This issue of the Journal is personal for me and thus my comments at the beginning of our 40th anniversary year are in that vein. As a practicing internist, every day of the week I deal with the frustrations of the electronic medical record (EMR) in our practice. As our guest editors highlight, the issue is usability, which they define as extent to which a system, product, or service can be used by specified users to achieve specified goals with effectiveness, efficiency, and satisfaction.

Now to put on my applied research hat on, for me money completely drives the extent to which a system is usable. Health care is fundamentally an economic activity, and we must recognize that the usability of the EMR was developed with payers uppermost in mind. The heart of the usability challenge is the manner in which the most important payer the Centers for Medicaid & Medicare Services (CMS) has implemented the vast majority of its initiatives tying payment to improved quality. That is instead of the process approach to payment (ie, E&M codes) and quality (did you do record this or that clinical attribute), today CMS could easily address the EMR morass by focusing ALL its payment-quality initiatives on a small (ie, 10 or less) number of better validated outcomes measures that are properly risk adjusted (Averill et al., 2016).

If we focused on this type of outcome, as I've written years ago, we would junk the E&M system and its piecework approach to measuring what primary care physicians (PCPs) aspire to accomplish (Goldfield et al., 2008). The E&M system is the exact antithesis of who we are as PCPs.

If we focused on this type of outcome, we would have interoperability that today is completely feasible. Interoperability would allow us to truly focus on improving public health outcomes that health care professionals are vitally interested in but CMS and other payers don't encourage (Auerbach, 2016).

If we focused on this type of outcome, we could realize the true promise of EMRs-their use by consumers-the ultimate beneficiary of our health care system. We know that an activated or confident consumer has the best clinical outcome and costs less for the system (Green et al., 2015; Wasson & Coleman, 2014).

Teamwork and evolution of roles are a critical ingredient to the success of EMR's and we include an article by Poghosyan on this topic. Shi et al add to our knowledge in the critical area of satisfaction with care on the part of patients with significant chronic illness.

I am honored that after 40 venerable years, The Journal of Ambulatory Care Management continues to be part of the Lippincott family of Journals. Each of the issues in this year will highlight a critical theme impacting ambulatory care. The EMR challenge is exactly the right place to start. Consumer confidence is next up.

-Norbert I. Goldfield, MD

Editor

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