1. United States Department of Health & Human Services Office of the Assistant Secretary for Preparedness and Response Ken Hopper Federal Patient Movement Coordinator Operations Division Office of Emergency Management Office of the Assistant Secretary for Preparedness and Response Federal Patient Movement

2. ASPR: Resilient People. Healthy Communities. A Nation Prepared. Acronyms APOE: Aerial Port of Embarkation APOD: Aerial Port of Debarkation ARF: Action Request Form BARDA: Biomedical Advanced Research and Development Authority (BARDA) DMAT: Disaster Medical Assistance Team DMORT: Disaster Mortuary Operational Response Team EMAC: Emergency Management Assistance Compact EMG: Emergency Management Group ESF: Emergency Support Function FCC: Federal Coordinating Center FMS: Federal Medical Station IRCT: Incident Response Coordination Team MA: Mission Assignment MRC: Medical Reserve Corps NDMS: National Disaster Medical System NRF: National Response Framework NSSE: National Special Security Event NTSB: National Transportation Safety Board PAHPA: Pandemic and All Hazards Preparedness Act PHE: Public Health Emergency PHS: US Public Health Service PSOW: Pre-scripted Statement of Work RDF: Rapid Deployment Force REC: Regional Emergency Coordinator SOC: Secretary’s Operation Center

3. ASPR: Resilient People. Healthy Communities. A Nation Prepared. NDMS Partners A federal sector partnership A Nationwide Medical Response System to :  Supplement State and local medical resources during disasters or major emergencies  Provide backup medical support to the military / VA medical care systems during a military health emergency HHS DoD VA DHS

4. ASPR: Resilient People. Healthy Communities. A Nation Prepared. Components of NDMS Medical Response Lead HHS Patient Evacuation Lead DoD / HHS Definitive Care Lead DoD/VA DMAT NMVT IMSuRT DMORT Specialty Teams DoD Aeromedical Evacuation Primarily Fixed Wing DoD/VA Federal Coordinating Centers 1 2 3 HHS

5. ASPR: Resilient People. Healthy Communities. A Nation Prepared. 5 Patient Evacuation Provide Patient Movement from the disaster area; air, bus, train Utilize all types of transportation ESF#8 Patient Movement Coordination Cell manages and staffs requests Primarily relies on aeromedical USTRANSCOM: Patient regulating, movement requests, staging, tracking ─Embarkation ─Debarkation Primary: DoD / HHS

6. ASPR: Resilient People. Healthy Communities. A Nation Prepared. AE Operations Definitive Care Patients from area hospitals, nursing homes DASF / MAC T at APOE FCC at APOD

7. ASPR: Resilient People. Healthy Communities. A Nation Prepared. National EMS Contract (aka FEMA Ambulance Contract) FEMA contract executed through HHS operational support Can only be utilized within a Stafford Act Activation/Declaration 7

8. ASPR: Resilient People. Healthy Communities. A Nation Prepared. 8 Quick Facts Centrally managed, regionally coordinated contract Provide a full array of licensed ground, air ambulance and para-transit services to assist states in accomplishing patient evacuation May be ordered as needed to supplement response to a disaster, act of terrorism or other public health emergency. State public health authorities determine there are unmet requirements to rapidly and safely evacuate patients with complex and ongoing medical needs; Initiate request for federal assistance; First zone in 24 hours or less; second zone in 48 hours.

9. ASPR: Resilient People. Healthy Communities. A Nation Prepared. 9 GROUND AMBULANCE ─300 ground ambulances (ALS & BLS) ─Typically a 70%/30% ALS/BLS split AIR AMBULANCE ─25 air ambulances, helicopter and/or fixed wing PARA-TRANSIT ─Ability to transport 3,500 individuals ─Not 3,500 vehicles Performance Requirements Per Zone BOTTOM LINE: LIMITED NUMBER OF RESOURCES

10. ASPR: Resilient People. Healthy Communities. A Nation Prepared. 10 Contract Zones

11. ASPR: Resilient People. Healthy Communities. A Nation Prepared. 11 In addition to the ground and air assets, there are approximately 150 EMTs (EMT-Basic and Paramedic) ─Patient triage, treatment & transport ─Conducting well-ness checks (aka “door-to-door missions”) ─Staffing shelters ─Distributing immunizations ─Hazard recognition ─Symptom surveillance & reporting ─On-scene medical standby ─Staffing emergency departments ─Setting up mobile medical units EMS Roles

12. ASPR: Resilient People. Healthy Communities. A Nation Prepared. Patient Tracking

13. ASPR: Resilient People. Healthy Communities. A Nation Prepared. 13 Needed a way to track Grandma when moved in the Federal Patient Movement system, from start to finish “FEDEX” for patients Web based application ─DoD legacy system – Joint Patient Tracking Application ─Easy to use; minimum training requirements One leg of the HHS disaster IT triad that makes up Disaster Medical Information Suite ─JPATS ─Electronic Medical Record ─Health Information Repository Joint Patient Assessment and Tracking System (JPATS)

14. ASPR: Resilient People. Healthy Communities. A Nation Prepared. 14 State Patient Tracking System Challenge Source: ASPR Regional Emergency Coordinator

15. ASPR: Resilient People. Healthy Communities. A Nation Prepared. Components of NDMS Medical Response Lead HHS Patient Evacuation Lead DoD / HHS Definitive Care Lead DoD/VA DMAT NMVT IMSuRT DMORT Specialty Teams DoD Aeromedical Evacuation Primarily Fixed Wing DoD/VA Federal Coordinating Centers 1 2 3 HHS

16. ASPR: Resilient People. Healthy Communities. A Nation Prepared. 16 Definitive Medical Care Approximately 1,882 civilian hospitals in the NDMS network nationwide ─Agree to make a number of inpatient beds available Beds categorized into 5 categories (burn, critical care, med- surg, psych, and pediatric) ─Heavy focus on trauma care Federal Coordinating Centers (FCCs) ─Concentrated in major metropolitan areas ─Air access ─Available hospital support ─Patient reception and distribution capabilities Primary Lead: VA / DoD

17. ASPR: Resilient People. Healthy Communities. A Nation Prepared.

18. 18 Definitive Medical Care Service Access Teams ─Follow patients to the NDMS facilities (track in JPATS) ─Ensure transportation, human services (language translation, food, lodging, etc) and arrangements for discharged patients and attendants ─Coordinate patient return

19. ASPR: Resilient People. Healthy Communities. A Nation Prepared. Federal Patient Movement Limitations and Gaps

20. ASPR: Resilient People. Healthy Communities. A Nation Prepared. Current Parts and Pieces 20 HHS ─Mobile Acute Care Strike Team ─Service Access Team ─Joint Patient Assessment and Tracking System (JPATS) Team DoD ─Disaster Aeromedical Staging Facility (DASF) ─Global Patient Movement Integration Center (GPMIC) / TRAC2ES ─Tactical Airlift Control Center (TACC) / Fixed-winged airlift ─FCCs / Patient Reception Area VA ─FCCs / Patient Reception Area ─Litter teams Other ─NDMS Hospitals ─National Ambulance Contract

21. ASPR: Resilient People. Healthy Communities. A Nation Prepared. 21 Feds can only move limited number of patients with limited transport resources. Additional APOEs problematic for AE ─DoD will not move: List of approx 15 no-fly conditions (e.g., must be 72 hours post- op, Seizure with in last 2 weeks, Hgb <8.5) Pediatric/neonate patients True burn patients requiring burn teams to transport Un-restrained psych patients…require chemical restraints National Ambulance Contract not the panacea—it is intended to augment state and local resources Limitations/Gaps 21

22. ASPR: Resilient People. Healthy Communities. A Nation Prepared. ESF #8 Patient Movement Planning Factors

23. ASPR: Resilient People. Healthy Communities. A Nation Prepared. Contraindications for DoD Aeromedical Evacuation Any medical condition not stabilized Pregnancy > 34 weeks Hemorrhaging (Hgb <8.5) Post-op <72 hours Acute Coronary Syndrome Post procedure < 7 days ─Open-heart surgery ─Craniotomy ─Spinal surgery Untreated pneumothorax Pneumocephalus Seizure with in last 2 weeks New onset cardiac dysrhythmia Unbivalved orthopedic casts Communicable disease Respiratory isolation including possible TB Agitation or other behavior distracting to flight Decompression Sickness 23 UNCLASSIFIED

24. ASPR: Resilient People. Healthy Communities. A Nation Prepared. Timelines 24

25. ASPR: Resilient People. Healthy Communities. A Nation Prepared. 25 Request to Move Patient Movement Operations 1000 600 Planning Factors - Laydown: 8 C-130s; 4 APOEs - C-130 schedule: 2 sorties per day - Average acuity: 20% critical care 35 patients per C-130 H-60 H-24 H-12 Reconstitution H-36 H-48 Evac Ops Cease Redeploy Complete 1200 Typical pre-storm start at H-54 = 840 patients evacuated Maximum Patient Movement Capability: 560 patients/day Total Patients H-72 H-18 400 200 800 H- Hour - Point at which tropical force storm winds reach landfall 7 Patient Movement Planning Factors Boots on the Ground Setup Teams Deploy 36 hrs of patient movement 36 hrs of patient movement

26. ASPR: Resilient People. Healthy Communities. A Nation Prepared. 26 “Notice” Incident H-48 H-72 H-48 H-24 H-96 H-120 FEMA Trigger Pt 1 H-Hour H-24 MA approved for NDMS patient movement AE Operations begin LA decision to evac patients H-hr – Point at which tropical force storm winds reach landfall Gulf Coast Pre-Storm Evac DoD surge mission assignment Patient Movement Cell conference call Patient Movement operations end at H-12

27. ASPR: Resilient People. Healthy Communities. A Nation Prepared. 27 Timelines compressed—no D-hour. Start at D-0. Will need patient movement requirements clearly stated. ─Requires best assessment of number and type of patients needing evacuation; ─Limitations to where patients are evacuated? Okay to take out of state? ─Identify APOE(s); for AE, need DoD to validate APOE. Do we commit all four APOEs? Are there alternate modes of transport that can be brought to bear? “No-Notice” Incident 27

28. ASPR: Resilient People. Healthy Communities. A Nation Prepared. 28 Need to increase capacity to move patients Need to build a more responsive federal patient movement system Need to improve network of NDMS medical facilities to include long-term care Need pediatric/neonate, and burn solutions Gaps…

29. ASPR: Resilient People. Healthy Communities. A Nation Prepared. 29 Is AE the ONLY solution for evacuation? Can “MEDEVAC” fill the gaps? ─Regulated vs unregulated patients Rewriting the Definitive Medical Care MOA for NDMS facilities Working with ONC to look at atypical methods to view bed capacity Developed Medical Evacuation of Patients with Highly Contagious Diseases paper Developing alternate modes of transport ─Air National Guard U.S. Coast Guard U.S. Forest Service General Aviation Ground ─Better utilize train transport ─Ground freight movement (e.g., tractor trailers, ISO containers) What we are doing…

30. ASPR: Resilient People. Healthy Communities. A Nation Prepared. 30 States must exhaust all available resources ─Pre-established mutual aid agreements ─State Guard engagement to conduct MEDEVAC missions ─Utilize all existing EMACs States will need to “hold the fort” until feds can mobilize ─May be as long as 72 hours Plans should consider bringing medical resources in to stabilize infrastructure What you can do… 30

31. ASPR: Resilient People. Healthy Communities. A Nation Prepared. Comments? 31

32. ASPR: Resilient People. Healthy Communities. A Nation Prepared. Find Us Online 32 PHE.gov: www.phe.gov/about/OPP/DIHS Facebook: www.facebook.com/phegov PHE.gov Newsroom: www.phe.gov/newsroom YouTube: www.youtube.com/phegov Flickr: www.flickr.com/phegov Twitter: twitter.com/phegov

33. ASPR: Resilient People. Healthy Communities. A Nation Prepared. Patient Tracking Backup Slides 33

34. ASPR: Resilient People. Healthy Communities. A Nation Prepared. JPATS Functionality 34 Step by step registration process Design leverages touch screen functionality, bar code scanning, and patient photographs for identification

35. ASPR: Resilient People. Healthy Communities. A Nation Prepared. 35 States and Local areas use a variety of applications to track patient movement. These systems should be able to share patient records using standard messages and message transport functionality. A standard needs to be created so all the systems can communicate, while addressing security and consent ESF #8 Patient Tracking “Interoperability”

36. ASPR: Resilient People. Healthy Communities. A Nation Prepared. ESF #8 Patient Tracking “Interoperability” Components Standard Message – “What data are we sending?” ─A standard message needs to be selected: Health Level Seven International (HL7) is the global authority on standards for interoperability of health information technology with members in over 55 countries. Other projects to create a standard message include the Tracking of Emergency Patients (TEP) message. This message is going through the Oasis standards body.

37. ASPR: Resilient People. Healthy Communities. A Nation Prepared. ESF #8 Patient Tracking “Interoperability” Components - cont Message Transport – “How are we sending the message?” ─The Office of the National Coordinator of Health IT (ONC) is leading the Health Information Exchange community in adopting Nationwide Health Information Network (NHIN) standards.

38. ASPR: Resilient People. Healthy Communities. A Nation Prepared. 38 ESF #8 Patient Tracking “Interoperability” Components Security and Consent – “Does the patient consent to us sharing their data?” and “Is the receiving system going to protect the record?” ─Need to take these two considerations into account. ONC is addressing these issues through Data Use and Reciprocal Support Agreement (DURSA) ─The Data Use and Reciprocal Support Agreement (DURSA) is a comprehensive, multi-party trust agreement that will be signed by all NHIN Health Information Exchanges (NHIEs), both public and private, wishing to participate in the Nationwide Health Information Network. The DURSA provides the legal framework governing participation in the NHIN by requiring the signatories to abide by a common set of terms and conditions. These common terms and conditions support the secure, interoperable exchange of health data between and among numerous NHIEs across the country.

39. ASPR: Resilient People. Healthy Communities. A Nation Prepared. 39 ESF #8 Patient Tracking “Interoperability” Direction Will work with ONC to ensure that interoperability standards adhere to their direction and Nationwide Health Information Network (NHIN) standards ─Make the most out of American Recovery and Reinvestment Act (ARRA) of 2009 – HITECH Act Meaningful Use funding. ─Hospital Adoption

40. ASPR: Resilient People. Healthy Communities. A Nation Prepared. 40 Common State Concerns Operating System ─States using variety of DB ─JPATS runs on Oracle…have MySQL version Cost of purchasing OS and associated hardware ─Annex will be included in implementation guide that shows hardware and software costs ─Grant funding (e.g., Hospital Preparedness Program) Local infrastructure and support concerns