????截至今年2月17日，美國政府已經向近2,000家醫(yī)院和41,000多名醫(yī)生支付了近31億美元的激勵資金，莫斯塔沙瑞希望醫(yī)院和醫(yī)生的數量在接下來的一年里能夠實現迅速的增長。

????古斯汀?霍的社區(qū)門診位于舊金山的唐人街，前來就診的老年人絡繹不絕?；翎t(yī)生的診所也是該項目的早期受益者之一。他的辦公室里堆滿了各種文件，唯一能證明診所里安裝了新的電子病歷系統(tǒng)的證據就是三個診室里都安裝了三星的平板顯示器?；翎t(yī)生說：“以前我們經常要說‘把這個復印一下’，‘把那個發(fā)傳真’，現在我只要按一下鈕，就可以把它整個發(fā)出去。”說話的時候，他的聽診器還吊在白大褂的口袋上。

????不過這依然是一個艱難的轉變?；翎t(yī)生承認：“對電腦我是外行。我用來對付電腦的精力好像比花在病人身上的還多?！辈贿^自從他把平板顯示器安裝到墻上的支架上以后，就再也沒收到過病人的投訴。診所里經常能看見這樣一幕：霍醫(yī)生走進診室，向一位患有心臟病的中年病人打招呼，然后把平板顯示器拉過來，兩個人一起轉過椅子，在顯示器上查看最近一次檢查的結果。

????莫斯塔沙瑞稱，這樣一個項目要想成功，“必須簡單易行，要讓小診所的醫(yī)生也覺得足夠簡單。這個系統(tǒng)不僅要為那些有錢的大型機構服務，也要為小診所的醫(yī)生服務?！?/p>

????不過，并不是每家醫(yī)院、每家診所都愿意參與這個計劃，有些人可能還會因為掉隊而付出代價。從2015年開始，那些屆時仍沒有采用電子病歷的醫(yī)生將發(fā)現，他們原本已經很低的醫(yī)療保險和醫(yī)療補助報銷金每年將被扣除1%，最多則可能被扣除5%。

????此外，有些摩擦難以避免，特別是有些人希望系統(tǒng)標準保持開放，而有些大公司則希望控制系統(tǒng)標準，以有利于自己的產品。印地安那大學（Indiana University）教授艾倫?卡洛爾醫(yī)生指出：“對于一家公司來說，最能符合他們利益的做法就是確保用戶無法從其它來源獲得數據。他們想讓用戶購買他們的產品。兼容性高的系統(tǒng)會損害他們的利益?！?/p>

????莫斯塔沙瑞批評一個行業(yè)標準委員會去年年底給這個項目拖了后腿。他說：“必須推動這個項目。原地踏步比推動某件不完美的事的風險更大。我們不能再等另一個五年，不能到那時再去推動（美國的醫(yī)療數據）交換。我們等不起?！?/p>

????莫斯塔沙瑞面臨的最大挑戰(zhàn)可能是個他無法完全控制的問題——保護患者的隱私。幾乎每周都有醫(yī)院報告病歷遭泄露的情況，流出的病歷常達數百、甚至數千份。比如去年有人把斯坦福醫(yī)院（Stanford Hospital）2萬多名患者的姓名和診斷代碼都貼在了一個商業(yè)網站上。某些主張保護消費者權益和隱私權的人擔心的事情還不止這些。電子前沿基金會（Electronic Frontier Foundation）的高級律師李天（音譯）說，許多公司都想染指病人的數據：“龐大的數據就是巨大的商機”。

????莫斯塔沙瑞也把隱私保護當成優(yōu)先要務，并表示隨著越來越多的醫(yī)生部署了數據分享系統(tǒng)，以及隨著各方對加密方法、訪問規(guī)則、密碼保護和審計追蹤投入特別關注，這個計劃將只會以“可信賴的速度”繼續(xù)推進。今年二月發(fā)布的指導方針提案主要針對電子病歷系統(tǒng)第二階段的有效使用，包括進一步強調對患者病歷的加密問題。

????盡管前面的任務還很艱巨，不過莫斯塔沙瑞的辦公室去年還是迎來了一個具有里程碑意義的事件：他們通過互聯(lián)網，借助一個（醫(yī)生可免費使用的）行業(yè)和政府聯(lián)合制定標準，利用電子郵件成功地發(fā)送了第一批電子病歷。它在人類通訊史上的意義可能無法同亞歷山大?貝爾在發(fā)明世界第一臺電話時所說的那句著名的“華生先生，到我這兒來，我想見見你”相媲美。但對于醫(yī)生來說，這是一個時代的開始。

????Kaiser Health News是亨利?愷撒家庭基金會的一個獨立社論項目，它是一個非公益、無黨派的醫(yī)療政策研究和交流機構，與Kaiser Permanente醫(yī)療集團無關。

????譯者：樸成奎

????As of Feb. 17, the government had disbursed $3.1 billion in incentive payments to nearly 2,000 hospitals and more than 41,000 doctors, and Mostashari expects that number will balloon in the coming year.

????Dr. Gustin Ho, whose community clinic in San Francisco's Chinatown is crammed with elderly men and women, was among the early beneficiaries. In an office lined with paper files, the only evidence of Ho's new electronic health record system is a few Samsung flat-panel monitors in each of three examining rooms. "Before it was 'copy this,' ' fax that,'" Dr. Ho says, stethoscope dangling from a lab coat pocket. "Now, I just hit a button and send the whole thing."

????The adjustment, however, was tough. "I was an amateur," Ho admits. "I seemed to be paying more attention to the computer than to the patients." After he switched to flat panel monitors, however, attaching them on wall swivels, patient complaints ceased. Entering an exam room to greet a middle-aged patient with heart problems, Ho pulls out the screen while both wheel their chairs together to go over the results of a recent test.

????For such an effort to succeed, "you've got to make it simple," Mostashari says. "Simple enough for the little guy. It has to work not just for the biggest, deep-pocketed organizations, but for the small docs as well."

????Not everyone is on board, and some may pay a price. Physicians who fail to convert to digital records will see their already low Medicare and Medicaid reimbursements cut back 1 percent a year, beginning in 2015, to a maximum 5 percent reduction.

????There's also friction between those who want system standards to be open and some large companies trying to steer standards to benefit their own products. "It's often in a company's best interest to make sure you can't get the data from other sources," says Aaron E. Carroll, a physician and professor at Indiana University. "They want you to buy their products. Easily compatible systems hurt their bottom line."

????Mostashari chastised an industry standards committee for foot-dragging late last year. "Push!" he said. "There is a sense in which not moving on anything is a greater risk than moving forward on something that may be imperfect. We can't afford to wait another five years before we have (health care data) exchange in this country."

????His biggest challenge may be something over which he has less control: safeguarding patient privacy. Every week, it seems, another hospital reports a breach of hundreds or thousands of patient records, such as last year's posting of the names and diagnosis codes of 20,000 Stanford Hospital patients on a commercial website. And it's not just breaches that worry some consumer and privacy advocates. Many companies would love to get their hands on patient data, says Lee Tien, senior staff attorney at the Electronic Frontier Foundation. "Big data is big business," Tien says.

????Mostashari counts privacy protection as a top priority and says the program will only move forward "at the speed of trust," as physicians implement data-sharing systems in increments, with special attention to encryption and rules on access, password protection and audit trails. Proposed guidelines for the second stage of meaningful use, released in February, put a stronger emphasis on encryption of patient records, for instance.

????While the tasks ahead are daunting, Mostashari's office last year celebrated the first transmission of electronic health records sent securely over the Internet via email using an industry-government standard available to doctors for free. In the annals of communications history, the event won't rank with "Mr. Watson, come here, I want to see you," but for doctors, it's a start.

????Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.