G their outcomes and yet fight every third-party effort to do so. 2 Similarly, it was only under the threat of reimportation that the drug companies became willing, reluctantly, to publish drug prices, which they began to do in 2004. Their stock prices have yet to recover for this and numerous other reasons, most of which re late directly to pricing transparency, delivered via the Internet Exceptions to the rule. all of these health system actors are allowed to in dulge in this economically self-serving behavior because, aside from two exceptions noted momentarily, there is no unifying economic stakeholder in the health status of any individual American. The persistence of job-based insurance--combined with the constant movement of the insured person across jobs, insurance plans, and care reimbursement. Lack of information, gross inefficiency any and persistence of FFS settings--galvanizes the fragmentation, economic conflict oddy quality generate more money for providers, and health insurers who should be motivated to do some thing about this are captive to conflicting business agendas that compel them to block access to information, slow down transactions, and hold onto money in the short run even at the expense of persistently gross inefficiency and shoddy quality over the long run. Viewed through this lens of " realeconomik, "it is easy to see that health cares IT problems are not It problems at all; they are health care system problems There are two glaring exceptions to this rule. Kaiser Permanente Health Plan and the Veterans Health Administration(VHA) have enterprisewide EMRs that are the envy of the rest of the health care system, and for reasons that are not coin cidental. 23 Although one organization is a commercial health plan and the other a government health plan, both are vertically integrated systems-that is, eachisre sponsible for both the financing and delivery of medical care to its members. Even more unlike the rest of the FFS health care system, Kaiser and the vha have busi ness models that control three key variables: (1)They own their own hospitals; (2) hey employ and thus control the workflow of their physicians, and (3)their mem bers do not jump in and out of the plans at will. All three features are central to the business case"for their expensive, useful, and robust clinical HIT syste kaiser Because the exception proves the rule, it is important to point out that and the vha are anathema to what is most sacrosanct within the U.S. health care system: consumer choice. By contrast to the choice-based system, they are de facto single-payer systems. Members go to hospitals owned by the payer and are treated by physicians employed by the payer. Friction is minimalized, data are captured and shared across the system, the business case for Hit emerges, and hit develop ment flourishes. Numerous single-payer systems overseas are digitizing in ways that we can only fantasize about in the United States, for exactly the same rear sons. 24 If Joe Wilson were a veteran instead of a commercially insured American, he would have been rushed to the va hospital in Las Vegas; as a result, his ER phy- sician would have had access to all of his prescriptions, avoided compounding one medication error with another, and not accidentally killed him. HEALTH AFFAIRS Volume 24. Number 5D o T - G o V their outcomes and yet fight every third-party effort to do so.^^ Similarly, it was only under the threat of reimportation that the drug companies became willing, reluctantly, to publish drug prices, which they began to do in 2004. Their stock prices have yet to recover for this and numerous other reasons, most of which re￾late directly to pricing transparency, delivered via the Internet. • Exceptions to the rule. All of these health system actors are allowed to in￾dulge in this economically self-serving behavior because, aside from two exceptions noted momentarily, there is no unifying economic stakeholder in the health status of any individual American. The persistence of job-based insurance—combined with the constant movement of the insured person across jobs, insurance plans, and care settings—galvanizes the fragmentation, economic confhct, and persistence of FES reimbursement. Lack of information, gross inefficiency, and shoddy quahty generate more money for providers, and health insurers who should be motivated to do some￾thing about this are captive to conflicting business agendas that compel them to block access to information, slow down transactions, and hold onto money in the short run, even at the expense of persistently gross inefficiency and shoddy quality over the long run. Viewed through this lens of "realeconomik," it is easy to see that health care's IT problems are not IT problems at all; they are health care system problems. There are two glaring exceptions to this rule. Kaiser Permanente Health Plan and the Veterans Health Administration (VHA) have enterprisewide EMRs that are the envy of the rest of the health care system, and for reasons that are not coin￾cidental.^^ Although one organization is a commercial health plan and the other a government health plan, both are vertically integrated systems—that is, each is re￾sponsible for both the financing and delivery of medical care to its members. Even more unlike the rest of the EES health care system. Kaiser and the VHA have busi￾ness models that control three key variables: (1) They own their own hospitals; (2) they employ and thus control the workflow of their physicians; and (3) their mem￾bers do not jump in and out of the plans at will. All three features are central to the "business case" for their expensive, useful, and robust clinical HIT systems. Because the exception proves the rule, it is important to point out that Kaiser and the VHA are anathema to what is most sacrosanct within the U.S. health care system: consumer choice. By contrast to the choice-based system, they are de facto single-payer systems. Members go to hospitals owned by the payer and are treated by physicians employed by the payer. Eriction is minimahzed, data are captured and shared across the system, the business case for HIT emerges, and HIT develop￾ment flourishes. Numerous single-payer systems overseas are digitizing in ways that we can only fantasize about in the United States, for exactly the same rea￾sons.-^'' If Joe Wilson were a veteran instead of a commercially insured American, he would have been rushed to the VA hospital in Las Vegas; as a result, his ER phy￾sician would have had access to all of his prescriptions, avoided compounding one medication error with another, and not accidentally killed him. HEALTH AFFAIRS - Volume 24, Number 5 1253