Good morning. I am Roslyne Schulman, senior associate director for health policy at the American Hospital Association (AHA). I am a member of the AHA’s hospital disaster readiness staff team and chair of the team’s resources subgroup. On behalf of the AHA’s nearly 5,000 hospitals, health systems, networks, and other providers of care, I appreciate this opportunity to present our views on how national preparedness could be enhanced through improvements to the national health information infrastructure.
The terrorist attacks of September 11, 2001 and the subsequent anthrax attacks have changed how Americans view safety and security. Over the past five months, the nation has focused on strengthening our national security and emergency readiness. As part of America’s vital health care infrastructure, hospitals play a central role in that effort – a role that is sure to be enhanced as we move forward. The attacks redefined the meaning of disaster readiness for hospitals. Hospitals are now compelled to plan for what was previously unthinkable -- disasters that are intentionally inflicted; involving large numbers of casualties; and involving the use chemical, biological or radiological agents.
Mass casualty incidents, by definition, overwhelm the resources of individual hospitals. They may overwhelm the resources of a community’s entire health care system. Therefore, the response to mass casualty incidents is likely to require a broad array of community resources to supplement the health care system and requires coordination between these components. The minimum components of an effective response will involve public health, hospitals, physicians, community emergency management officials and “traditional” first responder organizations (fire, police and emergency medical services (EMS)). State and Federal government resources will be tapped, depending on the scale of the disaster.
Mass casualty incidents that result from an infectious agent, as would occur in a bioterrorist attack, differ from other types of disasters in many ways, including:
In order to increase readiness to respond to mass casualty incidents, particularly those involving biological agents, the AHA believes that hospitals must adopt a community-wide perspective and broaden the scale and scope of their disaster plans to link with and involve community partners. For instance, hospitals should establish an open and ongoing relationship with the local health department and its leadership. Biological incidents, in particular, require community-wide surveillance and control effort to assemble apparently isolated symptoms into a recognizable pattern that alerts the community’s health care and public health system about the potential for an epidemic and initiates appropriate public health interventions, such as immunizations and prophylactic antibiotics. In addition, hospitals have an opportunity to use their existing EMS, trauma coordination, and other relationships as a framework upon which to build expanded relationships for mass casualty readiness. These existing programs also provide a framework for communications linkages, and data collection and sharing.
Establishing these community-wide relationships can serve readiness by facilitating the creation or linkage of data reporting systems to provide a community-wide assessment of health needs and health care resources. Because large-scale disasters increase the demand on all of the community’s health resources simultaneously, there will not be enough time or available staff to survey hospitals and other facilities in order to inventory capabilities after the incident starts. Systems that are designed to share a common architecture and that integrate real-time data from institutional operations will provide the best means to matching community needs to available resources. However, there are many challenges to making these community linkages work.
Improvements needed in the communications infrastructure
First, hospitals and others in the frontline responder community depend on
effective communications to provide emergency medical care, rescue accident
victims, and respond to disasters. One of the key lessons learned from the
September 11th terrorist attacks and the subsequent anthrax attacks is that we
must enhance our ability to gather information and to communicate it
efficiently to all relevant parties. In disasters, particularly those involving
large numbers of casualties, it is critical that hospitals have pre-established
communications linkages with other frontline responders that are reliable and
interoperable. However, in disasters, most organizations experience problems
with interoperability. Communications often degrade as a result of saturated
cellular phone systems, and wireless communications systems that interfere with
public safety communications. Public health services must be linked using
secure connections to the Internet. High speed, dedicated access to the
Internet should be available for all public and private health care facilities
and related organizations. There is a critical need for funding to upgrade,
modernize and link frontline responder communications systems and to address
interoperability problems.
Need for real-time assessment of health care capacity
In the event of a disaster, many communities are not able to assess, in a rapid
and accurate way, what health care resources are available for response.
Readiness could be enhanced if all communities had a real-time system in place
to assess hospital capacity. This would ideally include frequently updated
information on the number, type, and location of available hospital beds;
available stocks of drugs, supplies and equipment; and the number and location
of trained staff.
Appropriate staffing poses a special concern in mass casualty incidents. For example, most hospital disaster plans provide for staff augmentation by extending the working hours of present staff or by calling in supplemental staff. If all of the disaster plans in a community are collected, they appear to provide for a substantial increase of staff. This includes medical staff, nursing staff, technicians and technologists, and support services staff. However, it is common for each hospital’s disaster plan to be prepared individually. Thus, there is a real potential for double counting of potential staff. That is, two or more hospitals may envision using the same resources for staff augmentation. In a mass casualty incident, where the full human resources of the community are stressed, hospitals improve their preparedness by working together to develop an unduplicated estimate of the number and sources of additional staff.
In addition, disaster readiness would be enhanced by the development of a community-wide concept of “reserve staff” -- identifying physicians, nurses, and hospital workers who are retired; have changed careers to work outside of healthcare services; or now work in areas other than direct patient care. However, this concept of reserve staff will only be a viable alternative if adequate funds are made available to regularly train and update reserves so that they can immediately step into roles in the hospital.
Need for improvements in disease surveillance and disease reporting
systems
An effective public health and medical response to a covert bioterrorist attack
will also depend upon the ability of individual clinicians, field providers,
and public health departments to quickly detect, accurately diagnose, rapidly
contain, and effectively treat an uncommon disease or illness. Improving the
capacity of hospitals, public health departments, laboratories, and clinicians
to engage in disease surveillance and disease reporting will be critical in
determining that a cluster of disease may be related to the intentional release
of a biological or chemical terrorism agent and in expediting an effective
response. The monitoring of sudden changes in syndromic information gathered by
emergency departments, EMS communication centers, health departments and
telephone nurse triage call centers can also provide advance warning of
community health threats.
While disease reporting and syndromic surveillance systems are critical in responding to biological and chemical terrorist threats, they also could serve to improve the health of the public in other ways in the future, such as tracking population health status and health service utilization. In addition, data captured from surveillance systems, once analyzed, can generate appropriate follow-up actions such as the provision of “just in time” educational materials to providers to assist in the medical management of patients.
To facilitate this level of readiness, hospitals and public health departments will need adequate resources and significantly upgraded surveillance systems to detect and respond to unusual diseases or patterns of symptoms. Public health laboratories will need to upgrade their capacity to carry out their essential analytic and reporting functions. And all public health, laboratory, and medical partners will require enhanced electronic information and communications systems to assure rapid and secure reporting and information exchange.
Furthermore, a successful surveillance system will, to the maximum extent possible, utilize and build upon sources of information already collected by hospitals and emergency departments. Automated retrieval of existing data from clinical databases in hospitals is preferable to systems that require manual entry of data, and may represent the best solution for the rapid provision of surveillance data to public health departments. Such a solution should also be less burdensome and costly for providers. In an environment in which every hour of patient care provided in a hospital emergency department results in one additional hour of paperwork, it would be difficult to justify adding to this burden through new and manual data collection.
Challenge for hospitals: HIPAA restrictions on information sharing
The AHA would also like to raise with NCVHS a serious conflict between the
Health Insurance Portability and Accountability Act of 1996 (HIPAA) privacy
regulations and efforts to improve hospital disease surveillance capabilities.
The HIPAA privacy regulations place unnecessary roadblocks in the path of state
hospital associations’ efforts to share important health and demographic
information with the hospitals in their states. The ability to continue to
share such information could be critical to identifying an unusual pattern of
symptoms that could indicate that a bioterrorist attack has occurred.
While the privacy rules permit state hospital associations to aggregate and analyze medical data from their member hospitals, they would not allow hospital associations to share this “protected health information” from one hospital to another hospital. Further, while the regulations do include an exception that would allow public health agencies to collect “protected health information” without consent, it is not clear that state hospital associations would fall under this exception.
As a consequence, once the regulations go into effect in April 2003, state hospital associations would be barred from sharing critical disease surveillance data with contributing hospitals. Among the data that hospital associations would be prohibited from sharing are: county or neighborhood by zip code; specific age of the patient; and the date on which the hospital treated the injury or illness. These are data elements that are integral to disease surveillance activities. At a minimum, HHS should either reform or clarify the rules to allow state hospital associations to share the critical elements of data with contributing hospitals and health researchers. This could be done most effectively by carving out those data from the list of identifiable data included in the rule. In addition, HHS should permit the use of a master business associate agreement under which all contributing hospitals could share such data with their state association.
Thank you for the opportunity to testify. I would be happy to answer any questions.