[This Transcript is Unedited]

Department of Health and Human Services

National Committee on Vital and Health Statistics

Subcommittee on Populations

November 16, 2005

H. Humphrey Building
Room 425A
200 Independence Avenue, S.W.
Washington, D.C.  20001

Proceedings by:
CASET Associates, Ltd.
10201 Lee Highway, Suite 180
Fairfax, Virginia 22030
(703) 352-0091

P R O C E E D I N G S         [4:15 p.m.]

DR. STEINWACHS:  Well why don’t we just as a matter of practice I always try to go around and do introductions and we’ll do them and get them done here.

MR. HITCHCOCK:  I’m Dale Hitchcock, I’m with the Office of Data Policy in ASPE.

MR. HUNGATE:  I’m Bob Hungate, Physician Patient Partnerships for Health, member of the committee.

DR. STEINWACHS:  Don Steinwachs, Johns Hopkins, member of the committee.

MS. BURWELL:  Audrey Burwell, Office of Minority Health, lead staff.

MS. GREENBERG:  Marjorie Greenberg, National Center for Health Statistics, CDC, and executive secretary to the committee.

DR. VIGILANTE:  Kevin Vigilante, Booz-Allen, member of the committee.

DR. FREEDMAN:  Dan Freedman, not a member of the committee, private consultant.

MR. LOCALIO:  Russell Localio, University of Pennsylvania School of Medicine, member of the committee.

DR. SCANLON:  Bill Scanlon, Health Policy R&D, member of the committee.

DR. KENNEDY:  Cille Kennedy, also at ASPE — [off microphone.] —

MS. JONES:  Deborah Jones, CDC, National Center for Health Statistics and staff to the committee.

MS. SIDNEY:  Cynthia Sidney, NCHS, staff to the committee.

DR. STEINWACHS:  I appreciate all the staff support for this.  The plan was and many of you but not all of you were part of the last phone call or conference call we had was where we entertained several different ideas about what the agenda ought to be for this committee and I’ll say for the next year, that kind of framework.  And what I wanted to do was to try and move us toward talking about at least two of the areas that it seemed to me came out of that call as areas that were viewed as ones in which people were enthusiastic about what next steps we ought to take in terms of hearings or committee activities that could at least lead in the near term to some sort of letter report, some product.  And I think part of the reason for making it more product oriented early on is just that each of these areas is rather large areas and you want to try and make sure that going into them is both productive but that people can reassess periodically is it an area that’s continuing.

So the two areas it seemed, and people can correct me to be high on that list, one is an area that on the phone call Kevin Vigilante, Bill Scanlon, and I think there may have been some others not just the two of you sort of laid out as taking an expanded quality framework to look at disasters, Katrina being a case in point, and particularly focusing, and there were three areas I believe identified and I’ll turn to both Bill and Kevin to summarize that.  One had to do with surge capacity, the capacity within our health systems to take on the impact of, it could be either a natural disaster or it could be terrorism, so what information do we have, what kinds of standards and capacity and put it into a quality framework.

The second was around communication issues and it can tie back to things like electronic health record and that kind of capacity at that level, so there are different layers of communication and what in that area might pursue.

And the third, there was some discussion specifically about the electronic health record and sort of some of the kinds of questions came up before, to what extent did electronic health records, were they helpful, and there was some discussion at the full committee meeting about pharmacy data that was available through some of the pharmacy companies and they set up a website, the VA having the capacity to respond with theirs, and so sort of asking the question how do you have potential EHRs that would survive disasters and survive that area.  So that was one area.

The second area that seemed to get a lot of positive feedback and attention had to do with data linkages and Gene Steuerle, Nancy Breen and again there may have been some others involved put together and you have it in your packet the two pages on it, I don’t know whether we have a copy of what I think was distributed before from Kevin and Bill but we’ll let Kevin and Bill talk about it.  But the data linkages was specifically looking at exploring what the barriers are to what could be potentially very valuable linkages and you could even if you wanted to take this back into a kind of Katrina context, for instance if you wanted to answer the question about death, and not just the immediate death but mortality that have been related to Katrina that went out six months, 12 months, you go what datasets would you have to be able to bring together to do that.

Social Security might be one way where you could locate people before Katrina as being there and is a place where you collect mortality data.  Are there other datasets that you would, think of Medicare, potentially Medicaid, and so it was really trying to pick some areas and look at how we could explore barriers and potential ways to overcome what could be some critical data linkages.  And Social Security came up in that, Medicare came up in that, possibility of education data came up in that, there’s certainly also, someone mentioned the IRS data, we’d all like to have that I’m sure but Social Security, so since Gene and Nancy couldn’t be here what I asked them to do as soon as they got back was to come up with a plan of whether that’s one hearing or two hearings that they could suggest back and we could share or talk in a conference call as sort of next steps if we’re to go ahead and pursue that.

So those are the two that are sitting on the table and seemed to be the ones that were drawing most attention.  The disability has been withdrawn, we originally had an offer to get involved, that has been withdrawn.  Russell has raised, and he didn’t raise it as a specific proposal but brought our attention to stuff that he had written actually at the committee’s request, the subcommittee’s request a couple years ago on issues around data security and related areas.  It seems to me those will come up too in both of these and so that I saw that as something that needed privacy, data security needed to come into that and there are barriers certainly on the privacy side and some of these barriers fit very much with the linkage issues and access to multiple datasets so I think we had sort of a strategy to move in very specific ways.

MS. GREENBERG:  What about the, we have this document from Justine —

DR. STEINWACHS:  Tomorrow morning we were going to have more of a discussion around sort of the areas that relate to this idea of looking at some of the issues that arise around a quality framework being applied to natural disasters and emergencies and it seemed to me also Justine’s fit into this and Justine couldn’t be here because she’s at the Data Security, she will be here tomorrow morning in a joint meeting and I thought we could pursue that.

DR. VIGILANTE:  It is a bit of an artificial division in the sense that there’s another conversation that Bill and I were talking about around surge which was also of course related to preparedness and response to disasters, so that’s another piece of it that just happens to be more perhaps relevant to the Quality Committee, perhaps not actually but you know.

MS. GREENBERG:  But that’s more for tomorrow morning.

MR. HUNGATE:  I would hope we could get some good distinctions between what we try to do at the Quality Workgroup and what you try to do with Populations —

DR. VIGILANTE:  But I think Stan’s presentation just now actually fit quite nicely into the themes particularly around registries that are here.

DR. STEINWACHS:  Well let me ask Kevin, I know you have to leave at 5:00 and we need to wrap up at 5:15 anyway, and Bill, trying to help this group think through one of the areas sort of identified what you would suggest we focus on first, and two is have a group discussion about what kind of hearings, what we ought to be doing, with the idea that we might be trying to plan a hearing, whether that’s going to be February, something like that, but it seemed to me that as a subcommittee we could probably do and then Marjorie will tell me I can’t afford it, but we might be able I think do about three hearings over the next year and so I thought that between the linkages and this that if out of those three hearings we might be able to produce on or two letter reports then we’d probably view ourselves as hugely productive.  Maybe.

DR. VIGILANTE:  I think we started from the premise that there is an overlap conceptually between the notion of quality and preparedness just on the premise that if one is prepared to do things before they happen when you do it you probably do it at a higher level of quality then if you were unprepared.  Now although if you observe frankly the folks who are concerned about preparedness in the public health arena are not usually the same sort of cohort of folks who are concerned about quality in the clinical care setting.  There are two groups of folks with different emphases and in a sense that division is probably artificial at a certain level because there is a certain place where they certainly intersect and one of them frankly is surge capacity because the capacity for care giving institutions and caregivers to be able to surge the care they provide, provide basically more of it, has a direct impact on what support can be given to the population who’s under stress in a given event.

Now there are a variety of issues around surge, some of them are philosophical in the sense that just by providing more care, just volume, is in itself a metric of quality, the fact that you can surge so much rather then less then that enhances your ability to provide care and quality.  On the other hand, the flip side of that, when you surge you might make some compromise around the expectations of the quality of care actually delivered and you might say, or typically in our ICUs we have nurses who have a one to one ratio or a two to one ratio between patient and nurse but in this kind of scenarios we’ll be willing to accept three to one, four to one, whatever.  So I do think, so there are some nuanced relationships between quality, surge capacity and your ability to response.

There is also another dimension of this that is relevant to measurement in information and it is basically, one of these is how do you set targets for surge in a given community with a given population density, how do you measure whether you have the capacity to achieve those goals, and then how can you verify that in fact you have done that or will be able to do that in the future.  And that might be, if we’re looking for a circumscribed area of investigation Bill and I were hypothesizing that might be one, I mean it’s just sort of a casual perusal of different agencies whether it’s DHS or CDC or HRSA or DOD or VA suggests that they don’t all use the same metrics when they describe what it means to surge by how much and to what target —

MS. GREENBERG:  I’m shocked.

DR. VIGILANTE:  Right.  And so, and the metrics that I, there’s one metric that I know was on the table last year was talking about the ability to surge by 500 beds per million population.  Well what does that mean, a million population over what geographic area, what’s the density.  Are in fact the metrics we’re using actually of any value?  And it is a little bit humbling to think we’re this very tiny little committee and there’s a lot of folks spending a lot of time and money and effort thinking about this, one wonders whether what we can bring to the table here but on the other hand the silos are pretty thick between these organizations and if there’s anything that we can do perhaps is to work as a mediator of communication and identifying inconsistencies and perhaps suggesting harmonies where they’re appropriate.  And I think given the recent Katrina event this deliberation in particular may be one worth having.

Do you want to add to it, Bill?

DR. SCANLON:  I agree.  It goes back to what you started off with, that there’s a kind of division between the people that, from the public health side which I think focuses on this from a perspective of the social good, from the actual care deliverers, we have emphasized to them very strongly that they need to think about focusing on this as a private production process, be efficient, etc., and surge capacity is not part of being efficient, being efficient means that you’re full all the time, 24/7, because you don’t have any sort of down time for your equipment and staff and things like that.

And so I think there’s a real value taking, I mean in some respects it’s taking advantage of Katrina in the sense that we’ve got to focus on the issue that disasters can happen and that we need to think about this, what is our capacity to deal with them.  Because I think we need to eventually change this paradigm about what the role of the hospital is and what special considerations that we’re going to have to have for hospitals that are outside of the kind of normal economic forces that we’re trying to impose on health care more generally.

Even though I think we’re going to take advantage of them, many people are thinking about this, I’m not sure that they’re thinking about it in these terms so that’s an important sort of aspect of it.  And I think we’re also in a position to straddle these two groups, I think of why does HHS have FACA committees of insiders and it’s partly to bring people from that outside sector in to get their perspectives and so the perspective of the hospital community and others in the private sector is something that we have, are potentially a good conduit for us so I think it is a good topic.

And I’m particularly interested because this is something that we looked at at GAO a couple of years ago and I came away being very concerned, I mean the data that we got from a survey of hospitals in all metropolitan areas were frightening and I know that today we are not any better off then we were two years ago because there’s no shift in the incentives to try and improve the situation.

So I think continuing to focus, or maybe starting to focus the light on this would be a valuable thing and I think it is something that’s feasible to do in a relatively short term because I think we’re going to discover that gee we’re not that far enough along and that it’s appropriate to say we’re concerned and that we think you should be moving a lot more expeditiously in terms of trying to address this question.

MR. LOCALIO:  I’d like to distinguish between the type of surges that people are talking about, I think the surges that I heard you mention have to do with the need for beds which might reflect —

DR. VIGILANTE:  And staff and supplies.

MR. LOCALIO:  Okay, let’s just talk about beds.  So you may have a situation where there’s trauma problems, injuries, accidents, a lot of people injured, for example the earthquake in Pakistan and India, that would be one.  On the other hand from what I’ve heard from people who are onsite at Katrina the problem was not like that, the problem was the surge in the need for chronic care, principally chronic care medications for people who knew they needed medications but just couldn’t get them and they were ambulatory but they had typical chronic illnesses.  So when you talk about surge I think you have to divide that into the types of services that need to have extra capacity and some of those are more mobile then others.  It’s hard to put in new hospitals beds in a metropolitan area but it may be relatively easy to fly in and set up some pharmacies in a lot of places.

DR. VIGILANTE:  and in fact it’s really, when you get into it it actually has to be scenario specific, I mean an explosion like a chemical event can have a very sharp spike and then they degrade quickly.  A biological event has a slower startup and then it humps and then it comes down.  So there, if you’re exposed to radiation you have a marrow problem, bone marrow problem, so there’s all sorts of different kinetics to different events that imply different capacities to surge at different timelines.  So to say, it’s not as simple as it seems however I think at a certain level those who are actually thinking about it may have actually over simplified it.

DR. SCANLON:  In our work we looked at two things, one was isolation beds and the other was ventilators, and found sort of problems in both areas.  Now the ventilator issue was dealt with by putting ventilators into the service packs that are going to be delivered when you have an emergency, you can’t do that with the isolation beds.  If you’re talking about trauma you might be able to defer admissions and deal sort of on a more rapid basis with increasing trauma, but if you’re talking about an infectious disease that’s hard to kind of make a conversion in a hospital to deal with that.  I think you raise a good point that we need to take into account the types of surge needs that we might have.

DR. STEINWACHS:  Marjorie and then Cille.

MS. GREENBERG:  This is fascinating, the only caution, and you kind of alluded to that, but the only caution I would make if you want to pursue this and I don’t know whether you address this at all in your study at GAO but is that as this committee and the subcommittee of the national committee really need to be clear that you’re focusing on the metrics, the information aspects of this as opposed to the question itself as to whether we have the surge capacity, but to tease out what all the information issues are —

DR. VIGILANTE:  How do you measure it?

MS. GREENBERG:  And how do you measure it, because this happens all the time in the work that we do but the tendency of particularly I think in Populations is to sometimes jump to the bigger question which is really not the role of this committee as to whether we have the capacity or how we should get the capacity or all of that.  Those are very important public health issues but I don’t think they’re really NCVHS issues but again these things are very intertwined because if you can’t track these things or you can’t gather the information or you don’t know what the information means then you’re kind of dead in the water.

DR. VIGILANTE:  I think we agree.

DR. SCANLON:  We did have that discussion but I think that this is an example of where going through the logic of what’s the problem leads you to well then you really do want to ultimately measure what your capacity is and be able to know sort of how to deal with it —

MS. GREENBERG:  And what information —

MS. SCANLON:  — there are measurement issues, I mean there’s both the issue of the concept of what you’re trying to measure as well as is there a question of collecting this information and that’s where we think it does come under the purview of the committee.

MS. GREENBERG:  I like the issue too of looking across agencies what you can learn from, and try to harmonize to some degree.

DR. VIGILANTE:  I think the idea is not to sort of reinvent the wheel, if possible to actually show are there A, inconsistencies, two, potentially best practices, and three, harmonization where harmonization seems appropriate.

DR. KENNEDY:  Actually Marjorie’s refocusing of the discussion which I appreciate sort of puts aside what I was going to say but I’d still like to say it because it may feed back in so I don’t mean it to take away, but the previous discussion had talked about as if it was, everything was site specific for both the multiple hurricanes if you will and you think of future pandemics and stuff where the disasters can change sites and that could be the spreading effect, that may feedback into the information structure, I’m not sure how but I just needed to change that.

To get back to what Marjorie was saying, I was recently involved in an activity to try and find out just about the bricks and mortar, not even the beds but just the bricks and mortar because we didn’t know if we need to be organizing federal funding.  We could not identify the places much less whether there were staff or whatever, we had no data infrastructure for the places and these are the kinds of things that change every year, hospitals get certified, de-certified, new nursing homes, other ones die out.  So that in addition to having the actual information available because it would change it might not necessarily need to be available at a federal level but maybe at a state level or something but the network of where to go to find out information, almost the super structure if you will of the information, is also a piece.

DR. SCANLON:  I think our example relates to this question to population health but you’re raising a point which also is this which is that we don’t have very good information about the supply of services in this country — [off microphone] — there are a variety of institutions that also would fall into — when we try and go assess what is the capacity of a community it depends on how much time you’re willing to spend to discover what’s out there, you spend more time you find more resources.  And so NCHS at times has tried to collect information about this and I don’t know what the current status of those efforts are but in the past they’re been had real problems in terms of expanding to try and be more comprehensive about what the information they collect so I think we’re getting our toe in the door.


DR. FREEDMAN:  Let me just flit in a historical footnote here which is if you’re looking at institution specific information at a state level probably the best data are prior to 1985, NCHS was, unfortunately that’s the reality, NCHS was still funding data on facilities which at the time included hospitals, nursing homes, home health agencies, etc., etc., and at that point there was some sort of data infrastructure that was certainly not as well developed as vitals or cancer industries now but there was something where there was some commonality from state to state and now I think it’s probably completely state specific.

DR. STEINWACHS:  And so NCHS was using that as their sampling frame I assume, as sort of an inventory and sampling frame?

DR. FREEDMAN:  I think it was more essentially a census I believe.

MS. GREENBERG:  It was trying to build capacity, it was part of the Cooperative Health Statistic System and the only thing that then remained was the vital statistics part but the man power, the facilities, all of that, with the idea that eventually you would be able to, just like you do with vital statistics, build up to a state level.

DR. STEINWACHS:  In thinking about what might come out of this kind of discussion where you’re trying to get at the capacity to measure the capacity, our capability to measure the capacity or the capacity to measure the capacity of the system, and then there’s also the issue of what are the right kind of metrics to say is that capacity relative to what good enough or not and then even how do you measure capacity itself I guess is the metric.  Would it be useful do you think to have someone talk to us about what had been in place before ’85 in terms of an effort to try and sustain a national inventory, or a national, just because it seems to me that Cille you were talking about it, if you say what could we do right now because we might have a strategy, Dale is going to answer this.  Thank you, Dale.

MR. HITCHCOCK:  We may barking at the wrong tree here with NCHS, I was thinking as we’ve been talking about HRSA’s area resource file and wondering how updated and how comprehensive that is and that would be one of the first places —

DR. FREEDMAN:  Isn’t that all secondary sources?

MR. HITCHCOCK:  They’re secondary sources but not necessarily federal sources, it could be AHA —

DR. FREEDMAN:  But it’s generally something national.

MR. HITCHCOCK:  No, county level.

DR. FREEDMAN:  But the source is national, and the question is if we’re deteriorated to the point of where it’s individual states we’re doing a variety of thinks I’m not sure — [off microphone] —

PARTICIPANT:  I mean there are some, I mean you know better then I do, I mean there is certainly some consistent data across states but they’re not necessarily federally collected.

MS. SIDNEY:  I was just going to ask Marjorie and Dan what they know about what’s happening with the Healthy People objectives and the public health infrastructure chapter because it seems to me, I mean that was an area in which there were a lot of development objectives as I recall and what’s happening because right now in 2010 in the mid course review process there’s been a lot of discussion around data development and what are the challenges there for the objectives in that focus area.  So I don’t know if either one of you know what’s going on with that.

MS. GREENBERG:  I don’t but Richard Klein certainly would who has, well he met with the Quality Workgroup at that June meeting, he would certainly be, because NCHS has responsibility, he’s at NCHS, has responsibility for all of the data collection, not collecting the data but putting together all the data to track the objectives.

MS. SIDNEY:  And the other thing is we’re starting, I’m from the Office of Disease Prevention and Health Promotion, so anyway we are already starting the 2020 planning process so if you want to start thinking forward, we’re not entirely sure it’s going to have the same structure as it has for 2010 but I mean if you want to start thinking forward in terms of the kinds of objectives that ought to be in place as part of a national health promotion.

MS. GREENBERG:  That would be a good —

DR. VIGILANTE:  And the other thing that comes to mind, in addition to going across different agencies to see how they measure or would measure or would like to measure, frankly some international comparisons, the Israeli’s have more experience in this frankly then anybody and they have a very different approach to surge capacity, they do it by a percentage of hospital capability which to me is the most rational way to do it, assuming that your facilities are roughly mapped to your population everybody should be able to surge ten to 15 percent without any decrement in quality, everybody should be able to go to 25 percent with some acceptable agreed upon restructuring of how, I mean there are very rational, folks have really thought through this before in a way that I just so no evidence of in ours.

MR. HUNGATE:  An idea has occurred that may be irrelevant so you’ll have to tell me if that’s the case.  Thinking about Katrina and the related Healthy People program, the affect of Katrina on health will probably not be detected in the 2010 measures but at some level it must be, in other words at New Orleans level there must be a health impact of this disaster.  Do we have a mechanism to determine that health impact because how much that health impact is relates to how much capacity you want to have, and so how do we measure in geography what the health change is I guess, maybe —

DR. SCANLON:  Longer term interventions too because I mean we did see from CDC some briefing slots about the sort of post Katrina efforts to reestablish the public health report function, but I also, I mean I don’t know —

MS. GREENBERG:  When did you see that?

DR. SCANLON:  Debbie sent us some, but was there also an NCHS effort to survey people, a cross section, was there a survey effort talking about that?

DR. VIGILANTE:  I remember seeing a Power Point, there were two Power Points that were sent to us —

DR. SCANLON:  The Power Points but I thought they were both about kind of the reporting system as opposed to a survey to try and assess impacts in the population.

MS. GREENBERG:  I don’t really know what is being talked about so I think that would be another, you’d want to hear from obviously CDC, etc.  Also I know that in our health care surveys, and Jane Cist(?) is actually, she’s going to be I think at the meeting in the meeting, she was here, she’s not coming now, but in our health care surveys we induce, that’s not the word, when we induct, I don’t know what the verb is there, but we induct hospitals, we’re not inducing babies before 39 weeks or whatever, but we induct hospitals into the ambulatory care survey in particular and the ambulatory hospital care survey which includes outpatient departments in emergency rooms, etc.  We can gather some information about the facilities and I know we’ve added some kind of preparedness questions to them in that but that’s something that we can change and add to, etc., so you’d want to hear what they’re doing.  I’m not sure so much as whether they do that in the hospital discharge survey because that’s a little different, they get most of that information through like data tapes or —

— [Multiple speakers.] —

DR. VIGILANTE:  I hope this is not a conflict of interest, I know this because —

MS. GREENBERG:  But it’s not at the state level of course, I mean we couldn’t do —

DR. VIGILANTE:  I mean I know that AHRQ surveyed 2500 hospitals nationwide specifically to assess their level of preparedness, my understanding is the results are fairly close hold and so —

MS. GREENBERG:  They’re not revealing them you’re saying?

DR. VIGILANTE:  Right, and VA has done the same thing, so there is, so they at least have taken some steps in that regard but it still doesn’t solve the problem of what surge ought to be nor how one should measure it, I mean they’re assessing a different issue or different sets of issues.

MR. LOCALIO:  I just want to get back to the point I brought up about the chronic diseases and how to measure the needs and the capacity indirectly.  I mean if one had access to all of the pharmacy databases for the Gulf Coast you should be able to determine fairly well just how many people there are ailing, what their ages are, and if there was a disaster what you’d need to bring in.  of course the better example is if the Martians invaded New Jersey a second time how many —

— [Laughter.] —

MR. LOCALIO:  How much we’d need to drive up 95 to meet the needs —

So I mean there should, I guess what I’m going back to something that I used to do, there may be, how should I say elegant ways of using already existing databases to answer questions that you didn’t initially want to ask of those databases provided of course that you had access to them, that you could link them, you could do this kind of thing without having to get consent from everybody, I mean there are barriers and we have to understand them but I mean this would be a way to do something indirectly using maybe data that’s available, I don’t know.

DR. KENNEDY:  I don’t know the relationship say of Medicare data on drugs to just regular pharmaceutical things but you would have the chronically, severely chronically ill, the SSDI —

DR. SCANLON:  The Medicare data will be available probably 18 months from now after Part D is underway and there’s going to be a drug aggregator who’s going to, I mean all the plans have to send their data to one place so that it is going to be possible to look at all drug use, but you won’t get it historically because the elderly population had fragmented drug coverage, some had state Medicaid programs, some had Medi-gap plans, some had none, a lot had none, they’re buying sort of over the counter so nobody is reporting what’s happening with them —

MS. GREENBERG:  So you’re only going to have this data for people who elect Part D.

DR. SCANLON:  Right and it is a good deal, 75 percent subsidized, so if they can get past the confusion maybe we’ll have a lot of people that are doing it.

MR. LOCALIO:  But in any given area if you combine the big pharmacy chains that’s where all of the drugs regardless of insurance coverage or lack thereof, people are getting their prescriptions filled, somebody must know, have a pretty good profile of what ails people and what those needs are and if there was a disaster what kind of capacity would you need to fulfill those needs.  Trouble is I think that’s proprietary.

DR. STEINWACHS:  Well you go back to NCHS in concept you might be able to make some estimates off of the National Laboratory Medical Care Survey that collects prescription information along with visits if what you were looking for is some of those relationships and then you’d have to project it, it would mean more epidemiologic projections —

MR. LOCALIO:  They may not have the small area data that you need.

DR. STEINWACHS:  They would definitely not, I mean you’d be taking data more nationally and projecting it down to a small area.

MR. LOCALIO:  But if you had multiple sources, different sources, you could ask, query, do an analysis based on one dataset and say this is what we think the profile is and this is what we need, and then you validate it with another source and that would give you some assurances that you’re about right, and that would fulfill one of the needs about what type of capacity you need to replace those services in the event of flying saucers landing in New Jersey.

MR. HITCHCOCK:  It strikes me that we’re moving sort of close to what CDC and Biosense(?) is trying to do, they’re trying to gather information that is supposed to let folks know when there might be an outbreak because of certain medications that are being scoffed up or something at a higher rate, but there’s no reason that you couldn’t turn that around and use it as a baseline saying that in this particular, how were bio senses broken now, that this is sort of a norm for prescription medicine use —

DR. VIGILANTE:  Well actually there I believe, aren’t they looking at sort of OTC stuff?  I mean isn’t that easier to get —

MR. HITCHCOCK:  I think they’re getting both I think, what it is and how they have initially described it may be two different things but I think we’re talking IBM comes to the Data Council in January and I think they’re going to sort of roll out a new version of Biosense and it might be good to have them come and talk to either this subcommittee or —

DR. VIGILANTE:  But I do think there’s a real relationship here between the ability to track both the size and movement of an event through a population and be able to deploy resources in real time with that knowledge.  And I think that that’s probably the real valuable use of that kind of surveillance, I mean it’s been hypothesized that that kind of surveillance can be used to identify the first, second or third case of say an anthrax which I find highly dubious that it’s going to be ever that sensitive or specific but I do think that other role of once you know you have an outbreak on your hands that’s moving that that kind of information helps you track it and then map the resources accordingly and you know the scope of it and the size of it, so I agree with you.

MS. SIDNEY:  I was just wondering, did David Brailer talk about what they orchestrated as part of the post-Katrina response this morning in terms of the three PBMs that they pulled together and they were able to, you did talk about that?

DR. STEINWACHS:  Yes, he said that they put up a website where I guess for the three PBMs people could get access, I don’t know whether it was the people or the providers —

MS. SIDNEY:  It was providers I believe.

DR. STEINWACHS:  — access to websites to find out what medications individuals who lived in the area were on.

MS. SIDNEY:  So my understanding was that it was that they were not going to treat it as a one shot deal but that they were looking at it as a model for how to move forward on something like that, so he didn’t say anything about sort of what their future plans are with that?

DR. STEINWACHS:  No, it was just remarking about it sort of an example of what if we have EHRs it will be much easier to do but actually it was possible to do with just having prescription data.

Let me ask you because we’re going to run out of time shortly, if we were looking at a first hearing it sounded to me as if one area of discussion, one area in which we want people to come talk to us about is how do you measure surge capacity, what are the metrics, and I think part of the point that was made here was that you then to talk about what categories of services or needs, however you want to put them in needs or services —

DR. SCANLON:  Or types of surge.

DR. STEINWACHS:  Yeah, and so the two that I think we’ve spent the most time talking about, one is inpatient, the other is chronic disease and the community, there are others, and the inpatient it seemed to me it was at least two categories if you thought of an infectious disorder outbreak versus the trauma that comes with a catastrophic event like a hurricane and chemical could be part of that, the other things you could talk about, you could talk about the mental health part of this, it doesn’t probably show up on the inpatient, may or may not be —

DR. SCANLON:  Now Katrina actually creates a different kind of a problem which is that if you destroy the capacity first and then you have to think about how do I replace it and do it instantly because you can have one of these disasters but if the capacity stays in place then you can take advantages of the surges you planned for but when a Katrina comes in and you eliminate —

DR. STEINWACHS:  — I guess FEMA must have some of the kind of capacity, to what extent does that come into this.

MS. GREENBERG:  I guess I feel what is needed, I mean I will really show my ignorance and tell you that I wasn’t, well I didn’t even really know what you were talking about with surge, I thought you were talking about SARS at first when I heard this on the phone.  This is not something, and of course I’m in public health so that’s even more embarrassing maybe but it’s just not an issue, it just is not something that the committee has ever dabbled around at all.

So I think it’s really important, and maybe there is something we just don’t have it, but that there be something written up to say with the events of Katrina, etc., we see the need to come to the forefront, but I think it’s particularly important to have something like that and then these are the questions we want to ask, etc., then I think the hearings will flow from that.  But I think you need that both to present this back to the committee,  I mean not that they have to approve what you’re going to do but I think we usually when you embark on some new project we do try to bring it back to the committee and get their sort of ideas and blessing, or the Executive Subcommittee or whatever.  And then also to explain to the people that you’re going to be asking to come in and testify why it is the national committee is looking at this.  And what you’re hoping to achieve by doing so.  I remember seeing a paragraph I think but maybe there’s more.

DR. STEINWACHS:  It seemed like I brought everything with me, multiple copies of everything except, so I’ve done well.

Cynthia, do you know, do we have this in the packet for tomorrow, this is, what I thought is maybe we ought to tomorrow morning —

MS. GREENBERG:  I don’t think we have that now.

DR. STEINWACHS:  Would it be possible to make copies of this?  Can we borrow it and then have it for tomorrow morning and that would help.  My suggestion —

MS. GREENBERG:  I think at this point we’re about to end so if we could have it by tomorrow morning.

DR. STEINWACHS:  It seemed to me we have a small working group and it could be a larger one right now of Kevin and Bill and I was going to ask them and anyone else who’d like to join in that group to really do two things I guess, take this conversation into it but lay out at least a proposal for an initial set of hearings and I think just as you’re doing Marjorie, laying that out is to lay it out in such a way that we could take it and share it with the people we’re inviting so they know why and what we’re looking for in meeting with them and it seemed to me the two areas at least one is this idea of how do you measure surge capacity, what’s the metrics by which you talk about it, and the second is what are the data sources, how would we know what kind of surge capacity exists and then underlying that I guess is the third issue and that is how would you judge from a quality perspective that the surge capacity meets reasonable needs.  And I think Kevin was sort of talking about the levels at which disasters can strike and then how you might think of that but certainly metrics but then you have to have a context within which would help people at least understand how you’d interpret those metrics or how you might —

MR. HITCHCOCK:  When you’re looking at data sources you would uncover strengths and weaknesses and gaps and opportunities and make recommendations —

DR. STEINWACHS:  Right, it seemed to me that and well to the extent that there’s a reason to contribute to the metrics but certainly the data sources and how you can apply metrics to those data sources.

MS. GREENBERG:  On the third one, are you interested in going, I realize this is much more open ended but going into the issue of looking at outcomes, I mean whether in fact, how do you look at whether you’re successful or whether it was adequate or whether, what the impact was on at least short term health outcomes or whatever?

DR. STEINWACHS:  Well one of the ideas I had and we don’t have either of them here, either Gene or Nancy Breen, was if we did follow that with or at about the same time had a data linkages one it might be interesting if we wanted something to complement and we could raise that with them and have them come back with a proposal of something that deals with what datasets might you need to link together if you were going to try and begin to say what are, what’s the impact that we can measure in health outcomes and what kinds of outcomes of Katrina.  And that I think would talk to in almost all cases trying to access whether it’s Medicare claims data or that population and what happens to them subsequently, Social Security and others, that might be an idea.

I didn’t want, Marjorie I guess I was concerned about trying to take on too much because the outcomes part of it is very complex —

MS. GREENBERG:  It is, it is —

DR. STEINWACHS:  — you’d have to I think imbed it again in an issue that is not just us looking at outcomes because we’re not here to evaluate the response, but us looking at the data capacity and what kinds of datasets might you use to look at the outcomes of something, of displaced populations, so you have to be able to track them into different places.

DR. SCANLON:  Fortunately and unfortunately we don’t have many observations and when we’ve tested the capacity to see what the outcomes are —

DR. STEINWACHS:  And so in a sense this is an ideal one to try and —

DR. SCANLON:  I think that if people are in some respects modeling surge capacity needs they’re doing it from a conceptual perspective and a lot of theory is going to happen.

DR. STEINWACHS:  The idea of the potential risk of destroying the capacity that you were going to rely on for surge.

I think we’re supposed to —

DR. KENNEDY:  I have just one, I can’t come tomorrow so I would like to just bring this up, we started talking about mortality and I don’t remember what it said but on Sunday’s New York Times there was an article on a serious problem with mortality data from Katrina so whatever, I don’t even remember what it was but I just wanted to introduce that as a sidebar.

DR. STEINWACHS:  They were talking about the very poor coding and reporting of information and the lack of timeliness in getting it out and so the cause of death and things like that —

DR. KENNEDY:  But I don’t know if that has an impact on any of the other things that we’ll be talking about but I just didn’t want to forget it and I don’t have it at home anymore.

DR. STEINWACHS:  Thank you everyone and what we’ll do is get these proposals back out and have a conference call so that everyone can have in put into the planning and Marjorie, I was thinking that if we did hearings it probably makes more sense that it would either be late January or February, something like that, I don’t know when those next —

MS. GREENBERG:  Well December obviously is too late, it’s too soon —

DR. STEINWACHS:  Sort of Thanksgiving through the holidays is —

MS. GREENBERG:  I’m thinking that you might want to start with bringing, I mean getting national sources and so those would basically be people probably for the most in the metropolitan area, but then I would think —

DR. STEINWACHS:  Then we have to go to New Orleans next, is that what you’re telling me?

MS. GREENBERG:  You need to wait a little bit.  But I would think you would want to hear from some people at the state level, I don’t know whether some of the state organizations like ASTO, I mean some of the national organizations like ASTO or NACHO or again, you could hear from, but if you wanted to hear from some state people in particular then generally, and I think you would want to just to keep in mind that generally anybody who comes in from a state we’re going to have to pay for, so I think the local people that’s fine so we have to think strategically as to whom we’re going to bring in and how we’re going to hear from different geographic areas, etc., because clearly, sometimes even if you’re willing to pay for them it’s very hard to get state people to travel.  But in any event maybe we can think of some innovative ways —

DR. STEINWACHS:  You think we can find some state people who’ve been displaced due to Katrina?

MS. GREENBERG:  There also are a lot of people, actually feds, who were deployed and we might to try to reach out to that network through the commission for, I mean I personally know several people who were deployed, it’s quite a lot of people.

DR. STEINWACHS:  Lesley was on a call and Lesley was deployed and she was suggesting people and so I think your idea of trying to use some deployed people is helpful.  I thought at least if we could, I thought the idea of trying to cross agencies too on the metrics because it’d be interesting to hear even from someone in maybe like DOD but certainly Homeland Security I assume, they must have people who are supposedly thinking about this, they have a medical director now I gather —

MS. GREENBERG:  They do, yeah, we talked about actually six months or four months ago I think, at the retreat we talked about connecting with that person.

DR. STEINWACHS:  And the VA if the VA has a strategy, it seemed to me it might be nice to use this as a chance to —

DR. KENNEDY:  The Secretary’s command center.

DR. STEINWACHS:  Thank you.

[Whereupon at 5:14 p.m. the breakout session was adjourned.]