Written Friday, August 17, 2007

I’m sitting on an airplane, headed to Africa. It’s a 15-hour flight, so I’ll write for a few minutes before trying to sleep.

I just finished reading the first volume of the briefing material. This looks to be an extremely valuable trip. I’ll be in South Africa, Mozambique, Tanzania and Rwanda. I want to see, first hand, HHS and U.S. Government research, programs, staff and partners in action, especially in the President’s Malaria Initiative and our work on HIV-AIDS. I also hope the trip reinforces partnerships with those countries. I’ll be doing some public diplomacy events in each country. I worry not enough people know all the things our government does in health diplomacy. We need to tell the story better. Health is a universal language; people always appreciate it.

The schedule is packed every day so it is unclear to me how often I’ll be able to post thoughts. At very least, I’ll have someone post pictures from time to time. We will be going into some remote areas and I’m not sure what my access will be to the Internet.

Speaking of the Internet…

Today we had an important meeting at HHS related to electronic medical record standards. The development of standards for interoperable health information systems is one of my most significant goals. I believe the standards required to make this electronic medical records system work have to be collaboratively developed among various stakeholders. About two years ago we created the American Health Information Community for that purpose. Rather than try to write much about it I will ask one of my colleagues to insert a link here to the AHIC website: http://www.hhs.gov/healthit/community/background/

People have been talking about interoperable systems for years but the standards to make them work haven’t materialized. So, those who invest in electronic health records are isolated. Many others put investment off, waiting until the systems mature.

This is an extraordinarily complex problem but the biggest challenges aren’t technological; they’re sociological, i.e. conflicting economic interests and turf. AHIC has successfully created a place and process to sort through them in an orderly way. We are starting to make serious progress which you can read about on the website.

Our plan from the beginning has been to get the standards development process started inside the government and then once it is functioning create a non-profit entity that operates under a highly democratic governance system so the progress can be accelerated and perpetuated. I call the transition moving from AHIC 1.0 to AHIC 2.0.

The government will have to be the biggest participant in the process, but to get these things right, the entire health sector has to be at the table in a meaningful way. The federal government will not only be the biggest participant but we have also committed to use the standards developed there. The President signed an Executive Order last August making clear that all the federal agencies, including Medicare, Medicaid, the Veterans Administration, and Department of Defense etc. will adopt the standards. We need to insist those we pay do the same thing, over time.

Today we held a meeting with interested people and organizations to invite their help in creating the non-profit entity and its governance.

The last several years I have become rather interested in collaboration as a large scale problem solving tool. I’m persuaded skillful organization of collaborations is a 21st century skill set. It is a close cousin to network theory. In fact, I think collaboration is the sociology of network building.

Our world is intuitively organizing itself into networks. Networks require standards to operate. The skills to navigate the creation and governance of networks constitute the next frontier of human productivity. Organizations and societies that learn to solve complex problems using these skills will begin to out pace their competitors.

The development of AHIC 2.0 is a significant venture. I’m optimistic it can produce a vitally important institution but it will require our best statesmanship to overcome the natural tension of competing economic interests and turf.

If readers have a chance to look through the AHIC website, I’d be interested to hear your thoughts.

One last thing...

My heart has been with my fellow Utahn’s who are suffering through the coal mine disaster near Huntington. As Governor of Utah, I got to know the people of that area well and I went into the mines several times, so I have a picture in my mind of the environment those rescue workers and the trapped workers are working in. I’m grateful for the courageous action of the rescuers; sad for the families and community; mindful of the excruciatingly difficult decisions the mine safety people are faced with. They are all in my prayers.

-Mike Leavitt

Comments

[Allen]

Dr Leavitt,

I read your link (http://www.hhs.gov/healthit/community/background/ ) to AHIC.

To have an electronic prescription that *any* pharmacy can fill would be good.

To be able to see part or all of one's medical records. I can not remember my weight, cholesterol numbers, etc from two years ago or to see trends in those numbers. I do remember my Tethus shots, etc and my doctor was surprised to find out I remembered the right dates. I see how this helps empower the patient to monitor themselves and take a more active role in their health.

I thought HIPPA covered a lot of the data standards and information portabillity. Paramedics have a standard data format for collecting and transmitting patient information.

The biggest non standard area will be the free form text fields for notes and "Interpretations."

Now data can have multiple keys so there does not have to be one standard identification number across multiple systems.

The page does not list that police and federal agents will be able to view the data. Is there any provision for notifying the doctor or patient when this happens?

What about pictures? X-Rays and cat scans are stored electronically.

How is this system suppose to be as good as or better than HIPPA with regard to patient confidentiality? HIPPA breaks down in some places now.

I do hope this will help with a pandemic. Though a prescription is not much good if "According to FDA Congressional testimony in 2000, over 80% of the ingredients in U.S. medications are manufactured overseas."

Source http://www.therubins.com/geninfo/costeffec.htm

With the "just in time" delivery of medication to pharmacies there may be shortages. One can not stock pile controlled substances. People know that and they do worry.

The three rescue workers who also lost their life trying to rescue those trapped underground.

Regards,
Allen

[Manfred Sternberg]

Mr. Secretary, I appreciate your leadership in this area, but with all due respect I ask the following question. (You should ask as well as there is no justifiable excuse) Why is it that the @45 million Americans on Medicare/Medicaid have a plastic or paper ID card without any electronic information contained on it, when the Government seems to be seriously discussing leading the US Healthcare sector into the information age? Why can’t CMS lead the way and issue 45 million ID cards electronically containing people's demographic information and date of birth, a small but first step at administrative efficiency? No more information would be contained electronically than is on the printed side of the card so there is no greater loss of privacy than exists with the ID cards today. The cost cannot be much as the same technology that they use for a $2.00 one time parking transaction could be used for an ID card that changes infreequently.

Giving health insurance ID cards magnetic stripes, with basic plan information could be inexpensively and relatively quickly implemented. Government would set the standard so the multi-billion dollar private healthcare payer industry would follow and could soon be as technologically savvy as credit/debit card companies, libraries, grocery stores, parking lots, gyms and even the Texas Department of Public Safety (consider the magnetic stripe on the Texas driver’s license).

Unfortunately, although this concept is endorsed by physicians, hospitals and patients, the insurance industry appears to be against the idea. Could it be because the current cumbersome, error prone and patient-unfriendly system often allows insurance companies to delay and avoid reimbursement? One recent study by the Mid-America Coalition on Health Care found that 50% of all physician claims rejected by health plans are bounced back because of incorrect patient identification.

Nearly all health insurance plans already issue customers ID cards printed with the plan’s group number and often the patient’s co-payment. However, this is insufficient to help patients and providers correctly utilize coverage in an increasingly complex health care system. Smart cards for health insurance would give access to important, up-to-date medical and coverage information that can be retrieved during both routine and emergency care.

After setting the standard for a piece of plastic that most citizens already carry in their wallets, the Government should then step aside and let the free market take over. Virtually all credit and debit cards used commercially in the United States, and most other Electronic Benefits Transfer cards, use magnetic stripes that can be scanned by inexpensive readers designed for that purpose. The infrastructure to extend this technology to health insurance cards already is in place.

The alternative is to keep having to make photocopies, phone calls and simple data entry errors that often cause payment holdups. The insurance industry’s opposition to this simple concept is indicative of their collective foot dragging to keep the healthcare industry a paper based industry for as long as they can. Despite their feel good marketing campaigns, the reality is that the health insurance industry has no incentive to support change to what is already a highly profitable business that earns a part of its profit on the administrative inefficiency of the Healthcare industry itself.
My suggestion is to stop talking about consumer empowerment, and actually engage the consumer. I believe our oppurntuniy is actually hidden in plain sight in the consmer’s wallet today, their Medicare ID card. Why does HHS refuse to leverage that fact to empower the consumer?

Full disclosure: I am not in the card or magnetic stripe business. I am simply a Texas board-certified consumer lawyer in the Healthcare Information Technology (HIT) business who has been unable to get a valid answer to the question: Why do my grocery and health club cards carry accurate ID data on me, yet my healthcare benefit card is a plain piece of plastic requiring extended interaction for ID verification? (Meanwhile healthcare stakeholders and politicians are lamenting about the high costs of gross inefficiencies in healthcare and describing how HIT will help.)

[Julie Brainard]

Dr. Leavitt,
I just read an article about your current trip
on the internet, which led me here. I wanted to encourage you in the work you are doing for the betterment of our neighbors, especially those in the African nations. South Africa is particularly dear to my heart, having just returned from a church missions trip there in June. We were astonished at the complete hush about AIDS and the stigma attached to it. It is clearly affecting the community we worked in, Worcester, but no one is speaking about it except the church we partnered with, and even they acknowledge that is a difficult subject to broach. I applaud the President's efforts in AIDS relief and am firmly in favor of his approach to AIDS education. Education is critical in these areas where it continues to proliferate in an atmosphere of secrecy and shame. It is so discouraging to witness. Thank you for your service to this great nation, of which I am immensely proud to be a citizen, and for your service to humanity in general. I will follow your work with interest. Good luck in negotiating your next few days. I will pray for progress and receptivity. Sincerely,
Julie Brainard
Tucson, Arizona

[Bruce]

Mr. Secretary,

It is sad that on the very day you are traveling to Africa to try and do some good with respect to AIDS/HIV that HHS also chose to issue a letter to all 50 states that would restrict and cut coverage to thousands of children through the State Children's Health Insurance Program (SCHIP).

SCHIP is an incredibly successful program that has reduced the number of uninsured children in America by one-third. Why would we choose to backtrack on that success for children? As a nation, we should try to leave the next generation healthier and stronger than the last and investments in the health and well-being of children today reap long-term improvements and savings in the future.

The President promised to do whatever it takes to cover eligible but unenrolled children in Medicaid and SCHIP when he ran for re-election. What happened to that campaign promise? Or, was it just that -- a campaign promise that nobody intended to fulfill.

[Allen]

Dr. Leavitt,

I no longer envy your position. So many repercussions to consider from even small actions.

But alas, "Make no small plans. They have no magic to stir men's blood and probably will not themselves be realized." D. Burnham History is not made in small plans.

Magnetic strips wear out and offer no protection from un-authorized reading. Any one with a mag strip card reader can read what is put there. Some criminals have even put a second card reader on ATM machines to duplicate the card strip. (http://www.bankrate.com/brm/news/atm/20021004a.asp). Magnetic strips can also be updated or rewritten. RF-ID chips can be read at a distance and some can be updated.

Embedded chips hold so much information but offer password protection. Social security numbers where to be kept by one government office and never to be released - now they are mandatory. Still is the risk of not getting it right the first time any reason not to talk about solutions? Even two dimensional bar codes hold so much extra information.

You know I write about pandemic preparedness for those who are prepared suffer less than those who are not prepared.

Yesterday there was a heated discussion if ADHD medication is "quality of life issue at risk from pandemic." The consensus was yes but as one person remarked. "Weather it is diet or discipline people have no qualms over diabetes or heart medication yet ADHD medication is an emotional battle between deeply entrenched separate camps.'

I hope that while in Africa you see how difficult pharmaceutical drugs deliver can be. Problems arise more their controlled distribution and use than their manufacture.

Not only do I hope we can help other countries, learn what works in other countries but keep any and all the known problems from happening here.

Regards,
Allen
"Make no small plans. They have no magic to stir men's blood and probably will not themselves be realized." D. Burnham

[Allen]

Dr. Leavitt,

Two of the many news stories from FluWiki

Online computer game allosw people to simulates next pandemic
Source:
http://www.alertnet.org/thenews/newsdesk/N20310540.htm

Excerpt:
By Maggie Fox, Health and Science Editor

WASHINGTON, Aug 20 (Reuters) - A plague carried around the world by travelers, pets and curious teen-agers may show that experts have not taken everything into account when planning for an outbreak of disease, researchers said on Monday.

Luckily, the world involved is an Internet game.

The outbreak of "Corrupted Blood" indicates that specialists trying to predict what the next pandemic will look like might make use of a real-world laboratory -- the culture of online gamers.

British to grow poppies domesticly to have pain killers for possible pandemic
Source:
http://www.timesonline.co.uk/tol/news/uk/article2289283.ece
Excerpt:
"In Britain, 3,000 hectares (7,400 acres) of land has already been planted in the hope of making Britain self-sufficient in diamorphine and guaranteeing a supply should a flu pandemic put an impossible strain on drug manufacturers"

Regards,
Allen

[Stefanie]

Dr. Leavitt,

In your August 17th post regarding the AHIC, you state "The President signed an Executive Order last August making clear that all the federal agencies, including Medicare, Medicaid, the Veterans Administration, and Department of Defense etc. will adopt the standards. We need to insist those we pay do the same thing, over time."

I have a question about the "we need to..." portion of this statement. Does this administration currently have a plan to tie federal reimbursement to private health care providers to adoption of the standards set out by the AHIC? Or has this been a stumbling block in the plan for implementation? I agree with your assessment, we need to. Without this financial incentive private entities will be slow to adopt the standards.

An additional question-is there any plan for covering the cost of implementation for private health care providers?

Thank you for your time-Stefanie

[Bill Spooner]

With all due respect, Mr Secretary, we have decades of non-collaboration among the HIT community. Vendors work in their self-interest, which to date supports their positions of non-interoperability. The only thing moving the vendor community even slightly has been the hammer of CCHIT, HITSP, AHIC, etc. Turning AHIC into an industry collaborative will result in even slower progress, if any, towards agreement on standards adoption and interoperability.
Thank you for your efforts to date. Please do not lose what we have gained.