentive’s magnitude is probably sufficient to entice smaller practices to re-consider the costs and workflow changes necessary for EHR adoption. In this issue of JGIM, O’Malley and colleagues report on the results of 60 telephone interviews with small and medium group practice US physicians, highlighting six sentinel issues around EHR-related care coordination and provision. O’Malley demonstrates a need for additional integration of decision- support and inter-office communication into existing plat- forms. Additionally, her group identifies specific payment reforms that could help drive better communication between physicians (paying for intergroup care coordination, not just direct patient care), to further improve patient care. What will EHR adoption mean for the average patient? As is so often the case in health care, the answer is, “it all depends.” If the promise of seamless medical data capture and transmis- sion is realized, with simultaneous creation of patient portals for open healthcare access, the seismic transformation of medicine would be underway. In this idyllic health care environment, informed and activated patients would partner with health care providers longitudinally to improve their health. Patients and physicians would have access to decision-support tools tied to emerging evidence. Patients would be able to access health information easily, regardless of where in the country (or for that matter, in the world)they were located. Variability in the quality of care would diminish, with easier tracking of quality improvement pro- gram outcomes. Test duplication would be reduced. Encryp- tion technologies used for banking would safeguard patient data. Patients, armed with new data and enhanced motiva- tion, would modify their health behaviors, and be account- able for their own health decisions. How “blue sky” is this vision? O’Malley and colleagues point out that physicians identify a number of barriers to EHR adoption. Without additional governmental regulations to create interoperability, perhaps via health information exchanges or hubs, financial disincentives exist for health care companies to share data amongst themselves. While industry consolidation (currently occurring with enterprise level EHRs) is inevitable, the proliferation of small to mid-sized EHR companies will likely continue for the next 5–10 years. Patient EHR portals using cloud computing systems would need to be secured and customized, drawing from multiple information sources simultaneously. Although HIPAA provides some regu- latory protection of individuals, EHR-enabled patients would need to decide with whom and what health data to share—with serious implications for insurability and employment. And, disparities between those who have, and don’t have, access to these technologies could increase health disparities. Safe- guarding every patient, for every encounter, will be an enormous task across all socio-economic levels. Technological paradigm shifts, coupled with careful re- search, implementation and sufficient incentives will likely move American medicine forward in the next decade. While not as dramatic as new discoveries or innovations, well-reasoned health care legislation promises to move the dial in the direction of improved processes and outcomes in health care. Incentives to increase the adoption of new health information technology may be the right prescription for the times. Corresponding Author: Malathi Srinivasan, MD, Department of Medicine, University of California, Davis School of Medicine, 4150 V. S t re e t , S u i t e 2 4 0 0 , S a c r a m e n t o , C A 9 5 8 3 3 , U S A ( e - mail: malathi@ucdavis.edu). Published online February 17, 2010