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Jonathan B. Perlin, MD, PhD, MSHA, FACP Acting Under Secretary for Health

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.

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Jonathan B. Perlin, MD, PhD, MSHA, FACP Acting Under Secretary for Health

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  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

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