This is another highly expensive central planning boondoggle that proves why the federal government is more often the problem than the solution and it's really simple to explain why. Doctors really, really don't like it.
Bottom line is that most doctors now understand this is another way for the government to deny payment to the docs. And doctors, like everyone else, like to be paid for their work. Sadly, the current incarnation gives the government lots of ways to trip up docs if they get something wrong on the form's format.
And even the doctors who put up with it will be distracted. They will be more focused on immaterial technicalities of a form that get them paid than actually grating their patient. And I don't know about you, but I want my doctor's full attention when something is wrong.
Prediction, we will spend many tens of billions more before we admit it's a failure. Along the way, many more doctors will stop taking new Medicare patients.
Barak Hussien Obama. Mmmmm, Mmmmm, Mmmmm.
What "highly expensive central planning boondoggle"?
Electronic medical records are long past due. They'd help cut the cost of medicine, make medical practice safer and more effective. In fact, I'm of the opinion that it's governmental interference in the medical industry that's slowed the use of electronic medical records.
So what exactly are you referring too?
I would have thought electronic medical records would be more efficient and cost effective...
I love it. My records and results are there faster for me to see, I have my information readily available to pull up and track myself. It has been a real bonus for me to have this kind of information available at the touch of my fingers. I have a lot of blood work done on a regular basis so the tracking and graphs it provides me have proven helpful.
It is not changed how my doctor interacts with me. We have our little one on one and then she goes to the computer to update and even confirms with me on the spot what she is putting in....
I don't see a downside....
I work with a lot of doctors and i don't know a single doc who likes it. It makes it more awkward for them to document. And like I said, if they don't follow the procedural format correctly then they don't get paid. Doctors seeing 30 or 40 people in a day have one more thing to think about while attempting to treat you.
Yes guys, the idea of medical records is a wonderful idea just like the idea of socialism is very sweet too. Both lose something, however, when you actually put them into practice.
Like I said, talk to a few physicians if you don't believe me and specifically ask them how it will make it tougher for them to get paid for their work.
I think there's something being left unsaid here.
Pretty much everywhere I've ever heard of electronic records are superior to paper records in just about every regard. Cost, accessibility, searchability and a few "ibilities" it's too early for me to think of.
The only reason, beyond the usual self-involvement of doctors, and most other human beings, to object to electronic records is because it's being forced on them by someone/something that can ignore the shortcomings of the format/execution of the electronic records system. That doctors are getting a system that creates greater burdens without some offsetting value.
You guys really are talking about an abstraction and not the real situation.
1. Doctors don't like to not be paid for their work.
2. Doctors don't like to have others tell them how to practice medicine.
3. When doctors put that white coat on they really don't want to be told to do anything whether it be a good idea or not.
Talking about how wonderful things would be if we could force doctors to go against their nature and passively accept something they do not want is like talking about how many angels we could fit on the head of a pin. Until you can find a solution that doctors accept and buy into then this whole discussion is about a fantasy.
I like the idea. If I travel and get sick, then my records are readily availiable at any time. It certainly helps the doc who has never seen me before. I think I get better treatment, at least in that situation.
The same thing can be accomplished with a medic alert bracelet that has a little flash drive attached. On that flash drive you could easily scan the images of your medical records.
Once again, nice abstract thoughts aren't realistic until you guys figure out how to get doctors to buy into the process. And that was the point of my original post that no one seems to be addressing. How do you get doctors to buy into a system that makes it harder for them to get paid and creates, at least in their minds, an unnecessary distraction to their practicing medicine?
This attitude of imposing onerous operating procedures by politicians is exactly how you end up with a doctor shortage. This is just how we got so many people out of community banking back in the 80s too. You can't impose a solution on doctors they don't agree with and not think there will be a negative consequence. The world just doesn't work that way people.
Dan is talking about one thing and evryone else is talking about another. I'll explain when I get to my laptop...
Quote from: arpad on October 16, 2010, 05:27:17 PM
What "highly expensive central planning boondoggle"?
Electronic medical records are long past due. They'd help cut the cost of medicine, make medical practice safer and more effective. In fact, I'm of the opinion that it's governmental interference in the medical industry that's slowed the use of electronic medical records.
So what exactly are you referring too?
Imagine how fast a candidate's history of psychiatric counseling would surface, the fewer safeguards there are.
If you want a curious doctor's receptionist pawing through your record, or an insurance company selling data to, say, a pharmaceutical company in search of test subjects for a given malady, then consolidated on-line records are OK.
I prefer medical privacy.
Quote from: taxed on October 17, 2010, 05:07:54 AM
Dan is talking about one thing and evryone else is talking about another. I'll explain when I get to my laptop...
Bingo! Its like if I had said Obama's policy to give everyone a pony was a bad idea and then everyone decides to talk about how much they wish they had a pony. Not the practicality of having a pony or the the trade offs that come with Obama's free pony policy.
Quote from: quiller on October 17, 2010, 05:23:59 AM
Imagine how fast a candidate's history of psychiatric counseling would surface, the fewer safeguards there are.
If you want a curious doctor's receptionist pawing through your record, or an insurance company selling data to, say, a pharmaceutical company in search of test subjects for a given malady, then consolidated on-line records are OK.
I prefer medical privacy.
You do have a point on that although that is what the Health Insurance Portability and Accountability Act (HIPAA) laws are for, plus if the receptionist wanted to see my records she would have already pulled my paper file.... :) :)
As to doctors not appreciating being told what to do - I would think that in this case, electronic records, it would be more an age based problem. Older physicians more set in their ways would fight this. Younger doctors would probably see this as a convenience. :-X :-X
Joe the Plumber ring any bells about privacy of records, when Democrats are involved?
It is a bad idea to put this data on-line. Safeguards are meaningless.
Not at all ST. Young doctors have a problem with it too. Once again this is a great theoretical idea to people not in healthcare. Nut talk to Andes doctors and a few nurses and you will see how bad of an idea this will be in practice.
Having nonmedical people impose a healthcare solution on doctors is just as bad as Obama and his leftwing academics impose economic and tax policy on the business world. When you have people without practical knowledge of a situation making policies that will be imposed on the people in the field, then it's highly unlikely you will ever get a good outcome.
Quote from: quiller on October 17, 2010, 09:20:47 AM
Joe the Plumber ring any bells about privacy of records, when Democrats are involved?
It is a bad idea to put this data on-line. Safeguards are meaningless.
There are always one or two back door into everything. >:D
Quote from: walkstall on October 17, 2010, 09:27:36 AM
There are always one or two back door into everything. >:D
And there is a lot more than a couple of ways when you put everyone's records on a standardized format and then store it as part of a national database.
I tend to agree with both sides of the issue.
For example, as a disabled vet, my stay in the waiting room has been cut by more than two hours, what used to be an all day event, is now done in an hour.
Yes, I actually get to spend as much time as I need with my doctor, all thanks to electronic files.
Now on the other hand, as a Gov entity, I have no say over how my records are kept, which is an argument against socialist medicine.
A person should have the right to choose a doctor that refuses to electronically file his patients records.
This way it makes it much easier to trace who is responsible for leaking information about a specific person.
There is no fool proof method of safe keeping records, only the ethics of the people in charge of such info.
but one upside to electronic records, is there is always a record tracing back to the person that accessed them.
Quote from: Solar on October 17, 2010, 09:34:50 AM
I tend to agree with both sides of the issue.
For example, as a disabled vet, my stay in the waiting room has been cut by more than two hours, what used to be an all day event, is now done in an hour.
Yes, I actually get to spend as much time as I need with my doctor, all thanks to electronic files.
Now on the other hand, as a Gov entity, I have no say over how my records are kept, which is an argument against socialist medicine.
A person should have the right to choose a doctor that refuses to electronically file his patients records.
This way it makes it much easier to trace who is responsible for leaking information about a specific person.
There is no fool proof method of safe keeping records, only the ethics of the people in charge of such info.
but one upside to electronic records, is there is always a record tracing back to the person that accessed them.
Hmmm...What good is that when the cat is out of the bag. :o
Quote from: Dan on October 17, 2010, 09:20:55 AM
Not at all ST. Young doctors have a problem with it too. Once again this is a great theoretical idea to people not in healthcare. Nut talk to Andes doctors and a few nurses and you will see how bad of an idea this will be in practice.
Since you have obviously spoken to various doctors about this I will have to question mine next time I am in. Maybe they just put up a good show for me when I am there... :-\ :-\ :-\ :-\
Solar, if you are talking about the VA then I hope you will appreciate that it works very differently than private practice medicine. There a doctor has to justify the time he spends with you and doesn't get paid for reviewing your records before you guys meet. It just doesn't work that way chief. ;)
Quote from: Dan on October 17, 2010, 09:41:51 AM
Solar, if you are talking about the VA then I hope you will appreciate that it works very differently than private practice medicine. There a doctor has to justify the time he spends with you and doesn't get paid for reviewing your records before you guys meet. It just doesn't work that way chief. ;)
To the contrary, the VA doctor has to do the same.
I don't get your point?
Solar, the VA in Ann Arbor regularly featured a string of doctors who would ask me what was wrong, but never once opened the actual file. They are on a 15-minute-per-patient limit.
At various clinics, the file WOULD get opened, where someone wouldf find my last visit had not even been recorded, or tests run but no resul;ts entered (weeks after my last visit).
I cannot stress this enough. You do NOT want a VA-style health mismanagement program. You do NOT want anyone to just walk into an unoccupied office and call up a file, print is "spicy bits" for their use, and then walk out without ever signing in under their own password. There are no controls on access. There are no reparations possible trying to track down a culprit in such a large setting.
Quote from: quiller on October 17, 2010, 09:53:21 AM
Solar, the VA in Ann Arbor regularly featured a string of doctors who would ask me what was wrong, but never once opened the actual file. They are on a 15-minute-per-patient limit.
At various clinics, the file WOULD get opened, where someone wouldf find my last visit had not even been recorded, or tests run but no resul;ts entered (weeks after my last visit).
I cannot stress this enough. You do NOT want a VA-style health mismanagement program. You do NOT want anyone to just walk into an unoccupied office and call up a file, print is "spicy bits" for their use, and then walk out without ever signing in under their own password. There are no controls on access. There are no reparations possible trying to track down a culprit in such a large setting.
So you are saying they have no controls on access, or automatic log-offs, or that these people are dumb enough to just leave a computer up and logged on....WOW. :o :o :o :o
Do you leave your laptop up and out for people to just walk up and use?? :o
If you look at health insurance with Blue Cross or Cigna or United then the doctor will bill your insurance provider when he sees you. He will bill for a level 1 visit if he just sees you for 5 minutes. He will bill for a level 3 visit if he sees you for 15 minutes. If he sees you for an hour then he will bill a level 5 visit. For each type of visit he has to justify the medical necessity of billing that level. Levels 1-3 are simple. Level 4 or 5 visits require detailed justification and come under lots of scrutiny in post payment reviews. So your doc can't just see you for an hour just because. There either has to be a very specific issue or the doc will be unable to bill for much of the time he saw you. If the doctor does the later, then he will have trouble paying his own bills and making payroll.
And medical records are neither part of the delay or the reason he can bill firths time. Most doctors document the visit as they talk to you. And most dogs keep your prior records in a great big folder that can be reviewed in moments. There really isn't any added efficiency in time for the doctors. Quite the contrary. Ask taxed if you don't believe me. He talked tonsils people who were trying to set up a business doing the extra work for th doctors. Keyword being extra.
I was acquainted with a woman who use to transcribe all of our background investigation reports for the Sheriff recruiting office I worked in. She would take the tapes home (with all the juicy details) type them up and return the hard copy reports to the investigators.
In talking to her I found out she also had the contract for Kaiser Hospital - Typing up the doctors notes.... She, her husband, or anyone snooping around her house could have taken this information just as easily as you are suggesting they could at my doctors office...... Where obviously only idiots work.
Bottom line is if someone wants it bad enough they will get it. :o :o :o
Quote from: quiller on October 17, 2010, 09:53:21 AM
Solar, the VA in Ann Arbor regularly featured a string of doctors who would ask me what was wrong, but never once opened the actual file. They are on a 15-minute-per-patient limit.
At various clinics, the file WOULD get opened, where someone wouldf find my last visit had not even been recorded, or tests run but no resul;ts entered (weeks after my last visit).
I cannot stress this enough. You do NOT want a VA-style health mismanagement program. You do NOT want anyone to just walk into an unoccupied office and call up a file, print is "spicy bits" for their use, and then walk out without ever signing in under their own password. There are no controls on access. There are no reparations possible trying to track down a culprit in such a large setting.
Then your VA hospital needs to be closed immediately due to incompetence!
Not sure when the last time you visited, but I have been to three different VA hospitals in the last 5 years, two in Ca and one in Nevada, and the only person allowed to view my records at any given time, is the doctor, he has to log on with a pass code, that only he has, and when he is done he logs off.
Granted, there are office people that have access, but they too have a password, and if there are any discrepancies as to an invasion of my privacy, an investigation will reveal the person that accessed my records, including the doctor.
Like I said, there are good and bad about electronic records, the one bad thing, and I hope they pass legislation over it, is the length of time a history can be viewed.
Say a doctor wants to go back 5 years or more, he will need your personal permission to view them, as in a retinal scan or a finger print, this would assure your history stays private.
But as it stands, if you have a paper record on file with a doctors office, there is no way to trace back to the person that opened your records and photo copied them.
Cost was closely followed by Training Staff on EMR systems, which 79 percent of physicians are "very" or "somewhat" concerned about. Lowest on the list of concerns was "Loss of patient information."
Despite cost and staff training concerns, a narrow majority of the physicians surveyed believe EMR systems will prove to be a valuable resource in medical practices. Over 58 percent of the physicians surveyed responded that EMR systems will have a positive or very positive impact on the quality of patient care.
http://insurancenewsnet.com/article.aspx?id=226700&type=newswires (http://insurancenewsnet.com/article.aspx?id=226700&type=newswires)
Thought I would go looking around...ST
http://www.markle.org/downloadable_assets/20101007_bluebutton_pr.pdf (http://www.markle.org/downloadable_assets/20101007_bluebutton_pr.pdf)
current survey information.... Just seeing whats out there. ST
"This represents a remarkable agreement between the general population and doctors,"
Diamond said. "In fact, only 7 percent of the public and only 15 percent of the doctors
disagreed with a statement that patients should be able to download copies of their
pertinent health information."
Firing the Veterans Administration hospital system for incompetence? Hah! Nobody EVER gets disciplined. They can release the records of 100,000 vets (and have) and not one employee gets fired. It can't be done. They answer to the feds and not the patients.
You'd be amazed how many of those workstations remain logged-in all day, or (and THIS one REALLY surprised me) the password was in plain sight, on a card easily visible to anyone seated at the PC.
Veterans Administration mistakes got these Google hits....
http://www.google.com/#hl=en&expIds=26637,26992,27102&sugexp=ldymls&xhr=t&q=Veterans+Administration+mistakes&cp=31&pf=p&sclient=psy&aq=f&aqi=g5&aql=&oq=Veterans+Administration+mistake&gs_rfai=&pbx=1&fp=634607d52d82d8c1 (http://www.google.com/#hl=en&expIds=26637,26992,27102&sugexp=ldymls&xhr=t&q=Veterans+Administration+mistakes&cp=31&pf=p&sclient=psy&aq=f&aqi=g5&aql=&oq=Veterans+Administration+mistake&gs_rfai=&pbx=1&fp=634607d52d82d8c1)
Quote from: Solars Toy on October 17, 2010, 09:40:37 AM
Since you have obviously spoken to various doctors about this I will have to question mine next time I am in. Maybe they just put up a good show for me when I am there... :-\ :-\ :-\ :-\
I've talked to dozens of doctors about this subject and probably reviewed the progress notes of more than 150 different physicians over the past decade. I promise you I am speaking from experience.
I've talked to dos
ST, these surveys are interesting but they directly contradict more than a decade of first hand observations. Sorry, but I'm not convinced. I read nothing there to make me stop believing my eyes and ears.
A quick scan of the people running the markle foundation make me question it's objectivity on this liberal passion project.
Zoe Baird is the president of the board. She was Clinton's first nominee to the justice department.
Tom Bernstien was a member of Michael Bloomberg's transition team. He was president of board of directors for Human Rights First. He was connected to NPR.
Lewis Kaden is on the board of trustees for the century foundation and on the board of human rights first.
And likewise you probably won't convince me it is a bad thing. :) :) :)
Didn't this whole thing start under Bush?
Quote from: Solars Toy on October 17, 2010, 02:03:12 PM
And likewise you probably won't convince me it is a bad thing. :) :) :)
Didn't this whole thing start under Bush?
1. I'm not a huge Bush fan. Not sure how that's a point in it's favor.
2. What do you think about the liberal bias within the group that generated the poll you referenced?
3. Exactly how do you think that non medical types imposing a method of testing upon doctors, against their will, is supposed to be a good thing?
Quote from: Dan on October 17, 2010, 02:11:14 PM
1. I'm not a huge Bush fan. Not sure how that's a point in it's favor.
2. What do you think about the liberal bias within the group that generated the poll you referenced?
3. Exactly how do you think that non medical types imposing a method of testing upon doctors, against their will, is supposed to be a good thing?
1 - Just pointing out it didn't start with Obama...
2 - If they found only liberal doctors then that is a problem. But again my doctor seems to like it. It makes our yearly get together go much smother and she is able to quickly cover with me the visits I had with other doctor within her practice during the year.
3 - It's called progress....and if it makes it better and safer for the patient then why is it so wrong to you? Aren't our doctors suppose to be there for us finding better and more efficient ways to help us?
Also you say it is against their will - are you sure
all doctors feel that way. Maybe it is making their jobs easier.......allowing them to make better decisions regarding care and less mistakes during emergency situations. There are some upsides that you refuse to see.
You might also take into consideration HMO's where it is likely you will see a lot of different doctors I see this as invaluable to that situation.
You talk to one doctor once per year in the doctor patient relationship mode. I speak to lots of doctors during their down time, over drinks and even with their families. You decide if that brings anything relevant to the discussion.
As for leftwing bias, it can affect the wording of the questions, the selection of target populations and the determination of what information should be omitted. Preparer bias is everything when a leftwing group issues a self congratulatory study illustrating how right they were in the first place. Don't you think so?
As for progress, that word is long on emotion and short on substance. Will it be progress for private practice doctors to see their overhead go up and their revenue go down? Will it be progress to add one more inducement to having doctors decide to stop taking new Medicare patients? What about when a different doctor makes a mistake and the insurance company denies payment on a needed test because it contradicts the incorrect diagnosis of a prior doctor. There are going to be a ton of unintended consequences and you can bet your bottom dollar one of them is going to be to attack doctors on reimbursements for longer visits and expensive diagnostic tests. As such, I worry about EMR becoming an unintended cause for more deaths, not less.
The only way EMR works is if you standardize the format by which ALL doctors document patient visits. This will make the doctors more cautious, less intuitive and more clerical in their approach to medicine. Think of the guys behind the counter at the DMV. The personal aspects of healthcare will be limited as the doctors learn to practice medicine by the cookie cutter approach of the standardized format. Also think about what an incredibly short leash you are putting doctors on. Every decision they make will be at the finger tips of a reviewer or possibly a plantiff's attorney in a malpractice lawsuit. That pretty much insures these doctors will be in a constant ass covering mode. Treating you will be secondary consideration mo matter what kind of friendly chat you have with your doctor on your annual visit. ;)
I have heard both arguments. I am going to take a short recess and be back with my decision...
Quote from: taxed on October 17, 2010, 03:19:06 PM
I have heard both arguments. I am going to take a short recess and be back with my decision...
It takes must out of doctors pockets. It makes it harder for doctors to get paid for the work they do. And it will make it easier for the doctors to get sued. That's the "it ain't gonna work" trifecta.
Interesting points and things to consider. :-\ :-\ :-\ :-\
But I still like my ability to get my records and view my test results.... :) :) :)
Ok...
Dan is talking about process, not the actual medium and benefits of how a record is stored.
I think we all, Dan included, and doctors, would agree electronic records, secure, would be ideal. A doctor, in all reality, could care less how a record is stored. They couldn't care less if records were stored on napkins. They want to do it the way they always have, since the beginning of time, without added cost.
Doctors aren't like us regular folk. Think of the Einstein story of him walking to work without his pants. Their brains don't want to deal with all this extra technical crap that they have to get perfect or they get sued or don't get paid. They want to consult and diagnose the patient, read their previous history on paper in front of them, and write the new stuff down and call it the day.
If a doctor could just write it down as he always has, and hand the record off to an assistant for her to enter it into the EMR system and file, then this is a non-issue. However, the government (correct me if I am wrong Dan) doesn't allow that. They make the entire process a boobie trap that forces them into an insane process that no right minded person would accept and adhere to. if a doctor could just talk into a dictaphone the data, hand that off to a transcriber or whatever, and be done, then no issue. If he could have someone take the stuff down, format it, and have him review and correct errors before committing it, then no issue.
I would love a medical system with EMR, where doctors don't have to worry about the crap and can just be doctors, and let some private sector solution figure out the best way to do it by working around and adhering to the doctor.
From the little I know about it, I know that isn't possible, so would be adementaly against EMR, in the form it is in now. Give me the project, get the gov out and let me do it my way, let me talk to 1,000 doctors, and I would solve the problem in two weeks.
Quote from: taxed on October 17, 2010, 04:47:39 PM
Ok...
Dan is talking about process, not the actual medium and benefits of how a record is stored.
I think we all, Dan included, and doctors, would agree electronic records, secure, would be ideal. A doctor, in all reality, could care less how a record is stored. They couldn't care less if records were stored on napkins. They want to do it the way they always have, since the beginning of time, without added cost.
Doctors aren't like us regular folk. Think of the Einstein story of him walking to work without his pants. Their brains don't want to deal with all this extra technical crap that they have to get perfect or they get sued or don't get paid. They want to consult and diagnose the patient, read their previous history on paper in front of them, and write the new stuff down and call it the day.
If a doctor could just write it down as he always has, and hand the record off to an assistant for her to enter it into the EMR system and file, then this is a non-issue. However, the government (correct me if I am wrong Dan) doesn't allow that. They make the entire process a boobie trap that forces them into an insane process that no right minded person would accept and adhere to. if a doctor could just talk into a dictaphone the data, hand that off to a transcriber or whatever, and be done, then no issue. If he could have someone take the stuff down, format it, and have him review and correct errors before committing it, then no issue.
I would love a medical system with EMR, where doctors don't have to worry about the crap and can just be doctors, and let some private sector solution figure out the best way to do it by working around and adhering to the doctor.
From the little I know about it, I know that isn't possible, so would be adementaly against EMR, in the form it is in now. Give me the project, get the gov out and let me do it my way, let me talk to 1,000 doctors, and I would solve the problem in two weeks.
I would give it to you if I could....just remember I want my perks. ;D ;D ;D
Quote from: Solars Toy on October 17, 2010, 04:51:03 PM
I would give it to you if I could....just remember I want my perks. ;D ;D ;D
We'll bill the patients a $15 "EMR fee" and split that!
Quote from: arpad on October 16, 2010, 05:27:17 PM
What "highly expensive central planning boondoggle"?
Electronic medical records are long past due. They'd help cut the cost of medicine, make medical practice safer and more effective. In fact, I'm of the opinion that it's governmental interference in the medical industry that's slowed the use of electronic medical records.
So what exactly are you referring too?
As is now, not even close. A private sector solution, yes.
Quote from: quiller on October 17, 2010, 05:23:59 AM
Imagine how fast a candidate's history of psychiatric counseling would surface, the fewer safeguards there are.
If you want a curious doctor's receptionist pawing through your record, or an insurance company selling data to, say, a pharmaceutical company in search of test subjects for a given malady, then consolidated on-line records are OK.
I prefer medical privacy.
In my world, records would be encrypted with bio-metric keys, or, a key only doctors would have.... many possible options that would be FAR more secure than what we have now.
Quote from: walkstall on October 17, 2010, 09:27:36 AM
There are always one or two back door into everything. >:D
Not with my encryption algorithm.
Taxed, if you were in charge then I could get a lot more optimistic about the process. Unfortunately that's not the case and what we have is unworkable.
Quote from: Dan on October 17, 2010, 05:12:07 PM
Taxed, if you were in charge then I could get a lot more optimistic about the process. Unfortunately that's not the case and what we have is unworkable.
I agree with you.
There's no benefit without a cost but on balance I'd say we're a heck of a lot better off with the technological bargains we've made then we were without them.
If medical privacy is more vulnerable then we get better, faster, more effective treatment and faster-advancing medical knowledge. Like I wrote above, I think the reason we don't have a lot more in the way of electronic medical record-keeping is the degree of government interference in the market. Were it not for ERISA, Medicare and the other intrusions of government the pressure would've been greater to find ways to cut costs while improving service as is the case throughout the private sphere. But with Uncle Sam's bottomless wallet to tap in to, and the ever-changing rules and regulations, recording-keeping wasn't under the pressure to become less costly and more productive it would've been in a free market.