The Health Insurance Portability and Accountability Act (HIPAA) PL 104-191 was enacted in September 1996 to deal first with the administrative transactions in healthcare, and particularly Medicare and Medicaid, which had been seeing escalating costs due to the plethora of forms and electronic message formats. These transactions utilize only a small fraction of the data elements in the EHR and until this Act there was little incentive to agree on common conventions for the concepts used for these administrative transactions so that until this issue had been addressed there would be little leverage to move toward common conventions for the full EHR as had been recommended in the 1991 IOM Report (see Ref A3). For those healthcare enterprises not granted a waiver, the Transaction standards became effective in Oct 2002 and for the rest Oct 2003; the Privacy/Confidentiality Standards will become effective April 2003. These administrative transactions will be only the first step in establishing common conventions  (standards) for the implementing technology-independent conceptual content of the EHR. Certain of the Standards Developer Organizations (SDOs) who are members of the ANSI HITSP have been identified as Designated Standards Maintenance Organizations (DSMOs) with respect to the  HIPAA Transaction Standards.