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They will need federal assistance purchase cialis sublingual toronto erectile dysfunction doctor in atlanta, perhaps in the form of a Hill-Burton-type program 20mg cialis sublingual mastercard erectile dysfunction doctors. Wealthy institutions should perhaps receive some token federal assistance to underscore the timeliness of needed information sys- tem renovations order 20mg cialis sublingual with mastercard webmd erectile dysfunction treatment. But it is not sensible to substitute tax dollars for private dollars that would voluntarily have been spent digitizing hospitals’ clinical and operating systems buy cialis sublingual without prescription erectile dysfunction injections cost. Other Challenges and Considerations Earlier, it was argued that hospitals and physicians ought not to maintain the present balkanized medical information structure, with separate and nonlinkable medical records in the hospital and the physician’s office. Even where the climate of collaboration be- tween hospitals and physicians would permit a common record system to emerge, present federal laws raise barriers. Hospitals that provided connection by physicians to a clinical record system could be construed as violating federal fraud and abuse regulations, which forbid hospitals from offering services or payment to physicians for using their facilities (the modern variant of an ancient and ethically indefensible practice known as “fee splitting”). Moreover, for the 85 percent of all hospitals that are presently not-for-profit, federal and state tax laws forbid them from providing physicians anything of value. If inurement provisions did not exist, many not-for-profit institutions would function as mere front or- ganizations for profit-making enterprises, funneling tax-free dollars into individuals’ and businesses’ pockets. However, changes in federal law could work to minimize these risks in the public benefit. If clinical information systems by differ- ent vendors all used common formats, medical vocabularies, and coding schemes, no provider could achieve market leverage by “lock- ing in” physicians to using their proprietary medical records system, and the fraud and abuse risk could be alleviated. On the not-for- 164 Digital Medicine profit issue, one could reasonably argue for exempting clinical in- formation systems from inurement provisions on the grounds of markedly improved patient safety resulting from the free flow of clinical information among all the diverse actors in medicine. Moreover, an ethos of personal responsibility for health and health costs is vital to containing future health cost increases. However, the present policy climate in clinical information, on both the ven- dor and provider sides, approaches anarchy. Tens of thousand of lives are needlessly lost every year because of inadequate or poorly coordinated care. Creating the infrastructure and decision support to improve standards of care is a legitimate job for government. Current Medicare and private pay- ment policy contains inappropriate incentives, not only to maximize provider income by doing more, perhaps, than patients may need to care for them, but, by implication, to wait until a disease progresses far enough to justify more lucrative, high-technology intervention. Maintenance of health, disease management, advice and coun- seling—these are not the focus of the current healthcare payment schemes. Furthermore, as we enter an era of increasingly precise genetic prediction, the economy is already laboring to take care of the 5 percent of the population who are sick; how can it possibly finance care for everyone who has some genetic risk of illness? Ideally, physicians would be paid a monthly or annual subscription fee for each consumer who signed up to be cared for by the physician. Some of the emerging and controversial concepts in physician practice, like so-called “boutique medicine,” where consumers pay a fee to enter a physician’s practice, anticipate this subscription model. The key to the subscription is establishing electronic connectiv- ity between the consumer and the physician he or she has chosen. After electronic connectivity has been established between con- sumers and providers, maintaining electronic contact with con- sumers should be far less costly than under a visit-and-telephone- consultation system. Many interactions that required patient visits under the old system could be handled “asynchronously” under the electronic system, with software assistance supported by the physician’s office staff. Many functions, like prescription renewals, transmittal of vi- tal signs, scheduling, and billing, that were handled in person or through telephone interactions could be automated through Inter- net applications and managed by the physician’s or hospital’s staff. In addition, someone other than the physician may handle many requests for information. Subscription fees would cover maintenance of the 24/7 connec- tions, as well as the cost of most services the consumer would use in a year.

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