Rebuilding the Tower of Babel – A CEO’s Perspective on Health Information Exchanges

The United States is facing the largest shortage of healthcare practitioners in our country’s history which is compounded by an ever increasing geriatric population. In 2005 there existed one geriatrician for every 5,000 US residents over 65 and only nine of the 145 medical schools trained geriatricians. By 2020 the industry is estimated to be short 200,000 physicians and over a million nurses. Never, in the history of US healthcare, has so much been demanded with so few personnel. Because of this shortage combined with the geriatric population increase, the medical community has to find a way to provide timely, accurate information to those who need it in a uniform fashion. Imagine if flight controllers spoke the native language of their country instead of the current international flight language, English. This example captures the urgency and critical nature of our need for standardized communication in healthcare. A healthy information exchange can help improve safety, reduce length of hospital stays, cut down on medication errors, reduce redundancies in lab testing or procedures and make the health system faster, leaner and more productive. The aging US population along with those impacted by chronic disease like diabetes, cardiovascular disease and asthma will need to see more specialists who will have to find a way to communicate with primary care providers effectively and efficiently.

This efficiency can only be attained by standardizing the manner in which the communication takes place. Healthbridge, a Cincinnati based HIE and one of the largest community based networks, was able to reduce their potential disease outbreaks from 5 to 8 days down to 48 hours with a regional health information exchange. Regarding standardization, one author noted, “Interoperability without standards is like language without grammar. In both cases communication can be achieved but the process is cumbersome and often ineffective.”

United States retailers transitioned over twenty years ago in order to automate inventory, sales, accounting controls which all improve efficiency and effectiveness. While uncomfortable to think of patients as inventory, perhaps this has been part of the reason for the lack of transition in the primary care setting to automation of patient records and data. Imagine a Mom & Pop hardware store on any square in mid America packed with inventory on shelves, ordering duplicate widgets based on lack of information regarding current inventory. Visualize any Home Depot or Lowes and you get a glimpse of how automation has changed the retail sector in terms of scalability and efficiency. Perhaps the “art of medicine” is a barrier to more productive, efficient and smarter medicine. Standards in information exchange have existed since 1989, but recent interfaces have evolved more rapidly thanks to increases in standardization of regional and state health information exchanges.

History of Health Information Exchanges

Major urban centers in Canada and Australia were the first to successfully implement HIE’s. The success of these early networks was linked to an integration with primary care EHR systems already in place. Health Level 7 (HL7) represents the first health language standardization system in the United States, beginning with a meeting at the University of Pennsylvania in 1987. HL7 has been successful in replacing antiquated interactions like faxing, mail and direct provider communication, which often represent duplication and inefficiency. Process interoperability increases human understanding across networks health systems to integrate and communicate. Standardization will ultimately impact how effective that communication functions in the same way that grammar standards foster better communication. The United States National Health Information Network (NHIN) sets the standards that foster this delivery of communication between health networks. HL7 is now on it’s third version which was published in 2004. The goals of HL7 are to increase interoperability, develop coherent standards, educate the industry on standardization and collaborate with other sanctioning bodies like ANSI and ISO who are also concerned with process improvement.

In the United States one of the earliest HIE’s started in Portland Maine. HealthInfoNet is a public-private partnership and is believed to be the largest statewide HIE. The goals of the network are to improve patient safety, enhance the quality of clinical care, increase efficiency, reduce service duplication, identify public threats more quickly and expand patient record access. The four founding groups the Maine Health Access Foundation, Maine CDC, The Maine Quality Forum and Maine Health Information Center (Onpoint Health Data) began their efforts in 2004.

In Tennessee Regional Health Information Organizations (RHIO’s) initiated in Memphis and the Tri Cities region. Carespark, a 501(3)c, in the Tri Cities region was considered a direct project where clinicians interact directly with each other using Carespark’s HL7 compliant system as an intermediary to translate the data bi-directionally. Veterans Affairs (VA) clinics also played a crucial role in the early stages of building this network. In the delta the midsouth eHealth Alliance is a RHIO connecting Memphis hospitals like Baptist Memorial (5 sites), Methodist Systems, Lebonheur Healthcare, Memphis Children’s Clinic, St. Francis Health System, St Jude, The Regional Medical Center and UT Medical. These regional networks allow practitioners to share medical records, lab values medicines and other reports in a more efficient manner.

Seventeen US communities have been designated as Beacon Communities across the United States based on their development of HIE’s. These communities’ health focus varies based on the patient population and prevalence of chronic disease states i.e. cvd, diabetes, asthma. The communities focus on specific and measurable improvements in quality, safety and efficiency due to health information exchange improvements. The closest geographical Beacon community to Tennessee, in Byhalia, Mississippi, just south of Memphis, was granted a $100,000 grant by the department of Health and Human Services in September 2011.

A healthcare model for Nashville to emulate is located in Indianapolis, IN based on geographic proximity, city size and population demographics. Four Beacon awards have been granted to communities in and around Indianapolis, Health and Hospital Corporation of Marion County, Indiana Health Centers Inc, Raphael Health Center and Shalom Health Care Center Inc. In addition, Indiana Health Information Technology Inc has received over 23 million dollars in grants through the State HIE Cooperative Agreement and 2011 HIE Challenge Grant Supplement programs through the federal government. These awards were based on the following criteria:1) Achieving health goals through health information exchange 2) Improving long term and post acute care transitions 3) Consumer mediated information exchange 4) Enabling enhanced query for patient care 5) Fostering distributed population-level analytics.

Regulatory Aspects of Health Information Exchanges and Healthcare Reform

The department of Health and Human Services (HHS) is the regulatory agency that oversees health concerns for all Americans. The HHS is divided into ten regions and Tennessee is part of Region IV headquartered out of Atlanta. The Regional Director, Anton J. Gunn is the first African American elected to serve as regional director and brings a wealth of experience to his role based on his public service specifically regarding underserved healthcare patients and health information exchanges. This experience will serve him well as he encounters societal and demographic challenges for underserved and chronically ill patients throughout the southeast area.

The National Health Information Network (NHIN) is a division of HHS that guides the standards of exchange and governs regulatory aspects of health reform. The NHIN collaboration includes departments like the Center for Disease Control (CDC), social security administration, Beacon communities and state HIE’s (ONC).11 The Office of National Coordinator for Health Information Exchange (ONC) has awarded $16 million in additional grants to encourage innovation at the state level. Innovation at the state level will ultimately lead to better patient care through reductions in replicated tests, bridges to care programs for chronic patients leading to continuity and finally timely public health alerts through agencies like the CDC based on this information.12 The Health Information Technology for Economic and Clinical Health (HITECH) Act is funded by dollars from the American Reinvestment and Recovery Act of 2009. HITECH’s goals are to invest dollars in community, regional and state health information exchanges to build effective networks which are connected nationally. Beacon communities and the Statewide Health Information Exchange Cooperative Agreement were initiated through HITECH and ARRA. To date 56 states have received grant awards through these programs totaling 548 million dollars.

History of Health Information Partnership TN (HIPTN)

In Tennessee the Health Information Exchange has been slower to progress than places like Maine and Indiana based in part on the diversity of our state. The delta has a vastly different patient population and health network than that of middle Tennessee, which differs from eastern Tennessee’s Appalachian region. In August of 2009 the first steps were taken to build a statewide HIE consisting of a non-profit named HIP TN. A board was established at this time with an operations council formed in December. HIP TN’s first initiatives involved connecting the work through Carespark in northeast Tennessee’s s tri-cities region to the Midsouth ehealth Alliance in Memphis. State officials estimated a cost of over 200 million dollars from 2010-2015. The venture involves stakeholders from medical, technical, legal and business backgrounds. The governor in 2010, Phil Bredesen, provided 15 million to match federal funds in addition to issuing an Executive Order establishing the office of eHealth initiatives with oversight by the Office of Administration and Finance and sixteen board members. By March 2010 four workgroups were established to focus on areas like technology, clinical, privacy and security and sustainability.

By May of 2010 data sharing agreements were in place and a production pilot for the statewide HIE was initiated in June 2011 along with a Request for Proposal (RFP) which was sent out to over forty vendors. In July 2010 a fifth workgroup,the consumer advisory group, was added and in September 2010 Tennessee was notified that they were one of the first states to have their plans approved after a release of Program Information Notice (PIN). Over fifty stakeholders came together to evaluate the vendor demonstrations and a contract was signed with the chosen vendor Axolotl on September 30th, 2010. At that time a production goal of July 15th, 2011 was agreed upon and in January 2011 Keith Cox was hired as HIP TN’s CEO. Keith brings twenty six years of tenure in healthcare IT to the collaborative. His previous endeavors include Microsoft, Bellsouth and several entrepreneurial efforts. HIP TN’s mission is to improve access to health information through a statewide collaborative process and provide the infrastructure for security in that exchange. The vision for HIP TN is to be recognized as a state and national leader who support measurable improvements in clinical quality and efficiency to patients, providers and payors with secure HIE. Robert S. Gordon, the board chair for HIPTN states the vision well, “We share the view that while technology is a critical tool, the primary focus is not technology itself, but improving health”. HIP TN is a non profit, 501(c)3, that is solely reliant on state government funding. It is a combination of centralized and decentralized architecture. The key vendors are Axolotl, which acts as the umbrella network, ICA for Memphis and Nashville, with CGI as the vendor in northeast Tennessee.15 Future HIP TN goals include a gateway to the National Health Institute planned for late 2011 and a clinician index in early 2012. Carespark, one of the original regional health exchange networks voted to cease operations on July 11, 2011 based on lack of financial support for it’s new infrastructure. The data sharing agreements included 38 health organizations, nine communities and 250 volunteers.16 Carespark’s closure clarifies the need to build a network that is not solely reliant on public grants to fund it’s efforts, which we will discuss in the final section of this paper.

Current Status of Healthcare Information Exchange and HIPTN

Ten grants were awarded in 2011 by the HIE challenge grant supplement. These included initiatives in eight states and serve as communities we can look to for guidance as HIP TN evolves. As previously mentioned one of the most awarded communities lies less than five hours away in Indianapolis, IN. Based on the similarities in our health communities, patient populations and demographics, Indianapolis would provide an excellent mentor for Nashville and the hospital systems who serve patients in TN. The Indiana Health Information Exchange has been recognized nationally for it’s Docs for Docs program and the manner in which collaboration has taken place since it’s conception in 2004. Kathleen Sebelius, Secretary of HHS commented, “The Central Indiana Beacon Community has a level of collaboration and the ability to organize quality efforts in an effective manner from its history of building long standing relationships. We are thrilled to be working with a community that is far ahead in the use of health information to bring positive change to patient care.” Beacon communities that could act as guides for our community include the Health and Hospital Corporation of Marion County and the Indiana Health Centers based on their recent awards of $100,000 each by HHS.

A local model of excellence in practice EMR conversion is Old Harding Pediatric Associates (OHPA) which has two clinics and fourteen physicians who handle a patient population of 23,000 and over 72,000 patient encounters per year. OHPA’s conversion to electronic records in early 2000 occurred as a result of the pursuit of excellence in patient care and the desire to use technology in a way that benefitted their patient population. OHPA established a cross functional work team to improve their practices in the areas of facilities, personnel, communication, technology and external influences. Noteworthy was chosen as the EMR vendor based on user friendliness and the similarity to a standard patient chart with tabs for files. The software was customized to the pediatric environment complete with patient growth charts. Windows was used as the operating system based on provider familiarity. Within four days OHPA had 100% compliance and use of their EMR system.

The Future of HIP TN and HIE in Tennessee

Tennessee has received close to twelve million dollars in grant money from The State Health Information Exchange Cooperative Agreement Program.20 Regional Health Information Organizations (RHIO) need to be full scalable to allow hospitals to grow their systems without compromising integrity as they grow.21and the systems located in Nashville will play an integral role in this nationwide scaling with companies like HCA, CHS, Iasis, Lifepoint and Vanguard. The HIE will act as a data repository for all patients information that can be accessed from anywhere and contains a full history of the patients medical record, lab tests, physician network and medicine list. To entice providers to enroll in the statewide HIE tangible value to their practice has to be shown with better safer care. In a 2011 HIMSS editor’s report Richard Lang states that instead of a top down approach “A more practical idea may be for states to support local community HIE development first. Once established, these local networks can feed regional HIE’s and then connect to a central HIE/data repository backbone. States should use a portion of the stimulus funds to support local HIE development.”22 Mr. Lang also believes the primary care physician has to be the foundation for the entire system since they are the main point of contact for the patient.

One piece of the puzzle often overlooked is the patient investment in a functional EHR. In order to bring together all the pieces of the HIE puzzle patients will need to play a more active role in their healthcare. Many patients do not know what medicines they take every day or whether they have a living will. Several versions of patient EHR’s like Memitech’s 911medical id card exist, but very few patients know or carry them.23 One way to combat this lack of awareness is to use the hospital as a catch-all and discharge each patient with a fully loaded USB card via case managers. This strategy also might lead to better compliance with post in patient therapies to reduce readmissions.

The implementation of connecting qualified organizations began earlier this year. To fully support organizations to move toward qualification the Office of National Coordinator for HIE (ONC) has designated regional education centers (TN rec) who assist providers with educational initiatives in areas like HIT, ICD9 to ICD10 training and EMR transition. Qsource, a non-profit health consulting firm, has been chosen to oversee TNrec. To ensure sustainability it is critical that Tennessee build a network of private funding so that what happened with Carespark won’t happen to HIP TN. The eHealth Initiatives 2011Survey Report states that of the 196 HIE initiatives, 115 act independently of federal funding and of those independent HIE’s, break even through operational revenue. Some of these exchanges were in existence well before the American Recovery and Reinvestment Act in 2009. Startup funding from grants is only meant to get the car going so to speak, the sustainable fuel, as observed in the case of Carespark, has to come from value that can be monetized. KLAS research reports that 54% of public HIE’s were concerned about future sustainability while only 35% of private HIE’s shared this concern.

Hospital Implications of HIP TN (A Call to Action)

From a Financial perspective, taking our hospital into the future with EMR and an integrated statewide network has profound implications. In the short term the cost to find a vendor, establish EMR in and outpatient will be an expensive proposition. The transition will not be easy or finite and will involve constant evolution as HIP TN integrates with other state HIE’s. To get a realistic idea of the benefits and costs associated with health information integration. we can look to HealthInfoNet in Portland, ME, a statewide HIE that expects to save 37 million dollars in avoided services and 15 million in productivity reduction. Specific areas of savings include paper or fax costs $5 versus $0.25 electronically, virtual health record savings of $50 per referral, $26 saved per ED visit and $17.41 per patient/year due to redundant lab tests which amounts to $52 million for a population of 3 million patients. In Grand Junction Colorado Quality Health Network lowered their per capita Medicare spending to 24% below the national average, gaining recognition by President Obama in 2009. The Santa Cruz Health Information Exchange (SCHIE) with 600 doctors and two hospitals achieved sustainability in the first year of operation and uses a subscription fee for all the organizations who interact with them. In terms of government dollars available, meaningful use incentives exist to encourage hospitals to meet twenty of twenty five objectives in the first phase (2011-2012) and adopting and implement an approved EHR vendor. ARRA specified three ways for EHR to be utilized to obtain Medicare reimbursement. These include e-prescribing, health information exchange and submission of clinical quality measures. The objectives for phase two in 2013 will expand on this baseline. Implementation of EHR and Hospital HIE costs are usually charged by bed or by the number of physicians. Fees can range from $1500 for a smaller hospital up to $12,000 per month for a larger hospital.

The National Disaster Medical System, Can it Respond to a Major Southern California Earthquake?

Since the events of September 11, 2001 and the further highlighting of the state of our National vulnerability as demonstrated by the issues raised in the response to Hurricane Katrina in 2004, The Federal Government has focused enormous resources in developing a National Response Framework, Establishing National Preparedness Goals and implementing a National Incident Management System. However, in the midst of all of these changes and improvements, the Nation Disaster Medical System has been tossed like a ping pong ball from the Department of Health and Human Services (HHS) to FEMA, and then Subordinated to the Department of Homeland Security when FEMA was integrated into that new organization, and then tossed back to the Department of Health and Human Services as of January 1, 2007. During this time, publicly released documents continue to claim the NDMS has the capacity to respond to National Disasters. This article will look into the foundations of the NDMS, its current standing, and its capacity to respond to the California Earthquake scenario developed by FEMA, in conjunction with the State of California, in 1980.

Background:

After viewing the destruction wrought by the eruption of Mt. St. Helens in Washington State in May 1980, President Carter became concerned about the impacts a catastrophic earthquake in California, and the state of readiness to cope with the impacts of such an event. He directed that the National Security Council conduct a review of the state of preparedness of the Nation to meet such an event. FEMA determined that “the Nation is essentially unprepared for the catastrophic earthquake (with a probability greater than 50 percent) that must be expected in California in the next three decades” (Federal Emergency Management Agency, 1980). Casualties projected for this type of event ranged between three thousand and twenty three thousand dead, and between twelve and ninety-one thousand requiring hospitalization (based upon 1980 census data). The ranges were based upon the location of the epicenter and the time of day that the incident struck. The California Office of Statewide Health Planning and Development (OSHPD) recently found that nearly half of hospital floor space that needs retrofitting to meet current codes and comply with a 2013 state seismic safety deadline is in buildings that are considered vulnerable to collapse during a major earthquake (California Health Care Foundation, 2007). Current FEMA Scenario planning estimates that nearly two thirds of the Hospital Beds in Los Angeles, Orange, Riverside, and San Bernardino County will be non-functional (Science Daily, 2008). Based upon this estimate, a service population of approximately ten million, and that the United States presently maintains 3.6 Hospital Bed per 1000 people (Nationmaster, n.d.); this equates to a loss of approximately 24,000 patient beds, which for the most part are occupied with chronic and or acute patients, as well as the infrastructure to support them. These facilities would simultaneously be experiencing a surge of new patients presenting as a result of the injuries sustained from the Earthquake event. Even assuming occupancy rates of only 60% (low for the industry) approximately 14,400 patients would be displaced and require discharge, inter-facility transfer or evacuation outside the impacted area, without regard to the casualties that were generated by the event.

In 1981, President Ronald Reagan established the Emergency Mobilization Preparedness Board to develop a national medical response system (Kramer & Bahme, 1992). The board consisted of representatives from the Federal Emergency Management Agency (FEMA), the Department of Defense (DOD), the Veterans Administration, and the Public Health Service of the Department of Health and Human Services. This Board developed the National Disaster Medical System (NDMS); which was established by Presidential Directive in 1983. Originally conceived as a partnership to respond to the scenario of large numbers returning military personnel who were injured in an overseas conflict to an overwhelmed Continental United States (CONUS) military medical system; the NDMS was never activated to fulfill this original mission (Franco, E., Waldhorn, Inglesby, & O’Toole, 2007).

The mission of the NDMS evolved to create a system whereby civilian hospital beds, in non affected areas, could be used in the event of a disaster within the U.S. and Disaster Medical Assistance Teams (DMATs) who could respond to the impacted areas of a disaster (National Association of DMATS, n.d.). Prior to the NDMS, the assets available to fulfill these type missions were the one thousand-nine hundred and thirty Civil Defense Emergency Hospitals that had been pre-positioned throughout the country by 1964. The Civil Defense Emergency Hospitals, later renamed Packaged Disaster Hospitals, were 200 bed mobile hospitals based on mobile military hospitals that used the same federally procured military equipment. These hospitals were equipped with supplies for 30 days of operations. According to the 1964 DOD Office of Civil Defense Annual Statistical Report; “the Civil Defense Emergency Hospital (CDEH) is an austere but completely functional 200-bed general hospital designed to be set up within an existing structure such as a school, church, or community center. They required 15,000 square feet of floor space which permitted the separation of wards, operating rooms and other functional sections. The staffing requirement was for 316 personnel, including 10 physicians, 4 administrators and assistants, 34 professional nurses, 18 practical nurses, 6 anesthetists, 2 pharmacists, 128 medical aides and 124 other personnel, including dentists, laboratory technicians, X-Ray technicians, maintenance engineers, clerks, helpers, messengers, and housekeepers to be drawn from local resources” (Civil Defense Museum, n.d.). A little more than one half (25%) of the Civil Defense Emergency Hospitals pre-positioned in 1964 could conceivably have provided a total of 100,000 patient beds, with a staffing requirement of about 150,000 personnel. This number of beds exceeds the worst case scenario of developed by FEMA in 1980.

The NDMS System:

Presently the National Disaster Medical System has fifty-five Disaster Medical Assistance Teams. A Type I DMAT team is able to muster a 35 person roster in 4 hours, has 105 or more deployable personnel assigned including 12 physicians, has a Full Federal DMAT Cache of Equipment and Supplies, and is able to triage and treat 250 mixed category patients per day for three days. The DMAT is not and does not operate a field type hospital, but with augmentation from the national strategic stockpile and with additional personnel being recruited (local survivors with the needed skill sets), they can provide the Triage and Emergency room functions of a field type hospital with the patient holding capacity being provided by a co-located Federal Medical Station. The Federal Medical Station requires a team of 100 personnel and can sustain 250 stable primary care patients who require bedding services (U.S. Department of Health & Human Services, n.d.). Therefore, the maximal number of patient beds that the NDMS system can generate, providing that there was at least one Federal Medical Station (FMS) per DMAT team, and that all DMAT teams were at Type I readiness would be 13,750 patent beds, with a staffing requirement of 11,275 personnel. This number of beds does not even address the 14,400 patients would be displaced and require discharge, inter-facility transfer or evacuation outside the impacted area, without regard to the casualties that were generated by the event.

The rationale behind the apparent lack of concern for the additional 90,000 plus patient beds required for the worst case scenario presented is the over 110,000 pre-committed patient beds from the 1,800 participating National Disaster Medical System fixed facility hospitals. Community, teaching and trauma Hospitals across the nation have joined with the National Disaster Medical System, through Memorandums of Understanding, to make available their empty patient beds in times of disaster. Like the military combat medial delivery system, patients are to be evacuated out of the impacted (combat) area to the safe and secure Zone of the Interior (ZI).

The Challenges:

The challenge for this scenario is that the aero-medical and ground evacuation assets required to perform a mission of this magnitude are scarce. Mission planning factors for the aero-medical evacuation of a maximum of 6,000 patients a day from Iraq during Operation Just Cause accounted for 97% of the aero-medical evacuations assets available to the United States Military. Further, the actual mission accomplishment of 12,632 patents being evacuated on 671 Aero-medial flights averaged less than 20 patents per airframe (Green, n.d.). Thus, at this density, to evacuate even 50,000 patients would require 2500 airframes. Even assuming 250 flights per day, it would require ten days time to evacuate 50,000 patients. Other forms of transportation can also be used, such as railroad and bus assets; but these assets are not pre-configured, and the patients would require beds until such coordination was completed. It is reasonable to expect that a significant number of patients would not be able to be evacuated until at least ten days after the incident and therefore disaster level patient care beds should be planned for as they will be required to maintain the patients until evacuation assets became available.

To further confound the premise of evacuating the majority of patients requiring hospitalization to the Zone of the Interior is the harsh reality that patients must be first stabilized before they can be safely evacuated. Using techniques such as delayed closure, external fixation and the like, definitive care of some orthopedic and surgical patients can be delayed, without a significant increase in morbidity and with the attendant savings of the logistics overhead of providing the required supplies to perform these procedures in the austere medical environment expected within the impacted area. However, stabilization of internal injuries (crush) and other medical conditions must be attained before an aero-medical staging facility, or other evacuation management site will clear a patient for further evacuation. The general rule for military medical evacuation to the zone of the interior has been that the patient was expected to remain stable with onboard care supplies for at least 24 hours. In the case of an overwhelmed medical system within the impacted area, an evacuation policy that facilitated short haul evacuations for further stabilization to the closest medical facilities outside the impacted area could be envisioned; however, these facilities would likewise need to be transfer and evacuate their patients further into the zone of the interior. Additionally, to avoid becoming overwhelmed themselves, and lose their ability to receive new patients from the impacted area for lack of patient beds, they too would need to be augmented by resources from the National Disaster Medical System.

The Reality:

This returns our discussion to the present DMAT teams within the National Disaster Medical System. Unfortunately not all DMAT teams are at the TYPE I level of readiness. In fact, according to David G.C. McCann MD, Former Chief Medical Officer of FL-1 DMAT since 2003, a 2008 Senior Policy Fellow in Homeland Security at George Washington University’s Homeland Security Policy Institute, and Current Chair of the American Board of Disaster Medicine (ABODM), the “NDMS is being marginalized as DHHS (Department of Health and Human Service) prepares to upgrade the Commissioned Corps of the USPHS (United States Public Health Service) to serve as the “first-line” in disaster response” (McCann, 2008). To support this assertion Dr. McCann reflects that the number of voluntary members of the DMAT teams has dropped from over 7000 to about 5,000; that the contract that provided the training to DMAT members that was required for teams to be certified as being Type I expired October 31, 2005 and has not been renewed or replaced (University of Maryland, Baltimore County, 2005); that despite a budget increase of 6.3% for FY08 over FY07, teams have had their budgets significantly reduced and their administrative officer is forced to maintain the team’s credentials and records on little over 20% of the budget he had last year. Further, he asserts that there had been a complete freeze on hiring new NDMS personnel lasting over 2 years; consequently, “Maybe 10% of the 55 teams are at Type 1”. According to the RI-1 DMAT team Deputy Commander, Tom Lawrence, their team is one of the 31% of all NDMS team assets that have reached Type I readiness, and that they are also “very short on nurses” (Rhode Island Hospital, 2008).

Bill Hall, Spokesperson for the Department of Health and Human Services disputes Dr. McCann’s claims; he says the department remains “fully committed” to NDMS. “We are not closing down or eliminating teams. In fact, for fiscal 2009, HHS is proposing a $7 million increase for NDMS”. The commanders of six Florida-based DMATs posted a letter online on the National Association of DMATS website (Kruschke, et al., 2008) saying they had “confirmed through multiple independent sources” within the department that HHS officials are “engaged in a systematic plan to deemphasize” NDMS and to replace DMATs with new PHS Commissioned Corps Health and Medical Response (HAMR) teams; but Hall insisted that the HAMR teams will play a “complementary role” to DMATs. “Nobody is being replaced”. (Garza, 2008)

Regardless of the validity of the claims made by either the Commanders of the Florida DMATS or the Spokesperson of the Department of Health and Human Services, it becomes readily evident that the current status of the DEMAT teams within the National Disaster Medical System is sub optimal. In a presentation on their website targeting elected officials, the National Association of DMATS express their concern over the HAMR teams, Budget Issues, the loss of Warehouse Space, Inability to use Team owned equipment, Training, and Delays in Application Processing. They close their remarks with the statement “NDMS team members feel we are less prepared now to respond to a disaster than before Hurricane Katrina. This is a direct response to action taken by ASPR to dismantle NDMS. As the primary disaster medicine response agency we feel our elected leadership must look into the problems facing NDMS and the citizens of the United States who are the potential victims of the next disaster, natural or man-made” (National Association of DMATS, n.d.) .

In September 2008, The National Biodefense Science Board (NBSB) provided feedback to the U.S. Department of Health and Human Services on the review of the National Disaster Medical System (NDMS) and national medical surge capacity as required by the Pandemic and All-Hazards Preparedness Act (PAHPA) and as specified by Paragraph 28 of Homeland Security Presidential Directive (HSPD)-21. (National Biodefense Science Board, 2008). The report, marked confidential was available on the open web. It made thirteen recommendations which have been condensed and listed below:

1. Strategic Vision: NDMS…does not represent an overall system to provide for the medical needs of patients at a time of national need.

2. DEVELOPMENT OF AN NDMS / ESF-8 ADVISORY GROUP: The establishment of ongoing civilian advisory groups for the National Disaster Medical System.

3. MONITORING AND DOCUMENTING NDMS IMPROVEMENT; previous studies have identified opportunities for improvement in the NDMS… there does not appear to be an organized methodology to track and monitor attempts to address these identified issues.

4. MEDICAL RESPONSE PERSONNEL: To achieve full staffing and operational status for all NDMS response teams… An improved, streamlined application process for DMAT membership is necessary. A training curriculum should be developed, adopted and implemented.

5. NDMS FIELD PERSONNEL CAPABILITY AND GAP ANALYSIS: Consideration should be given to improving the NDMS personnel capability especially in terms of volunteers’ conflicting obligations and time to respond, for multiple specified national scenarios.

6. DEFINITION OF THE NDMS PATIENT: The definition of what constitutes an “NDMS patient” should be reviewed and expanded for the purposes of reimbursement.

7. REFINEMENT OF PATIENT MOVEMENT CONCEPT OF OPERATIONS: The ability to implement an effective, smooth mass evacuation of patients from an impacted area remains an unresolved issue.

8. NDMS ELECTRONIC MEDICAL RECORD (EMR): Although the advantages of the EMR are many… Its use must not compromise the efficiency of the healthcare providers in the field.

9. IMPROVED COMMUNICATION WITH STATE/LOCAL REPRESENTATIVES: Serious consideration should be given to returning the DMAT program to its original intent of first building local and state capability, and then exporting these volunteer resources through the NDMS for federal assistance to other parts of the country impacted by a disaster.

10. DEVELOPMENT OF IMPROVED NDMS STANDING CAPACITY: Serious consideration should be given to establishing improved alliances between NDMS and the public/private healthcare sector to provide assistance in field care, patient transport and definitive patient care.

11. FEDERAL REGULATIONS: Criteria should be developed in advance to specify when health-related federal regulations (e.g. HIPPA) should be considered for temporary suspension.

12. OVERALL NDMS FUNDING: It is clear that the funding level for NDMS is inadequate to support even the current level of the NDMS operation.

13. The Department of Health and Human Services is requested to respond to these recommendations in writing during their summer 2009 Public meeting.

Conclusion: The materials presented herein clearly show a National Disaster Medical System that is not ready to respond to an earthquake of major magnitude in California. The NDMS system can currently be safely called broken, and the challenge of the next administration is to address these issues in a timely manner before the system needs to be called upon to respond to the medical needs of our citizens during a major or catastrophic event.