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Is Interoperability A Technical Or Business Challenge In Healthcare?

October 29, 2019 By Dan Munro

JULY 7, 2015

NB: This article first appeared as a 3-part series on Health Standards in July of 2015. Much of the insight and information is unchanged ‒ and it is as relevant today in 2020 ‒ as it was over 4 years ago.

(approximately 4,250 words ‒ or about 20 minutes)


The voices around healthcare interoperability are becoming louder, more frequent and more urgent ‒ which is a great thing. Recently the fires were stoked again by both Leonard Kish (here) and then even more urgently by Paul Levy with this provocative headline ‒ “We’ve been swindled.” The key quote by Paul ‒ at least for me ‒ is this one:

Our national interest does not coincide with those corporate strategic interests.

He’s right, of course, but it also made me think of another quote by Florida Governor Rick Scott.

How many businesses do you know that want to cut their revenue in half? That’s why the healthcare industry won’t reform the healthcare industry.

We can debate Rick’s personal credibility for this quote another time, but as the founder of Columbia Hospital Corporation (at age 34) which bought HCA (in 1994) to become (in 1997) the world’s largest commercial healthcare enterprise ‒ his business credibility for this exact quote is beyond debate.

For those who follow me on Forbes ‒ I’ve written about interoperability in healthcare a fair amount starting early last year with a 5‒part series on the topic. That series launched with coverage of a keynote by Malcolm Gladwell (here) at a daylong summit on interoperability sponsored by West Health. The importance of the topic and the intersect with other aspects of healthcare IT (patient safety and cybersecurity to name just two) have prompted me to continue adding coverage to this critically important healthcare topic.

Some of the latest demanding insistence around interoperability in healthcare misses many of the key historical overlaps which I think are worth reviewing. Two in particular.

The world of packet-switching technology had a similar dilemma during the early days of its evolution as the driving force behind the internet using a very young standard called internet protocol (or IP). As a group, the emerging router and switching vendors ‒ names like Cisco, 3Par, Juniper, Brocade, Ascend Communications, and Lucent ‒ even truncated the word so that it could become more manageable.

In that world, interoperability is referenced simply as “interop.” They still hold an annual event called simply Interop ‒ but the needs around basic packet switching have been largely resolved (or avoided) and so the needs have greatly diminished ‒ as has the size and scope of the annual event.

Before moving to Las Vegas in 1994, the show attracted about 65,000 attendees and then consumed the Las Vegas Convention Center, often in its entirety. Today it’s a much smaller event at the Mandalay Bay with about 10,000 attendees each spring and about 300 vendors. In fairness, Interop now has four distinct venues around the world ‒ so the show is more globally dispersed. For purposes of comparison ‒ HIMSS ‒ the annual healthcare IT extravaganza is well on its way to about 40,000 in attendance and over 1,000 vendors.

My point with that is simply to recognize the trajectory and intersect of an important technical discipline ‒ networking and data interop. Whether we realize it or not we’ve successfully navigated the unknowns of network interop for over 45 years. That world has had its battles and most of those have been successfully navigated or avoided outright. Today, the global internet largely works (and sometimes fails) because of those technical and business settlements.

That’s not to say all is perfect harmony or without big glaring challenges, however, and that’s the technical vulnerability of networks that interoperate easily (security and privacy). I’ve also written about the challenge of security and privacy because it intersects so directly with what’s becoming the richest single gathering of individual data at scale ‒ our health data.

Part 2:

In Part 1 of this three-part series we saw how the world of packet-switching technology truncated the word “interoperability” to just “interop” and how that world successfully navigated many of the early technical challenges inherent in building an infrastructure for the benefit of an entire vendor community and global industry.

The parallels are similar to healthcare except for a few key variables ‒ and one in particular. A lack of urgency by many in the healthcare IT community to act cooperatively for the benefit of both consumers and an entire industry. Given the life-and-death consequence associated with health data interop some consider this to be outright criminal negligence ‒ even if there’s no legal basis for prosecution. Those are serious ‒ some might say exaggerated ‒ charges. Legal matters are for the courts to decide, of course, but here are some useful definitions:

Negligence: Failure to act with the prudence that a reasonable person would exercise under the same circumstances.

Criminal negligence: Recklessly acting without reasonable caution and putting another person at risk of injury or death (or failing to do something with the same consequences).

In fairness, it’s not entirely the fault of vendors who design and sell software. As a software engineer myself, I know that all too often it’s the buyers who pay for design specs that protect their commercial interests as well ‒ so it’s really a shared culpability.

Today, most of the focus for healthcare interop revolves around the lack of Electronic Health Records (EHR) to easily share patient data, but that’s only part of the whole story. There’s also an urgent need for broader healthcare interop that includes medical devices, wearables and other sensors that are destined for our health future. Many of these devices are also hampered by lack of data interop ‒ and in some cases ‒ even direct patient access. In these battles, patients are caught squarely in the middle of competing commercial interests around systems that have been optimized for revenue and profits ‒ not safety and quality. Two patient cases highlight the challenge beyond just the EHR.

In November 2011, Hugo Campos took to the TEDx stage in Cambridge to share the story of his implantable cardiac defibrillator (ICD). While the device literally collects every beat of his heart, the manufacturer (Medtronic) considers the digital data “stream” to be their rightful and legal property. An entirely separate device (used to capture the data for clinical interpretation) is also proprietary to Medtronic as a part of the closed-loop ICD “system.” Hugo is the host for their device ‒ but not considered an active participant.

In the world of medical devices, the truly antiquated thinking has often been that patient access to this type of clinical data is simply inappropriate and should only be collected and interpreted by clinicians. Using this antiquated logic, why should the format be anything BUT proprietary?

As a Type-1 Diabetic, Anna McCollister‒Slipp described her frustration in trying to manage data from four different electronic devices (clinically prescribed) because each of the devices has its own proprietary data formats.

These are amazing machines – it’s incredible technology – and the care of diabetes has improved dramatically because of them and because of some of the newer insulins that we have on the market. However, one of the most important things for me and for others like me with Type 1 in terms of managing our disease is understanding [the] patterns and right now all of my medical devices use different data formats, different data standards [and] they don’t communicate. The View of Digital Health From an ‘Engaged Patient’ – Forbes

Dr. Bob Wachter described the history behind some of the more immediate challenges with EHR software (including a 39‒fold overdose of a common antibiotic) in his recent book ‒ The Digital Doctor. The book should be required reading (almost a textbook) for everyone in healthcare IT because understanding the history of “wiring healthcare” (his phrase) is critical to understanding many of the current business tensions. Not surprisingly, he also arrived at a conclusion that many of us have been arguing for years.

“Underlying many of the discussions regarding personal health records, health exchanges, and interoperability is the need for a universal patient identifier, and ultimately a universal patient record that would be accessible anywhere to you or others who need it. Congress passed and President Clinton signed a law banning the use of federal funding to create such a number. This means that any effort to share records between hospitals, or even to access your medical history if you arrive at the ER unconscious, has to begin by solving the high-stakes Sudoku game of figuring out who the hell you are.” [bold emphasis mine ‒ page 189 of The Digital Doctor]

This particular “Sudoku game” is fraught with errors. In a 2012 Recommendation to Congress HIMSS cited this sobering statistic.

Patient-data mismatches remain a significant and growing problem. According to industry estimates, between eight and 14 percent of medical records include erroneous information tied to an incorrect patient identity. The result is increased costs estimated at hundreds of millions of dollars per year to correct information. These errors can result in serious risks to patient safety. Mismatches, which already occur at a significant rate within individual institutions and systems will significantly increase when entities communicate among each other via HIE ‒ a Meaningful Use Stage 2 requirement ‒ that may be using different systems, different matching algorithms, and different data dictionaries.

Dr. Wachter found additional support from Michael Blum (CIO of UCSF Medical Center) who called the Congressional ban on establishing a universal patient identifier “the biggest single failure in the history of health IT legislation.” [page 189 of The Digital Doctor]

The natural fear ‒ and the one that has derailed all efforts to this point ‒ remains patient privacy. That’s not an unreasonable fear because in the course of less than 12 months, the U.S. healthcare system lost almost 96 million records (about 30% of the U.S. population) to cybertheft. This happened without a national patient identifier. That’s not to say the records would have been safe by simply adding a national patient identifier, but we need more technical security ‒ including an intelligent identifier ‒ not just a name, social security number and home address.

The technical reality is that without modern data standards in healthcare, our personal health information is at greater risk as long as we rely on antiquated methods of simple numbers and text fields (that are prone to easy data entry errors ‒ and then require complex games of Sudoku to figure out who the hell we are).

Healthcare is certainly not unique as an industry that has struggled with standards. Without going into the rich and colorful history of health IT standards ‒ competing commercial interests often create an endless loop. This loop isn’t unique to healthcare, of course, but the stakes in healthcare are quite literally measured in human lives.

standards_comic
Courtesy of XKCD (http://xkcd.com/927/)

There is, however, another industry that does parallel healthcare in some important ways relative to data interop and the comparison might be surprising ‒ auto manufacturing.

Auto manufacturing had a interesting data interop problem from about 1954 to 1981. During those years ‒ as auto manufacturing was growing rapidly ‒ each auto manufacturer developed their own vehicle identification numbering system. Chaos ensued in that it was virtually impossible to track vehicles quickly ‒ let alone nationally. Vehicle tracking is important across at least five important vectors.

  1. Theft
  2. Accidents
  3. Damage (floods, tornadoes etc…)
  4. Recalls
  5. “Lemons”

Like the healthcare industry, auto manufacturing also has many stakeholders with a wide range of needs to track vehicles nationally and quickly.

  • Consumers
  • Law enforcement
  • Insurance companies
  • Manufacturers
  • Legislation around vehicle and consumer safety

Much like healthcare, transportation (including vehicle identification) is largely an issue of consumer safety.

So, in 1981, the National Highway Traffic Safety Administration (NHTSA) mandated the use of a 17 character VIN (based on International Standard Organization ‒ ISO 3779), and while it’s not perfect – it does make it much easier to track cars nationally with relative ease. It has become so successful that auto manufacturers now stamp the VIN on almost all of the major components of each new car. The success of CarFax today hinges not on being able to get the information quickly online ‒ but the underlying VIN standard for tracking cars nationally from assembly to salvage ‒ and every step in between. It’s a simple database query.

Part 3

In Part 2 of this series we saw how Vehicle Identification Numbers (VINs) were established by the National Highway Transportation and Safety Administration (NHTSA) and how they brought order to the chaos of vehicle tracking on a national scale.

In fact, there’s a much larger list of NHTSA standards beyond just vehicle identification. Under Title 49 of the United States Code, Chapter 301 ‒ Motor Vehicle Safety ‒ the NHTSA has a legislative mandate to issue Federal Motor Vehicle Safety Standards (FMVSS) and Regulations “to which manufacturers of motor vehicle and equipment items must conform and certify compliance.” 

With some dating as far back as 1968, Part 571 of FMVSS lists a range of standards around just one safety category called Crash Avoidance. To understand the level of detail, here are the first four standards in that sub-category.

  • Standard No. 101 ‒ Controls and Displays
  • Standard No. 102 ‒ Transmission Shift Lever Sequence
  • Standard No. 103 ‒ Windshield Defrosting and Defogging
  • Standard No. 104 ‒ Windshield Wiping and Washing System

What we’ve collectively determined ‒ and need to consider for healthcare ‒ is the enormous safety benefit that national standards  bring to a wide range of industries like motor vehicle manufacturing and air transportation. Relative to our health data, national standards can and should be leveraged for patient safety, security and privacy. First for electronic health records, of course, but also for devices, sensors and apps that collect and manage patient data.

Health data that’s interoperable and searchable is also a core requirement to larger objectives around transforming our healthcare system. Strategies like population health, personalized medicine, patient engagement and Accountable Care Organizations are largely dependent on accurate, near real‒time access to health data by everyone across the entire healthcare delivery ecosystem. Absent these basic capabilities, the U.S. is falling behind other countries that are able to forge ahead as true pioneers.

Finland is among the first countries to consolidate EHR data as a way to build a national patient archive. They see true population health as not only a strategic and competitive advantage for the whole country (population of about 5.5 million), but also as way to build patient trust around sensitive health information.

So far, people are really rather happy about these services, not just because the information is available at their fingertips but also because they think it is a good way to guarantee data security. When they check their information, they can also access a log that tells them exactly which organizations have been looking at their data – and this helps build trust in the system. Anne Kallio, Head of Development at the Ministry of Social Affairs and Health in Finland

The American system, on the other hand, has elected to optimize health data for revenue and profits ‒ not safety and quality. In our system, health data is used for billing, of course, but it’s also considered proprietary and siloed as a way to intentionally lock patients into networks of health plans and/or provider networks. Sometimes our health data is de-identified and sold to the highest bidder.

In other cases, providers charge patients a “copy fee” for accessing their own health data. Naturally, the higher the fee, the less likely we are as patients to switch providers. A recent study proves the captive effect of higher costs for patients to access their own health data.

In states that imposed caps on fees for medical records, patients changed their primary doctors 11% more frequently and their specialty doctors 13% more frequently. The Hidden Cost in Changing Doctors [Stanford Graduate School of Business ‒ June, 2015]

Revenue aside, we’ve also created a culture of fear around protecting data that is so irrational that it often trumps clinical safety outright. Paul Levy described a recent example with his article ‒ We’ve Been Swindled.

Upon arrival, he was whisked through the ED and was being prepped for surgery, but the doctors wanted to have a clearer sense of the location of the [kidney] stones.  His kidneys were in no condition to have another CT with contrast, and so they wanted to look at the CT scan that had been taken just an hour earlier at the urgent care facility. There was no way to electronically deliver the image to the BWH team.

To solve this basic lack of simple transferability (unrelated to the more complex task of interoperability), the CT scan was burned onto a thumb drive and walked (0.3 miles) for hand delivery. This isn’t just absurd or comical in 2015 ‒ it’s morally repugnant and indefensible. In cases like this (and countless others), technology is an outright impediment to life‒saving clinical care. The charade here is that vendors, payers and providers are uniform in their insistence that this is necessary to “protect our privacy.”

Standards that do allow for communication in healthcare are largely the domain and primary function of several organizations, such as Health Level Seven International (HL7).

Founded in 1987, Health Level Seven International (HL7) is a not-for-profit, ANSI-accredited standards developing organization dedicated to providing a comprehensive framework and related standards for the exchange, integration, sharing, and retrieval of electronic health information that supports clinical practice and the management, delivery and evaluation of health services. HL7’s 2,300+ members include approximately 500 corporate members who represent more than 90% of the information systems vendors serving healthcare.

Without going into the history of the standards work HL7 International has done successfully for the last 28 years, there’s an exciting development with a new standard called Fast Health Interoperable Resources or FHIR (pronounced ‘fire’). Adding fuel to the excitement are quotes like this.

FHIR is the “HTML” of healthcare. It’s based on clinical modeling by experts but does not require implementers to understand those details. Historically healthcare standard were easy for designers and hard for implementors. FHIR has focused on ease of implementation. John Halamka ‒ CIO at Harvard and Beth Israel Deaconess Medical Center ‒ Setting Healthcare Interop on Fire ‒ Forbes

Today, FHIR is working its way to becoming an official standard in healthcare. Later this fall, it will move from DSTU1 (Draft Standard for Test Use version 1) to DSTU2 ‒ at which point it will be considered enough of a standard to be openly supported (if not officially endorsed) by the Office of the National Coordinator (ONC). Developers have already started building, testing and deploying actual solutions using its framework.

So is FHIR the long awaited answer for true interop in healthcare?

One of the principal architects and lead developers of FHIR is a software engineer named Grahame Grieve. The development of FHIR represents a significant engineering achievement (spanning years and thousands of hours). As the FHIR project lead, his engineering domain expertise on FHIR is literally second to none.

One of several remaining challenges ‒ unsolved by FHIR ‒ is a key field called Master Patient Index ‒ or MPI. FHIR is a “framework” that can easily support an MPI ‒ but it isn’t an MPI itself. An MPI ‒ any MPI ‒ must be developed outside of FHIR (for use with FHIR). Which begs the question ‒ if FHIR is the emerging standard for interop in healthcare ‒ do we even need an MPI? I posed this question to Grahame. His reply was steeped in the engineering tradition and discipline of efficient coding.

Yup. MPI is unavoidable.

FHIR may well be the HTML of healthcare, but we still need an MPI for any system to determine “who the hell we are.” Anyone can generate an MPI of course and every electronic health record solution includes an MPI, but each one is different. There is no standard (and none pending) for this critical field used throughout the entire healthcare delivery ecosystem.

We could have one ‒ we should have one (in much the same way that we have a VIN for vehicles) ‒ but Congress reversed their original intent for this even though it was baked into the 1996 legislation known as HIPAA (see Who Stole U.S. Healthcare Interop?) .

The original legislation called for the creation of a National Provider Identifier and a National Patient Identifier. The Provider Identifier was implemented, but the Patient Identifier was subsequently “de-funded.” In effect, HHS (and by extension ONC) is legally banned from any work toward a National Patient Identifier ‒ which is equally reprehensible and indefensible. This isn’t the fault of HHS/ONC, of course, but it is absolutely the fault of Congress.

“It’s time that Congress recognize the inability to accurately identify patients is fundamentally a patient safety issue. CHIME Interim Vice President of Public Policy Leslie Krigstein ‒ Patient ID Highlighted as Barrier to Interoperability during Senate HELP Hearing
A false positive match occurs when two truly non-matching records are declared to match, while a false negative match occurs when two truly matching records are declared to be a non-match. While a majority of CIOs believe their false negative and false positive error rates are at or below industry standard, a considerable percentage believe their health records have rates that far exceed 8 percent.

“Of the nearly 65 percent of CIOs reporting use of unique identifiers, over half (58%) are using at least one other strategy – probabilistic, deterministic, biometric, etc. Yet, even with the use of such varied strategies, false negative and false positive error rates are still unacceptably high.” Summary of CHIME Suvery on Patient Data‒Matching ‒ May, 2012

Clearly many of the healthcare industries largest associations also agree with this assessment. I’ll close with this lengthy passage from one such coalition which wrote to Congress in May of 2011. (bold emphasis mine).

“An informed national-level patient identity solution would enhance, not compromise, the privacy and security of patient health information. An informed national-level patient identity solution does not mean a national identity number or card. Technological advances now allow for much more sophisticated solutions including patient onsent, voluntary patient identifiers, metadata identification tagging, controlled segmented access, access credentialing, sophisticated algorithms, and other echnologically advanced solutions.

“In the absence of an informed national-level patient identity solution, the states, health IT Regional Extension Centers (RECs), large health plans, various consortiums, and individual electronic health record vendors have had to develop their own patient identify solutions. As the nation moves forward with greater urgency toward the system-wide adoption of electronic health records, this essential core functionality to ensure the match of a patient with his or her information remains conspicuously absent. The multitude of different solutions and the lack of a national coordinated approach to patient-data matching pose major challenges for our health information infrastructure. Patient safety, privacy, and security depend on getting this core element right and soon.

“An informed identity solution provides unambiguous identification, is cost effective, and is tremendously effective in reducing false negatives in the patient matching process. As a result, an informed patient identity solution is an essential building block to achieving the nationwide exchange of health information, as well as improving patient safety and reducing healthcare costs, fraud, and abuse. As the nation works to achieve the “meaningful use of certified EHR technology” and widespread information exchange, an informed patient identity solution becomes an ever more critical factor for healthcare.”

Letter of Recommendation to Congress by The Coalition for an Informed Patient Identity Integrity Solution ‒ comprised of the American Health Information Management Association (AHIMA); American Medical Informatics Association (AMIA); Association of Medical Directors of Information Systems (AMDIS); College of Health Information Management Executives (CHIME); Healthcare Information and Management Systems Society (HIMSS); HIT Now Coalition; and the National Association of Healthcare Access Management (NAHAM).

We can debate the logic of comparing vehicle identification to patient identification, but that’s really just an academic distraction. It’s patently obvious that people are not cars, but as long as there are enormous commercial interests that intersect with millions of consumers daily ‒ like auto manufacturing or healthcare ‒ it’s the obligation of every government to tilt the market in favor of safety and quality ‒ not revenue and profits.

Nowhere is this more obvious or critical than healthcare. Driving and air travel are largely optional. Arriving on a gurney at an ER is not. Of all the fears that people may have as passengers on that gurney, the ability to share important, life-saving health data at the point of care shouldn’t be one them.

Until we solve the first riddle of who we are to the healthcare system, true data interop will remain the chew toy of competing commercial interests and the Kabuki dance of “information blocking” will continue unabated. Playing on the fears that we’re somehow safer without a national patient identifier is effective marketing, but it’s technically false. We’re actually less safe (and less private) using an antiquated, 9‒digit numbering system developed in the 1930s.

Mandating a unique ‒ and technically superior ‒ patient identifier may not be the biggest problem in healthcare IT, but it is absolutely the first. Absent this critical standard, we will continue to struggle with competing interests, technical workarounds, and hand‒delivered data. Contrary to the headline question for this series, interoperability isn’t a business or technical challenge at all. Specific to healthcare, it’s really a moral one of the highest priority.

Filed Under: Interoperability Tagged With: data, healthcare, interop, interoperability

50 Reasons Trump Is Indebted To Putin

April 1, 2019 By Dan Munro

On March 30th – Timothy Snyder (Levin Professor of History at Yale) started a 50 tweet thread – except that the thread wasn’t connected. It was just 50 separate tweets. In an effort to add clarity to the thread – and to make it easier to see all 50 tweets in the order he wrote them, I’ve reassembled them here in one post.

I’ve linked to the first tweet, but not each subsequent tweet. Again, the purpose here was to help with readability on an important historical thread from an important historian. Each tweet is also accompanied by a page number (in parentheses) from his book … The Road to UnFreedom: Russia, Europe, America. As per his twitter profile (@TimothyDSnyder), his author’s website is here: timothysnyder.org


Why we do think that Mr. Trump owes a debt to Mr. Putin? Here are fifty reasons. All of the facts are a matter of public record, and all of the sources can be found in my book “The Road to Unfreedom.”

  1. In 1984, Russian gangsters began to launder money by buying and selling apartment units in Trump Tower (p. 220).
  2. In 1986, Mr. Trump was courted by Soviet diplomats, who suggested that a bright future awaited him in Moscow (p. 220).
  3. In 1987, the Soviet state paid for Mr. Trump to visit Moscow, putting him up in a suite that was certainly bugged (p. 220).
  4. In 2006, Russians and other citizens of the former Soviet Union financed Trump SoHo, granting Mr. Trump 18% of the profits — although he put up no money himself (p. 221).
  5. In 2008, the Russian oligarch Dmitry Rybolovlev in effect gave Mr. Trump $55 million in an unusual real estate deal. In 2016, Mr. Rybolovlev appeared in places where Mr. Trump campaigned (p. 221).
  6. In 2008, Donald Trump Jr. explained that the Trump Organization was dependent upon Russia. (p. 221).
  7. In 2010, the Russian propaganda server RT helped American white supremacists to spread the lie that Barack Obama was not born in the United States. In 2011, Mr. Trump became the most prominent backer of this lie. (p. 223).
  8. Mr. Trump was endorsed by the Russian political technologist Konstantin Rykov in 2012 (p. 102).
  9. In April 2013, the FBI busted two gambling rings inside Trump Tower, which according to authorities were run by a Russian citizen. The US attorney who ordered the raid was later fired by Mr. Trump (p. 103).
  10. Mr. Trump expressed the wish, on 18 June 2013, to be Mr. Putin’s “best friend.” (p. 102).
  11. Mr. Trump was paid $20 million by Russians to spectate at a beauty pageant in summer 2013. The man who did the work, Aras Agalarov, would later help to arrange a meeting between the Trump campaign and Russians. (p. 102).
  12. In summer 2014, a Russian advance team was sent to the United States to plan the cyber war of 2016. (p. 194)
  13. In 2014 Mr. Putin’s advisor Sergey Glazyev anticipated the “termination” of the American elite. (p. 226)
  14. In 2014 a Russian think tank, the Izborsk Club, outlined the principles of a new information war to be fought against the United States. (p. 226)
  15. Steve Bannon met with Russian energy executives in 2014 and 2015, and tested messages about Putin on American voters. He would later run Mr. Trump’s campaign. (p. 194)
  16. In late 2014 Russia penetrated the email networks of the White House, the Department of State, and the Joint Chiefs of Staff. (p. 194)
  17. When Mr. Trump announced his candidacy in June 2015, Russia’s Internet Research Agency created and staffed a new American Department. (p. 227)
  18. In October 2015, while running for president, Mr. Trump signed a letter of intent to have Russians build a tower in Moscow and put his name on it. The Trump Organization planned to give its penthouse to Mr. Putin as a present. (p. 222)
  19. In October 2015, Mr. Trump tweeted that “Putin loves Donald Trump.” (p. 222)
  20. Felix Sater, who had brokered deals between the Trump Organization and Russian investors, wrote in November 2015 that “Our boy can become president of the United States and we can engineer it.” (p. 222)
  21. Mr. Trump was endorsed in late 2015 by the think tank of the pro-Kremlin oligarch Konstantin Malofeev. (p. 150)
  22. In early 2016, the chair of the foreign relations committee of the Russian parliament said that Mr. Trump could “drive the Western locomotive right off the rails.” (p. 218)
  23. In February 2016, Mr. Putin’s cyber advisor boasted: “We are on the verge of having something in the information arena that will allow us to talk to the Americans as equals.” (p. 227)
  24. Russian military intelligence penetrated the Democratic National Committee in March 2016 as well as personal accounts of leading Democrats. Stolen emails were then used to discredit Hillary Clinton and aid Mr. Trump. (p. 232)
  25. George Papadopoulos, a foreign policy advisor of the Trump campaign, is told by Russians in April 2016 that “dirt” on Hillary Clinton is available. He then met with Mr. Trump. He was later convicted of lying to the FBI. (p. 240)
  26. A Russian military intelligence officer bragged in May 2016 that his organization would take revenge on Hillary Clinton on behalf of Mr. Putin. (p. 227)
  27. Carter Page, an advisor of the Trump campaign, traveled to Moscow in July 2016. He then worked with success to make the Republican platform friendlier to Russia at the Republican National Convention. (p. 214)
  28. General Michael Flynn, an advisor of the Trump campaign and then Mr. Trump’s national security advisor, called himself “General Misha” and followed and retweeted Russian material from five Russian accounts. He later confessed to a federal crime. (p. 241)
  29. Mr. Trump requested, on 17 June 2016, that Russia search for Hillary Clinton’s emails. That same day Russian military intelligence began a phishing campaign to do just that. (p. 232)
  30. Some 22,000 emails stolen by Russia were released right before the Democratic National Convention, on 22 July 2016. (p. 232)
  31. Thanks to Russia’s Internet Research Agency, 126 million Americans saw Russian propaganda designed to aid Mr. Trump in 2016. Almost none of them were aware that this was happening. (p. 230)
  32. Over the course of 2016 some fifty thousand Russian bots and some four thousand human accounts exploited Twitter to influence American public opinion on behalf of Mr. Trump. Almost no Americans were aware of this. (p. 230)
  33. In 2016, Russia sought to break into the electoral websites of at least thirty-nine American states. (p. 231)
  34. Throughout 2016, Russian elites referred to Mr. Trump as “our president.” (p. 218)
  35. Throughout 2016, Russian journalists were instructed to portray Mr. Trump positively and Hillary Clinton negatively. (p. 218)
  36. In June 2016 the leaders of the Trump campaign, Jared Kushner, Donald Trump, Jr., and Paul Manafort met with Russians in Trump Tower as part of, as the broker of the meeting called it, “the Russian government’s support for Trump.” (p. 261)
  37. Mr. Trump’s campaign manager Paul Manafort resigned in August 2016 after news broke that he had received $12.7 million in cash from a pro-Russian Ukrainian politician. Mr. Manafort was later convicted of crimes. (p. 236)
  38. When Mr. Trump seemed to be in trouble when a tape of his advocacy of sexual assault was published on 7 October 2016, emails stolen by Russia were released to change the subject. (p. 233)
  39. Mr. Trump personally encouraged his followers to explore the emails that Russia had stolen in tweets of 31 October and 4 November 2016. (p. 232)
  40. In the months between Mr. Trump’s nomination as the Republican candidate and the election, anonymous limited liability (”offshore”) companies furiously purchased his properties. (p. 222)
  41. After Mr. Trump was accorded the victory in the presidential election in November 2016, he was given a standing ovation in the Russian parliament. (p. 218)
  42. After Trump was accorded the victory in the presidential election, he called Mr. Putin to be congratulated. (p. 218)
  43. In December 2016, before the inauguration, Michael Flynn illegally met with Russian officials to discuss Russia-friendly policy. One of his aides explained: “Russia has just thrown the U.S.A. elections to” Mr. Trump. (p. 242)
  44. After Mr. Trump’s victory, the leading man of the Russian media, Dmitry Kiselev, celebrated the end of human rights and democracy as US policy. (p. 218)
  45. In May 2017, Mr. Trump fired James Comey for taking part in an investigation of Russia’s cyberwar against the United States, and then bragged about doing so to Russian officials in the Oval Office. (p. 245)
  46. In June 2017, Mr. Putin essentially admitted that Russia had intervened in the election, saying that he had never denied that “Russian volunteers” had carried out a cyberwar on behalf of Mr. Trump.
  47. In June 2017, Mr. Trump ordered the firing of Robert Mueller, who had been tasked to carry out an investigation of Russian interference. The White House Counsel refused to carry out the order.  Russia then began a campaign to slander Mr. Mueller. (p.246)
  48. In September 2017, a Russian parliamentarian said on national television that the American security services “slept through” as Russia chose the US president. (p.225)
  49. 2017-2018 Mr. Mueller’s investigation led to the indictment of Russia’s Internet Research Agency, several Russian military intelligence officers, and multiple associates and campaign officials of Mr. Trump. It also produced a report that we have not yet been allowed to read
  50. In June 2018, Mr. Putin confirmed before the international press that he had wanted Mr. Trump to win. At that same summit, in Helsinki, Mr. Trump said that he trusted Mr. Putin more than his own advisors. (p.227)

Filed Under: Trump

Nick Adkins and the #pinksocks tribe

January 21, 2019 By Dan Munro

Traveling to a healthcare event last year, I shared a long ride from Amsterdam’s Schiphol airport to Nijmegen with Nick Adkins. Nick is one of those larger than life characters in healthcare that’s amassed a sizeable and loyal following — both in real life and on social media channels like Twitter. To that point, we had only traded tweets — so it was a great chance to meet him in person. If there’s an opposite to the character of a grifter or con artist it’s a gifter — someone who gives freely of their time and energy. That’s probably the best single description I can think of for Nick. He’s a gifter.

Nick Adkins

So just what is his gift? He has many (including some amazing stories), but as an extension of his overall generosity, he freely and liberally gives out pairs of pink socks wherever he goes — and pretty much to anyone who will accept the gift. At major healthcare events (and some minor ones), he has boxes shipped in and they’re usually available as a part of a speaking engagement — mostly where Nick is talking about building a tribe of people that wear pink socks.

There’s a twitter hashtag #pinksocks, a website, and the interwebs are littered with pictures of this growing tribe. Maybe you’ve seen the tweets, the people, the pictures — or even wear a pair yourself. Here’s just one example.

The tribe is growing — and officially includes Royalty — literally. Here’s Nick gifting a pair to Princess Laurentien of The Netherlands.

Nick gave me a pair as well, of course, but I was both hesitant and skeptical of the meaning and purpose behind the gift. By wearing pink socks, what I am signing up for? What cause or group am I visually endorsing? Who pays — and who benefits? It’s a reporter’s instinct — at times a curse — but it also comes from years of covering healthcare where truly free gifts are rare (valet parking?) and many of the stories I seem to come across are variations of horrific or criminal abuse — often at scale.

And then recently I came across a story that was published years ago on Reddit — and it made me think of Nick and his pink socks. Absent a formal meaning I think the Reddit story is a worthy contender for what the #pinksocks could mean. At least it is to me. It’s also a great road story — for all of us on the journey ahead. Maybe you’ve already seen it (originally posted here), but it’s well worth another read.

This past year I have had 3 instances of car trouble. A blow out on a freeway a bunch of blown fuses and an out of gas situation. All of them were while driving other people’s cars which, for some reason, makes it worse on an emotional level. It makes it worse on a practical level as well, what with the fact that I carry things like a jack and extra fuses in my car, and know enough not to park, facing downhill, on a steep incline with less than a gallon of fuel.

Anyway, each of these times this shit happened I was DISGUSTED with how people would not bother to help me. I spent hours on the side of the freeway waiting, watching roadside assistance vehicles blow past me, for AAA to show. The 4 gas stations I asked for a gas can at told me that they couldn’t loan them out “for my safety” but I could buy a really shitty 1-gallon one with no cap for $15. It was enough, each time, to make you say shit like “this country is going to hell in a handbasket.”

But you know who came to my rescue all three times? Immigrants. Mexican immigrants. None of them spoke a lick of the language. But one of those dudes had a profound effect on me.

He was the guy that stopped to help me with a blow out with his whole family of 6 in tow. I was on the side of the road for close to 4 hours. Big jeep, blown rear tire, had a spare but no jack. I had signs in the windows of the car, big signs that said NEED A JACK and offered money. No dice. Right as I am about to give up and just hitch out of there a van pulls over and dude bounds out. He sizes the situation up and calls for his youngest daughter who speaks English. He conveys through her that he has a jack but it is too small for the Jeep so we will need to brace it. He produces a saw from the van and cuts a log out of a downed tree on the side of the road. We rolled it over; put his jack on top, and bam, in business. I start taking the wheel off and, if you can believe it, I broke his tire iron. It was one of those collapsible ones and I wasn’t careful and I snapped the head I needed clean off. Fuck.

No worries. He runs to the van, gives it to his wife and she is gone in a flash, down the road to buy a tire iron. She is back in 15 minutes, we finish the job with a little sweat and cussing (stupid log was starting to give), and I am a very happy man. We are both filthy and sweaty. The wife produces a large water jug for us to wash our hands in. I tried to put a $20 in the man’s hand but he wouldn’t take it so I instead gave it to his wife as quietly as I could. I thanked them up one side and down the other. I asked the little girl where they lived, thinking maybe I could send them a gift for being so awesome. She says they live in Mexico. They are here so mommy and daddy can pick peaches for the next few weeks. After that they are going to pick cherries then go back home. She asks if I have had lunch and when I told her no she gave me a tamale from their cooler, the best fucking tamale I have ever had.

So, to clarify, a family that is undoubtedly poorer than you, me, and just about everyone else on that stretch of road, working on a seasonal basis where time ismoney, took an hour or two out of their day to help some strange dude on the side of the road when people in tow trucks were just passing me by. Wow.

But we aren’t done yet. I thank them again and walk back to my car and open the foil on the tamale cause I am starving at this point and what do I find inside? My fucking $20 bill! I whirl around and run up to the van and the guy rolls his window down. He sees the $20 in my hand and just shaking his head no like he won’t take it. All I can think to say is “Por Favor, Por Favor, Por Favor” with my hands out.

Dude just smiles, shakes his head and, with what looked like great concentration, tried his hardest to speak to me in English: ‘Today you … tomorrow me.’

In our travels, sometimes gifters present with a car jack and a tamale. Other times it’s a simple pair of socks to remind us of our humanity and vulnerability. Often their handiwork isn’t visible beyond a single act of unseen kindness, but sometimes we can see it in something as simple as an article of clothing. If you happen to come across someone wearing a pair of #pinksocks, just remember — it’s likely because a lone gifter named Nick decided to make a tribe out of people who were actually presented with more than just a pair of colorful socks. They were also presented with a free and simple choice. To join.

Filed Under: pinksocks, Social Media

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About Dan

Dan Munro is a writer who lives outside of Phoenix, Arizona. He is authored and writes about the intersection of technology and policy for a variety of online and print publications.

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