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Why Did US Physicians Give Up Their Ability to Enforce Their Own Professional Standards?

In his recent review of Dr Ezekiel Emanuel's book, (Healthcare, Guaranteed: A Simple, Secure Solution for America,) Dr Arnold Relman, Editor-Emeritus of the New England Journal of Medicine, <a href="http://www.nybooks.com/articles/22798">discussed </a>the history of the deprofessionalization of American physicians. <blockquote> The behavior of US physicians has been changed by the commercialization of medical care, and this too has increased costs. US medical practice has traditionally relied on fee-for-service, which has always given it some of the attributes and incentives of a business. However, the American Medical Association (AMA) maintained for many years that medical practice was a profession, not a business. The AMA's ethical guidelines therefore advised physicians to limit their income to reasonable earnings from the care of patients, and to refrain from advertising and from entering financial arrangements with drug and device manufacturers. Those restrictions were lifted after the US Supreme Court decided in 1975 that lawyers, and by extension members of other professions, including physicians, are engaged in interstate commerce and therefore must be subject to antitrust law (from which they had largely been exempt).(1) This decision had an enormous effect on the medical profession, but its consequences have received relatively little public attention. Although the courts did not initiate the commercialization of medicine, they certainly accelerated it and gave it legal justification. In 1980, after medical organizations lost some costly antitrust trials, in which they were accused of such offenses as limiting doctor fees or denying staff privileges, the AMA changed its ethical guidelines, declaring medicine to be both a business and a profession. This lowered the AMA's barriers to the commercialization of medical practice, allowing physicians to participate in any legal profit-making business arrangement that did not harm patients. Nearly a half-century ago, Stanford economics professor Kenneth Arrow, later a Nobel laureate, convincingly argued that medical care cannot conform to market laws because patients are not ordinary consumers and doctors are not ordinary vendors. He said that sick or injured patients must rely on physicians in ways fundamentally different from the price-driven relation between buyers and sellers in an ordinary market. This argument implied that, contrary to the assumptions of antitrust law, market competition among physicians cannot be expected to lower medical prices. And since physicians influence decisions to use medical services far more than patients do, the volume and types of services provided to patients—and hence total health costs—need to be controlled by forces other than the market, such as professional standards and government regulation. But Arrow's argument was largely ignored in the rush to exploit health care for commercial purposes that ensued after the passage of Medicare and Medicaid in 1965.(2) </blockquote> Writing about the decline of physicians' professionalism in 2007 [ Relman AS. Medical professionalism in a commercialized health care market. JAMA 2007; 298: 2668-2670. [link <a href="http://jama.ama-assn.org/cgi/content/full/298/22/2668">here</a>) ], Dr Relman had briefly alluded to the effect of the 1975 Supreme Court decision, (see our post <a href="http://hcrenewal.blogspot.com/2007/12/relman-in-jama-on-threats-to-physicians.html">here</a>): <blockquote>The law also has played a major role in the decline of medical professionalism. The 1975 Supreme Court ruling that the professions were not protected from anti-trust law undermined the traditional restraint that medical professional societies had always placed on the commercial behavior of physicians, such as advertising and investing in the products they prescribe or facilities they recommend. Having lost some initial legal battles and fearing the financial costs of losing more, organized medicine now hesitates to require physicians to behave differently from business people. It asks only that physicians' business activities should be legal, disclosed to patients, and not inconsistent with patients' interests. Until forced by anti-trust concerns to change its ethical code in 1980, the American Medical Association had held that 'in the practice of medicine a physician should limit the source of his professional income to medical services actually rendered by him, or under his supervision, to his patients' and that 'the practice of medicine should not be commercialized, nor treated as a commodity in trade.' These sentiments reflecting the spirit of professionalism are now gone. </blockquote> It seems to me that Dr Relman has elucidated one of the "missing links" that help explain the current sorry state of physicians' core values, and the broader continuing health care crisis. I am amazed that this bit of history seems to have been so thoroughly forgotten. Dr Relman did write about it before 2007, but in publications that few physicians and other health care professionals were likely to see. Other than Dr Relman, almost no one writing in the medical and health care literature seems to have interest in this issue. (It has been discussed in the Journal of Health Politics, Policy and Law, and the Stanford Law Review by M. Gregg Bloche, but these unfortunately also could have easily been missed by nearly all physicians and health care professionals.) So we have another example of the anechoic effect. Yet in my humble opinion, every physician and health care professional ought to know that the profession once foreswore the commercialization of medical practice, but gave up on its ability to police its own conflicts of interest after the US Supreme Court decided that professionals are subject to anti-trust law. But knowing this important bit of history raises more questions than it answers: <ul><li>The Supreme Court decision apparently involved interpretation of law, not the constitution. Therefore, why didn't organized medicine pursue a change in the law that would allow physicians to continue to enforce their traditional professional values? </li><li>The Supreme Court decision was primarily directed at lawyers, not physicians. Since the decision, to my knowledge, the law profession has maintained strict rules about conflicts of interest. (For example, no legal CME is sponsored by corporations whose products they seek to have the attendees favor.) Why did the decision wreck physicians' but not lawyers' abilities to regulate their own conflicts of interest? </li><li>The Supreme Court decision only affects US law. Why have physicians in other countries also abandoned their traditional values about commercial entanglements? </li><li>Why did this application of US antitrust law have such significant effects during an era when antitrust enforcement in health care was generally declining? (Insurance companies and hospitals that dominate local markets have not feared antitrust enforcement.)</li><li>Why did only Dr Relman and Prof Bloche seem to care about this up to now?</li></ul> Inquiring minds want to know.... And answering these questions might bring us back on the path of true medical professionalism. Hat tip to Merrill Goozner <a href="http://www.gooznews.com/node/2971">in the GoozNews blog</a>. References (from Relman) 1. Goldfarb v. Virginia State Bar, 421 U.S. 773 (1975). 2. Kenneth J. Arrow, "Uncertainty and the Welfare Economics of Medical Care," The American Economic Review, Vol. 53, No. 5 (December 1963).

Why Did US Physicians Give Up Their Ability to Enforce Their Own Professional Standards?

In his recent review of Dr Ezekiel Emanuel's book, ( Healthcare, Guaranteed: A Simple, Secure Solution for America ,) Dr Arnold Relman, ...

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We have a winner for the Google Photography Prize

Huge congratulations to <a href="http://www.google.com/intl/en/landing/photographyprize/vote.html#theme15">Daniel Halasz</a> from Hungary, who was awarded the <a href="http://www.google.com/intl/en/landing/photographyprize/">Google Photography Prize</a> this week. This was a global student competition to create themes for <a href="http://www.google.com/ig">iGoogle</a>. More than 3,600 students from across the world entered, and a couple of weeks ago we asked you to <a href="http://googleblog.blogspot.com/2009/06/voting-for-igoogle-photo-themes-now.html">vote on the shortlist</a>. The six finalists who got the most public votes were <a href="http://www.google.com/intl/en/landing/photographyprize/vote.html#theme2">Amelia Ortúzar</a> (Chile), <a href="http://www.google.com/intl/en/landing/photographyprize/vote.html#theme13">Fahad AlDaajani</a> (Saudi Arabia), <a href="http://www.google.com/intl/en/landing/photographyprize/vote.html#theme24">Matjaz Tancic</a> (U.K.), <a href="http://www.google.com/intl/en/landing/photographyprize/vote.html#theme26">Mikhail Simin</a> (U.S.) and <a href="http://www.google.com/intl/en/landing/photographyprize/vote.html#theme33">Vesna Stojakovic</a> (Serbia) — congratulations to all of them! From that group, a jury of respected art critics and artists chose Daniel as the winner. They also gave a special commendation prize to <a href="http://www.google.com/intl/en/landing/photographyprize/vote.html#theme17">Aliyah Hussain</a> from the U.K. You can see the work Daniel and the other finalists submitted at the Saatchi Gallery in London until Sunday, June 28th. Come by if you're in town, or have a look at their photographs on <a href="http://www.google.com/photographyprize">google.com/photographyprize</a>, where you can also add them to your <a href="http://www.google.com/ig">iGoogle homepage</a>. Posted by Posted by Louise Rigby, Consumer Marketing Team

We have a winner for the Google Photography Prize

Huge congratulations to Daniel Halasz from Hungary, who was awarded the Google Photography Prize this week. This was a global student comp...

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Google Voice invites on their way

A couple of months ago we <a href="http://googleblog.blogspot.com/2009/03/here-comes-google-voice.html">announced Google Voice</a>, a service that gives you one phone number to link all your phones and makes voicemail as easy as email. We are happy to share that Google Voice is beginning to open up beyond former GrandCentral users. If you <a href="https://services.google.com/fb/forms/googlevoiceinvite/">requested an invitation</a> on the Google Voice site or previously on GrandCentral, keep your eye out for an invite email. Once you receive your invitation, just click on the link and follow the instructions to setup your new Voice account. To help you find a Google number that is personalized to you, we've added a number picker that lets you search by area code and text. See if you can find a number that contains your name, a specific word or a number combination. <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjNodkQUmj8oVrQNU5Ez6zFoBFyG2iGg65BlV92dKSG6Cl8KeHeZMTdPDTZRBc9f6TACwJWeAP-3jOxMUNimp2bXrJXKqplLpAa8g3YdVCtI7agj_bAPrfvA-vo0IsEIGjKPnbTmss-9Ejf/s1600-h/picker+-+awesome.png" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5351303399178489650" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjNodkQUmj8oVrQNU5Ez6zFoBFyG2iGg65BlV92dKSG6Cl8KeHeZMTdPDTZRBc9f6TACwJWeAP-3jOxMUNimp2bXrJXKqplLpAa8g3YdVCtI7agj_bAPrfvA-vo0IsEIGjKPnbTmss-9Ejf/s400/picker+-+awesome.png" style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 400px; height: 288px;" /></a> To learn more about Google Voice, check out the video below. If you haven't signed up for a Google Voice invite, make sure to get on the list by leaving us your email address at <a href="http://www.google.com/voiceinvite">www.google.com/voiceinvite</a>. <object height="344" width="425"><param name="movie" value="http://www.youtube.com/v/m4Q9MJdT5Ds&hl=en&fs=1&"><param name="allowFullScreen" value="true"><param name="allowscriptaccess" value="always"><embed src="http://www.youtube.com/v/m4Q9MJdT5Ds&hl=en&fs=1&" type="application/x-shockwave-flash" allowscriptaccess="always" allowfullscreen="true" height="344" width="425"></embed></object> Posted by Craig Walker and Vincent Paquet, Product Managers, Google Voice

Google Voice invites on their way

A couple of months ago we announced Google Voice , a service that gives you one phone number to link all your phones and makes voicemail as ...

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The RUCkus Continues: Former Medicare Administrator Calls the "RUC Process" "Incredibly Flawed," and the AMA Chair Says He's "Inaccurate"

We have posted frequently about the role of the RBRVS Update Committee (RUC) in fixing the rates at which Medicare pays physicians. These payment rates have been much more generous for procedures than for "cognitive" services, (that is, services including interviewing and examining patients, making diagnoses, forecasting prognoses, recommending tests or treatments, and counseling patients.) Several authors have suggested that how the RUC fixes payment rates is a major cause of the decline of primary care. (See our previous posts on this <a href="http://hcrenewal.blogspot.com/2007/03/on-disparities-between-reimbursement-of.html">here</a>, <a href="http://hcrenewal.blogspot.com/2007/12/is-sustainable-growth-rate-main-problem.html">here</a>, <a href="http://hcrenewal.blogspot.com/2008/05/payments-for-patient-centered-medical.html">here</a>, <a href="http://hcrenewal.blogspot.com/2008/07/can-we-fix-medicare-while-pretending.html">here</a>, <a href="http://hcrenewal.blogspot.com/2008/12/no-such-ruc-new-england-journal-takes.html">here</a>, <a href="http://hcrenewal.blogspot.com/2009/02/what-ruc-again-one-of-worlds-most.html">here</a>, and <a href="http://hcrenewal.blogspot.com/2009/06/letter-from-ruc-and-my-reply.html">here</a> and important articles by Bodenheimer et al,[1] and Goodson.[2]) An Interview with a former Medicare administrator Health Affairs just published an interview(3) with Kerry Weems, a recent administrator of the US Center for Medicare and Medicaid Services (CMS) under the Bush administration, who had some remarkable criticism for the RUC. <blockquote> Iglehart: The last question I wanted to ask you relates to the Specialty Society Relative Value Scale Update Committee [RUC] of the American Medical Association. The AMA formed the RUC to act as an expert panel in developing relative value recommendations to CMS. The twenty-nine-member committee essentially determines, through the relative values it establishes for the codes that form the basis of Medicare payments, how much doctors will earn from providing services to beneficiaries. In recent years the RUC has come under criticism based on the view that its specialty- dominated composition undervalues primary care services and, in some instances, overvalues specialty services. I have two questions, Kerry, regarding the RUC. You have been in government for twenty-six years; have you ever heard of an administration that has seriously questioned the RUC process, and whether CMS ought to somehow internalize it or delegate it to another body? Weems: I think there is a general consensus that the RUC has contributed to the poor state of primary care in the United States. In many ways the supposition behind the RUC process, behind the whole relative value scale, is incredibly flawed. It's an input measurement system, so it asks, What's the cost of my inputs, and that's how I'm going to price my outputs. It has no relationship to perhaps the market value of what you might buy. So because it's highly procedure based, it's prejudiced against just standard primary care evaluation and management [E&M] visits, because in an E&M visit it's hard to document what happens in the same way that it is when you remove a mole, or perform some other procedure. So the process itself is flawed. I don't think that we can make a change without a statutory change giving us the ability to do that. But it's something that is drastically needed. You know, it's funny that we talk about better coordination of care and creating the medical home. Well, the place where this can occur is in an E&M visit, which has been highly undervalued by the RUC. Iglehart: You say that the RUC process is seriously flawed and needs to be overhauled. Was there ever any discussion during the eight years of the George W. Bush administration about doing that? Weems: There were a number of discussions, but it's a hard nut to crack. Those discussions never ripened to the point where we could say we've got something better. Iglehart: But you'd anticipate under the Obama administration that those discussions will continue? Weems: Sure. And, you know, you can even see the early attempts at trying to crack that. Representative [Pete] Stark [D-CA] introduced last year the so-called CHAMP [Children's Health and Medicare Protection Act] bill, in which he proposed to develop a new payment approach that would have provided more money to primary care physicians. He split it up into several different categories. This probably wasn't the right approach, but again, he was trying to work through the problem, trying to provide more money for primary care. His heart was in the right place. </blockquote> There are a number of important points here. First, a former CMS administrator charged that the RUC has a substantial role in the decline of primary care in the US. Such charges have been made by well-reputed academics who have analyzed the role of the RUC from the outside. But as we have said before, aspects of what the RUC does are obscure, especially because the proceedings of RUC meetings are not made public. But now someone more directly involved has made the same charges. Second, a former CMS administrator has called the "RUC process ... incredibly flawed." Even the second Bush administration felt these flaws were sufficient to have "a number of discussions," but found "it's a hard nut to crack." Hence he said that although there is something fundamentally wrong with the "RUC process," the government could not easily fix it. Yet RUC leadership has repeatedly said that the RUC is merely a private advisory committee which gives recommendations to CMS using its rights to free speech and to petition the government. (Note also that above, Inglehart first said that the RUC was formed as "an expert panel" to make "recommendations." But then he said the committee "determines ... how much doctors will earn.") If the RUC is simply an advisory committee, and CMS did not like the advice the RUC was giving, why couldn't CMS leaders simply ignore the RUC? Weems' remarks do not make sense if the RUC is merely an outside private group providing advice. But they do make sense if the RUC is acting like a government agency. So this interview once again raises the question: why does CMS rely exclusively on the RUC to update the RBRVS system, apparently making the RUC de facto a government agency, yet without any accountability to CMS, or the government at large? A response by the Chair of the Board of the AMA Within days of this interview, Dr Rebecca Patchin, the Chair of the Board of Trustees of the American Medical Association (AMA), wrote a response to the Weems interview. (Amazingly, the response appeared as a <a href="http://healthaffairs.org/blog/2009/06/24/the-rucs-record-defending-primary-care/#more-1469">blog post </a>on the Health Affairs Blog.) First, she implied that a former CMS administrator did not know what he was talking about when it came to the RUC. <blockquote>In the interview, inaccurate statements were made about the role of the AMA/Specialty Society RVS Update Committee (RUC), which advises CMS regarding the relative levels of reimbursement for different medical procedures performed by physicians. </blockquote> Now I feel like I am in good company. The leaders of the RUC have charged that I made inaccurate statements about the RUC as well (see post <a href="http://hcrenewal.blogspot.com/2009/06/letter-from-ruc-and-my-reply.html">here</a>). However, Dr Patchin failed to identify any particular statements by Kerry Weems or his interviewer as inaccurate, much less provide any evidence to that effect. Note that while the RUC leaders also charged me with making inaccurate statements, they did not specify any particular statements as inaccurate, much less produce evidence in support of their contentions. Next, Dr Patchin wrote: <blockquote>Every time the RUC has been asked to review payments for E&M (evaluation and management) codes, the RUC has sent CMS recommendations that would lead to higher payments. </blockquote> This may be so, but it ignores an important issue. While the RUC may have made some recommendations to increase payments for cognitive services, it has made many more recommendations to increase payments for procedural services. Furthermore, while payments for individual procedures went up, and the volume of procedures also went up, the global budget for physicians' services, called the Sustainable Growth Rate (SGR), resulted in across the board cuts. Since raises for procedures were larger and more frequent than raises for cognitive services, the net effect was that payments for procedures increased relative to cognitive services. Even more important, it begs that question: what has the RUC done at times when no one asked it "to review payments for E&M ... codes?" After all, the RUC leadership has argued again and again that it is only a private advisory committee (and see below for another such argument). As such, it should be able to choose how often it deals with payments for cognitive services. It should not have to wait to be asked to review them. So why wasn't the RUC reviewing these payments more frequently? Then, Dr Patchin reiterated: <blockquote>To clarify: The RUC makes recommendations to CMS, and then CMS makes its payment decisions. </blockquote> and again, <blockquote> Bottom line: the RUC makes recommendations, CMS makes payment decisions. </blockquote> This, once more, begs the questions. Why didn't the RUC make more recommendations to improve payments for cognitive services? Why doesn't CMS get recommendations about payments to physicians from sources other than the RUC? Why doesn't CMS make the process for setting physicians' payments, and updating and revising the RBRVS system more broad-based and transparent? Why did the administrator of CMS feel unable to change or ignore the "RUC process?" I don't have the capacity to find out the answers to these questions. Answering them might take some investigative reporting, or even a Congressional investigation. Given that physicians' payments are key incentives driving the health care system, and that payments favoring procedures are likely to be a major cause for rising volume and costs of procedures, which, in turn, is likely to be a major reason our health care system is so expensive, why do we know so little about how these payment rates are set? References 1. Bodenheimer T, Berenson RA, Rudolf P. The primary care-specialty income gap: why it matters. Ann Intern Med 2007; 146: 301-306. Link <a href="http://www.annals.org/cgi/content/full/146/4/301">here</a>. 2. Goodson JD. Unintended consequences of Resource-Based Relative Value Scale reimbursement. JAMA 2007; 298(19):2308-2310. Link <a href="http://jama.ama-assn.org/cgi/content/short/298/19/2308">here</a>. 3. Iglehart JK. Doing more with less: a conversation with Kerry Weems. Health Aff 2009; <a href="http://content.healthaffairs.org/cgi/content/full/hlthaff.28.4.w688/DC1">http://content.healthaffairs.org/cgi/content/full/hlthaff.28.4.w688/DC1</a>

The RUCkus Continues: Former Medicare Administrator Calls the "RUC Process" "Incredibly Flawed," and the AMA Chair Says He's "Inaccurate"

We have posted frequently about the role of the RBRVS Update Committee (RUC) in fixing the rates at which Medicare pays physicians. These pa...

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Announcing the AdSense for Mobile Applications beta

You don't have to be a mobile expert to see how smartphones are revolutionizing our daily lives. Lower prices, faster network speeds and unlimited data plans mean that people often reach for their cell phone rather than their computer when they are seeking information. As a result, mobile applications have become more and more popular, helping people find music, make restaurant reservations or check bank balances — all on their phone. We want to contribute to the growth of these mobile applications, which is why we're happy to announce our beta launch of <a href="http://www.google.com/ads/mobileapps">AdSense for Mobile Applications</a>. After all, advertisers are looking for ways to reach potential customers when they are engaged with mobile content, and application developers are looking for ways to show the best ads to their users. We have already had a successful trial of this service with a small number of partners, and are excited that we can now offer this solution to a broader group. AdSense for Mobile Applications allows developers to earn revenue by displaying text and image ads in their iPhone and Android applications. For our beta launch, we've created a <a href="http://www.google.com/ads/mobileapps">site</a> <link: com="" ads="" mobileapps=""> where developers can learn more about the AdSense for Mobile Applications program, see answers to frequently asked questions and sign up to participate in our beta. Advertisers can also learn about the benefits of advertising in mobile applications. We're excited to open up this beta to more developers, and look forward to offering new features for our mobile advertisers and publishers in upcoming releases. We also want to say a big thank you to the partners who worked with us on the trial stages of this project including Backgrounds, Sega, Shazam, Urbanspoon and more. Check out this short video of Howard Steinberg, Director of Business Development at <a href="http://urbanspoon.com/">Urbanspoon</a>, discussing his experience with AdSense for Mobile Applications. <object height="340" width="560"><param name="movie" value="http://www.youtube.com/v/AaMDikYsO_g&hl=en&fs=1&rel=0"><param name="allowFullScreen" value="true"><param name="allowscriptaccess" value="always"><embed src="http://www.youtube.com/v/AaMDikYsO_g&hl=en&fs=1&rel=0" type="application/x-shockwave-flash" allowscriptaccess="always" allowfullscreen="true" height="340" width="560"></embed></object> Posted by Susan Wojcicki, Vice President, Product Management</link:>

Announcing the AdSense for Mobile Applications beta

You don't have to be a mobile expert to see how smartphones are revolutionizing our daily lives. Lower prices, faster network speeds and...

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The Day in the Cloud Challenge has begun

Today, we invite you to take part in the <a href="http://www.dayinthecloud.com/?utm_source=google&utm_medium=blog&utm_campaign=ogb">Day in the Cloud Challenge</a>, an online scavenger hunt that's being played simultaneously on the ground and in the air aboard Virgin America flights across the U.S. The Day in the Cloud demonstrates how people can use <a href="http://www.google.com/apps/">Google Apps</a> to stay connected with friends, family and co-workers when they're away from their homes — even at 35,000 feet in the air. <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh1okR5FMDKhZzof8y_cD1_jawsFmevVmntFZSaXo6GZH7hXsYUhcEXQlYLVzbhDn5IfKTtNvDJyAzvaRSJsPafeRhY6-RLp8DwWeLjIOXcN_5l6hmCF5ZuR9y9GME-wS9fAINcPX1SLVVs/s1600-h/Game_Play_Screen.png" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5350913163529906818" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh1okR5FMDKhZzof8y_cD1_jawsFmevVmntFZSaXo6GZH7hXsYUhcEXQlYLVzbhDn5IfKTtNvDJyAzvaRSJsPafeRhY6-RLp8DwWeLjIOXcN_5l6hmCF5ZuR9y9GME-wS9fAINcPX1SLVVs/s400/Game_Play_Screen.png" style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 400px; height: 237px;" /></a> The <a href="http://www.dayinthecloud.com/?utm_source=google&utm_medium=blog&utm_campaign=ogb">online game</a> will be available until 11:59pm PDT today, so find a quiet spot, do some finger stretches, and take the challenge. Posted by Vivian Leung, Google Apps Team

The Day in the Cloud Challenge has begun

Today, we invite you to take part in the Day in the Cloud Challenge , an online scavenger hunt that's being played simultaneously on the...

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Let's make the web faster

From building data centers in different parts of the world to designing highly efficient user interfaces, we at Google always strive to make our services faster. We focus on speed as a key requirement in product and infrastructure development, because our <a href="http://googleresearch.blogspot.com/2009/06/speed-matters.html">research</a> indicates that people prefer faster, more responsive apps. Over the years, through continuous experimentation, we've identified some performance best practices that we'd like to share with the web community on <a href="http://code.google.com/speed">code.google.com/speed</a>, a new site for web developers, with tutorials, tips and performance tools. We are excited to <a href="http://groups.google.com/group/make-the-web-faster">discuss</a> what we've learned about web performance with the Internet community. However, to optimize the speed of web applications and make browsing the web as fast as turning the pages of a magazine, we need to work together as a community, to tackle some larger challenges that keep the web slow and prevent it from delivering its full potential: <ul><li>Many protocols that power the Internet and the web were developed when broadband and rich interactive web apps were in their infancy. Networks have become much faster in the past 20 years, and by collaborating to update protocols such as HTML and TCP/IP we can create a better web experience for everyone. A great example of the community working together is <a href="http://en.wikipedia.org/wiki/HTML_5">HTML5</a>. With HTML5 features such as AppCache, developers are now able to write JavaScript-heavy web apps that run instantly and work and feel like desktop applications.</li></ul><ul><li>In the last decade, we have seen close to a <a href="http://www.webmonkey.com/print/blog/Google_Throws_Its_Weight_Behind_HTML_5">100x improvement</a> in JavaScript speed. Browser developers and the communities around them need to maintain this recent focus on performance improvement in order for the browser to become the platform of choice for more feature-rich and computationally-complex applications.</li></ul><ul><li>Many websites can become faster with little effort, and collective attention to performance can speed up the entire web. Tools such as Yahoo!'s <a href="http://developer.yahoo.com/yslow/">YSlow</a> and our own recently launched <a href="http://code.google.com/speed/page-speed/">Page Speed</a> help web developers create faster, more responsive web apps. As a community, we need to invest further in developing a new generation of tools for performance measurement, diagnostics, and optimization that work at the click of a button.</li></ul><ul><li>While there are now more than 400 million broadband subscribers worldwide, broadband penetration is still relatively low in many areas of the world. Steps have been taken to bring the benefits of broadband to more people, such as the <a href="http://googlepublicpolicy.blogspot.com/2008/11/vote-for-broadband-in-white-spaces.html">FCC's decision</a> to open up the white spaces spectrum, for which the Internet community, including Google, was a strong champion. Bringing the benefits of cheap reliable broadband access around the world should be one of the primary goals of our industry. </li></ul>To find out what Googlers think about making the web faster, see the video below. If you have ideas on how to speed up the web, please <a href="http://moderator.appspot.com/#15/e=79951&t=79d39">share</a> them with the rest of the community. Let's all work together to make the web faster! <object height="340" width="560"><param name="movie" value="http://www.youtube.com/v/IWWBnJEsUtU&hl=en&fs=1&rel=0"><param name="allowFullScreen" value="true"><param name="allowscriptaccess" value="always"><embed src="http://www.youtube.com/v/IWWBnJEsUtU&hl=en&fs=1&rel=0" type="application/x-shockwave-flash" allowscriptaccess="always" allowfullscreen="true" height="340" width="560"></embed></object> Posted by Urs Hoelzle, SVP, Operations and Bill Coughran, SVP, Engineering

Let's make the web faster

From building data centers in different parts of the world to designing highly efficient user interfaces, we at Google always strive to make...

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