When disaster strikes, it rarely impacts just one jurisdiction. Many catastrophic disaster plans include support from neighboring jurisdictions that likely will not be available in a regional disaster. Bringing multiple stakeholders together from sectors that do not routinely work with each other can augment a response to a disaster, but can also be extremely difficult because of the multi-disciplinary communication and coordination needed to ensure effective medical and public health response. As many communities within a region will have similar vulnerabilities, a logical step in planning is to establish responsibilities and capacities, and be able to work toward common goals to address all-hazards when the entire region is affected. To explore these considerations, the Institute of Medicine’s (IOM’s) Forum on Medical and Public Health Preparedness for Catastrophic Events organized a series of three regional workshops in 2014 to explore opportunities to strengthen the regional coordination required to ensure effective medical and public health response to a large-scale multi-jurisdictional disaster. The purpose of each regional workshop was to discuss potential mechanisms to strengthen coordination among multiple jurisdictions in various regions to ensure fair and equitable treatment of communities from all impacted areas.
Each of the three workshops covered different topics that may strengthen regional disaster response. The first workshop, held in Irvine, California, explored issues of community planning and engagement. Dis-
1The planning committee’s role was limited to planning the workshop. This workshop summary has been prepared by the rapporteurs as a factual summary of what occurred at the workshop. Statements, recommendations, and opinions expressed are those of individual presenters and participants, and are not necessarily endorsed or verified by the IOM and should not be construed as reflecting any group consensus.
cussions centered around the concepts of engaging non-traditional partners in the community around emergency planning and broadening health care coalitions to include these partners and encourage stronger community involvement. The forum convened a second regional workshop in Minneapolis, Minnesota, bringing together key stakeholders to examine how information and incident management can augment response efforts in a complex, regional emergency. Coordination of information among stakeholders during a disaster can often be a challenge, especially when introducing multiple levels of government and nonprofit and private-sector involvement. Improving this type of communication, especially in real-time, could improve situational awareness throughout a region. The third and final workshop in this series was held in New Orleans and considered how the first two topics of community engagement and information sharing could impact issues of surge management across the public health and health care spectrum. This includes patient tracking and evacuation, reducing the surge burden on clinical health care facilities, and improving services available within public health and community programs.
For the purposes of this workshop series, a “region” is defined as a multi-county or multi-state affected area, not necessarily abiding by the defined Federal Emergency Management Agency (FEMA) or U.S. Department of Health and Human Services (HHS) regions. As discussed in the 2009 IOM report Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations, regional health care coalitions are generally organized around functional medical referral areas. They may be within a jurisdiction, represent an entire jurisdiction, or overlap several jurisdictions or even states (IOM, 2009). That same concept was used across this workshop series, as defining specific regions, within and/or across states, can be particularly challenging because sectors often have overlapping regions. For example, one town may belong to one region for regional health planning, but in the case of regional law enforcement planning, they belong to another one with a separate set of partners. The need for integration and coordination of federal funding streams and cooperative agreements2 is discussed in further detail throughout this report. In addition, considerations for the coordination and integration of
2These include, but are not limited to, the Public Health Emergency Preparedness (PHEP) grant, the Hospital Preparedness Program (HPP) grant, Federal Emergency Management Agency (FEMA) preparedness grants, and the Urban Area Security Initiative (UASI) grant.
regions for robust regional emergency preparedness planning will be shown as well.
Released in 2013, the NHSPI is designed to provide an accurate portrayal of our nation’s health security using relevant, actionable information to achieve a higher level of health security preparedness.3 Consisting of 5 domains, 14 subdomains, and 128 individual measures, the NHSPI offers a snapshot of national preparedness levels and identifies areas for improvement. Development of the NHSPI was coordinated by the Association of State and Territorial Health Officials (ASTHO), in conjunction with about 30 public and private organizations, including the Centers for Disease Control and Prevention (CDC), American Red Cross, and American Public Health Association. The workshop series planning committee chose to focus each of the regional workshops on one of three domains of the NHSPI that were ranked in 2013 as warranting greater attention: community planning and engagement; information sharing and incident management; and surge management. As this type of measurement and evaluation will change with corresponding progress or failures, the 2014 NHSPI was released in December 2014 with updated data and new content, including new categories. “Surge Management” has been reframed as “Health Care Delivery” and “Environmental and Occupational Health” was created as a new domain.
Community Planning and Engagement
Community Planning and Engagement measures the coordination of organizations, partners, and stakeholders in a community, their collaborative efforts to plan and prepare for health incidents, and their capacity to respond to and recover from such incidents when they occur (NHSPI, 2013). Vigorous community planning and engagement are marked by cross-sector collaborations, plans to support vulnerable populations within a community, the existence of a pool of volunteers to assist in emer-
gency situations, and strong social cohesion within a community (Bies and Simo, 2007).
Information Sharing and Incident Management
Information Sharing and Incident Management measures the ability of a community to mobilize and respond to all aspects of a health incident. Factors include a community’s ability to marshal all necessary resources, establish and maintain command and control and coordinate during a health incident, provide legal and logistical support, and work across jurisdictional and disciplinary boundaries (NHSPI, 2013). Increasingly, health information technology (HIT) has become a large part of information sharing during response to an incident, and those issues are explored in this summary as well.
Health Care Delivery and Surge Management
Health Care Delivery measures a community’s capacity to prevent, diagnose, treat and manage illness, and to preserve mental and physical well-being through the services offered by the medical, nursing, and allied health professions (NHSPI, 2013). Because a community’s ability to deliver health care during a health incident is inextricably tied to its ability to deliver health care under conventional conditions, Health Care Delivery incorporates both environments into preparedness measurements (Hick et al, 2004). Surge Management, the label this category was given in the first iteration of the NHSPI, refers to the ability to augment the health care system in a way that accommodates a large increase in patient flow throughout jurisdictions.
On March 26, July 24, and November 15, 2014, the IOM’s Forum on Medical and Public Health Preparedness to Catastrophic Events organized a series of 1-day workshops at locations around the country to gather input from varied participants about the opportunities to strengthen regional coordination to ensure effective medical and public health response to a large-scale, multi-jurisdictional disaster. Represented sectors included state and local public health, emergency management, emergency medical services, hospital preparedness planners, academic
researchers, city and regional planners, community organizations, federal agency stakeholders, and others. Each regional workshop included discussions of mechanisms to strengthen planning, response, and recovery to disasters among multiple jurisdictions in individual regions to ensure fair and equitable treatment of communities. The specific meeting objectives for each workshop in the series are listed in Box 1-1.4
Community Planning and Engagement:
March 26, 2014 – Irvine, CA
- Examine how Community Planning and Engagement strengthen regional preparedness initiatives.
- Discuss community collaboration with schools, businesses, and community organizations across regions.
- Explore needs of at-risk populations and programs to assist them in emergencies.
- Identify gaps that still exist for specific populations.
- Discuss management of volunteers in emergencies across regions.
- Explore ways to better coordinate groups on regional use of national networks.
- Identify ways to incorporate local organizations into coordination planning.
- Consider factors that improve social capital and cohesion and the effect on community resilience during emergencies.
- Consider how grant guidance can be aligned with existing needs.
Information and Incident Management:
July 24, 2014 – Minneapolis, MN
- Examine best practices for information sharing and incident management in disasters.
- Explore pieces of information management during disasters through various recent case studies.
- Identify gaps that still exist for specific disasters (i.e., slow moving, no-notice, natural disaster, etc.).
4The full statement of task can be found in Appendix C.
- Discuss best uses of information sharing, integration of health systems, and private-sector partners in information centers.
- Explore ways to better coordinate groups regionally using national networks.
- Consider potential for using systems to augment response and situational awareness during an incident.
- Discuss coordination at the federal, state, and local levels.
- Highlight challenges leading to an uneven knowledge base or gaps in information.
- Explore methods to leverage private partnerships.
- Consider how improved information sharing and data collection capabilities can support decision making of policy makers.
November 15, 2014 – New Orleans, LA
- Define and discuss the challenges of evacuation and rapidly surging health systems across a region.
- Examine coordination of patient tracking within and across jurisdictions.
- Explore processes that are built into a region to successfully integrate public health and human services into a surge response.
- Discuss possible strategies to enhance medical capabilities and ameliorate burden on hospitals.
- Describe strategies that help to protect acute care hospitals in a region from being overwhelmed, and maximize use of other health care facilities across multiple communities.
- Discuss coordination across the diverse health sector players to achieve surge capability for health medical and social services.
- Discuss coordination of all organizations in a region that are active in emergency planning.
This workshop series summary is organized around three main topic areas that encapsulated much of the discussion throughout the three meetings. At the end of each content chapter, ideas highlighted by speakers or participants on how to strengthen preparedness in each domain are described. Chapter 2 explores issues of evacuation, patient tracking, and information sharing. Chapter 3 explores common remarks related to pub-
lic health surge capacity and community resilience. Chapter 4 looks at the overlapping presentations and discussion areas of coordination of a community response across the meetings. Chapter 5 summarizes challenges presented and potential opportunities for moving forward.
Throughout the series, several participants highlighted many important opportunities for advancing regional, multi-jurisdictional response to a large-scale disaster. A number of ideas emerged across multiple workshop presentations and discussions on the topics above. The topics below are discussed further in the report that follows.
Importance of Inclusive Coalition Building and Sustainability
Government agencies, whether federal, state, or local, have difficulties handling disaster preparedness alone. By forming partnerships and creating regional coalitions that represent the diverse needs of communities, more progress can be made. As many speakers pointed out in the workshop on community engagement, these health care coalitions typically include the obvious partners, such as the Red Cross, Salvation Army, and local health care providers, but also non-traditional partners, such as schools, community organizations, special needs organizations, and large employers. Coalitions are not only crucial during the planning and engagement period prior to disasters, but also during a disaster and the recovery process. These partners can help in disseminating preparedness information to their diverse populations, as well as potentially assist in the event of mass vaccinations across a region by becoming a closed point of dispensing for countermeasures. Following a disaster or emergency, they can also be valuable during recovery and rebuilding representing the whole community.
5Rapporteurs’ summary of main topics and recurring themes from the presentations, discussions, and summary remarks by the meeting and session chairs. Items on this list should not be construed as reflecting any consensus of the workshop participants or any endorsement by the IOM or the Forum.
Collaborating with the Private Sector
In addition to planning and recovery improvement, sharing and strong management of information during a disaster across multiple spectrums can be much more dynamic and transparent when members from a broad spectrum of the community are included and systems are pre-established to enable the cross sector communication. These types of members can also be leveraged to transmit informational messages to the public. For example, non-traditional private-sector partners such as Amazon, Facebook, or Google are adept at personalizing messages and engaging the public and use their methods often in their daily business. Richard Serino, former deputy administrator for FEMA, commented that a new initiative called Operation Dragonfire is working along with the White House initiative on Innovations for Disaster Response and Recovery6 to better analyze available data to improve disaster response. He said Facebook and Google have expressed interest in becoming involved. They can already track items that are “trending” and quickly analyze large amounts of data, so leveraging their abilities can assist health authorities working across large regions. Working more to engage them in this type of regional planning on the front end could lead to better data surveillance in the future, suggested Dan Hanfling, contributing scholar at UPMC Center for Health Security. Building out regional coalitions can also help to address specific gaps within smaller communities—as a weakness in one jurisdiction could be a strength in another—so working at a regional level can help to ensure weaknesses are accounted for and resources are appropriately dedicated if available.
Keeping Partners Engaged
Erosion of collaborations and sustained partnerships have been occurring due to loss of key staff, and failure to maintain the regional communication and trainings that have been built in the past decade, asserted Rosanne Prats, executive director of emergency preparedness at the Louisiana Department of Health and Hospitals. This decrease in funding and overall support from the national level makes it difficult to persuade hospital administrators that regional preparedness is a valuable effort to their institutions. One of the key challenges within the area of
6For more information on the White House initiative and efforts, see http://www.whitehouse.gov/sites/default/files/microsites/ostp/white_house_innovation_for_disaster_response_-_2014-july29.pdf (accessed March 2, 2015).
coalition building, also pointed out by Prats, is to sustain coalitions in so-called “peace time,” that is, the period between disasters. All too frequently coalitions that arise during or immediately following a disaster fade later. This not only hinders planning between disasters but can also thwart the disaster response if new groups are coming together in a piecemeal fashion. Jim Craig, director of health protection, Mississippi State Department of Health, argued that communities need to devise ways to sustain coalitions so that partnerships need not be dissolved and reassembled for each disaster and recovery. One approach is to develop registries of coalition partners indicating what resources they can and cannot contribute during a disaster. Other alternatives include engaging the “whole of community” in frequent planning and tabletop exercises. Active coalitions consisting of broad-based nongovernmental organizations (NGOs) can contribute to community cohesion and social capital that also can contribute to community resilience in the wake of a disaster.
Incorporating the Medical Community into Intelligence Centers
Although some of the discussions about inclusion during the meeting series revolved around NGOs and private-sector partners, several participants also highlighted the challenges of bringing health expertise into law enforcement and public safety intelligence centers. Serino described the operations of the Medical Intelligence Center in Boston and how the partnership with the Boston Regional Intelligence Center allows synergy of health-related information exchange. Even if a strong synergy like his example cannot be accomplished right away in other regions, John Osborn, operations administrator at the Mayo Clinic, noted that adding health expertise into fusion centers7 around the country could allow for better situational awareness in health emergencies. The impact on health from a disaster may not always be seen immediately, so having that expertise included as the response unfolds could be valuable.
The Integration of Information Technologies
Many types of software programs are used to monitor the movement of evacuees, to conduct pre-hospital tracking of patients, and to keep
7(Fusion centers) serve as primary focal points within the state and local environment for the receipt, analysis, gathering, and sharing of threat-related information among federal, state, local, tribal, and territorial (SLTT) partners. For more information, see http://dhs.gov/national-network-fusion-centers-fact-sheet (accessed April 6, 2015).
electronic health records (EHRs) in the hospital. This is becoming increasingly common both during a disaster and in everyday routine care, thanks to recent regulations and incentives through the Health Information Technology for Economic and Clinical Health Act (within the American Recovery and Reinvestment Act)8 in 2009 and the Patient Protection and Affordable Care Act (ACA)9 in 2010.
Expanding interoperability among all of these systems and their operators remains an ongoing challenge. As reported to Congress in a June 2013 update, “enabling exchange will involve reducing the cost and complexity of electronic health information exchange, ensuring trust among the key participants of exchange, and encouraging exchange of information, particularly during transitions of care” (ONCHIT, 2013, p. 10). Jim Blumenstock, chief program officer for public health practice at ASTHO, emphasized the need for an interoperable, universal tracking platform for different modules to collect real-time data on patients and evacuees. He added that the information should be kept “unsiloed” so if one system is down during a disaster, information can be transferred easily to another system without any data loss. But until then, the lack of integration of the programs across different health care settings, as well as across jurisdictions, can lead to redundancies and a lack of situational awareness among local, state, and regional levels. The lack of interoperability means that evacuees cannot be tracked across jurisdictions, patient record transfer across state lines is difficult if not impossible, and patient care itself is delayed, unnecessarily duplicated, or adversely affected.
Patient Tracking Standardization
To add to the confusion, there is an absence of standardization across systems as far as what fields are reported and what information can be input. Because of certain information that federal agencies request during disasters, some jurisdictions have trouble using software “off the shelf” and instead develop their own tracking systems and work with their re-
8For the full text on the Health Information Technology for Economic and Clinical Health Act, see https://www.govtrack.us/congress/bills/111/hr1/text (accessed March 2, 2015).
9For the full text on the Affordable Care Act, see http://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdf (accessed March 2, 2015).
gional catchment areas, as Cynthia Davidson, Region 1 emergency management coordinator at Louisiana Department of Health and Hospitals, described. Blumenstock added that the federal systems, such as the Joint Patient Assessment & Tracking System (JPATS), run through HHS may also be collecting similar information, but there was a lack of clarity about how all of these systems could most efficiently and effectively interact. Understandable challenges lie in the difficulty in sharing proprietary information among competing hospitals, accountability of completing information correctly, as well as rules under the Health Insurance Portability and Accountability Act.10 But continuing emphasis in this area, seeing where the gaps lie within large-scale events such as Hurricanes Katrina and Gustav, and achieving standards and interoperability among systems in this area, can assist in ensuring successful outcomes and greater transparency for a regional disaster. Opportunities for the integration of HIT systems are described further in Chapter 2.
Connecting Disciplines to Change Approaches
As discussed throughout this report, federal preparedness funding streams and program objectives can often be limited in scope, targeted to accomplish a narrow set of goals within a specific sector. As Blumenstock mentioned previously, this can sometimes lead to duplication of efforts, inefficient uses of funding, or lack of situational awareness between entities working toward similar goals. Bruce Clements, preparedness director at the Texas Department of State Health Services, noted that in their region they often have multiple risk assessments being completed across sectors as a requirement of cooperative agreements or funding. This results in multiple risk assessments being conducted in a non-systematic manner. With regard to public health and primary care, a 2012 IOM report also showed that competing funding streams from the federal level discourage integration at the local level and instead create silos among entities (IOM, 2012a). Recently, more emphasis has been placed on the integration of programs and intersection of fields to accomplish common objectives, as with coordinated objectives within Public Health Emergency Preparedness (PHEP) and Hospital Preparedness Program (HPP) cooperative agreements from CDC and the HHS Office of the Assistant Secretary for Pre-
10More information on HIPAA privacy rule and regulations can be found at http://www.hhs.gov/ocr/privacy/hipaa/understanding/index.html (accessed March 2, 2015).
paredness and Response (ASPR),11 respectively. However, traditional methods and the acknowledged funding issue can be challenging. The IOM report also found that problems that stem from this separation have long been recognized, but new opportunities are emerging for bringing the sectors together in ways that will yield substantial and lasting improvements in the health of individuals, communities, and populations (IOM, 2012a). Building diverse coalitions and combining efforts can allow for more innovation, through variations in abilities and knowledge, in accomplishing goals important to a range of stakeholders (Niebuhr, 2010).
Trying a Multi-Use Approach
Across all three meetings in this series of workshops in 2014, individual participants highlighted ideas that were “multi-use”—solve more than just one problem—or approach problems in sync to affect greater overall improvement. In an era of uncertain funding and program support, Craig Vanderwagen, senior partner at Martin, Blanck & Associates, noted that governments, community groups, and the private sector across regional boundaries can accomplish greater regional preparedness as well as improved overall health and sustainability if sectors can successfully integrate goals and objectives. Through this integration, new innovations and approaches could be realized to address common problems that have historically been undertaken in a more insular manner. For example, building communities that encourage social cohesion, active living, and resilient infrastructure can contribute to healthier residents overall, but also safer and more resilient communities during a disaster. Engaging members of the community and collaborating across sectors can not only build community resilience and mitigate exposure to some disasters, but it can also reduce the clinical surge burden and keep people out of hospitals by leveraging other community services. A few participants also noted that broadening coalitions to include the private sector, including information technology, can help to disseminate important public messages quickly in a health emergency, and they can increase capabilities for systems monitoring during an ongoing response. In addition, recognizing children, especially unaccompanied, as an at-risk population and broadening coordination efforts with local and state human service agencies to address their needs could improve a comprehensive response.
11For more information on this alignment of agreements, see http://www.cdc.gov/phpr/documents/HPP-PHEP-BP3-Continuation-Guidance_Supplemental-Information.pdf beginning on page 3 (accessed March 2, 2015).