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3.3. Link a Limited Number of Feeder Systems to the National System
During Phase I, only a limited number of feeder systems should be linked to the National System in
order to demonstrate that the overall approach for the Phase I system is
feasible, to develop guidelines to assist in linking other feeder systems in
subsequent phases, and to build support for broader implementation of the
National System. Selection of the Phase I feeder systems should consider the
likelihood that patients or evacuees would encounter a particular feeder system
during an actual incident. Priority should therefore be given to feeder systems
that operate in higher-risk areas of the country. Another consideration is the
likelihood that the owners of the feeder system will be able to link their
feeder system to the National System according to the Phase I schedule (go to Section 3.6). During Phase I, the Phase I feeder systems would need to be modified so that the Phase I data elements would be transmitted to the National System.
These systems would then need to undergo a to-be-defined certification process
to verify that data are transmitted according to specification. The links
between these feeder systems and the National System would also be tested
during the pilot test scheduled near the end of Phase I (Section 3.6).
We recommend that the Phase I feeder systems include
(1) any available Federal (e.g., Department of Defense [DoD] and/or Department of Health and Human Services [HHS]) patient and evacuee tracking
systems and (2) hospital admission and discharge systems at one (or possibly
two) hospital systems that are affiliated with a major health information technology
vendor. Federal tracking systems are included in Phase I because they
are intended to be used nationwide, rather than at just a single location. As
a result, in a multi-jurisdictional incident, patients and evacuees are very
likely to encounter staff who use these systems. A hospital system is included
because it is critical to start the process of getting hospital systems linked
to the National System, and starting with a hospital system that is affiliated
with a major health information technology (Health IT) vendor—as opposed to a small
vendor or a hospital with a "home grown" system—increases the likelihood that
the number of hospitals linked to the National System can be increased rapidly in
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Federal Tracking Systems
The Phase I implementation plan assumes that either the
DoD or HHS (or both) will develop, test, and implement a system (or systems)
that agency employees and/or National Guard personnel will use to track
patients and evacuees that they treat and/or transport. The implementation
plan makes no assumptions about the particular system developed, only that the
system(s) be able to serve as feeder systems to the National System and that
they will undergo a certification process for the National System during Phase
I. Options for DoD and HHS include "civilianizing" the Joint Patient Tracking
Application (JPTA), which the DoD currently uses to track patients at military
hospitals; further developing the Emergency Tracking Accountability System
(ETAS), which currently exists as a prototype; expanding use and access to
TRAC2ES; or obtaining a new system. (JPTA, TRAC2ES, ETAS, and other tracking
systems are discussed in Appendix C.) Independent of the timeline for the
National System (or whether it is implemented at all), the Federal government
should commit to implementing at least one of these systems.
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Information Systems at Hospital Systems
During Phase I, the admission and discharge system used by
a network of hospitals that is affiliated with a major health care information
technology (Health IT) vendor will be linked to the National System. At the beginning
of Phase I, a major health care system (or two such systems) should be
recruited to participate in the project. This health system should have
hospitals in at-risk areas for disasters and, as noted above, use systems
purchased from a major Health IT vendor. As noted in the previous section, the
vendor would have to develop a computer program that would be run (if the
National System is activated) at a pre-specified interval that would extract
the required data elements on patients who were admitted or discharged from the
hospital because of the disaster and then transmit that data file to the
National System. IT staff at the network of hospitals would have to test this
procedure on a test server and then install it on their production server.
The experiences linking this feeder system to the National
System will benefit other health care providers who will link their systems to
the National System in subsequent phases of the project. In particular, Phase
II will link the Phase I health IT vendor's other major hospital and nursing
home clients to the National System, as well as work with other major health IT
vendors. The groundwork for this expansion—establishing contacts with other
health care systems, developing a detailed implementation guide, etc.—will be laid in Phase I.
The hospital systems with whom the project staff have spoken have indicated that their willingness to participate in Phase I depends on:
- whether participation will interrupt day-to-day operations at
- whether linking to the National System will be voluntary or a
- the anticipated costs (primarily IT staff time) of modifying
their system and whether they will be reimbursed for their costs.
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Disaster Shelter Registration Systems
It may be possible ultimately for the Phase I feeder systems to include registration systems currently being explored at American Red Cross (ARC) disaster shelters. Evacuees would obviously encounter such as system during any incident in which the National System is activated. The ARC's long term goals include
implementation of a client registration system for its disaster shelters, but
such a system is unlikely to be available for Phase I. Even when these systems
are implemented, privacy considerations will likely preclude transmitting
identifying person-level data to the National System. Possible alternatives
include providing only aggregate data (e.g., the number of evacuees at a
shelter, by health status category) or allowing evacuees to voluntarily
register themselves in the National System. Another option is to explore
whether systems used by the Coordinated Assistance Network (CAN) to coordinate
benefits and other services for evacuees could be linked to the National
System. CAN is a multi-organizational partnership that includes the ARC and
some of the Nation's other leading nonprofit disaster relief organizations.13
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Focus on a Limited Number of Health Care and Transportation Resources
Timely and accurate information on the availability of key
health care and transportation resources is essential for making sound
regulating decisions—that is, to ensure that a patient is transported on a
vehicle that is staffed and equipped appropriately and transported to a
location that will have an available bed, staff, and equipment.
The project team and the steering committee recommend that the Phase I system focus on assembling for the National System information on a limited number of key resources:
- Hospital beds (baseline number at each hospital).
- Nursing home beds (baseline number at each nursing home).
- Disaster shelter beds (baseline number at each disaster shelter).
- Ground ambulances (baseline number for major owners).
- Air ambulances (baseline number for major owners).
- Buses (baseline number for major owners).
- Airplanes (baseline number for major owners).
- Trains (baseline number for major owners).
Data collection procedures for the three types of beds
already exist (hospital bed capacity, via the American Hospital Association's
annual survey; nursing home bed capacity, via the Centers for Medicare &
Medicaid Services' (CMS) Online Survey, Certification, and Reporting (OSCAR)
System; and disaster shelter bed capacity, via the Red Cross's National Shelter System.
By contrast, there are no existing procedures or systems for
obtaining location-specific baseline data on other high priority resources
identified by the steering committee—i.e., ground
ambulances, helicopter ambulances, buses, and airplanes. For these
resources, we recommend that during Phase I a process be established for
on-going collection of baseline capacity data from the major owners of
the resources. Once this process is established, expanding it to include other
owners of these resources can be considered for Phase II.
Additional background information on resource availability systems appears in Appendix E.
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3.5. System Operation
Below we provide a brief, high-level, and illustrative
overview of how the Phase I National System would operate, in terms of (1)
pre-population of data, (2) system activation, (3) data exchange, (4) data
access, and (5) system deactivation. A key task during development and testing
of the Phase I system is development of detailed operating procedures and data protocols.
Pre-Population of Data
The goal of this stage is to minimize the amount of work
necessary in the next stage (system activation) by populating the National
System with as much data as possible prior to an incident. As noted in the previous
section, the Phase I system would be populated with baseline bed capacity data
from all hospitals, nursing homes, and disaster shelters, and baseline capacity
data from the major owners of ground ambulances, helicopter ambulances, buses,
airplanes, and trains. Other system configuration data—to be defined early
in Phase I—would also be populated in the National system, such as facility
locations and key user organizations (e.g., Emergency Operations Centers, public health agencies, Federal
Emergency Management Administration [FEMA], HHS, Department of Homeland Security [DHS]).
The decision to activate the National System will follow a
predefined and to-be-developed protocol. Once this occurs, the administrator
of the National System ensures that a number of tasks are completed. Most
importantly, the system administrator ensures that owners of the Phase I feeder
systems activate the processes that transmit data from their feeder systems to
the National System. Other tasks include creating an incident in the National
System (so that all subsequent data can be linked to that incident), activating
the National System's data access portal, alerting authorized users that the
National System has been activated, and answering questions from the National System users.
After system activation, feeder systems begin submitting patient and evacuee data to the National System. The following scenario illustrates when and how patient/evacuee data will be transmitted to the National System.
- John Doe is injured in a mass casualty incident. The local emergency medical service (EMS) agency, using its own tracking system, logs John into their system. For the purposes of this illustration, this local tracking system is assumed not to be linked to the National System, so information about John is not transmitted to the National System at this time.
- John is transported and admitted to a local hospital, which (for
illustrative purposes) is assumed to have a feeder system that is linked to the
National System. A hospital administrator records information about John in
the hospital admissions system. According to a pre-determined interval (e.g.,
every 4 hours), a computer process that was developed and tested as part of the
feeder system certification process runs and pushes the minimum data elements
(go to Section 3.1) through the Internet to the National System. An initial record of John is now established in the National System.
- The next day John needs to be evacuated to a hospital in another State.
After John's departure is recorded in the first hospital's information system,
a process (similar to the one described in the previous bullet) transmits the
minimum data elements to the National System. The National System now has two
records for John: one indicating that he arrived at the first hospital and one
that he departed that hospital.
- John arrives at a airfield near the first hospital, where a
Federal tracking system is operational and logs in arriving patients and
evacuees.14 After John is logged into the Federal system, a process is run on that system which transmits the minimum data elements to the National System. The Federal
feeder system uses the same algorithm to produce a unique identifier as the first
hospital's feeder system, thus enabling the National System to associate John
Doe's arrival at the airfield with his previous arrival and departure at the
hospital. The National System now knows that John arrived at this airfield; if
this same Federal tracking system were used at the airfield where the plane
arrives, the National System would know that John arrived at this second
- At the arriving airfield, John boards an ambulance and is taken
to another hospital which, for the purposes of this illustration, does not have
a feeder system linked to the National System. Thus, to authorized users
accessing the National System, the most current information on John Doe's
location is that he arrived at the second airfield.
A key task in Phase I (Section 3.6) is to determine
policies regarding access to data in the National System. These policies must
consider the needs of authorized users while at the same time adhering to
privacy and confidentiality regulations that are in effect at the time of the
incident. Data access rules and access privileges will vary for different user
groups. Illustrative rules include:
- Allowing the hospital from which John Doe was evacuated to view
where their (former) patient is located following the evacuation.
- allowing emergency health care providers to view patient
identifiers and health status information of persons arriving via airplane and
then to download the patient-level information into a local regulating system.
- Allowing emergency operations center personnel and public health
officials to view aggregate data on the health status and location of patients
and evacuees, as well as hospital, nursing home, and shelter bed capacities.
After logging on to the National System, authorized users
will be presented with a list of available reports and query options that
reflect the type of data that they are allowed to view. Security access will
be assigned so that only those with a need to see individual data can do so
(e.g., physicians providing care), while others might only need to view
aggregate data at the location, county, or incident level.
Policies regarding system deactivation would be developed
during Phase I (Section 3.6). Presumably, this would happen in stages.
First, the feeder systems that have been transmitting data to the National
System would stop doing so. At a later time, depending on National System
policies, authorized users would no longer have access to data obtained during
the incident. Deactivation policies would also cover the release of archived
data for after-action reports or for future preparedness planning and
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3.6. Implementation Plan and Estimated Costs
An implementation schedule and 21-month task plan for the Phase I National System is shown in Exhibit 3.1. The 21-month time period does not include the time required to secure funding for the Phase I system.
The proposed schedule is aggressive; in particular, it assumes that formal agreements can be reached
quickly with Phase I partners, that oversight committees and subcommittees can
be formed and convened quickly, and that the Phase I feeder systems are
operational (but not linked to the National System) by month 10.
The implementation plan is divided into five major tasks: project start up, system specification, system development and testing, pilot test, and documentation.
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Task 1: Project Start-Up
Task 1 includes four subtasks. At the start of the project, the recommendations here should be revisited, and if necessary revised, in light of developments occurring since the end of Abt Associates' AHRQ Task Order.
Second, Phase I partners need to be identified and
recruited as soon as possible, ideally even before the start of Phase I. This
includes a private contractor that will oversee the entire project and an
information technology contractor that will be responsible for developing the
National System's central infrastructure. Working relationships with the
organizations that control the Phase I feeder systems need to be formalized as
well. As discussed earlier in Section 3.3, we recommend that these
organizations include a major hospital system (or two) affiliated with a major
health IT vendor and Federal agencies that will use tracking systems during a major disaster (e.g., DoD and HHS).
Third, oversight committees and subcommittees must be
formed. An oversight committee will be established to advise and bring broader
perspective to the project. Committee members will serve on subcommittees that
will focus on specific critical issues, such as data protocols, data security,
privacy concerns, user requirements, standard terms of reference, and IT
development. Committee members should include representatives from the Phase I
partners, major national health care associations, Federal agencies with ESF 8
responsibility, and other national associations whose member organizations will
be asked to participate in the National System following completion of Phase I.
Finally, legal, regulatory, and security issues related to
the Privacy Act, Health Insurance Portability and Accountability Act (HIPAA) waiver, Health Information Exchange, and other related
concerns need to be evaluated in terms of how they impact and constrain the
Phase I work. As discussed at length in appendix B, the exchange of
identifying information presents various legal and regulatory issues, including
protection of identifiable health information (HIPAA) and other privacy
standards, patient information systems and retention of records, complaint and
incident reporting, hospital requirements for discharge planning, reportable
diseases, isolation and quarantine, and contact tracing. The privacy
subcommittee should also address the issue of whether and how the general
public will be allowed to search the National System's list of patients and evacuees.
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Task 2: System Specification
In this task, the subcommittees, under the direction of
the project manager, will formulate system requirements, including those
focusing on data protocols, functional requirements, and security
requirements. For example, detailed protocols and procedures need to be
developed for invoking and disabling the system, effecting data exchange during
an event, generating the common algorithm for unique ID numbers, providing data
access both during and following an event, and archiving and retrieving data
following an event. Broad acceptance of these requirements is critical to the
success of the project, as is adherence to existing standards and related
initiatives, such as EDXL and the Office of the National Coordinator for Health Information Technology.
The end product of this task is a system design and
technical specification document. This document will be provided to the IT
firm that will develop the security, data receipt, storage, query, reporting,
and archiving features of the central repository. In addition, the document
will be provided to the organizations that own the Phase I feeder systems, and
guide their task of modifying their feeder systems so that they can transmit
patient and evacuee data to the National System.
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Task 3: System Development and Testing
During Task 3, the central infrastructure of the National System, which will receive data from certified feeder systems, allow authorized users to query the system and generate reports according to predefined data access rules, and provide tools to administer the system, will be developed and
tested. Options for completing this work, as noted earlier in Section 3,
include developing an entirely new system or enhancing an existing system
(e.g., a Federal tracking system). Both a development and a production
environment (hardware, software, and connectivity) will need to be obtained and set up for this.
Also during Task 3, the Phase I feeder systems will need
to be modified (according to the system design and technical specifications
document developed in Task 2), so that they can transmit patient and evacuee
data to the National System. As noted earlier in Section 3, these changes are
not, from a technical perspective, difficult.15
Once these modifications are completed, a formal certification process (also
developed in Task 2) will be undertaken for each feeder system to ensure that
the patient and evacuee data are correctly transmitted to the National System.
The Phase I schedule assumes that modifications to the
feeder systems will occur during a 6-month period starting on month 11. The
schedule therefore assumes that these systems will be operational (but not
linked to the National System) by month 10. This is not an issue for hospital
systems participating in Phase I (since they will already have working
admission and discharge systems), but may be for other Phase I feeder systems,
in particular, Federal tracking systems.
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Task 4: Pilot Test
While system development is occurring, a pilot test using the Phase I system will be planned. The pilot test is scheduled for month 19.
Also during Task 4, the resource availability data that
will be included in the Phase I system will be collected and made accessible to
the National System (either by directly loading the data or by establishing automated
links to existing databases). As noted in Section 3.4, these resources include
baseline numbers of hospital beds (at each hospital), nursing home beds (at
each nursing home), disaster shelter beds (at each disaster shelter), ground
ambulances (for major owners), air ambulances (for major owners), buses (for
major owners), airplanes (for major owners), and trains (for major owners).
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Task 5: Documentation
Phase I documentation will include after-action reports on
the pilot test, a National System policies and procedures manual, a guide for
operating and maintaining the National System's central repository, and a
"National System Participation Guide" for organizations that will participate
in subsequent phases of the project.
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Estimated Phase I Costs
The cost to implement the five tasks described above is estimated to be between $1 and $1.5 million. At the conclusion of task 2 (System Specification), a more precise estimate of the costs of tasks 3 thru 5 can be made.
Key assumptions in this estimate include:
- A private contractor, working collaboratively with Federal agencies, will oversee all aspects of the project.
- The Phase I partners, which will be identified and recruited in Task 1, will be reimbursed for their time and expenses for serving on working groups, modifying their feeder systems, and participating in the pilot test.
- Five working groups, with representatives from the project management firm, Federal agencies, Phase I partners, and non-Federal officials hired as consultants, will be needed for Task 2.
- The central infrastructure will need to be built (or, alternatively, major modifications and enhancements will need to be made to an existing system).
- A test and production environment (system software and hardware) for the National System's central infrastructure will need to be purchased and maintained.
12. In our proposed approach for Phase I, activating the National System will not affect day-to-day operations at locations with feeder systems linked to the National System because line staff will not be required to enter data into a separate system.
13. Go to http://www.can.org for more information.
14. The Federal tracking system could be a DoD-developed tracking system (e.g., a civilianized JPTA system or ETAS) or an HHS-developed tracking system.
15. From a technical perspective, the modifications are not difficult, because we propose that a "batch process" be developed and run against the feeder system's database. This batch process would not involve changes to the feeder system's core processing functions or user interface.
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