The sound of one hand clapping is occurring regarding matters of utmost importance to the United States Health Information Technology infrastructure. The ‘Stimulus bill’ passage has come and gone with $19 billion and an enormous sea-change for Health Information Technology with far too many things staying the same. Visitors to Linux Medical News have had several intellectually honest but admittedly provocative articles presented: Un-Answered Questions in ARRA of 2009, A Generous, Virtuous Society, Your Money and Medical Privacy Gone, CBO: Health IT Deficit of $17 billion over 10 Years, Obama’s Health IT Dilemma: The ‘Some Dude’ Problem and Call For Ban on Federal Money for Proprietary EMR’s. Yet apparently no one, NO ONE, in these weeks, including national health IT leaders has seriously challenged or seriously debated the thinking or the solution presented in those articles while back-room dealing and incestuous relationships between government and vendors seem to have occurred. Unfortunately, the nation is currently poised to continue in-effective proprietary methods all over again only this time with gargantuan expenditure. The government seems to be favoring opacity rather than transparency. This course of action is perilous at best for the United States.

I have had one person tell me to tone down my rhetoric as though the things that I have said are merely rhetoric and not what I and other serious thinkers with years of hard experience and degrees think are an accurate portrayal of what has happened and what could likely occur. I have had several contact me privately and say that they agree with me. No National Health IT leaders have engaged publicly or privately in a serious discussion or debate on the warnings I have raised or real solutions to vexing problems presented. They have given me replies along the knee-jerk, hand-wringing lines of: what will proprietary vendors think, what will proprietary vendors think?

I am worried.

The nation, its medical records and its health care do not belong to GE, Cerner, Epic, Microsoft, Google, or any other proprietary software Health IT company. These companies are NOT entitled to federal Health IT profits simply by existing, having the purchasing power to achieve weak certification or being able to generate the most marketing or lobbying noise. They must perform. As a group the proprietary Health IT industry has not performed because its lack of transparency makes it structurally unable to. It is highly unlikely that this will change even with federal billions. Transparency of EMR software is the issue here and nothing in the current law guarantees that.

The government has authorized enough money to purchase EMR transparency for the nation. Instead the government appears set to double down on opaque proprietary lock-down. The government currently appears poised to purchase serfdom instead of freedom and performance for patients, practitioners and the nation. A intellectual and financial servitude to proprietary EMR companies for little or no gain. A truly bad bargain.

It seems as though multiple people and ideals are getting mugged here with this near silence and un-willingness to engage: the taxpayer, rationality, fairness, privacy, security, performance, and the nations future. This is serious, serious stuff whether people are willing to look at it or not. The oft used saying ‘failure is not an option’ applies. Demographic trends of an aging US population, health care costs consuming an ever-larger proportion of GDP along with a fragmented un-coordinated system are all common knowledge. The nation truly needs the most bang for the buck that it can get from its Health IT. Yet it is pursuing virtual certain failure on obtaining that bang for the buck. The current law allows expenditure of federal funds for purchasing proprietary Electronic Medical Record Software and current certification strategies favor big and proprietary players. This is a recipe for fiscal and performance disaster that is exactly predicted by the Congressional Budget Office. In a nutshell it says that the nation will spend $30 billion on Health IT to lose $17 billion over 10 years with no break-even point known.

Those numbers are probably optimistic knowing the smashing fiscal success that is most government programs and will likely result in a poorly performing, opaque national Health IT at a high price. Similar to what the nation has now only more of it. It has happened before in other countries like the UK that took a big bang approach that went awry and after many, many years still does not fulfill the promise of Health IT.

What the government really needs to do is establish a true transparent market, which proprietary Electronic Medical Record software is the antithesis of. True markets flourish when there is information symmetry between buyers and sellers. Proprietary EMR software is loaded with opaque ‘black box software’ and potential tollbooths that drastically tips the balance of information and control towards the seller with the predictable result of a chronically ill EMR market that does not perform. Sound familiar? Certification is still not likely to achieve an adequate level of transparency between buyers and sellers. Licenses like the Affero General Public License (AGPL) levels the playing field between buyers and sellers and have a much likelier chance of producing a real market or at least the hoped-for interoperability which never seems to occur in real life. The current law is inadequate on many, many levels in that it does not fundamentally address any of this, is likely to favor proprietary EMR software even more and makes no hard decisions other than to spend enormous amounts of money.

I have been told (but not debated with and I am paraphrasing) that a one-size fits all solution is not likely to be pursued. This answer indicate a lack of serious thought on these issues. The rights in the United States Bill of Rights are encapsulated in simple basic sentences. This time it is no different: ‘All Electronic Medical Record software purchased with federal funds must be licensed under the Affero General Public License version 3.’ This guarantees the requisite transparency. This needs to be written into the law yesterday to ensure our nations Health IT future is a bright one.