Govt in Healthcare Causing Critical Doctor Shortage

Posted on May 31, 2017May 31, 2017 by Denise Simon

Affording medical school, impossible, paying back college loans, impossible, paying all the administrative/paperwork labor costs in practice, impossible, relying on prompt payments from government on Medicare, impossible, care by government compliance standards, impossible.

Burnout = Probable

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Blame Obamacare and Congress for the coming drought of doctors

When you go to the Internet or phone book today, there are hundreds of physicians listed in most urban areas. But in the next two decades, you can expect more difficulty finding a physician in your hometown — a major physician shortage is looming, thanks to Obamacare and Congress.

In the last year, I have seen many mid-career physicians leaving the practice of medicine. While the growth of mid-level hospital administrators has ballooned by nearly 3,000 percent in the last 30 years, fewer students are entering medical school. In fact, according to Compdata surveys, hospital administrators now account for a large proportion of the costs of healthcare.

The pending physician shortage will affect both primary care as well as numerous essential subspecialties. When I was in medical school, I was told that specialists, such as cardiologists, would be in abundance and I would not be able to get a job. My classmates and I were pushed towards jobs in primary care.

However, many of us chose to pursue our passions — for me, it was cardiovascular medicine. I have been a practicing cardiologist for almost 17 years now — I never had any issue with finding a job in my chosen field.

Based on a new report from the Association of American Medical Colleges, it is expected that we will see a shortfall of nearly 100,000 doctors by the year 2030. A closer look at the predictions show that we will have a shortage of 40,000 primary care physicians, as well as a shortage of nearly 60,000 physicians in specialties such as allergy and immunology, cardiology, gastroenterology, and infectious disease. In general surgery, the report predicts that there will be 30,000 fewer surgeons than are needed to provide care to those who need it.

Why Are Doctors Leaving Medicine?

A 2016 report from the Physicians Foundation found an alarming growth in burnout and dissatisfaction among practicing physicians — 47 percent of respondents in the survey indicated plans to “accelerate” their retirement and move into areas outside of clinical medicine.

The most common reason for leaving medicine included regulatory burdens and electronic health records. Nearly 63 percent indicated that they have negative feelings about the future of healthcare and only half of all physicians would actually recommend a career in medicine to their children. Many of my colleagues feel they have no voice and have no way to impact healthcare policy — even in their own institution.

As regulatory requirements and non-clinical tasks continue to mount, physicians are finding themselves spending less and less time with patients. According to 2016 research from the Annals of Internal Medicine, most doctors only spend 25 percent of their day engaging with patients — the bulk of the time is spent on non-clinical electronic and regulatory paperwork. In fact, for every hour of direct patient contact, physicians have an additional 2 hours of electronic paperwork.

Most of this is due to either mandatory electronic medical record coding (to help the hospital systems bill at the maximal levels) or due to government-mandated documentation (such as asking about gun use during office visits — most of which has never shown a survival or outcome benefit).

What Is the Solution?

These statistics should be incredibly troubling for all Americans seeking healthcare. With access already an issue in the healthcare system for many and more reforms on the way, we must do more to entice bright young minds to medicine—and retain those that are currently delivering care to millions of patients.

While the AAMC argues that the answer to averting a shortage lies in creating more training spots and allowing advanced practice nurses and physician assistants to do the work of trained physicians, the real answer to the pending crisis lies in Washington.

Congress must act to save healthcare. Years of Obamacare and the resulting increase in regulations applied to physicians have begun to erode the very core of medical care — the doctor-patient relationship. Physicians are now tasked with checking boxes and filling out forms rather than bonding with patients.

Congress has spent the first 6 months of this year simply posturing and grandstanding about healthcare rather than actually working on meaningful reform. Once again, no real physician input into the creation of a workable healthcare reform bill has been sought by those in Washington (reminiscent of how Obamacare was created). Those in Congress must listen and act now:

1. Limit Meaningless Electronic Paperwork

Currently doctors spend far too much time with electronic medical records. Electronic records, while touted to be a patient safety tool, are nothing more than a way for hospitals and healthcare systems to ensure that they are billing patients at the highest levels — capturing all possible charges. Physicians are forced to click through myriad pathways in the record in order to document their care and work and all of these pathways are carefully designed to maximize billing codes. Most doctors take home two or more hours of electronic documentation nightly in order to keep up with patient care loads.

We must streamline paperwork and balance documentation with patient care. Doctors should not be billers and coders for the healthcare system.

2. Remove Hospital Administrators from the Care Equation

In some institutions, there are more mid-level managers than physicians. These executives are not physicians and are not trained in the practice of medicine. Their primary focus is to increase market share for the healthcare system and to “manage” healthcare professionals by creating algorithms of care and regulations. Administrators will claim that their activities will help with quality improvement and patient safety. However, most of these individuals are highly compensated and I am not aware of any data that suggests their activities have ever been shown to improve patient outcomes. For most physicians, administrators are a mechanism for increasing cost of care.

Physicians should be part of the decision-making process in any healthcare system and should have a voice — currently there are very few physicians in the C-suite.

3. Remove Barriers to Patient Care

Nothing frustrates doctors more than not being able to provide care to patients. We must make healthcare more accessible and provide physicians with the resources they need to efficiently provide high-quality affordable care. We must promote the use of telemedicine and digital tools to enhance the doctor-patient interaction.

We must allow physicians and patients to build long term relationships and facilitate and promote engagement. No longer can we allow networks and insurers to dictate which doctor a patient can see — “If you like your doctor, you can keep your doctor.”

4. No Longer Allow Insurance Companies to Dictate Care

As a practicing physician, I spend a great deal of time battling with insurance companies over appropriate care for my patients. I find myself spending hours each week on the phone with an insurance company bureaucrat arguing that a particular test or therapy is indicated (even though these are supported by clinical guidelines) rather than caring for patients. We must not allow insurers to dictate how highly-trained physicians should care for their patients.

Insurers must abide by the practice guidelines and indications for tests and procedures that have been approved by major national organizations, such as the American College of Cardiology, for example.

Toronto Uni. Report on Russian Information Warfare

Posted on May 25, 2017May 25, 2017 by Denise Simon

The Citizen Lab is an interdisciplinary laboratory based at the Munk School of Global Affairs, University of Toronto, Canada focusing on advanced research and development at the intersection of Information and Communication Technologies (ICTs), human rights, and global security. The Citizen Lab’s ongoing research network includes the Cyber Stewards Network, OpenNet Initiative, OpenNet Eurasia, Opennet.Asia. The Citizen Lab was a founding partner of the Information Warfare Monitor (2002-2012).

Russian spies may have backed email phishing campaign in effort to spread disinformation

218 email accounts across 39 countries targeted, report by University of Toronto’s Citizen Lab finds

New evidence of a global espionage campaign involving email phishing attacks and leaked falsified documents emerged on Thursday, with clues suggesting the Russian government might have been involved.

The targets spanned government, industry, military and civil society groups, each with ties to Russia or Russian interests, a report by the University of Toronto’s Citizen Lab suggests.

Although there is no definitive proof of Russia’s involvement in the attacks, there is “overlap” with previously reported Russian espionage activities — in particular, the work of a Russia-backed hacking group known as APT-28, or Fancy Bear.

Notably, Citizen Lab’s researchers say “an identical approach” to the phishing campaign described in their report was used in a March 2016 attack targeting Hillary Clinton’s presidential campaign and the Democratic National Committee.

“While we have no ‘smoking gun’ that provides definitive proof linking what we discovered to a particular government agency … our report nonetheless provides clear evidence of overlap with what has been publicly reported by numerous industry and government reports about Russian cyberespionage,” wrote Citizen Lab director Ron Deibert in a blog post.

U.S. reporter’s documents leaked, manipulated

The report focuses in part on what the authors have termed “tainted leaks,” leaks of stolen documents that are largely authentic but have been manipulated in certain parts to achieve a particular goal — in this case, a political one.

In the incident Citizen Lab examined, documents obtained through a phishing operation in October 2016 that targeted the email account of U.S. journalist David Satter were selectively modified in an apparent attempt to discredit Satter and his work and then posted online. Satter has reported on Russia for decades and was expelled from the country in December 2013.

In unpacking that particular leak, Citizen Lab then identified a further 218 unique email accounts spanning 39 countries that had been targeted using the same phishing method used to fool Satter.

The accounts belong to members of governments — including “a former Russian prime minister, members of cabinets from Europe and Eurasia, ambassadors, high-ranking military officers, CEOs of energy companies” — but also members of civil society organizations, such as academics, activists, journalists and employees with non-governmental organizations that have been critical of the Russian government or investigated its activities.

The scope of the targets, the report says, “suggests a well-resourced actor, such as a nation state.”

Fancy Bear

U.S. intelligence officials believe Russian-backed groups conducted a series of cyberespionage campaigns throughout 2015 and 2016 in an attempt to interfere with and potentially sway the outcome of last year’s presidential election.

One group in particular was mentioned frequently in coverage of the attacks: APT-28, sometimes referred to by the nickname Fancy Bear. It is believed that the group is backed by a nation state, if not a nation state itself — namely, Russia.

While Citizen Lab’s researchers could not make a “conclusive technical link” between their findings and Fancy Bear, they identified a number of similarities with the group’s prior attacks.

For example, some of the domain names used in the campaign Citizen Lab studied bear a striking similarity to a Fancy Bear linked phishing operation identified by the cybersecurity research firm Mandiant last year. There are also similarities with the methods used to break into the email account of Clinton’s campaign chairman, John Podesta — suggesting, at the very least, two separate actors are sharing the same code.

Tainted Leaks

Civil society groups are particularly rich targets for cyberespionage campaigns, as they tend to lack the resources of larger or better funded organizations to deal with digital attacks. Of note, the researchers say that 21 per cent of those targeted in the campaign they studied were activists, academics, journalists, and NGOs — the second-largest set after government targets.

“Many of the civil society targets seem to have been singled out for the perception that their actions could pose a threat to the Putin regime,” the report said.

In Satter’s case, leaked documents were selectively modified in such a way that the majority remained authentic, but misinformation was seeded throughout, in an attempt to lend legitimacy to otherwise false information. The researchers compared Satter’s case with that of a prior attack on the grant-making organization Open Society Foundations (OSF).

For example, one document was modified “to make Satter appear to be paying Russian journalists and anti-corruption activists to write stories critical of the Russian government,” the report said.

In the OSF case, modifications were made to documents detailing a budget and funding strategies to make it appear as if the U.S.-based group was sponsoring Russian opposition leader Alexei Navalny’s Foundation for Fighting Corruption.

Earlier this month, falsified documents appeared in a trove of documents taken from staff on French President Emmanuel Macron’s election campaign.

Described as “fakes in a forest of facts,” the report concludes that such tainted leaks “test the limits of how media, citizen journalism, and social media users handle fact checking and the amplification of enticing but questionable information.”

However, University of Toronto political science professor Seva Gunitsky says the practice of tainting leaks with false information could ultimately backfire.

“If they actually discover something politically damaging in a future phishing attack, it will be hard to credibly claim it was a real find,” he said. “Of course, if the overall goal is just to sow informational chaos, tainted leaks are a good way of doing that.”

Germany’s Secret Bundeswehr

Posted on May 24, 2017May 24, 2017 by Denise Simon

The secret German army, with soldiers from other countries has a variety of duties. There is a growing concern in Europe, but what about NATO? That question goes to President Trump. The secret is, no one is talking about it openly, further there was no real reason given on why VP Pence travel to meet top NATO officials to calm the nerves regarding the viability of NATO due to President Trump. Article 5 remains a large question with European leaders.

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The original Bundeswehr has a scandalous history. Nazi Veterans Created Illegal Army

First, there will be cyber soldiers

The German military (Bundeswehr) on Wednesday is launching a brand new “cyber army” to fight against digital attacks on networks and weapons systems. But some are concerned about how this new unit might engage in cyber assaults itself.

Defence Minister Ursula von der Leyen will announce the new unit in Bonn on Wednesday afternoon. The ministry wants to deploy around 13,500 soldiers and civilian workers by 2021 to protect the Bundeswehr’s networks and weapons systems, but the unit must also be capable of launching their own attacks against hackers.

The Chief of Staff of the new cyber army is Lieutenant-General Ludwig Leinhos, who is an expert in electronic warfare.

Cyber attacks are a growing concern in Germany, with the Federal Office for Information Security (BSI) reporting last year that the government’s computer networks are hit by around 20 highly specialized attacks per day.

German intelligence agencies and the BSI last year began work on setting up their own special cyber response teams.

According to broadcaster N-tv, the Bundeswehr’s new cyber soldiers will be on equal ranking with their colleagues in the army, air force and marines – and their new beret colour will be grey.

Parliamentary ombudsman for the Bundeswehr, Hans-Peter Bartels (SPD), warned that the new cyber unit should be kept under parliamentary control, though, as part of their work would entail launching cyber attacks of their own.

Bartels told the Neue Osnabrücker Zeitung on Wednesday that the cyber army must seek permission from the Bundestag (German parliament) before launching such assaults.

“Every offensive measure of our constitutionally enshrined parliamentary army needs to have the explicit mandate of the Bundestag,” Bartels said, adding that this policy goes for not only military assaults, but also virtual attacks on the data network of an adversary.

Bartels stressed that the cyber army was desperately needed to protect the Bundeswehr’s computer and weapons systems. But he also criticized the fact that the new unit is only now being created.

“Germany is not a pioneer here,” he said. “One can already learn from the experiences of other countries, like the USA or Israel.”

Second, the conventional forces

Germany is to increase the size of its armed forces amid growing concerns over the security of Europe.

Troop numbers in the Bundeswehr will be raised to almost 200,000 over the next seven years, under new plans announced on Wednesday.

The move comes days after Mike Pence, the US vice-president, called on Nato’s European members to increase military spending.

President Donald Trump has repeatedly demanded Europe pay more towards the cost of its own defence.

The move also comes amid growing concern in European capitals over Mr Trumps’ commitment to Nato, after he described the alliance as “obsolete”.

Under the new plans, Germany will recruit 20,000 more troops by 2025, bringing its total service personnel to 198,000.

That is slightly more than the British armed forces’ current strength of 196,410.

In a statement announcing the plans, Ursula von der Leyen, the defence minister, said: “The Bundeswehr has rarely been as necessary as it is now.

“Whether it is the fight against Isil terrorism, the stabilization of Mali, continuing support of Afghanistan, operations against migrant smugglers in the Mediterranean or with our increased Nato presence in the Baltics.”

The announcement came as Germany deployed tanks and hundreds troops to Lithuania as part of a Nato force to deter Russian aggression.

During the Cold War, West Germany was considered the first line of defence against a Soviet invasion and at its height the Bundeswehr had 500,000 active service personnel.

But in the years following the fall of the Berlin Wall and German reunification defence spending dropped sharply.

Germany ended conscription in 2011 and troop numbers fell to an all-time low of 166,500 in June last year.

Cold War historians described West Germany’s army as “perhaps the best in the world”.

But in more recent years it has been better known for embarrassing equipment shortages that saw soldiers forces to use broomsticks instead of guns on Nato exercises, and use ordinary Mercedes vans to stand in for armoured personnel carriers.

The German air force was forced to ground half of its ageing Tornado fighters last year over maintenance issues, including six that are deployed on reconaissance missions against Islamic State in Iraq and the Levant (Isil) in Syria.

There are growing calls for Europe to do more to secure its own defence after Mr Trump described Nato as “obsolete” in an interview in January, and earlier this month Angela Merkel’s government was forced to take the unusual step of denying that it is interested in becoming a nuclear power.

Mr Trump has repeatedly accused Nato’s European members of not paying enough towards the cost of their defence and during the US presidential campaign Mr Trump warned the US may not necessarily come to the aid of Nato allies if they are attacked.

German Bundeswehr Soldiers of the ‘battalion of armored infantryman’ called ‘Panzergrenadierbataillon 122’ sit on a wrecker called ‘Bueffel’ during vehicles wait to be loaded onto a train in Grafenwoehr, Germany, 31 January 2017, before being deployed as part of a NATO force in Lithuania Credit: LUKAS BARTH/EPA

Mr Pence sought to reassure jittery European allies in a speech at Nato headquarters in Brussels on Monday in which he said the US’ “commitment to Nato is clear”. But he demanded “real progress” in increased European defence spending.

Ms von der Leyen has been attempting to reverse the decline of Germany’s armed forces, and already announced a smaller increase in troop numbers last year. Those targets were revised upwards with Wednesday’s announcement.

It is estimated the increases will cost Germany between around €900m (£760m) a year. But the amount is still far short of the extra €25.4bn Germany would have to spend on defence each year to meet Nato’s annual target of 2 per cent of GDP.

The UK is one of only five Nato members to meet the target at present, along with the US, Greece, Estonia and Poland.

Despite boasting the largest economy in Europe, Germany lags far behind, spending only 1.19 per cent of its GDP on defence in 2016.

U.S. is Doing ‘That’ Extreme Vetting in Australia

Posted on May 23, 2017May 23, 2017 by Denise Simon

Remember on the campaign trail when President Trump said it was stupid to take the Syria refugees Australia was holding on a remote island that was under agreement by Barack Obama? Remember when there was a discussion between President Trump and the Prime Minister of Australia where apparently Trump hung up the phone, terminating the conversation. The Prime Minister visited the Trump White House and now all is allegedly fine between the two countries.Remember when VP Pence finally agreed to honor the deal and accept those refugees? The reason? The US. is accepting a number of those refugees.

Exclusive: U.S. starts ‘extreme vetting’ at Australia’s offshore detention centers

Reuters: U.S. Homeland Security officials have begun “extreme vetting” interviews at Australia’s offshore detention centers, two sources at the camps told Reuters on Tuesday, as Washington honors a refugee swap that U.S. President Donald Trump had called “a dumb deal”.

The Trump administration said last month the agreement to offer refuge to up to 1,250 asylum seekers in the centers would progress on condition that refugees satisfied strict checks.

In exchange, Australia has pledged to take Central American refugees from a center in Costa Rica, where the United States has expanded intake in recent years, under the deal struck with former President Barack Obama.

DailyMail

The first security interviews finished last week at Papua New Guinea’s Manus Island detention center, two refugees who went through the process told Reuters.

The refugees told Reuters that interviews began with an oath to God to tell the truth and then proceeded for as long as six hours, with in-depth questions on associates, family, friends and any interactions with the Islamic State militant group.

VOANews

“They asked about why I fled my home, why I sought asylum in Australia,” said one refugee who declined to be named, fearing it could jeopardize his application for U.S. resettlement.

The security interviews are the last stage of U.S. consideration of applicants.

Manus Island is one of two Australian-operated detention centers, which hold nearly 1,300 people who were intercepted trying to reach Australia by boat.

Human rights groups have condemned the intercept policy and the harsh conditions of the camps. Australia says offshore processing is needed as a deterrent after thousands of people drowned at sea before the policy was introduced in 2013.

A decision on the fate of the first 70 people interviewed is expected to be reached within the next month, a different source who works with refugees said.

A spokesman for Australia’s immigration minister refused to comment on the resettlement process.

A U.S. State Department spokeswoman said that refugees from the Australian-run facilities will be subject to the same stringent vetting applied to all refugees who are being considered for entry to the United States.

“The United States remains deeply committed to safeguarding the American public, just as we are committed to providing refuge to some of the world’s most vulnerable people. These goals are not mutually exclusive,” she said.

The White House did not immediately respond to questions.

U.S. President Donald Trump’s plans for extreme vetting have extended to those traveling to the United States from Muslim countries.

Australia’s relationship with the new administration in Washington got off to a rocky start when Trump lambasted Australian Prime Minister Malcolm Turnbull over the resettlement arrangement, which Trump labeled a “dumb deal”.

Details of an acrimonious phone call between the pair soon after Trump took office made headlines around the world. Australia is one of Washington’s staunchest allies and has sent troops to fight alongside the U.S. military in conflicts in Iraq and Afghanistan.

The relocation of asylum seekers to the United States is designed to help Papua New Guinea and Australia proceed with the planned closure of the Manus detention center on Oct. 31.

But the fate of approximately 200 men deemed non-refugees is uncertain.

Those not offered resettlement in the United States will be offered the chance to settle in Papua New Guinea or return home.

Australia has already offered detainees up to $25,000 to voluntarily return home; an offer very few have taken up.

Moscow’s Igor Sergun: Cong. Rohrabacher to your ‘Like Button’

Posted on May 19, 2017May 19, 2017 by Denise Simon

One part of this Moscow mess began in 2012, when the FBI held a private session with Congressman Dana Rohrahacher, (CA), Mike Rogers, Michigan, and according to one former official, Representative C. A. Dutch Ruppersberger, telling them they were the targets of Russian influence and possible targets of recruiting.

Of note, Igor Sergun died in January of 2016, but his operations were already underway.

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Sergun is credited as an important figure in the renaissance of the GRU, which had suffered deep staff and budget cuts prior to his arrival. Under Sergun, the agency regained political power within the Russian government as well as control over the Spetsnaz special forces, making it “crucial in the seizure of Crimea and operations in the Donbas,” as well as “as the lead agency for dealing with violent non-state actors.”

Perhaps the United States should take a hard look at the actions Ukraine has taken regarding Russian intrusion.

Poroshenko this week ordered Ukrainian Internet providers to block Vkontakte and Odnoclassniki. The sites are similar to Facebook and are two of the most popular social networking sites in the former Soviet space.

More than 25 million Ukrainians, in a country of about 43 million people, use the Russian sites to connect with friends, join groups and use the online messaging systems.

Poroshenko said the new restrictions were necessary to further protect Ukraine from Kremlin hybrid warfare, including disinformation campaigns, propaganda and military attacks. The two neighbors and former Soviet republics have been embroiled in a brutal, three-year war that has killed more than 10,000 people and displaced about 1.7 million eastern Ukrainians.

Supporters of the ban said it would also protect Ukrainians from the Russian security services’ ability to monitor and gather metadata from the sites’ users. Ukrainian government officials said the sites are closely monitored by Russia’s FSB, the successor agency to the KGB. More here from LATimes.

One must take the time to see the evidence the domestic intelligence agencies and private cyber companies along with data analysis experts are uncovering and studying. Further, since we citizens cannot attend meetings, some in classified settings that are held in Congress and we don’t get any information from the investigations, there are some interviews with professionals that are sounding the alarm bells.

Are you sick of Russia and hearing about Putin? Sure you are, but so is our government and other global leaders, rightly so. You are going to have to understand some facts and buckle in….there is more to come. Until the United States crafts a policy, decides on responses and pass legislation, Russia has nothing to stop their actions. What actions?

In part from Time: On March 2, a disturbing report hit the desks of U.S. counterintelligence officials in Washington. For months, American spy hunters had scrambled to uncover details of Russia’s influence operation against the 2016 presidential election. In offices in both D.C. and suburban Virginia, they had created massive wall charts to track the different players in Russia’s multipronged scheme. But the report in early March was something new.

It described how Russia had already moved on from the rudimentary email hacks against politicians it had used in 2016. Now the Russians were running a more sophisticated hack on Twitter. The report said the Russians had sent expertly tailored messages carrying malware to more than 10,000 Twitter users in the Defense Department. Depending on the interests of the targets, the messages offered links to stories on recent sporting events or the Oscars, which had taken place the previous weekend. When clicked, the links took users to a Russian-controlled server that downloaded a program allowing Moscow’s hackers to take control of the victim’s phone or computer–and Twitter account.

As they scrambled to contain the damage from the hack and regain control of any compromised devices, the spy hunters realized they faced a new kind of threat. In 2016, Russia had used thousands of covert human agents and robot computer programs to spread disinformation referencing the stolen campaign emails of Hillary Clinton, amplifying their effect. Now counterintelligence officials wondered: What chaos could Moscow unleash with thousands of Twitter handles that spoke in real time with the authority of the armed forces of the United States? At any given moment, perhaps during a natural disaster or a terrorist attack, Pentagon Twitter accounts might send out false information. As each tweet corroborated another, and covert Russian agents amplified the messages even further afield, the result could be panic and confusion.

***

Americans generate a vast trove of data on what they think and how they respond to ideas and arguments–literally thousands of expressions of belief every second on Twitter, Facebook, Reddit and Google. All of those digitized convictions are collected and stored, and much of that data is available commercially to anyone with sufficient computing power to take advantage of it.

That’s where the algorithms come in. American researchers have found they can use mathematical formulas to segment huge populations into thousands of subgroups according to defining characteristics like religion and political beliefs or taste in TV shows and music. Other algorithms can determine those groups’ hot-button issues and identify “followers” among them, pinpointing those most susceptible to suggestion. Propagandists can then manually craft messages to influence them, deploying covert provocateurs, either humans or automated computer programs known as bots, in hopes of altering their behavior.

That is what Moscow is doing, more than a dozen senior intelligence officials and others investigating Russia’s influence operations tell TIME. The Russians “target you and see what you like, what you click on, and see if you’re sympathetic or not sympathetic,” says a senior intelligence official. Whether and how much they have actually been able to change Americans’ behavior is hard to say. But as they have investigated the Russian 2016 operation, intelligence and other officials have found that Moscow has developed sophisticated tactics.

In May 2016, a Russian military intelligence officer bragged to a colleague that his organization, known as the GRU, was getting ready to pay Clinton back for what President Vladimir Putin believed was an influence operation she had run against him five years earlier as Secretary of State. The GRU, he said, was going to cause chaos in the upcoming U.S. election.

What the officer didn’t know, senior intelligence officials tell TIME, was that U.S. spies were listening. They wrote up the conversation and sent it back to analysts at headquarters, who turned it from raw intelligence into an official report and circulated it. But if the officer’s boast seems like a red flag now, at the time U.S. officials didn’t know what to make of it. “We didn’t really understand the context of it until much later,” says the senior intelligence official. Investigators now realize that the officer’s boast was the first indication U.S. spies had from their sources that Russia wasn’t just hacking email accounts to collect intelligence but was also considering interfering in the vote. Like much of America, many in the U.S. government hadn’t imagined the kind of influence operation that Russia was preparing to unleash on the 2016 election. Fewer still realized it had been five years in the making.

Putin publicly accused then Secretary of State Clinton of running a massive influence operation against his country, saying she had sent “a signal” to protesters and that the State Department had actively worked to fuel the protests. The State Department said it had just funded pro-democracy organizations. Former officials say any such operations–in Russia or elsewhere–would require a special intelligence finding by the President and that Barack Obama was not likely to have issued one.

After his re-election the following year, Putin dispatched his newly installed head of military intelligence, Igor Sergun, to begin repurposing cyberweapons previously used for psychological operations in war zones for use in electioneering. Russian intelligence agencies funded “troll farms,” botnet spamming operations and fake news outlets as part of an expanding focus on psychological operations in cyberspace.

One particularly talented Russian programmer who had worked with social media researchers in the U.S. for 10 years had returned to Moscow and brought with him a trove of algorithms that could be used in influence operations. He was promptly hired by those working for Russian intelligence services, senior intelligence officials tell TIME. “The engineer who built them the algorithms is U.S.-trained,” says the senior intelligence official.

Soon, Putin was aiming his new weapons at the U.S. Following Moscow’s April 2014 invasion of Ukraine, the U.S. considered sanctions that would block the export of drilling and fracking technologies to Russia, putting out of reach some $8.2 trillion in oil reserves that could not be tapped without U.S. technology. As they watched Moscow’s intelligence operations in the U.S., American spy hunters saw Russian agents applying their new social media tactics on key aides to members of Congress. Moscow’s agents broadcast material on social media and watched how targets responded in an attempt to find those who might support their cause, the senior intelligence official tells TIME. “The Russians started using it on the Hill with staffers,” the official says, “to see who is more susceptible to continue this program [and] to see who would be more favorable to what they want to do.”

Finish reading this remarkable report here. There is much more detail, including cyber operations, candidates, analysis and concocted political scandals. If one wonders why there is yet no evidence presented yet by the FBI and what the members of Congress are told, you now have a clue. This investigative process is a very long one and attributions as well as analysis is cumbersome and heavy on expert resources.