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Posted Sep 07 2008 8:39pm
This writer had the opportunity to participate in some AHIC Successor discussions this week. Although it is early in the process and the overall scope and intent are not clear by purpose and will evolve, the need for some group to convene and reconcile various sincere efforts seems important. With the diversity of talent and (by and large) altruistic intent of the many individuals who spent some hours in the BrookingsIntitution this week, optimism in the democratic process should be the dominant theme.

But even optimists need focus. At present, the process resembles the classic "prisoner's dilemma" known to every student of game theory. In one room sits a group of prisoners thinking though the governance of the organization; in a separate room sits a group of prisoners thinking about membership; in a third sits a group concerned a group of prisoners reflecting on how a nascent organization with no clear membership will be sustainable. Later (only 24 hours) convenes a group to transition from the current AHIC to the successor.

When the prisoners get together in the prison yard (or the "plenary session") they are inclined to speak with humor and diplomacy. All are too uncertain of the positions of others to make strong declarations. (The guards are watching; premature disclosure and commitment may have serious consequences.)

Fortunately in this case, the resolution to the prisoner's dilemma - information exchange - is under the stewardship of a talented group from Brookings. Informed and highly focused coordination is essential at this juncture.

Those who confuse broad concepts and generic white papers with the coordination required of this task need to get out and talk to the various stakeholders who are too busy holding their stakes to attend a seemly endless array of meetings. To relate to the current airline inspection quandary, the travellers suffering from the inspection debacle are all waiting in line - they are not in a position to solve the problem, but they are the ones actually affected by it.


Perhaps an analogy to America's space program is relevant. Long ago, John Kennedy said "we're going to put a man on the moon within the decade." That was an idea the nation identified with and it left to the engineers the difficult tasks of making it happen. One can argue that all we did was fly up there, take some great pictures, and exchange our cameras for a few rocks. Or one can argue that the collateral benefits were enormous and help define the productivity we enjoy today.

But Kennedy didn't say "Let's convene a public-private, inclusive partnership to address in a broad and aggressive way all of the problems of outer space, because, well, you know space is important and if we don't figure it out someone else will." He didn't emphasize astronomer participation or anything else. He left that to the collective talents of those responsible. Those individuals did not translate the President's clear vision into a public rhetoric that emphasized "thruster milestones" and "interoperability between the fuel-sensors and the whatchamacallits." He just said "get to the moon." Although there were strict requirements emphasizing safety, mistakes were made (astronauts literally were cooked, if one remembers the tragic 1967 Apollo 1 catastrophe), but we got to the moon and those who participated in this effort developed new an unimagined technologies that were applied outside of the moon project to the public and private good. Neither Kennedy nor NASA had people who said "let's certify asteroids because, well, they can destroy the earth; we don't want to be the next dinosaurs, do we?" Cooler heads prevailed. Milestones were set, and collectively things were accomplished.

This writer suggests that although the analogy to "space exploration and understanding" is the right long term goal and the analogy to "thruster technology interoperability" is essential, these are not the right means of leading an effort and either capturing nor maintaining the public imagination.

Our current President did that. He said something like "Let's make sure everyone has an EHR by 2014." Clearly such an effort requires a lot of moving parts, and it must be effective. But the vision was clear. In this writer's view, " EHR" really stands for "availability of my health information when - and only when - I need it for my care." It is a broad mandate.

The 2004 Brailer and Thompson report elaborated on this by articulating four very important goals.
  • Informing clinical practice
  • Interconnecting clinicians
  • Personalize care
  • Improve population health
These goals again can be simply articulated to the public and to the health care community - although the interpretations will vary. They have been further enhanced by Secretary Leavitt's"four conerstones" approach. Great ideas that will make an enormous difference.

Such ideas are not partisan and should transcend administrative changes at the federal and state level. They are aspirations we as patients all should internalize and act on.

This writer was inspired by the talents trying to work through some very important issues. There seemed a great belief that there is a window of opportunity governed more by our Nation's health care needs and technology evolution than by the electoral calendar. There is a commitment here that should be refined and supported.

From this writer 's perspective, let's find the people who can focus on a path toward a more effective health care system. Let's stay highly focused on a "version 1.0" and let it grow. Let's keep all essential parties focused on technical matters in the back room and bring them out with someone who can translate to the many beneficiaries of technology. Let's charge the "let's certifyasteroids" and others who lose the forest for the trees with a very important task within their capabilities: Ask them to go out and return coffee and snacks while reasoned minds learn from our past mistakes and drive a critical agenda forward. We'll worry about the asteroids later.

If we do not focus on a few, generic initiatives that will, of their own accord, raise in a rational way all of the broader concerns, we will not have met public expectations and we will have squandered a precious opportunity.
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