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HHS Publishes Health Privacy Regs In 368 pages of the Federal Register, the Clinton administration November 28 spelled out in detail what health care providers must do to protect the privacy of an individual's medical information. The regulations apply to personal medical records in all forms--paper records and oral communications as well as electronic records--and they require that physicians, hospitals, and health care plans get written consent from patients for the release of even routine medical information. The regulations were issued by the U.S. Department of Health and Human Services, which was required by law to issue the rules after Congress failed to do so. In brief, the new standards:
Advance written consent for routine purposes will be similar to what most patients are accustomed to when they visit a doctor or hospital today, the regulators explained, but the new rules give added protection by requiring that patients be given detailed written information about their privacy rights and how their information will be used. In an exception to the general prohibition on release of information,
the rule gives health care providers "full discretion" to decide what
personal health information to include when they send patients' medical
records to other providers for purposes of treatment. However, companies
that sponsor health plans will no longer be able to access personal
health information from the plan for employment-related purposes without
authorization by the patient Relationship to Schools "For example," the regs say, "individually identifiable health information of students under the age of 18 created by a nurse in a primary or secondary school that receives federal funds and that is subject to FERPA is an education record but not protected health information. Therefore, the privacy regulation does not apply." That doesn't mean students do not have medical privacy rights, the
regs note, but simply that those rights have been guaranteed by Congress
under a different program. Relationship to Federally Funded Programs The regs also note that some information the federal Food and Drug Administration needs to track adverse reactions to a new drug or device may necessarily be personally identifiable. Health care providers can therefore disclose such information to the FDA without violating the privacy rules. The new health privacy regulations could be withdrawn by the incoming Bush administration. Otherwise, they will go into effect in two years. The full text of the regulations, if you are brave enough to download 368 pages, is available electronically at http://aspe.hhs.gov/admnsimp/ or www.access.gpo.gov/su_docs/aces/aces140.html. ----------------------------------------------------------------- Monitoring the Future Survey Finds Ecstasy Use Up, Cigarettes Down Use of the drug "ecstasy" (MDMA) by American adolescents rose sharply in the past year, according to the 26th national survey in the Monitoring the Future series, which annually surveys students in grades 8, 10, and 12. Research scientists at the University of Michigan Institute for Social Research, which conducted the survey, expressed concern at the growing popularity of ecstasy among 8th graders, where use rose from 1.7 percent of students in 1999 to 3.1 percent in 2000, as well as among 10th graders, where use rose from 4.4 percent to 5.4 percent, and among 12th graders, where use rose from 5.6 percent to 8.2 percent. "Ecstasy is thus used by more American teenagers today than is cocaine," the report notes. In other findings, marijuana remains the most widely used of the illicit drugs, with 16 percent of 8th graders, 32 percent of 10th graders, and 37 percent of 12th graders indicating some use in the prior 12-month period. The survey found, however, that recent classes of 8th graders have begun to see marijuana as dangerous to the user and have become more disapproving of its use, which probably helps to explain why prevalence of use by 8th graders declined from 18.3 percent to 15.6 percent between 1996 and 2000. "The younger teens are less likely to have an established pattern of drug-using behavior than older ones, of course, which probably makes them the most responsive to new influences in society," said survey leader Lloyd Johnston. "They were the first to show many of the upturns in substance use of various sorts early in the '90s." In addition to marijuana, he noted, the more recent downturns in use of drugs such as crack cocaine, cocaine powder, tranquilizers, Rohypnol, smokeless tobacco, and cigarettes started first and have been most sustained among the 8th graders. With respect to cigarette smoking, the survey found "encouraging ongoing decline" after significant rises in tobacco use in the early '90s. "We haven't yet regained all the ground lost early in the nineties, but have nearly done so with the younger ones," Johnston said. The survey found that in 2000, 15 percent of 8th graders, 24 percent of 10th graders, and 31 percent of 12th graders had smoked at least once in the prior 30 days; and 7 percent, 14 percent, and 21 percent were daily smokers. That compares with 21 percent of 8th graders, 30.4 percent of 10th graders, and 36.5 percent of 12th graders who were current smokers in 1996. The full text of the Monitoring the Future survey is available online at www.monitoringthefuture.org. --------------------------------------------------------- Researchers Measure Risks of Exemptions from Vaccination Researchers who studied medical records for the state of Colorado, where it's relatively easy for parents to request exemption from school-entry immunization requirements, found that children ages 3 to 18 years who were never immunized were 22 times more likely than immunized children to come down with measles and nearly six times more likely to have whooping cough. For elementary school-age children (ages 3 to 10), the risks were greater--unimmunized children were 60 times more likely to get measles and 16 times likelier to come down with pertussis. That measures the extent to which an individual child may get sick, a risk that some parents may be willing to take, but it doesn't address the major reason for immunization requirements in the first place--protecting public health--say doctors Daniel Feikin and Robert Chen of the Centers for Disease Control and Prevention and colleagues who co-authored an article in the December 27 issue of the Journal of the American Medical Association. Here, the researchers found that counties with the largest numbers of exemptors also had the largest numbers of immunized children coming down with measles or whooping cough. An immunized child can be infected by an unimmunized child because measles and pertussis vaccines are not 100 percent effective and a fraction of fully immunized children remain vulnerable to infection, Dr. Feiken explained. Most of the time that doesn't matter, because "herd immunity" keeps everyone safe. When immunized children in the study came down with measles or whooping cough, it was likely that they picked up the infection at school, the researchers found. Schools with measles outbreaks had more exemptors, as did schools with pertussis outbreaks. In the 18 measles outbreaks included in the study, 179 children became ill, 25 percent of them exemptors. Forty-two percent of the exemptors acquired measles through contact with another exemptor. Most young parents have never seen a case of either measles or whooping cough, and Internet websites and other media may persuade parents that the dangers involved in having children vaccinated are greater than the dangers of the diseases themselves, the researchers found. If all vaccine-preventable diseases were confined to the individual (tetanus, for example), the consequences of foregoing immunization would fall only on the child whose parents made that decision; but most vaccine-preventable diseases are spread from person to person, and if a lot of parents opt to forego vaccination, the entire community is affected, they point out. The article, "Individual and Community Risks of Measles and Pertussis Associated with Personal Exemptions to Immunization," by Feiken, Lezotte, Hamman, Salmon, Chen, and Hoffman, appeared in the December 27 issue of the Journal of the American Medical Association. Reprints are available from Dr. Feikin at e-mail drf0@cdc.gov. ---------------------------------------------------------------- Study Finds More Children, More Medications, More Errors Nearly half of the school nurses in a recent survey reported medication errors in their schools during the past year, according to a University of Iowa study reported in the November issue of Journal of School Health. The survey, which was completed by 649 nurses throughout the United States, looked at medication administration in schools, including policies and guidelines for dispensing drugs to students, the types of medication commonly administered, and which school personnel are authorized to dispense medications. Some findings:
Few if any national studies have previously looked specifically at the administration of medications in schools, according to lead researcher Ann Marie McCarthy, Ph.D., associate professor of nursing at the University of Iowa. "The larger context is that there simply are more children in school with health conditions requiring medication than there were in the past," McCarthy pointed out. She noted particularly the rise in number of children diagnosed as having attention deficit hyperactivity disorder and receiving medication to control it. "When you put it all together--more children, more health problems, and more medications--there are more opportunities for errors to occur. As we learn more about how medications are actually administered in schools throughout the country, we can begin to identify the best practices and use these to establish standards for health and safety for all students." Another Look at Ritalin "No other drug in American history has had this kind of success in achieving and maintaining such a grip on its market," Sax points out, "--not Valium, not Prozac, not Viagra. The United States, with less than 5 percent of the world's population, now accounts for 85 percent of the world's consumption of Ritalin." Asking how that happened, and why Ritalin is not prescribed as extensively in other countries, Sax notes that "Ritalin has been on the market for almost 40 years. Nothing has changed in terms of its classification as a prescription drug under U.S. law; nothing has changed in the manner of its production or delivery. So why has its used increased roughly 500 percent over the past 10 years and roughly 4,000 percent over the past 25 years? Is ADD/ADHD becoming more common? Or, if it has always been with us, why are doctors suddenly so much more willing to prescribe Ritalin?" Sax ventures some guesses, which he labels generally as "television, testing, and Prozac." Noting that children who began elementary school in the 1980s are the first generation to be raised watching cable television, or spending time at the computer playing an action game, he wonders if the fast pace of those media is changing children's perceptual orientation. And he points to pressure on schools to achieve good test results as removing many of the outlets--even recess--that let active children, boys especially, blow off steam during the school day. Finally, he looks at the 1987 introduction of Prozac, a "completely safe" drug with few side effects that changed the way physicians prescribe psychiatric medications. But even putting all of those together, Sax asks how other nations cope with the same problems without putting schoolchildren on drugs. "Despite their stubborn refusal to medicate their children with Ritalin, France, Germany, and Japan do not lag behind the United States in academic performance, according to the most recent studies." "It's hard to resist the conclusion that American culture, particularly as seen in school systems, has played a role in increasing Ritalin usage over the past 20 years," he concludes. Leonard Sax, M.D., Ph.D., is a physician in private practice in Montgomery County, Maryland. His article, "Ritalin: Better Living Through Chemistry?" can be accessed at www.worldandi.com/public/2000/november/sax.html. -------------------------------------------------------------- 'Social Influences' Tobacco Prevention Program Did Not Work A landmark program that taught children how to resist social influences to smoke--the main focus of smoking prevention education and research for more than a decade--apparently did no better than ordinary health classes in persuading young people not to smoke, according to a study that followed thousands of students in Washington State for 15 years, the longest study ever conducted in smoking-prevention research. The federally funded study, called the Hutchinson Smoking Prevention Project, set out to find if a school-based smoking prevention program using a social-influences approach can keep young people from smoking through and beyond high school. The study began in 1984 and continued through 1999 and involved nearly 8,400 students and 600 teachers in 40 school districts in Washington State. Questionnaires completed by students during their senior year and again two years after high school showed almost identical rates of smoking in groups that had the social-influences curriculum and those who did not. That's particularly troubling, said principal investigator Arthur Peterson, because care was taken to assure that the social-influences curriculum was rigorously designed and faithfully followed by well-trained teachers. "The results show the current approach to smoking prevention via school programs isn't enough to deter youth from smoking," Peterson said. Peterson said the smoking prevention program was designed not only to help youth identify and resist influences to smoke--from peer pressure to tobacco advertising--but also to correct their inaccurate perceptions about smoking and to motivate them to be tobacco-free. The program was delivered by regular classroom teachers who had been specifically trained by Hutchinson Center staff. The program included the "essential elements" for school-based tobacco prevention programs recommended by a national panel convened by the National Cancer Institute and met the guidelines for planning and implementing effective school-based programs for tobacco prevention recommended by the Centers for Disease Control and Prevention. Lessons engaged students in a wide range of activities: third graders made paper-bag puppets and performed a puppet play about the dangers of second-hand smoke; seventh and eighth graders used role-play and coaching exercises to practice skills for countering offers of tobacco; and ninth graders re-enacted testimony from tobacco-liability trials that revealed the tobacco industry's attempts to conceal the consequences of smoking. "The teachers did their darnedest and the educational materials were top-notch," Peterson said. "The inability of the program to affect change in smoking behavior comes down, in our judgment, to one thing: the failure of the social-influences strategy of the last 25 years. It simply didn't work." Further information is available at website http://news.excite.com/news/pr/001219/wa-fred-hutchinson. -------------------------------------------------------------- WORTH NOTING Standards Set for Cultural, Linguistic Health Services The Office of Minority Health in the U.S. Department of Health and Human Services December 22 published the first national standards for culturally and linguistically appropriate services in health care. All recipients of federal funds are expected to abide by the 14 standards, which include being able to recognize and respond to health-related beliefs and cultural values, disease incidence and prevalence, and treatment efficacy. Language services are to be available to each individual who seeks services, regardless of the size of the individual's language group in the community. The complete report, along with supporting materials, is available online at www.OMHRC.gov.clas. ----- Health Care Required in Child Support Orders States are required to ensure that health care coverage is part of child support orders, under final regulations issued December 27 by the Office of Child Support Enforcement in the U.S. Department of Health and Human Services and by the U.S. Department of Labor. Specifically, states will use a uniform National Medical Support Notice to inform employers about an employee's child support obligations, which may mean making sure the child is included in the noncustodial parent's employer-sponsored health plan. The group health plan is then notified that the named employee is enrolled and is obligated by a court or administrative child support order to provide medical support coverage for the named children. The full text of the new regulation appeared on pages 82154-82176 of the Federal Register December 27. ----- Institute to Study Effects of Lack of Health Insurance The nation's largest health care foundation, the Robert Wood Johnson Foundation, has made a $3.7 million grant to the Institute of Medicine in the National Academy of Sciences for a three-year research project to determine what happens to the approximately 43 million people in the United States--about one in six--who have no health insurance. The study will try to measure both the health and economic consequences of not having access to health care. Among the questions to be examined are what care the uninsured receive, who pays for it, and how public health and productivity are affected by the uninsured. "The Institute of Medicine can assemble all the pieces of this puzzle and make it clearer. Nobody's really done that," said Robert Wood Johnson Foundation President Dr. Steven Schroeder. ----- Survey Shows Teen Boys Confused About Sex Teenage boys are confused about what constitutes "sex" and what "abstinence," is, according to a national survey of adolescent males by the Urban Institute. Fifty-five percent of teenage males report having had vaginal sex, but two-thirds say they've had non-coital experiences such as oral or anal sex, and most of them don't believe that they can contract viral diseases like herpes and hepatitis B or bacterial infections such as gonorrhea, syphilis, and chlamydia from such contacts. And many boys consider they are "abstinent" if they engage only in oral or anal sex. "The most important message of these findings is to encourage communication about the whole range of sexual behavior," said Ward Cates, past director of the Division of Sexually Transmitted Diseases at the Center for Disease Control and Prevention. The report of findings from the National Survey of Adolescent Males appeared in Family Planning Perspectives, a publication of the Alan Guttmacher Institute.
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