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

1. Jonathan B. Perlin, MD, PhD, MSHA, FACP Acting Under Secretary for Health Veterans Health Administration Department of Veterans Affairs 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

2. 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

3. Pneumococcal Vaccination Rates --BRFSS 90th-- --BRFSS-- • Iowa: Petersen, Med Care 1999;37:502-9. >65/ch dz • HHS: National Health Interview Survey, >64

4. Closing the Quality Chasm (IOM) Reducing Variation:From Evidence to Practice… Operationalize Knowledge Possess Knowledge Patient Need Met Patient With Need Pneumococcal Pneumonia Vaccination Indications Performance Measurement & Accountability + Supporting Technologies Computerized Health Information System  System Changes

5. Fully Deployed Electronic Health Record

6. 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

7. Goals of Influenza Preparedness • Reduce the Burden of Disease • Decrease the Social Disruption • Decrease Economic Impact

8. 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”

9. 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

10. 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 Planning & Preparedness: • 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

11. Public Sector: Infrastructure for state/local surveillance Syndromic surveillance Electronic health record Private Sector: Use of innovative technologies/models Receptor Site Improved Epidemiology • 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

12. 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

13. Public Sector: Stimulate R&D (CRADAs) Fast Track FDA review Conditional Licensure Early injury compensation agreements Advanced purchase guarantee Private Sector: Depth & breadth in pharmaceutical & biotech industries Entrepreneurial focus Novel Vaccine and Therapeutics Development • Opportunity: • Catalyze new approaches to vaccine, therapeutic and diagnostic development • Improved incentives to enter (remain in) market • Expedited testing and distribution of needed products

14. 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 Vaccine and Anti-Viral Drug Delivery Strategies • 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)

15. 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!

16. Challenges: Health Care Workers potentially affected Nursing shortage already acute in certain areas Worried well phenomena Health care system/hospital surge capacity limited Provision of Medical Care • 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)

17. 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 Community Education and Information • Opportunity: • Deliver education/information via traditional modes • Develop social marketing approach to all aspects of influenza public health campaign

18. 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 Decreasing Economic Impact • 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)

19. 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

20. 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

21. Back-up Slides VA approach to Influenza, Pandemic Influenza, and BT

22. 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

23. VA Pandemic Influenza Programs/PreparationsBuilding 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

24. 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

25. 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

26. 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