Executive Summary

Since this report was finalized with the national steering committee charged with guiding and informing the project (Appendix A), efforts have been ongoing to develop a national tracking system in the Department of Homeland Security (DHS), Department of Health and Human Services (HHS), and Department of Defense (DoD). Some of those recent efforts may not be reported here.

In October 2005 the Agency for Healthcare Research and Quality (AHRQ) awarded a contract to Abt Associates and its subcontractor, Partners Healthcare, to support development of a national strategy for the design, development, and implementation of an interagency mass patient and evacuee movement, regulating and tracking system.  The National Response Plan assumes that up to 100,000 patients and evacuees may require transport, regulating, and tracking during a catastrophic incident. 

The project had two overall goals:

• Develop recommendations for a National Mass Patient and Evacuee Movement, Regulating, and Tracking System—herein referred to as the "National System"—that could be used during a mass casualty or evacuation incident for the purposes of locating, tracking, and regulating¹ patients and evacuees, as well as provide decision support to persons and organizations with responsibility for patient and evacuee movement and care, health care and transportation resource allocation, and incident management. 
• Build a Web-based Mass Evacuation Transportation Planning Model for use before a mass casualty/evacuation incident to estimate the transportation resources needed to evacuate patients and evacuees from health care facilities and other locations.

This report addresses the first of these two project goals, the development of recommendations for a National System.  A separate report to AHRQ contains the Mass Evacuation Transportation Planning Model, available on the AHRQ Web site for use by Federal, State, and local emergency planners. The model may be accessed at https://www.ahrq.gov/prep/massevac/.

Methodology

To develop the recommendations for the National System, a key initial step was recruiting, in collaboration with AHRQ, a national steering committee that would guide and inform the project.  Committee members who attended at least one of the three steering committee meetings are listed in Appendix A; the panel consisted of Federal, State, and local government officials and non-governmental experts in emergency management, public health, health care, transportation, and information technology. 

Project staff also undertook the following steps:

• In-depth discussion during three day-long steering committee meetings (December 1, 2005, April 12, 2006, and October 27, 2006) at Abt Associates' Bethesda office.
• Search and exploration of existing locating, tracking, regulating, and resource availability systems via participation in conference calls, Internet searches, literature reviews, national conferences, discussions with the AHRQ Task Order Officer, Web-based demonstrations, and general scanning and informal networking activities.
• In-depth project team discussions with other Abt Associates staff with expertise in health care, shelters, correctional facilities, transportation, and information technology design.
• Discussions and meetings with representatives of urban, suburban, and rural health care, emergency management, and information technology organizations.
• Steering committee review of prepared documents.

National System Goals and Objectives

The project team was instructed to consider a National System that is as inclusive and comprehensive as possible.  In that sense, "national" refers to geographic scope, rather than to a level of government.  In particular, the National System does not focus exclusively on patients and evacuees transported or cared for by Federal agencies, but rather on any person affected by a multi-jurisdictional incident who seeks medical attention, is unable to self-evacuate to a safe area, or needs assistance with transportation or shelter. 

An ideal National System would update location and health status information of patients and evacuees at any location where they are treated, housed, sheltered, or transported, including overnight facilities, locations where patients and evacuees board or get off vehicles, or other temporary gathering points.  This information would be made available to authorized persons with responsibility for housing, transporting, or treating patients and evacuees, both at the person-level (e.g., to determine where a specific person is or has been and to alert health care professionals and emergency responders at reception centers to the medical condition of patients and evacuees who will be arriving shortly) and at the aggregate-level (e.g., to determine the number of patients or evacuees, by health status, at various locations within a county, a multi-county region, a State, a multi-State area, or nationwide).  

An ideal National System would also: contain timely location and health status information that is updated as soon as possible after the patient or evacuee arrives at or leaves one of these locations; include comprehensive medical information, so that health care professionals can provide appropriate medical care to patients and evacuees; ensure patient and evacuee confidentiality; and adhere to all Federal privacy regulations such as the Health Insurance Portability and Accountability Act (HIPAA), and guard against stalkers or other predators; support patient/evacuee movement and regulating decisions by providing information on the availability of medical and transportation resources in both an affected area and unaffected areas where patients and evacuees could potentially be transported; and support decision making, monitoring, and reporting for emergency response and recovery. 

Summary of Recommendations

Developing the ideal National System described above is an enormous undertaking and therefore must be implemented in phases.  As soon as possible, the Federal government should fund development of a "Phase I" National System.  The Phase I system will be a fully-functioning system that could be activated in the event of a national disaster.  The Phase I system will also be a platform on which the system can be expanded in subsequent phases.

In the Phase I system, as patients and evacuees arrive and depart from different locations, a minimum set of data elements would be collected on each patient and evacuee.  The following eight elements constitute that minimum data set: unique patient/evacuee identifier, name, gender, date of birth, health status, location identifier, arrival or departure indicator, and date and time of arrival or departure. 

The central challenge for the National System is obtaining these data.  In particular, any strategy that requires emergency responders and health care staff to enter additional data in the midst of a disaster will fail.  Fortunately, much of the data needed to track the location and health status of patients and evacuees are already collected by existing systems at health care facilities, disaster shelters, and other locations.  For example, hospitals collect this information on every patient who is admitted.  We refer to these systems as "feeder" systems. The National System will obtain the minimum set of patient and evacuee data electronically from feeder systems.  Feeder systems will only transmit data to the National System if the National System is activated.  In discussions with health care providers and health information technology (Health IT) vendors, we have confirmed that, from a technical perspective, the changes that need to be made are not difficult.

During Phase I, only a limited number of feeder systems should be linked to the National System to demonstrate successfully that the overall recommended approach of the National System is feasible, to develop guidelines to assist linking other feeder systems in subsequent phases, and to build political support for broader implementation of the National System.  Selection of the "Phase I feeder systems" should also consider the likelihood that patients or evacuees would encounter a particular feeder system during an actual incident. 

We recommend that the Phase I feeder systems include:

1. Any available Federal (e.g., DoD and/or HHS) patient and evacuee tracking systems.
2. hospital admission and discharge systems at one (or possibly two) hospital systems that are affiliated with a major health information technology vendor. 

In particular, the Phase I plan assumes that either the DoD or HHS (or both) will implement systems that will be used to track patients and evacuees that Federal agencies treat and/or transport.  Independently of the timeline for the National System (or whether it is implemented at all), the Federal government should commit to implementing these Federal tracking systems. 

Regulating depends not only on timely and accurate patient and evacuee tracking information, but also on resource availability information, especially the availability of health care and transportation assets.  As a first step toward providing a regulating capability, the Phase I system would include baseline inventory levels of a limited number of key resources, including beds (at hospitals, nursing homes, and shelters from available secondary datasets) and transportation assets (ground ambulances, air ambulances, buses, airplanes, and trains controlled by major owners of these assets). 

A recommended 21-month plan has been developed for implementing and testing the Phase I National System.  The plan includes a pilot test of the system during month 19.  The cost to implement the Phase I National System is estimated to be $1-$1.5 million.  

At the end of Phase I, an assessment should be made regarding the future direction and priorities for the National System in light of the implementation issues and obstacles that may arise during Phase I, whether future participation in the National System would be voluntary or required, and the likely future funding streams for the National System.  The highest priority item for subsequent phases is linking as many feeder systems to the National System as possible, including institutional records systems and tracking systems used at the local or county level.  Subsequent phases should also focus on improving the quality of health care and transportation resources availability data that are critical for regulating, incident management, and resource management. 

Report Outline

The remainder of this report is divided into four sections and a series of appendixes.  The four sections provide background information on the project (Section 1), discuss the goals and objectives of the National System (Section 2), discuss our recommendations for a Phase I National System (Section 3), and list priorities for subsequent phases (Section 4).  The appendixes list project staff and steering committee members (Appendix A), review relevant legal issues (Appendix B), and discuss existing feeder systems that could be linked to the National System (Appendixes C, D, and E).    

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1. Regulating is a process that attempts to ensure that a patient or evacuee is transported on an appropriate vehicle to a location that has the staff, equipment, and other supplies that are needed to care for this person.

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