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Perspectives on the Nation’s Capacity to Respond to Threats to Health, Safety, and Security

The workshop’s first two panels provided different perspectives on the nation’s capacity to respond to threats to health, safety, and security. The first panel, moderated by Nicolette Louissaint from Healthcare Ready, featured four speakers who addressed the perspective of the private sector, which delivers the bulk of care in the United States. The four panelists were Brent James, formerly at Intermountain Healthcare and now at the Institute for Healthcare Improvement; Michael Wargo from the Hospital Corporation of America (HCA); Ronald Stewart from the University of Texas School of Medicine at San Antonio and the Southwest Texas Regional Advisory Council (STRAC); and David Witt from Kaiser Permanente. The second panel, which provided insights on the federal perspective, was moderated by Thomas Kirsch from the Uniformed Services University of the Health Sciences (USUHS). The four panelists were Kevin Hanretta from the VA; Melissa Harvey from ASPR; Anthony Macintyre from the Federal Emergency Management Agency (FEMA); and Jody Wireman from the U.S. Northern Command (USNORTHCOM) Headquarters.

PRIVATE HEALTH SYSTEM PERSPECTIVES

The first panel began with each panelist talking about the capabilities of their respective organizations. Wargo explained that as HCA’s enterprise vice president of preparedness and response, he has oversight of nearly 200 hospitals and just below 2,000 outpatient facilities in 22 states. These are divided into 14 divisions that implement a framework of governance, operations, and tactics to deal with emergency operations and prepared-

ness. Witt explained that Kaiser Permanente has, over the past 30 years, developed and drilled on a number of disaster scenarios and responded to several, including the explosive fire season that affected California in 2017.

James said that Intermountain Healthcare’s preparedness activities began in conjunction with the 2002 Winter Olympics, which were held in Salt Lake City. That effort, which included a coordinated community response, focused in part on a potential bioterrorism attack. One result of that planning was that several hospitals in the region changed their physical infrastructure to be able to cordon off parts of the hospital in response to an infectious agent outbreak. Other outcomes included the development of GermWatch, an automated system for transmitting reportable diseases to the state health department, and a data system that can track local store supplies of over-the-counter medications to track epidemics, both of which are used today. James noted that the emphasis on community-wide coordination led to the development of hospital go-to designations for specific problems. “Frankly, dealing with this at a community level was dramatically easier than dealing with it at a facility level, and it seemed to make a real difference,” said James.

From Ronald Stewart’s perspective as chair of STRAC’s executive committee, the regional trauma system serves as a great framework for disaster response, in large part because every health care system in the region—including emergency medical services (EMS), public and private health care, and public safety and public health—is included in the trauma system. The resulting diversity of facilities and capacities means the system is flexible and adaptable, said Stewart. Another advantage of this approach, he said, is that the trauma system, unlike a large health system, controls nothing but influences nearly everything, making it scalable, practical, and sustainable because the people who would respond to a large-scale event are the same ones working everyday tending to normal life events in their respective organizations. “I really do think it gets the right people, the right organizations, and the right leadership in the room together,” said Stewart, “and when you get that group of people in a room together you can get creative problem solving.”

Louissaint then asked the panelists to talk about how their organizations track events and determine what capabilities they will bring to bear in the subsequent response. Wargo explained that for situational awareness, HCA uses both internal and external communication systems, including off-the-shelf commercial products that scan social media such as Twitter as an initial indicator that something is happening in the community. If the number of tweets passes a threshold above normal, for example, his office then reaches out to HCA’s divisions or regional advisory councils to gain additional intelligence. An internal incident management system provides real-time situational awareness across every HCA entity. “Situational

awareness across the entire enterprise is critical to our operation so we can scale resources and mobilize from division to division or within a division so as to not stress any one facility or one area and to support those areas,” said Wargo.

Kaiser Permanente’s situational awareness activities, said Witt, began with preparations for the new millennium and when it was asked to prepare for a potential bioterrorism attack at the Rose Bowl. In response, Kaiser established a national group that addresses all threats and hazards and can garner and coordinate resources across the entire organization. One benefit that comes from this group is that representatives from each of Kaiser’s regions meet regularly, enabling them to develop trusted relationships with one another. If any region has a concern, the group assesses it and assembles a team of experts that would be ready if an event develops. For Witt, a high point for this group has been its involvement in responding to influenza season, an annual large-scale disaster that kills tens of thousands of people and overloads every emergency department in the country. “We pretend this is a staffing issue, but it is really an infectious disease disaster, and we are finally using this mechanism to make sure that the command centers are open, and we are actually functioning in a disaster mode,” said Witt.

James said he agreed with Stewart’s statement that response systems work best when they involve those who work on a daily basis with a particular component of the system. He added, though, that coordination occurs more effectively within a big integrated system than outside of that system, particularly concerning communication. Stewart noted that communication breakdowns are the common thread in failures that occur during wide-scale events. His region has a consolidated communication system that coordinates some 400 hospital-to-hospital transfers annually among two military and one civilian trauma centers. This communication system is now funded by all health systems in the southwest Texas region. Today it also coordinates transfers of mental health patients between facilities. At times of an emergency, such as when there was a bombing the night before the workshop at a FedEx facility located between San Antonio and Austin, the center sends out notifications to the appropriate people and coordinates communication among the relevant parties needed to respond to the developing situation.

Calling the STRAC center an incredible model for coordinating and communicating, Louissaint then asked the panelists to talk about what works in coordinating activities by the public and private sectors. Wargo applauded the development of the Sector Coordinating Council, a public–private partnership operating under the auspices of the critical infrastructure branch of DHS and HHS. This council allows Wargo and others from the private sector to share information openly with colleagues in the public sector and gain both national and global situational awareness of potential

threats. Communication is bidirectional, he stressed, in that it allows the private sector to inform government partners and leaders of what is happening in the private sector in the event of a large-scale emergency, such as hurricanes or the mass shooting in Las Vegas. “We are able to give real-time awareness to leadership, so they can scale appropriately and be more informed on the direct impacts,” said Wargo. Another positive development, he said, has been the creation of community-based coalitions through the HHS-funded HPP that not only help communities to work together to ensure safe, uninterrupted care within communities in the face of a disaster, but also enable relationships across the various sectors in a community.

Witt noted that the structures that STRAC and Intermountain Healthcare have developed create a good framework for communication, but perhaps more importantly, for relationship building and cooperation among organizations that normally compete with one another in the private health care sector. In addition, said Witt, these frameworks create stability, institutional memory, and a cooperative culture that can withstand the inevitable turnover in personnel. One concern James has concerning Intermountain’s communication system, though, is that 80 percent of the population in Utah lives along the geologically active Wasatch Front. In the event of a major earthquake, all of the region’s communication capabilities would go down at the same time. Regarding the ability of regional councils to build strong relationships among private-sector health care organizations that are often intense competitors, Stewart said that these relationships help create needed redundancy in leadership that could come into play should the leadership of one system be knocked out of commission by a disaster.

Turning to the subject of gaps, Wargo said that information sharing among competitors is still a challenging prospect. Coalition models such as the regional advisory councils in Texas can help address that gap by serving as a consolidator of information on available beds and supply chain issues that would be closely held business intelligence, but critically important to have in the event of a large-scale disaster. He noted that the biggest challenges for HCA arose from the combination of Hurricanes Harvey and Irma, when communication among the various levels of government and the private sector was less than ideal. Too often, he said, there was conflicting information coming from boots on the ground and state and federal sources.

Witt said there are many issues concerning the interactions between the public and private sectors. For example, public health does not really deliver health care, but its surge plans call for taking over private health care facilities. “The one thing that would gum up our response would be someone appropriating our equipment and distributing it in a way they think is best,” said Witt. In addition, while all organizations are risk averse to some extent, those in the public sector are particularly risk averse, which

can be crippling at the time of a large-scale event. As an example, he said the delay in the Centers for Disease Control and Prevention (CDC) declaration that the H1N1 virus was not a novel agent likely cost the U.S. health care system $1 billion in wasted isolation equipment, created gridlock in hospitals, and caused harm to patients who were kept needlessly in isolation units. “We knew that this was not a novel virus for 8 months before that declaration was made,” said Witt.

A step that is imperative, he said, is to figure out how the public sector can take some risks and accelerate its decision-making process. He suggested working with the private sector, mining its expertise, and creating memorandums of understanding to specify how the private sector would assume some of that risk. He noted that Kaiser participated in some exercises with the military during Fleet Week in San Francisco, and while the exercise was valuable, it became obvious that in the event of a giant disaster, 3 days would pass before the military could establish its medical facilities and aid in San Francisco’s response. “There really are gaps between what the public sector believes it can do and what the private sector will have to do, and I think we need to work on those,” said Witt.

James said the Utah State Department of Health and Utah Hospital Association used to serve as effective coordinators of regional activities in Utah. However, when he checked with his former colleagues prior to the workshop, he learned that the system is not as strong as it was when he was still at Intermountain Healthcare. The problem, as he understands it, is that the system has not been stressed for some time, and that the level of coordination needed requires active maintenance. That realization, he said, raises the issue of how to maintain a level of coordination and communication during good times.

Noting that STRAC served as the main coordinating center during Hurricane Harvey and the Sutherland Springs, Texas, church shooting that killed 26 people, Stewart said those two events stressed the system in different ways and revealed there was value in information sharing and coordination in general. The biggest gap those events revealed were in the coverage provided by the patchwork of trauma and emergency health care systems. In his mind, an affordable and feasible way to fill that gap would be to establish a set of minimum interoperable standards that would provide a framework for a trauma system designed intentionally for disaster response. This framework would include every public and private health care entity in a region.

Regarding his region, Stewart said he has noticed that private health care systems have become efficient, lean organizations over the past 20 years, which creates problems during a wide-scale event because each organization will have little excess capacity. “But with a diverse, inclusive system [with components that are] sharing information with each other,

while one facility may have very limited surge capacity, you can distribute that across the entire system and balance that load,” said Stewart. He noted that during Hurricane Harvey, health systems preferred to transfer patients among their own facilities, but STRAC was prepared to help find capacity outside of those systems when it was needed. “The critical issue during a widespread event is bed capacity, but that can be dealt with at least in part by improved coordination and sharing across health systems,” he said.

For Wargo, a major concern is the potential for cyber threats to take down utilities in a region. He believes the health care system has not mapped its interdependencies as thoroughly as it should to understand the long-term impact of losing the electrical grid or water supply. The saline shortage that occurred during Hurricane Maria is a case in point, he said.

Louissaint, noting that most health care in the United States is provided by the private sector, asked the panelists to comment on who they believe should be responsible for issues of health and security during a large-scale regional or national event. “I think everyone is responsible, even to the level of the single community member,” said Wargo, referring to individuals providing nuggets of information about what is happening on the ground. When it comes to the response and coordination aspects, Wargo said, the initial response needs to come from the local community, which needs to establish who has command and control authority. He noted that each organization, public and private, brings different resources and capabilities to the response, and it is important to establish a scalable chain of command and information pathways to coordinate how each partner can contribute to the response. Unfortunately, he added, during the recent hurricane season, FEMA had one approach, HHS had another, and DoD brought a separate set of capacities to the table. The private sector, meanwhile, did not have the information to understand the whole of the community and public-sector response, and thus, was slow to brings its resources to the response effort.

In Witt’s opinion, everyone in the public sector and private sector knows they are responsible for doing something, but the key is having one entity coordinating those responsibilities. He has a genuine concern about the medical community not accepting its responsibility for planning and training. Much of the training, he said, has been developed for prehospital care, yet the core response to most disasters will be to provide hospital-based or urgent care. James agreed that coordination is key to bringing together the different scales of responsibility to produce an effective and efficient response. His concern relates to the occasional conflicting messages he has received from those who think they are in authority and the potential damage that can result from conflicting messages.

Stewart agreed that everyone is responsible in a disaster, but having a framework to facilitate that responsibility helps. He noted that preparation

is key for responding to wide-scale events, but with most private health care systems it is difficult to get leaders’ attention to prepare for a low-probability event, even if the potential impact is high. “Having a framework that facilitates preparation is key,” said Stewart, who acknowledged that public health, law enforcement, and the fire department are better able to respond to a disaster because they have a structure that allows for training and preparation. Health care, in general, lacks such structures, so having a framework that gets public safety, health care, and public health working together through the regional trauma system can create a trauma system that serves as a regional disaster health response system. He said the Texas regional trauma center, which operates every day at the local level, provides such a framework. A regional not-for-profit organization has contractual obligations to the state to coordinate activities to improve the system, Stewart added. HCA, said Wargo, has added leadership that is responsible and accountable for readiness, response, and recovery. Witt noted that he is responsible for ensuring that Kaiser’s operations in northern California will be able to continue to deliver services during and after a disaster. He added that government can best serve as a facilitator or a responsible party, rather than a director.

DISCUSSION

Ricardo Martinez from Adeptus Health started the open discussion by asking the panelists to comment on how the private sector can interface with public health when the response to a regional disaster, such as Hurricane Harvey, has to transition from an acute care mode to one that has to provide care for someone who is homebound and cannot get an oxygen delivery, for example. HCA, said Wargo, has a hurricane playbook that starts 120 hours before the hurricane, continues through the hurricane, and turns to community resilience once the immediate event has passed. This playbook accounts for whether the HCA system is intact or has structural damage that alters its ability to care for its community, and if so, how it can mobilize clinical resources or equipment from other parts of its system to address the needs of the affected community. In the case of Hurricane Harvey, where HCA’s East Houston Medical Center was flooded and remains closed, the organization had to turn to its partnerships through the regional councils to understand where its community members would migrate for their care and how it could draw internal resources to deliver care. “Sharing risk and sharing impact across the community versus burdening any one individual health system is the approach that we take,” he said. Wargo added that HCA, in partnership with NDMS, had worked out ahead of time that its hospitals, augmented with state and federal resources, would serve as triage centers during Hurricane Harvey. The key point was that

this plan was made in advance, rather than having the federal or state government commandeer HCA’s facilities and making a game plan on the fly.

Witt said that Kaiser, as a fully integrated health system, has an easier task in those situations because it can draw on its home hospice program, for example, to deliver services in individuals’ homes rather than stress the capacity of the hospitals and emergency departments. Every hospital also has connections to coordinate and work with home health organizations to expand home health care capacity in such situations. James added that an integrated health system, such as Intermountain or Kaiser, can also draw on all of the components of the system, such as walk-in primary care facilities, in its response. His advice was to consider the entire system, not just the hospitals, in planning for a long-term adverse situation.

Craig Vanderwagen from East West Protection noted the tension he had heard from the panelists between network coordination and hierarchical failure, and he asked the panelists how the public sector could be more effective in supporting network thinking given that the public sector is largely driven by hierarchical thinking. Stewart replied that the first step would be for the public sector to accept the importance of the network and the system as a whole. The Texas trauma system, for example, is built on a professional model of evidence-based self-government rather than on a regulatory framework. “I have professional freedom, but I have the responsibility to do the right thing for the patient,” he explained. His advice would be for the federal government to create a set of principles and minimum standards—with input from the private professional community of doctors, nurses, paramedics, and others—that it would use to facilitate the formation and activities of regional systems.

James noted that networks rely on information transfer, so government agencies should explore what they can do to improve information transfer. Wargo suggested that the federal government could develop a standard framework to address compliance issues related to moving staff across geopolitical borders during a crisis. During the 2017 hurricane season, some entities were applying for 1135 waivers¹ in a coordinated manner, while others were not. Having a mechanism in place to execute those waivers quickly would accelerate resilience, he said.

Lewis Kaplan from the University of Pennsylvania Perelman School of Medicine wondered if large health care systems should have a single disaster preparedness dashboard that everyone in a region can access and that can interface with government resources. He also asked if hospitals should be viewed as sites of expertise that can be exported to the public health system to create a durable and embedded link for distributed competence

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¹ See https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/1135-Waivers.html (accessed April 19, 2018).

during a prolonged emergency. Witt replied yes to both questions and noted that Kaiser recently adopted an electronic emergency department visibility system for all its hospitals. “That is just within our system, but it would be great to have for a region,” said Witt. Wargo said that Pennsylvania has an electronic system that could provide that capability, but it is only updated monthly or so. He would like to see the establishment of regional advisory councils that would oversee an interoperable system where health systems would deposit information in real time. In fact, he said he has called for the creation of standards and requirements for interoperability across dashboard systems.

John Hick from the Hennepin County (Minnesota) Medical Center asked the panelists for their ideas on how to balance the tension between the ability to standardize and synthesize across different systems and the ability of an individual system to create its own standard workflow. Wargo said that HCA’s number one mandate to its facilities is to integrate locally first. For example, the local coalitions have standardized which powered air-purifying respirators they will use, and HCA’s warehouses now have a cache of that equipment. “You have got to have local integration in whatever the framework,” said Wargo, “but if we are looking at a national model, having a national standard is a start so that we can then take the disparities across all our coalitions and maybe bring it down into a tighter framework so we have more interoperability.”

Stewart agreed that local integration followed by regional integration is the right approach, with the federal government providing some standards to encourage interoperability, particularly regarding electronic health systems and dashboards. He added that in the Texas system, there is a mindset of health systems learning from one another and working together to focus on what is needed when the next big disaster occurs.

Duane Caneva from the National Security Council noted the fragmentation of the medical system and called for a matrixed approach that would capture local, regional, and national standards as well as the interdependencies across critical sectors. Disasters, he said, are not just one-time events because the threats are ongoing, including the annual influenza disaster that Witt discussed earlier. “What is the organizing structure at the national level that we can look to that allows the house of medicine to become a house unified?” asked Caneva. Witt replied that there are structures that exist yet are problematic, such as electronic health record systems that do not talk to each other, even though they should and could if there were national standards and defined elements. Wargo suggested that the elements exist, but the organization does not. “I think we need a clearly defined mission structure of where we want to start tackling that,” said Wargo. Stewart said that if the various sectors and professional societies committed themselves to approach things from a professional, evidence-based self-governance

model, with a commitment to civility, collegiality, and professionalism, standards and frameworks for interoperability could be developed.

Brendan Carr from ASPR remarked that a central theme of the panelists was to build on functional day-to-day systems to create a larger disaster-ready system. Given that, he wondered if there is a proxy that can provide insights about which parts of the day-to-day systems would be best able to respond when the system is pushed to its maximum capability. As an example, he noted the way that hospital readmission rates and hospital-acquired infection rates have served as proxies to identify quality improvement priorities for health care systems. James replied that one mistake at the national level has been to define standards from the top-down for an immature industry, as that suppresses innovation in industries that need innovation and advancement. This was the case, he said, when the meaningful-use standards were issued, which had a chilling effect on electronic health record innovation. He suggested a focus on transparency in terms of making information available to those who need to execute using that information when it is needed. He also pointed out that building something at the systems level so that it does not require constant attention helps with sustainability and makes it easier for people to do the right thing.

Stewart said that if he was informing federal policy, he would not recommend competing around quality, because quality should be what everyone is enabled and encouraged to do. In that regard, pay for performance, in his opinion, encourages health systems and providers to meet a metric, which he believes is a major distraction. Instead, he would encourage the process of improvement by setting standards that raise the quality of care and ensure development of the right infrastructure.

John Dreyzehner from the Tennessee Department of Health noted that the nation’s preparedness for a predictable disaster—the annual influenza season—is designed to fail given that the nation only makes about half of the vaccine needed to immunize everyone in the country. Given that, he asked the panelists how they would redesign the current system to prevent the majority of influenza-related deaths and illnesses. Witt replied that he wished he had the answer to that problem, though he noted that the rate of influenza vaccination has improved dramatically in the United States. One problem, he said, is that the nation charges for influenza vaccine, which is a barrier for some people. Another problem is that the health care system does not require all employees to be vaccinated. “There are conflicting issues of autonomy versus society benefit that have not been solved,” he said.

For the final question of the session, Sara Roszak from the National Association of Chain Drug Stores asked the panelists if they had ideas for quality metrics that could be used for preparedness purposes. The problem, replied Witt, is identifying what a metric in emergency preparedness would

be. Metrics would have value, he said, but it will be important to identify the unintended consequences of a metric before implementing it.

FEDERAL PERSPECTIVES

Before having the members of the workshop’s second panel describe their agencies’ activities, moderator Thomas Kirsch said that from his perspective as a first responder, emergency physician, and director of the National Center for Disaster Medicine and Public Health, engaging the private sector is critical for preparing the nation to respond to large-scale disasters. Moving on to the panelists, Keven Hanretta explained that the VA is the second largest department in the federal government, with more than 374,000 full-time employees, nearly 200,000 contractors, and 100,000 volunteers and affiliates. They support the health care of more than 9 million veterans at 1,700 points of care across the United States. In the event of a disaster, the VA expands its responsibility to deliver care to the 19 million living veterans in the United States.

Given that all disasters are local, the local VA facilities are often just as affected as private health systems, so its first responsibility following an event is to stabilize the VA facility so that it can continue to provide health care for its veterans, Hanretta said. At the same time, FEMA can call on the VA to provide support to state and local governments, as can HHS as part of NDMS. In fact, Hanretta explained, the VA provides 50 of the 63 NDMS coordinating centers spread across the nation. These coordinating centers provide the staff who coordinate the reception of patients coming out of a disaster area into civilian hospitals. The VA also has the congressionally mandated responsibility to be DoD’s contingency hospital system in the event that DoD evacuates casualties from the battlefield and requires surge capacity. “Whether it is FEMA asking us, HHS asking us, or DoD asking us, [the] VA has that responsibility to be a national asset, to step up and be able to share the resources that we have across the United States,” said Hanretta. In that regard, he added, the VA is involved in all disasters that occur in the United States.

Melissa Harvey then described ASPR’s HPP, which focuses on engaging the private sector through a cooperative agreement grant program currently funded at $255 million per year. Since 2002, in response to the 9/11 and anthrax attacks, these funds have gone to the health departments in every state, territory, and freely associated states, as well as the District of Columbia, New York City, Chicago, and Los Angeles, to build capacity and capabilities among the largely private U.S. health care system. While the program’s initial efforts were directed at building surge capacity at individual hospitals, it has expanded to build capacity across regional health care coalitions after recognizing that hospitals will be overwhelmed during

an emergency unless other components of the health care system cannot be somewhat resilient on their own and be integrated into regional response plans.

Currently, 470 health care coalitions, composed of some 31,000 member organizations, participate in HPP, but Harvey expects that number to drop given a new requirement that every HPP-funded coalition must include four core members, of which two must be hospitals, as well as local emergency management and local public health. Though the number of coalitions will fall, largely through the merger of smaller coalitions to meet the new requirement, the number of member organizations is expected to increase substantially because of the new CMS Emergency Preparedness Rule that went into effect in November 2016.² This rule, explained Harvey, applies to nearly 70,000 different providers and suppliers, and establishes a baseline of preparedness for those individual health care entities. Hospitals will already meet these standards because they are the same as those required for accreditation by the Joint Commission, but these standards will be new for many outpatient providers, dialysis centers, urgent care centers, and other types of facilities. “Emergency preparedness in some cases is completely new to them, and that’s why we think that this is a huge step forward,” said Harvey. She noted, though, that even with these new baseline standards, the challenge will be to engage the executive leadership in health care in preparedness, readiness, and the importance of joining these coalitions.

FEMA, said Macintyre, is best known for its role in coordinating interagency relief efforts for presidentially declared disasters and emergencies and for administering the Disaster Relief Fund as outlined in the Stafford Disaster Relief and Emergency Assistance Act.³ As he explained, the Stafford Act contains specific details about how FEMA and other federal agencies can engage and support regions affected by these presidentially declared incidents. He noted that FEMA, working through specific federal agencies such as HHS, provides assistance that the affected state, territory, or tribal government has requested or prioritized, though that can play out in unexpected ways. As an example, Macintyre recounted one incident following a recent hurricane in which the governor of the affected state requested assistance, but when his search and rescue team arrived at one town, the sheriff and mayor stood at the bridge leading into town and told them they did not want any assistance from the federal government.

In addition to its Stafford Act roles, FEMA can be called on to coordi-

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² See https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/Emergency-Prep-Rule.html (accessed April 20, 2018).

³ See https://www.fema.gov/media-library/assets/documents/15271 (accessed April 20, 2018).

nate other interagency responses to other crises. Examples include the 2014 presidentially declared unaccompanied children humanitarian crisis along the U.S.–Mexican border and the HHS-led response to the Zika outbreak in Puerto Rico. Macintyre explained that HHS, not FEMA, is the primary federal entity responsible for health and medical preparedness, but FEMA does work with HHS on multiple initiatives, such as the Biological Incident Annex, which outlines the actions, roles, and responsibilities associated with response to a human disease outbreak of known or unknown origin requiring federal assistance.⁴

The North American Aerospace Defense Command (NORAD), explained Jody Wireman, director of the Force Health Protection Division, is part of USNORTHCOM, and therefore it serves as the DoD operational lead for events that occur in the United States, and in particular, for those that fall under a FEMA mission assignment to support local, state, and regional authorities. USNORTHCOM’s response capabilities are divided into chemical, biological, radiological, and nuclear and other kinds of events such as hurricanes and earthquakes. The CBRN response enterprise includes 27 National Guard response groups and one large DoD response group, the latter of which includes four Army and two Air Force units. Wireman noted while responses to hurricanes and earthquakes typically take longer than a CBRN response, DoD medical units do respond once the danger of a subsequent CBRN event has passed. During the 2017 hurricane season, DoD mounted its largest response ever to an event in the United States, she said.

Wireman explained that USNORTHCOM’s medical capabilities are under the command of the individual services, and local-level support would be at the installation level. In some regions, such as southwestern Texas, the trauma capabilities of the local military facilities are well integrated with civilian capabilities. In other regions, the opportunity exists to form better relationships that would benefit both local capacity and DoD operations, she said. Across the United States, USNORTHCOM relies heavily on regional planning efforts, and would welcome the opportunity to be more engaged with and integrated into those planning activities.

With the introductions complete, Kirsch asked the panelists to talk about how their agencies were involved in the responses to the Ebola epidemic and the 2017 hurricane season. Regarding the hurricanes, Harvey said one of the big lessons was that each coalition is unique in its operations. The Texas coalitions, she said, were built without HPP funds on top of an established, high-functioning trauma system, and they did an excellent job during Hurricane Harvey. The Houston-area coalition has a physical

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⁴ See https://www.fema.gov/media-library/assets/documents/25550# (accessed April 20, 2018).

location for its Catastrophic Medical Operations Center that coordinated information sharing and did a good job orchestrating the task of transferring patients from affected hospitals to those sites that could receive patients. When a regional psychiatric residential treatment facility, which was able to shelter its patients in place, began running out of the medications their patients needed, the operations center worked with area hospitals to get those medications and with the volunteer group of boat owners that called themselves the Cajun Navy to pick up the medications and deliver them to that residential facility. That type of coordinated response, said Harvey, kept the limited number of mental health beds in hospitals from being overwhelmed.

This type of exceptional response is not something that occurs with all 470 coalitions, many of which are either too small or too dispersed geographically to effectively plan, let alone operationalize, a disaster response scenario. Too often, she said, coalition members do little more than exchange business cards and then revert to their individual roles in their own individual health care facilities when an emergency takes place. “Those coalitions have to stand up and be able to share information and coordinate resources,” said Harvey.

Harvey noted that ASPR received some 1,800 comments from coalitions who responded to the new requirements, and the clear majority said that health care coalitions are planning bodies only, not response entities. “I don’t know about you, but I do not know what you are planning for if you are not going to respond,” she said. Ironically, the physicians at those facilities all consider themselves to be frontline responders, which in Harvey’s view makes their facilities frontline responders. “That means we have to make sure the coalitions view themselves as having a role,” she said. In some cases, the coalitions are designated to vet resources, move them around, and serve as logistical coordinator. When that is not the case, it is still important in ASPR’s view that these health care systems have a good situational awareness and an idea of what resources they can bring during an event.

During the Ebola outbreak, surge capacity was not an issue, but surge capability was, in the sense that the dozen or so patients brought to the United States taxed the infectious disease capabilities of the health care system to their maximum. What was interesting about that event, said Harvey, was that never in HPP’s history had there been such a high level of executive engagement around an emergency. “If we could figure out a way to bottle up that engagement and that energy around what was an event that really impacted only a dozen patients, I really think that is where we can make some major progress,” she said. As a final thought, Harvey said that while she and her colleagues at ASPR talk about how coalitions need to be based on a good trauma model, Ebola was not an event that depended on a well-

developed trauma system. In her opinion, that fact points to the need to take a systems approach, rather than just a trauma-based approach, to be ready to handle mass shootings or infectious disease outbreaks.

Macintyre noted that FEMA is still undergoing its after-action exercise from the 2017 hurricane season, but in his opinion, there is more work to be done to improve private-sector resiliency even with the considerable progress that has occurred with the development of best practices gained from real experiences. As an example, the private-sector dialysis system in Puerto Rico was tremendously well organized and had generators ready for most of the clinics there. “Clearly, they still needed support after the storm, but if those pieces had not been in place, we would have been looking at an exodus of somewhere on the order of 6,000 people within 48 to 72 hours who needed dialysis,” said Macintyre. Where there is room for improvement is in what he called big-ticket items that involve large capital outlays. He recounted an effort that DHS led in the National Capital Region nearly a decade ago that examined the infrastructure of every hospital in the region and developed recommendations for how to fortify water and power systems, for example. At the end of the day, however, there was no funding to make the recommended improvements. In his opinion, the nation needs to develop some innovative methods for funding those types of improvements.

Other places where Macintyre sees room for improvement are in information management and sharing and in hardening communication facilities. He also noted that the trend to provide more care outside the hospital means there will be a large population of people receiving care outside the health care system who will need support during a disaster. “I know ASPR is paying attention to this, and FEMA is certainly paying attention to this, but it is going to become more of a problem,” he said. “We certainly saw challenges with this population during the last hurricanes.”

When responding to the 2015 earthquake that devastated Nepal, Macintyre and a colleague had a wonderful view of the international efforts that helped the country respond and recover. One asset, though, proved to be particularly vital to the medical response—NGOs that focused on rehabilitation and were designed to get people out of hospitals. “Having those organizations that could decompress the acute care facilities really saved the day, so that is an area for us to focus on,” he said.

The mantra for DoD in engaging during a disaster, said Wireman, is last ones in, first ones out to avoid getting in the way of what local, state, and regional entities are doing and to make sure that assets are available when requested by the local authorities. DoD’s response in Puerto Rico was challenging, she said, because while it had teams ready to go, it was difficult to integrate information coming from the island about prioritized requirements for food and water with the island’s medical needs. Another

challenge was that DoD doctrine calls for sending out its “platform tonnage” along with its people, and that can take a long time to deploy, raising the question of whether it would be possible to just send medical teams and just the necessary equipment in future responses. “I do not think we have explored that well enough,” said Wireman.

At the same time, while the military response can be slow, the delay offers the opportunity to accurately assess needs following the first 72 to 96 hours of response, when the initial responders may be at the point of exhaustion and stockpiled supplies are being drawn down. Wireman noted that DoD can deploy worker health and safety people sooner, and in the case of Puerto Rico, DoD was able to work with the Puerto Rican Health Department on water quality and mosquito trapping.

For the Ebola response, Wireman said she is not sure the U.S. government or even DoD realizes how integrated DoD was with the public and private responses to the outbreak. In fact, DoD looks to established private and public facilities as the first choice of where DoD members would go if they were infected with the virus. Even for training, there were efforts by the individual services to link with the University of Nebraska to supplement the limited capacity of the Army’s Institute for Infectious Disease. “In many ways, we look to the public and private sectors to gain information that we can incorporate into our processes,” said Wireman. In the case of Ebola, that meant using the regional mechanism that HPP has established for Ebola and other biological agents.

DISCUSSION

Harvey Ball from the Administration for Children and Families asked the panelists if anyone has looked at whether HPP dollars save the government money by preventing the deployment of federal assets, which can be expensive. Harvey replied that ASPR has just started that analysis and added that nobody believes that grants can fund all the nation’s preparedness needs. “Demonstrating return on investment is important, but there needs to be a recognition that these programs need to be sustained and moved further along with state and local support,” Harvey said. Macintyre added that much of what happens at the federal level helps engender and build systems at the state and local levels in ways that are tangible, but difficult to measure. For example, HPP, by funding coalitions, is building systems that help address everyday emergencies in a more efficient manner, he said.

Kaplan, noting that the coalition system is spread unevenly across the nation, suggested that ASPR should leverage the computing capabilities of the U.S. National Laboratories to ask the question of where coalitions are needed most and overlay that with the existing map of trauma centers. That

would enable matching infrastructure that already exists to support new coalition activity. Doing that, said Kaplan, could open the door to conversations with health system leadership that might engage them in preparedness. Harvey thanked Kaplan for that suggestion. She pointed out, however, that rural areas in particular have little capacity and yet in some ways need the type of coordinating capabilities a coalition would offer

Noting the absence of someone from CMS on the federal perspectives panel, Daniel Hanfling from the Johns Hopkins Bloomberg School of Public Health asked if there was a role for the federal government, perhaps through CMS, to incentivize health systems to build facilities that would be more resilient in the face of a natural disaster. Macintyre replied that some guidance already exists in the safe hospitals program that the Pan American Health Organization (PAHO) and the World Health Organization have espoused. He acknowledged that health care systems could pay more attention to facility resilience and perhaps less to architectural beauty when planning new facilities.

Eileen Bulger from the University of Washington and the American College of Surgeon’s Committee on Trauma asked the panelists for their thoughts on how to encourage a relationship between health care coalitions and existing, high-functioning trauma systems in the way that Texas has and to leverage health care coalitions to strengthen day-to-day responses in rural areas or regions where there are gaps in trauma capabilities. Harvey cautioned not to leverage the coalitions in areas where the trauma systems are not very strong because the way those systems were developed is not necessarily going to lend themselves well to day-to-day operations. In those cases, she said, it may be necessary for ASPR to work with organizations such as the American College of Surgeons and local trauma leaders to build a trauma system that can then serve as a foundation for a coalition.

Bulger then commented that the American College of Surgeons is working closely with DoD on integrating and strengthening military and civilian capabilities for local trauma systems. That type of integration proved to be important during the Las Vegas mass shooting event, when military personnel were allowed to help in civilian trauma centers. Harvey agreed that type of cooperation should play a role in strengthening local resiliency for disaster response.

Dreyzehner asked about the VA and DoD positions on vaccinating their health care workers against influenza and how they provide vaccine for veterans and active duty personnel. Hanretta replied that the VA takes the possibility of an influenza pandemic very seriously. It stressed its vaccination program every year and achieves a vaccination rate among its employees of about 64 percent. While the VA cannot mandate vaccination, the agency for the first time did not deploy VA employees who were not vaccinated during Hurricane Harvey. Regarding the veterans under its care,

the VA vaccinated some 2.5 million individuals, which does not count the ones its pays for when they are vaccinated at their local drug stores.

Wireman said all members of the military are required to get their annual influenza vaccination. What he said he would be interested in is whether it would be possible to set aside funding for some of the public–private entities supported by BARDA to produce vaccine, particularly in years when the initial designation of the target viral strains was wrong. DoD also has a public–private pharmaceutical initiative that might be able to support such a program.

Hick asked the panelists for their ideas on how the nation could do a better job with medical intelligence and resource matching. Harvey replied that information sharing and management is something that could be done better at the federal level and that the coalitions are doing a better job getting information from their members using various information technology platforms, though by the time that information trickles up to the federal level that information is too old to be of much value. One problem in addressing this challenge is that the federal government has not clearly defined what it needs to know and what the benefit to the private sector would be for sharing that information. “There has got to be a value proposition, and that is something we need to begin to tackle,” said Harvey. Wireman added that USNORTHCOM, the Transportation Command, and HHS are working to have teams that coordinate information dissemination, and Hanretta noted that the VA needs more help with both communication technology and telehealth. Better telehealth capability would have made a tremendous difference in Puerto Rico, he said. In a final remark to close the session, Mashid Abir from the University of Michigan Medical School wondered if the VA and private hospitals could share intensive care unit and burn care capabilities in a bidirectional manner.