An Influenza Pandemic – Innovating Past Barriers : An Integrated Health System Perspective on Public & Private Sector Coordination

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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 MDs
• Largest provider of health professional education
• Most US health professionals (70 MDs) have some
  training in VA
• 1.7 Billion Research Program
• Basic, Clinical (Cooperative Studies),
  Rehabilitation, Health Services

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Pneumococcal Vaccination Rates
--BRFSS 90th--
--BRFSS--

• Iowa Petersen, Med Care 199937502-9. gt65/ch dz
• HHS National Health Interview Survey, gt64

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Reducing VariationFrom Evidence to Practice
Operationalize Knowledge
Possess Knowledge
Patient Need Met
Patient With Need
Pneumococcal Pneumonia Vaccination Indications
Performance Measurement Accountability Support
ing Technologies Computerized Health
Information System ? System Changes
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Fully Deployed Electronic Health Record
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Clinical Reminders
Links Reminder

• Contemporary Expression of Practice Guidelines
• Time Context Sensitive
• Reduce Negative Variation
• Create Standard Data
• Acquire health data beyond care delivered in VA

With the Action
With Documentation
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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
• Framework for Planning
• Funds for Preparations
• Population Focus
• Population Health Framework
• Population Data

• Private Sector
• 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
• Infrastructure for state/local surveillance
• Syndromic surveillance
• Electronic health record

• Private Sector
• 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)
• Presidents Goal EHR for most Americans in 10
  yrs

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Novel Vaccine and Therapeutics Development

• Public Sector
• Stimulate RD (CRADAs)
• Fast Track FDA review
• Conditional Licensure
• Early injury compensation agreements
• Advanced purchase guarantee

• Private Sector
• 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
• Establish standards
• Purchase/distribute product
• State/local Heath Dept role
• Schools/public event vaccinations
• Model public health approach (think Tb)

• Private Sector
• 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 WorkConsolidated Mail
Outpatient Pharmacy

• 200 Million 30 Day Equivalents / Year
  (40K per shift per CMOP)
• 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
• 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
• Establish standards and education materials for
  wide use
• State/local Heath Dept roles
• Schools/public events

• Private Sector
• 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
• 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

• Private Sector
• 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,
  VA Office of Public Health and Environment
  Hazards
• 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/PreparationsBuildi
ng 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
  employees

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VA Bioterrorism Preparedness/Planning Activities

• VA Role in Federal Response Plan
• VA Emergency Response Program Guidebook
• Medical Emerg Radiological Response Team
• EMSHG Roles
• 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