MICHAEL A. SACHS I thank Drs. Basch, East, and Middleton for their commentaries on my article and their perspectives on the future of information technology in healthcare. It is reassuring to observe that all commentators seem to agree that the future includes a more robust application of IT in the delivery of healthcare services. My article presumed that we are 10 years beyond today's realities and envisioned what our health delivery system could look like as technology takes that decade leap forward. Getting from here to there is never easy. The scale of investment is enormous and the implementation challenges large. As Peter Basch states, Healthcare is very Depending on one's perspective, this is either an absolute truth or a misconception. For the physician laboring under a reimbursement system that pays on a piecemeal basis, with some services highly compensated and others not at all, healthcare does, in fact, look very broken. For a patient waiting for hours to receive care, it is a failed system. But for the patient who recently experienced a massive stroke without suffering any neurological deficit or death thanks to new targeted treatments, the system is nothing short of miraculous. We have a multilayered, multitiered delivery system comprising thousands of delivery organizations and millions of skilled workers. A centralized approach to fund IT infrastructure or provide a uniform system, although alluring in simplicity, is fraught with disaster. Successful implementation of large-scale, uniform systems only works in a unified organizational alignment. We may have one payer, Medicare, that drives consistency in payment over 50 percent of the industry, but we deliver medical services through 450,000 independent physician agents and over 5,000 hospitals. IT implementation will be driven by organizational self-interests to improve operating margins, reduce errors, and deliver improved service. Today, the most automated element of our health delivery system is the large-scale retail pharmacy chain. Anyone can bring a paper prescription to a pharmacy, and within seconds staff can determine insurance eligibility and copayment amounts, check for drug interactions with other prescriptions, print patient instructions, and organize a fulfillment chain to deliver the drugs within minutes. Furthermore, that prescription can be refilled anywhere in the country where another store in the chain is located. The government did not pay for the implementation of these systems, and the pharmacists in those stores did not seek to customize the screens to meet their individual work habits. Rather, the pharmacies implemented the systems to help them compete in a low-margin, high-volume service industry in which a zero-error environment is essential. Sounds like a business similar to hospitals. In a like manner, sophisticated IT systems can be implemented by individual hospitals and physicians in the coming decade. Implementation is never easy; return on investment analysis is useful but not the only economic tool to use in making implementation decisions. …