Hospitals

Typology and Definitions

U.S. hospitals vary considerably by function, ownership, location, bed size, special services offered, and affiliation.  The following table shows the types and numbers of hospitals in the U.S. classified in various ways.  Bed size ranges from under 20 beds in some small rural hospitals, to over 500 beds in urban tertiary medical centers.  Thirty-five percent of U.S. hospitals are rural. (Many of these are also quite small).

Type of Hospital	Number Registered in U.S.
Total Number of All U.S. Registered Hospitals	5,756
Number of Nongovernment Not-for-Profit Community Hospitals	2,958
Number of Investor-Owned (For-Profit) Community Hospitals	868
Number of State and Local Government Community Hospitals	1,110
Number of Federal Government Hospitals	226
Number of Nonfederal Psychiatric Hospitals	456
Number of Nonfederal Long-Term Care Hospitals	118
Number of Hospital Units of Institutions (Prison Hospitals, College Inpatient Infirmaries, Etc.)	20
Number of Rural Community Hospitals	2,009
Number of Urban Community Hospitals	2,927

Some of these hospitals' patients will have special evacuation transportation needs.  For example, many patients in rehabilitation hospitals are in wheelchairs or in traction devices, some in long-term care hospitals are comatose, many in both types of hospitals will be on ventilators. Psychiatric hospitals have special evacuation needs, mainly assuring sufficient staff to accompany patients and continue to provide care at the destination facility, and bringing a temporary supply of medications for these patients.  And children's hospitals would try to evacuate parents with their children whenever possible, doubling the transportation needs.  Ill inmates in prison hospitals will need security during transport, and so on.

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Hospital Intake and Discharge Processes

Data from the most recent Healthcare Information and Management Systems Society (HIMSS) survey indicate that almost all hospitals use automated patient registration systems.⁵²  Some of these systems where purchased from vendors years or decades ago and have not been upgraded, but many are modern systems.  Some hospitals purchase just the system and retain/process the data in-house.  That is, their data are not exported to the vendor for processing and storage. Some of these hospitals have off-site storage they own or control, but some keep all their data on-site where it is vulnerable to whatever disaster affects the hospital (floods, power failures, etc.)  Other hospitals contract with vendors entirely.  Data are processed and stored on the vendor's servers, not those of the hospital itself.  In the latter case it will be easier to incorporate data directly from off-site, vendor controlled databases.  Hospitals routinely collect identifying and billing information, including:

• Name.
• Address.
• Date of birth.
• Sex.
• Social Security number.
• Payor/insurance(s), (if any,) and insurance policy number(s).
• Family contacts/next of kin/emergency contact/guarantor.
• Employer.
• Demographics-sociodemographics (e.g., race/ethnicity, family income, primary language spoken).
• Referring physician name.
• Primary/presenting diagnosis (not universally included).
• Unique ID.

Patients presenting at a hospital emergency department are logged in but are not considered "admitted" to the hospital unless they will be staying 24 hours or longer. Some hospitals' ED systems simply indicate that the patient is present and contain no electronic information about presenting diagnosis, medications, etc. 

Similarly, hospitals collect electronic information about discharged patients, including their discharge destination (nursing home, home, etc.).  The discharge process may be handled by a distinct discharge department which enters the data or may be centralized.  Some discharge information systems contain/report detailed data that are helpful to the next institution caring for the patient (medications, etc.).

When patients are transferred between hospitals or between a hospital and a nursing home, paper records often accompany the patient (or arrive at the destination just before or after the patient does).  Even hospitals that have electronic records systems rarely share electronic data unless they are co-owned or closely affiliated in an integrated network.  Thus a hospital may have complete electronic data on all physician orders, lab test results, medications, etc., but will print this out for transfer to the patient's next destination.  Similarly, incoming patients arrive with their paper charts.  Patients are often transferred with standard film x-rays and images, or with a CD containing digital images. 

Hospital Evacuation Transfers.  We interviewed hospitals in four States and all but one have evacuation plans, although in some cases the plan is to simply "shelter in place".⁵³  In an evacuation situation, most hospitals anticipate using paper records (nursing "reports"—see below) that would physically accompany patients who are being transferred, generally because they may be uncertain where the patients ultimately will end up.  Patients would be discharged and transported with a 1-3 day supply of important medications, in case the receiving institution does not have an adequate supply.

An exception to this plan of using paper discharge summaries is when patients are evacuated from one "sister" hospital to another—hospitals that are co-owned or part of the same provider network or where a memorandum of agreement is in place.  In such cases, if one hospital is in the mass casualty incident zone and a sister hospital is not, the imperiled hospital will discharge patients to the safer hospital.  In a hurricane area, there is usually enough time to send electronic records to the receiving hospital. (Affiliated hospitals often share an information technology (IT) platform and can easily share records.)  Staff from the higher risk hospital may be trained/drilled to fit comfortably into the routines of the lower risk hospital⁵⁴, and drills include both transport and reestablishing patient care at the receiving hospital. Some hospitals in hurricane areas have perfected data tracking systems for use during such a circumstance.  For example, a group of three sister hospitals in Florida have repeatedly used a patient tracking form (Exhibit D.1) during evacuations; it lists each patient with pertinent medical and transportation information.  It is populated from their electronic patient registration/census system, so they know who is in the evacuating hospital and can track each patient's progress.  They update it as each patient is transported, indicating the destination and other pertinent medical information that the receiving hospital will need.  The receiving hospital completes the update when the patient arrives, noting the room and the physician to which the patient has been assigned.

When a major storm is within 3 days, the hospital stops admitting patients and discharges every possible patient—they usually have about 30-40% remaining that must be evacuated to the sister hospital.  Soon a decision is made to evacuate and the entire evacuation of the remaining patients (a few dozen at most) requires no more than 6 hours. The evacuation must be completed before winds become too severe for air evacuation, and before the risk of flooding (which would immobilize ambulances).  This orderly evacuation with automated tracking would probably not work as well in a situation where there is no advance warning of the need to evacuate, no power, and rapid evacuation is essential (following a bomb, an earthquake, a fire, etc.).

For hospitals without shared electronic systems, a hard-copy form resembling a Nursing Report would accompany evacuated patients to the receiving hospital, and would contain data like the following:

• Triage class: emergency, urgent, non-urgent.
• Discharge condition: critical, stable, expired.
• Mode of transport: private care, ambulance, air evacuation.
• Height, weight, age.
• Physician name.
• Chief complaint/method of injury.
• Speech: coherent, incoherent, silent, baby, slurred, crying.
• Skin color (normal, pale, mottled, cyanotic, jaundiced) and skin temperature (warm, hot, cool, cold).
• Mental status (conscious, lethargic, confused, unconscious, oriented, combative, hysterical, unresponsive, baby).
• Immunizations, tetanus, allergies.
• Current medications IV information (time, solution, amount, rate).
• Nursing observations.

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Existing Hospital Information Technology Systems with Population-Level or Client-Level Data

Hospital Admission/Discharge IT Systems.  The top 10 registration/ADT system suppliers accounted for 89.37 percent of the market in 2005.  Top vendors include MEDITECH (26.20) percent), McKesson Provider Technologies (18.97 percent) and Siemens (17.38 percent). Cerner Corp., CPSI, Healthcare Management Systems Inc., IDX, Epic Systems Corp., and Dairyland Healthcare Solutions each had small market shares. Another 4.08 percent of the market uses self-developed applications.  In 2005, 3,941 hospitals had either installed registration/ADT software or had signed a contract to do so. This represents 98.28 percent of the hospitals tracked in the sample.⁵⁵  The data collected to uniquely identify an individual vary depending on the software vendor and hospital preferences.

Hospital Clinical Data Systems.  Vendors selling enterprise electronic medical records distribute software in an application environment consisting of clinical data repository, clinical decision support, controlled medical vocabulary, order entry, computerized practitioner order entry, pharmacy, and clinical documentation. Some hospitals purchase (or create) separate IT packages for some or all of these functions, while others purchase an integrated product for the entire enterprise. In addition, 4.23 percent of the market uses self-developed applications. In 2005, 2,260 hospitals had either installed enterprise EMR software or had signed a contract to do so. This represents 56.36 percent of the hospitals tracked in the sample.⁵⁶ 

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Hospital Perceptions: Benefits of Evacuation Tracking

When a community experiences a mass casualty incident, family members are often unable to locate their loved ones and begin calling all hospitals in the vicinity, tying up hospital phone lines.  Some hospitals have installed a special phone line for this purpose.  In rural areas, some counties take this responsibility and centralized information from the hospitals (although this does not always prevent families from calling hospitals as well).  A major benefit all hospital interviewees mentioned for a patient tracking system was to avoid having to answer all the incoming calls.

Another benefit hospitals foresee is being able to know or learn where their patients are sent, whether they arrive in good shape, and whether the receiving hospital needs more information to provide good care.  As hospitals evacuate, they often send nurses with patients, effectively emptying the imperiled hospitals of staff as well as patients.  They would like to be able to track where the patients end up, in part to know where their staff end up.⁵⁷ 

Finally, hospitals in a "destination" city (receiving incoming patients from an MCI area) want to know how patients are being distributed—to assure that each hospital accepts responsibility for a "fair share" of the incoming patient-evacuees.  Hospitals in a competitive environment may all agree to forego "diversion" to accommodate the incoming patients, but they want to be sure that they are not being overtaxed while their competitors are idle.

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Hospital Privacy and Confidentiality Issues

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) sets standards to protect patients' medical records and health information provided to health plans, physicians, and health care providers.  The rule sets limits on how health plans and providers may use individually identifiable health information.  Patients must sign a specific authorization before the provider may release their medical information to an outside business for purposes not related to their health care.  (Go to Appendix B for more detail about patient privacy and confidentiality issues.)

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Nursing Homes

Nursing homes house and care for elderly persons and others with physical disabilities who cannot care for themselves.  In a major disaster, nursing home residents are not able to self-evacuate and many require handicap vans, access to care, and specialty aids or medical equipment in order to evacuate.  Benefits of a national system, privacy and confidentiality issues, existing admission and discharge procedures, and existing information technology systems for nursing homes were examined through discussions with nursing home administrators and directors of nursing in urban and rural areas of Florida and California. 

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Nursing Home Typology and Definitions

A typical nursing home resident can not be cared for at home or in the community due to physical, emotional, or mental problems and require access to care 24 hours a day. Chronic care residents remain in the nursing home from months to years, while post-acute care residents who are admitted to a nursing home following an acute care hospitalization and require intensive rehabilitation are typically discharged after a month.  There are approximately 1.6 million nursing home residents in the US; 90% of nursing home residents are elderly (65 and over).⁵⁸

Nursing home residents receive a range of care including nursing services, prescription and non-prescription medications, personal care, nutritional services, social services, and help with equipment or devices.⁵⁹  Many require assistance with several activities of daily living (bathing, dressing, eating, etc.) daily and the majority requires aids and/or assistive devices (62% of residents use wheelchairs and 25% use walkers).⁶⁰ 

There are approximately 18,000 nursing homes in the United States containing 1.88 million beds.  The majority of nursing homes are for-profit (67%), others are nonprofit (27%) or government and other (6%).⁶¹  Forty percent of nursing homes are independently owned and 60% are part of a chain.  Almost all (97%) nursing homes are Medicare and/or Medicaid certified, but 3% of nursing homes are not certified.⁶²  The discussion presented in this section relates only to certified nursing homes because non-certified facilities do not transmit any data to State or national data systems.

Nursing home residents represent a fairly large number of evacuees in urban areas.  In Miami-Dade County, there are 51 Medicare and/or Medicaid certified freestanding nursing homes that have between 46 and 462 certified beds.  An additional nursing home is located within a hospital.  Only two nursing homes (with 120 certified beds each) are in Monroe, a rural county in southern Florida.⁶³  In Los Angeles County, there are 358 Medicare and/or Medicaid certified non-hospital based nursing homes that have between 7 and 391 certified beds and an additional 40 Medicare and/or Medicaid certified nursing homes located within a hospital.  In the southern California rural county of San Luis Obispo, there are 8 certified freestanding nursing homes, with between 23 and 162 certified beds and one additional hospital-based nursing home.

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Nursing Home Intake and Discharge Processes

Admission and discharge procedures are similar across all Medicare and/or Medicaid nursing homes.  Once a person has been accepted as a patient, a social worker or director of nursing reviews an admissions agreement with the patient, including review of resident's rights and financial information.  If the patient is transferring from a hospital, medical records and medications are faxed from the hospital and medical charts are created (often paper).  Information is entered into the nursing home billing system, including:

• Name.
• Date of birth.
• Social Security number.
• Payer/insurance (if any) and insurance policy number.
• Family contacts/next of kin/emergency contact.
• Demographics.
• Physician name.
• Diagnosis.

Some facilities attach identification bracelets to their patients and others do not (unless the patients frequently wander). 

Many nursing home patients remain in the nursing home until they die.  In these cases, the day of expiration is entered into the records, the medical charts are put away, and all records are closed.  For those patients who are discharged to home or an acute care setting, a discharge assessment (head-to-toe assessment of health status) is completed.  The business system reflects the discharge, but the destination location is not necessarily entered in any electronic system.  Some nursing homes enter the discharge address in a clinical system but not in the billing system.  

In an emergency evacuation, administrators said they would not use normal check-out procedures; it would be a "grab and run" situation.  One nursing home's system is backed up weekly, and in an emergency the patient data would be taken with the staff on a CD.

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Existing Nursing-Home Information Technology Systems with Population-Level or Client-Level Data

Several systems have population-level or client-level data on nursing home residents. Most nursing homes have electronic systems for their business data and some clinical data, but these systems may or may not be linked.  A few major vendors for these systems dominate the market and no interviewed facilities had home-grown systems.  Many nursing homes still use paper medical charts for their clinical medical records. These systems use unique identifiers for each patient, but these identifiers are not developed the same way across systems.  One facility uses the medical records number, another uses a medical record number and an account record number that is created by their system, and another uses the patient's Social Security number.

Nursing Home Business/Billing IT Systems.  Nursing homes have electronic business/billing system to provide data to payer sources so the facility can be paid.  Business systems have timely, client-level information—they are updated when a patient is admitted and when a patient is discharged.  Data entered into the business system include name, date of birth, diagnosis, secondary diagnosis, physician, and demographics, but not health status. 

The business system is also used by the facility to compile an internal daily census report at midnight.  The daily census report includes at least all patients names and payer source and may also include room number, medical record number, age, physician, and diagnosis.  In addition to the generated census report, the system can be accessed by staff throughout the day.

Nursing Home Clinical Data Systems.  Many facilities continue to use paper medical charts, but Medicare and/or Medicaid certified nursing homes are required to transmit Minimum Data Set (MDS) patient-level data to the States.  The Nursing Home MDS is a standardized, primary screening and assessment tool of health status; it measures physical, medical, psychological, and social functioning of nursing home residents.  The general categories of data and health status items in the MDS include demographics and patient history, cognitive, communication/hearing, vision, and mood/behavior patterns, psychosocial well-being, physical functioning, continence, disease diagnosis, health conditions, medications, nutritional and dental status, skin condition, activity patterns, special treatments and procedures and discharge potential.  Demographics collected include gender, age, marital status, race or ethnicity, current payment sources and health status.  Other data collected include social security number, Medicare beneficiary number, facility provider number, date of entry into the facility, and mode of locomotion.

MDS data is collected for all residents in a Medicare and/or Medicaid certified nursing and long-term care facilities.  Data is collected on admission (by day 5), quarterly, annually, and when the resident experiences a significant change in status.  The data is collected and entered more frequently for residents that are receiving Medicare nursing home Prospective Payment System payment (5, 14, 30, 60, 90 days).  Nursing homes electronically transmit this person-level health data to the State licensing agency where the data reside. Each State is responsible for preparing MDS data for retrieval by a national repository established by the Centers for Medicare & Medicaid Services (CMS).

Comparison of Nursing Home Data Systems.  A nursing home's business/billing system holds the most up-to-date patient-level data; admissions and discharges are reflected in the system on the same day as the event.  This system does not necessarily have health status information but does have patient-identifying data and each patient's primary and secondary diagnosis.  MDS systems also have patient-level data and have detailed health status data, but it is less up-to-date than a business system because the MDS does not need to be completed until the fifth day after admission to the facility.  This data is transmitted to State databases and then to a national repository.  Online Survey, Certification, and Reporting (OSCAR) System and Nursing Home Compare facility-level data are accurate as of the facility's last survey inspection but provides a quick way to identify how many facilities are in a given area and the number of certified beds at each facility.

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Nursing Home Evacuation Plans

Current nursing home evacuation plans are probably sufficient in a limited scenario, such as a hurricane affecting a small geographic area.  In these situations, nursing homes can use the transport agreements they have established with the local ambulance/ambulette companies or other local services.  None of the interviewed nursing homes have had to evacuate their facilities before, but an administrator spoke of a neighboring facility's evacuation (due to localized flooding) and the need for a more systematic approach to client movement.  It took the nursing home 3 full days to adequately evacuate the facility (including using staff private cars). The facility was part of a large corporation, so residents were moved to other facilities that had beds available.  We spoke with a rural California nursing home that plans to use a nearby Indian reservation's handicap vans and the local school system handicap vans.  Another facility has its own transportation van that can hold nine passengers, but has no transportation for patients on ventilators.

Nursing home evacuation plans include mutual transfer agreements with other local facilities, but many nursing homes do not have transfer agreements with facilities outside of their local area (away from the disaster zone).  One rural California nursing home has plans to evacuate their residents to a previously used acute campus that is one-half mile away from the facility. The administrator does not know where his residents would go in a larger-scale evacuation.  Another rural California nursing home has transfer agreements with local facilities and the local hospital, but knows that in a larger evacuation neither would have sufficient space to accept all their residents.  One urban nursing home routinely transfers patients to three nearby facilities when demand exceeds their capacity, but has no plan for relocating their entire patient population in a situation where the entire county must evacuate.

Many nursing homes (60%) are part of a larger organization that operates other facilities, but often these "sister" nursing homes are not close enough for the evacuating facility to transfer residents.  One southern Florida nursing home we interviewed is part of a corporation that also operates hotels, but the hotels cannot be used in an evacuation because residents can only be transferred to a facility with the same or higher level of care (nursing home or hospital).

Larger nursing homes will need to disperse their residents to several different facilities in an evacuation, because individual nursing homes do not have enough open beds to accommodate all residents.  One administrator noted he would not want to send residents to hospitals because the hospitals would be overwhelmed with other evacuees and anyone injured in the disaster.

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Nursing Home Perceptions: Benefits of Evacuation Tracking

Although every certified nursing home must have an evacuation plan, most plans are developed for facility-level evacuations or small-scale evacuations.  Benefits for nursing homes participating in a national system include assistance with coordination of transportation for residents and identifying destination locations.

In the event of a large-scale evacuation, nursing homes do not know who will transport their residents.  The local ambulance/ambulette companies will only be able to assist one or two facilities because all the local facilities have transport agreements with the same companies.  Many residents have intensive care and technology needs and cannot be transported on buses. In urban areas, a large-scale evacuation causes concern about transportation because of the volume of nursing home patients that would need to be moved. One nursing home administrator felt national involvement would be necessary to help move the 15,000 nursing home patients in Miami-Dade County.

Other perceived benefits of a national system include providing a more systematic way to track where residents are moved to and providing support to facilities with limited staff resources.  One rural California nursing home has detailed paper forms that the staff will use to keep track of where the residents go and what to send with them (medical charts, medications, etc.).  Although the paper forms are helpful for the facility to keep track of the patients, an electronic system would provide staff and family members with an easier way to track them.

Another benefit of a national system is the assistance it would provide to busy nursing home staff.  During an emergency, staff will be concerned about their own family and evacuation so any assistance from a national system will be appreciated.  Many areas in the country have nursing shortages and a fear of administrators is that they will not be able to get enough staff to come to the facility to coordinate the resources to evacuate patients. 

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Nursing Home Privacy and Confidentiality Issues

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) sets standards to protect patients' medical records and health information provided to health plans, physicians, and health care providers.  The rule sets limits on how health plans and providers may use individually identifiable health information.  Patients must sign a specific authorization before the provider may release their medical information to an outside business for purposes not related to their health care. 

One administrator noted that HIPAA is intended to safeguard patients and their information, so it might be acceptable for client-level information to be transmitted to a national system in a major disaster.  It is important that receiving facilities have access to as much information as possible about the resident medical records to provide the most appropriate care for them.  In a large-scale evacuation scenario, it may also be important for the transportation services to have information on the residents' medical status because travel from the evacuating facility to the receiving facility may take a long time. 

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52. Annual Report of the U.S. Hospital IT Market; 2004 complete and 2005 first quarter data. HIMSS Analytics.
53. Generally speaking, smaller hospitals in remote rural areas, especially places without much risk for natural disasters, do not anticipate evacuating and may not have a full evacuation plan even for circumstances like fires. They are often the only hospital in their vicinity and there are few ambulances or other transportation, and few accessible hospital beds nearby.
54. Nurses from the evacuating hospital generally accompany their patients and continue to provide care at the receiving hospital, augmenting that hospital's staff.
55. Ibid.
56. Ibid.
57. When hospitals are evacuated (as happens with some regularity in Florida and other Gulf Coast States) they rarely get "their patients" back. Patients become the responsibility of the receiving hospital until they are will enough to be discharged elsewhere.
58. Centers for Disease Control and Prevention, National Nursing Home Survey, 1999.
59. Ibid.
60. Ibid.
61. Ibid.
62. Ibid.
63. Nursing Home Compare, http://www.medicare.gov/NHCompare/Include/DataSection/Questions/SearchCriteriaNEW.asp.

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