Transcript An Integrated Health System Perspective on

An Influenza Pandemic – Innovating Past Barriers :
An Integrated Health System Perspective on Public &
Private Sector Coordination
Forum on Microbial Threats - Board on Global Health
Institute of Medicine
Washington, DC – June 16, 2004
Jonathan B. Perlin, MD, PhD, MSHA, FACP
Acting Under Secretary for Health
Veterans Health Administration
Department of Veterans Affairs
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2004: Who is “VA” ?
Veterans Health Administration
 VHA is Agency of the Department of Veterans Affairs
 5.1 million patients, ~ 7.5 million enrollees
 ~ 1,300 Sites-of-Care, including 158 medical centers or hospitals,
~ 850 clinics, long-term care, domiciliaries, home-care programs
 ~ $27.4 Billion budget
 ~193,000 Employees (~15,000 MD , 56,000 Nurses, 33,000 AHP)
 13,000 fewer employees than 1995
 Affiliations with 107 Academic Health Systems
 Additional 25,000 affiliated MD’s
 Largest provider of health professional education
 Most US health professionals (70% MD’s) have some training in VA
 ~ $1.7 Billion Research Program
 Basic, Clinical (Cooperative Studies), Rehabilitation, Health Services
J. Perlin, Veterans Health Administration - June, 2004
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Pneumococcal Vaccination
Rates
Percent Vaccinated
100
80
--BRFSS 90th--
60
--BRFSS--
40
20
0
FY 95
4th Qtr
97
4th Qtr
98
FY 99
VHA
Iowa 99*
Health People 2010
FY 00
CHG
FY01*
FY02
FY03
Healthy People 2000
NHIS
•Iowa: Petersen, Med Care 1999;37:502-9. >65/ch dz
•HHS: National Health Interview Survey, >64
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Reducing Variation:
From Evidence to Practice…
Closing the Quality Chasm (IOM)
Possess Operationalize
Knowledge Patient
Patient Knowledge
Need
With
Performance
Pneumococcal
Met
Need
Measurement
Pneumonia
Vaccination
Indications
&
Accountability
+
Supporting
Technologies
Computerized
Health Information
System

System Changes
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Fully Deployed Electronic Health
Record
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Clinical Reminders
Contemporary
Expression of
Practice Guidelines
• Time &
Context
Sensitive
• Reduce
Negative
Variation
• Create
Standard Data
• Acquire
health data
beyond care
delivered in VA
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Goals of Influenza
Preparedness
 Reduce the Burden of Disease
 Decrease the Social Disruption
 Decrease Economic Impact
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Preparedness and Planning
Guidance in Place
 1999: WHO “Influenza Pandemic
Preparedness Plan”
 2002: ASTHO Preparedness Planning for
State Health Officers
 Various State Plans (CA, FL, MA, MD . . .)
 2004: DHHS “National Influenza
Preparedness and Response Plan”
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BT Preparedness
Experience Relevant
 Federal, State, and Local BT Preparedness Initiatives
 Smallpox vaccination program
 Public health and health care response teams
 SARS surveillance, education, communication
 Lessons Learned – How to Prepare for Pandemic Flu:
 Early and continuous communication and coordination between
public & private sectors in all major preparedness domains
 VA transformation to “system function” parable for improved
communication, interaction, success
 VA as “Living Laboratory” for observation of Policy, Resources,
Practice, and Outcomes
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Planning & Preparedness:
 Public Sector:
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 Private Sector:
Framework for Planning
Funds for Preparations
Population Focus
Population Health Framework
Population Data
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Health Care Provision
Patient Focus
Patient Data
Minimize Economic Impact
Implementation Focus
 Opportunity:
 Early (pre-event) preparation of implementation
schema for all scenarios
 Translation of public/population needs to
individual/patient care perspective
 How to minimize economic impact and protect health
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Improved Epidemiology
 Public Sector:
 Private Sector:
 Infrastructure for state/local
surveillance
 Syndromic surveillance
 Electronic health record
 Use of innovative
technologies/models
 Receptor Site
 Opportunity:
 How to improve data capture from receptor site
 How to best detect signal from noise at collection sites
 Joint modeling of epidemic scenarios to project
vaccine, antiviral and health care utilization needs
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Improved Information
Systems
 VA Partnering with HHS to release “VistA-Lite”
 Electronic Health Record available “free” to all
 In use in 31 non-VA settings, including DC Department of
Public Health, public & private sector, other countries
 NHII (National Health Information Infrastructure)
 Allows “Cooptition” – cooperation for data exchange
and competition
 e.g., Internet (Mac & PC, Netscape & Explorer) or VISA
(Bank of America & Wachovia)
 President’s Goal: EHR for most Americans in 10 yrs
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Novel Vaccine and
Therapeutics Development
 Public Sector:
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 Private Sector:
Stimulate R&D (CRADAs)
Fast Track FDA review
Conditional Licensure
Early injury compensation
agreements
 Advanced purchase guarantee
 Depth & breadth in
pharmaceutical & biotech
industries
 Entrepreneurial focus
 Opportunity:
 Catalyze new approaches to vaccine, therapeutic and
diagnostic development
 Improved incentives to enter (remain in) market
 Expedited testing and distribution of needed products
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Vaccine and Anti-Viral Drug
Delivery Strategies
 Public Sector:
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 Private Sector:
Establish standards
Purchase/distribute product
State/local Heath Dept role
Schools/public event
vaccinations
 Model public health approach
(think Tb)
 Health Professional Groups,
systems, HMOs, insurers
 Vaccination delivery via private
gatherings; employers, grocery,
pharmacy, churches, clubs, bars,
malls, homeless pgms, shelters,
food banks
 Opportunity:
 Support foundation of usual vaccine and drug delivery
 Establish new strategies for distribution of vaccines,
prophylactic & therapeutic antiviral medication
 Home drug distribution via (e.g., VA CMOPs)
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CMOPs:
Technology at Work
Consolidated Mail Outpatient
Pharmacy
 ~ 200 Million “30 Day Equivalents” / Year
(40K per shift per CMOP)
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Performance: 5.85 Sigma
 Wrong Medication:
0.0007%
 Patient Satisfaction Rating: 90% VG/E
 Helped hold per patient pharmacy costs virtually constant
for 54 months (8.5% over 54 months), despite more Rxs
per patient & increased ingredient cost!
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Provision of Medical Care
 Challenges:
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Health Care Workers potentially affected
Nursing shortage already acute in certain areas
Worried well phenomena
Health care system/hospital surge capacity limited
 Opportunity:
 Coordinated, early vaccination of HCW
 Registry of potential HCW (also vaccinated)
 Community nursing, health care delivery
 Coordination with suppliers, distribution of material
 Innovative care arrangements (advanced home care,
telemedicine, internet advice, etc)
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Community Education and
Information
 Public Sector:
 Private Sector:
 Establish standards and
education materials for wide use
 State/local Heath Dept roles
 Schools/public events
 Use Madison Avenue approach
 Deliver education in private
gatherings; employers, grocery,
pharmacy, churches, clubs, bars
 Health Professional Groups,
systems, HMOs
 Opportunity:
 Deliver education/information via traditional modes
 Develop social marketing approach to all aspects of
influenza public health campaign
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Decreasing Economic
Impact
 Public Sector:
 Private Sector:
 Encourage leave for exposed
& sick workers
 E.g. Tax credit for lost wages
(corporate or personal)
 Public Leader ‘bully pulpit’ for
innovative private actions and
public health
 Prevent decimation of workforce
by encouraging exposed & sick
workers to stay home
 Non-punitive leave
 Management Enthusiasm
 Inconsistent public health mission
 Opportunity:
 Work now with postal workers (distribution), insurers
(incentives), unions (employee responsibilities; e.g.,
not presenting sick, not abusing leave) and employers
(liberal leave in self-interest)
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Pubic and Private Sector
Coordination
 Early and continual coordination
 Focus needed for each important domain
 Planning/Preparations
 Improved Epidemiology
 Vaccine and Therapeutics Development and
Delivery
 Provision of Medical Care
 Community Education and Information
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Acknowledgements:
 Lawrence Deyton, MD, MPH
 Director of Public Health,
Office of Public Health and Environment
Hazards
VA
 Gary Roselle, MD
 Program Director for Infectious Diseases,
VA Office of Patient Care Services
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Back-up Slides
VA approach to Influenza,
Pandemic Influenza, and BT
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VA Pandemic Influenza
Programs/Preparations
 Annual VA-wide vaccination program;
employees and patients
 Flu Vaccine Tool Kit to all facilities
 2003-2004 season - 1.3M doses of trivalent
vaccine given
 Aggressive Hand Washing/Respiratory Hygiene
Campaign
 Pneumococcal vaccine program (prevention of
post-influenza pneumonia) – a Performance
Measure
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VA Pandemic Influenza
Programs/Preparations
Building on BT & SARS Plans
 VA Committee on Urgent Public Health Issues
catalyzes VA-wide programs, policies, and
coordination:
 Education programs for providers (case definition, triage,
medical care issues, hand/respiratory hygiene, etc)
 Education programs for patients (recognition, public health
measures, hand/respiratory hygiene)
 Laboratory readiness
 Occupational health issues and policies
 PPE supply and distribution
 Antiviral drug supply and distribution
 Quarantine and triage algorithms
 Communications/Public Information
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VA Bioterrorism
Preparedness/Planning
Activities
 Pocket cards cards on diagnosis, treatment and
infection control for biologic, radiological and
chemical WMD (started 11/01- updated 04)
 Decontamination Units established & training
programs completed (at 77 VA facilities)
 VA Pharmaceutical Caches (at 143 VAMCs (large
cache to treat 2000 for 1-2 d, small for 1000)
 VA stores/maintains 5 NDMS pharmaceutical caches
 VA-wide clinician education on CDC Category A
agent diagnosis, treatment and infection control
 VA –wide education/information on emergency
response (200k resource info wallet cards
distributed)
 Family Emergency Planning Guide distributed to
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employees
VA Bioterrorism
Preparedness/Planning
Activities
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VA Role in Federal Response Plan
VA Emergency Response Program Guidebook
Medical Emerg Radiological Response Team
EMSHG Roles:
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AEMs, coordination with states
DoD Contingencies (65 receiving centers, etc)
NDMS (medical surge capacity)
Disaster Emergency Medical Personnel System
VA Emergency Response Teams
 Smallpox vaccination program, HCRTs/VRTs
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VA Coordination/Collaboration
with CDC - Bioterrorism
 VA Contribution to CDC National
Biosurveillance Program - daily
transmission to CDC of deidentified clinical
data from entire VA system
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