Transcript Slide 1

Modeling Mutual Assistance Among Hospitals: Innovations in
Response to the 2009 H1N1 Influenza (and future) Outbreaks
James G. Hodge, Jr., J.D., LL.M.
Professor, Johns Hopkins Bloomberg School of
Public Health; Executive Director, Centers for
Law and the Public’s Health: A Collaborative
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Acknowledgments
Evan Anderson, J.D.
Research Associate, Johns Hopkins Bloomberg School of Public Health
Senior Fellow, Centers for Law and the Public’s Health: A Collaborative
Stephen P. Teret, J.D., M.P.H.
Professor, Johns Hopkins Bloomberg School of Public Health
Co-Principal Investigator
Jon S. Vernick, J.D., M.P.H.
Associate Professor, Johns Hopkins Bloomberg School of Public Health
Investigator
Thomas D. Kirsch, M.D., M.P.H., F.A.C.E.P.
Associate Professor and Director of Operations
Department of Emergency Medicine, Johns Hopkins University
Investigator
Gabor Kelen, M.D.
Professor and Chair, Department of Emergency Medicine
School of Medicine, Johns Hopkins University
Co-Principal Investigator, PACER
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Principal Objectives
• Briefly discuss the need to align health care services and resources
among hospitals during emergencies
• Examine the use of MOUs between hospitals during emergencies to
help coordinate services and allocate resources
• Explain our research and methodology to develop a Model MOU
• Summarize the central features of the Model MOU
• Examine how the Model MOU helps to address key legal and policy
issues during actual emergencies, including the H1N1 influenza
outbreak
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Project Steps to Create a Model MOU
•
Comprehensive examination of existing MOUs and various legal
issues [September 2007]
•
Creation of a Blueprint Outline identifying critical provisions of a
Model MOU [April 2008]
•
Vetting of the Blueprint Outline with Experts in Hospital
Emergency Preparedness [May – October, 2008]
•
Drafting and Vetting the Model MOU [November – May 2009]
•
Completion of the Model MOU [May 13, 2009]
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Public health emergency preparedness - 1
• During government-declared emergencies, medical and health
resources can become scarce…
leaving hospitals and other health care providers overwhelmed and
challenged in their abilities to render patient care.
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Public health emergency preparedness - 2
• Hospitals and other health care
providers may need to share
resources (e.g., personnel,
equipment, supplies) to meet
patient surge capacity during
declared emergencies.
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Public health emergency preparedness - 3
• Collaboration among
hospitals and health care
entities in specific regions
can be vital to securing the
health of individuals and
populations.
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Key Challenges to Collaboration
• Creating consistency among hospital response efforts
• Facilitating policy decisions in times of medical triage
• Defusing obstacles to sharing resources and personnel,
including concerns about:
– Liability
– Reimbursement
– Coordination
• Providing clear directions for responses that convey and
meet expectations
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Hospitals’ Use of MOUs in Emergencies - 1
• Memoranda of Understanding (MOUs) offer hospitals and
administrators an important tool to coordinate personnel and
resources in specific regions
• Nationally, hundreds of emergency care hospitals and other health
care entities have executed MOUs over the last decade to facilitate
collaborative efforts.
• However, these MOUs differ extensively in breadth, scope, quality,
and utility.
• Many of these agreements do not reflect critical legal issues that
may be implicated during declared states of emergency.
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Hospitals’ Use of MOUs in Emergencies - 2
The goal of Project B2 is to develop a national model
MOU for acute care hospitals (and potentially other
healthcare entities within a regional health care system)
that reflects legal principles and best practices during
declared emergencies.
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Construction of the Model MOU
•
Drafted for those who may primarily rely on the document
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Construction of the Model MOU
•
Drafted for those who may primarily rely on the document
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Construction of the Model MOU
•
Unlike some existing MOUs, the Model MOU is not
constructed as a binding contract.
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Model MOU - 1
•
Definitions [Section 1.1]
•
Activation of the Hospital Mutual Aid Network
[Section 1.3]
•
Effect of Emergency Laws [Section 1.4]
•
Effect of National Incident Management System
(NIMS) Requirements [Section 1.8]
•
Requesting and Sharing Resources [Section 2.0
et seq.]
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Model MOU - 2
•
Transfer of Resources [Section 2.2 – 2.4]
•
Transfer of Personnel (employees, contractors,
volunteers) [Section 2.5]
•
Scope of Practice [Section 2.6]
•
Transfer of Patients [Section 2.9]
•
Liability of Hospitals and Healthcare Personnel [Section
3.1]
•
Financial Obligations [Section 3.2]
•
Mediation and Dispute Resolution [Section 4.2]
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Major Topical Themes in the Model MOU
• Legal Environment in Declared
Emergencies
• Transferring Patients
• Liability of Individuals and Institutions
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Legal Environment During Declared
Emergencies - 1
Once an emergency has been
declared (as in response to
the H1N1 outbreak), the legal
landscape changes.
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U.S. Confirmed Cases of 2009 H1N1 Flu
Legend
No confirmed cases
>1 confirmed case(s)
>10 confirmed cases
>50 confirmed cases
Last Updated: May 27, 2009
Source: CDC http://www.cdc.gov/h1n1flu/
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Multiple Levels of Emergency Declarations
International
Federal
WHO
State
Local
Emergency
Public
or
Health
Disaster
Emergency
Emergency
Public
or
Health
“HHS”
“FEMA”
Public
Emergency
Health
Emergency
Disaster Emergency
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Public
Health
Emergency of
Intl
Concern
Emergency
Declarations
By Intl Govs
2009 H1N1 Flu - WHO
• April 25, 2009: WHO Director General,
Dr. Margaret Chan, declares first-ever
public health emergency of international
concern pursuant to the International
Health Regulation (2005)
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2009 H1N1 Flu - DHHS
• April 26, 2009: U.S. DHHS Acting
Secretary, Charles Johnson, declares
a public health emergency
 Via the Public Health Service Act, 42
U.S.C. § 247d
 Allows federal, state, and local
agencies to utilize federal resources to
prevent and mitigate H1N1 flu
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Emergency, Disaster, and Public Health
Declarations in Response to H1N1 Flu
Sonoma County
Alameda County
San Francisco
San Mateo County
San Bernardino County
Ventura County
Los Angeles County
LEGEND
Federal DHHS Public Health
Emergency Declaration
Emergency Declaration
American Samoa
(U.S. Territory)
Disaster Declaration
Public Health Emergency Declaration
Emergency and Public Health Emergency Declarations
Last Updated: May 27, 2009
Localities Declaring Emergencies/Disasters/Public
Health Emergencies
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Multiple Levels of Emergency Declarations
International Govts Emergency Declarations
International W.H.O. Public Health
Emergency of International Concern (PHEIC)
Federal “DHHS” public health emergency
Federal “FEMA” emergency
State public health emergency
State emergency or disaster
Local public health emergency
Local emergency or disaster
Authorities, powers, actors, liabilities, immunities, and other critical legal
issues vary depending on the type of declared emergency
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Maryland Emergency Declarations
May 1, 2009:
• Declaration of an Emergency
• Declaration of Public Health
Emergency [Catastrophic health
emergency]
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Maryland Emergency Declarations
Declaration of Public Health Emergency
What the Declaration Authorizes:
Potential Impact on Hospitals:
Isolation and quarantine of
individuals or groups
Immunizes health care providers
from civil or criminal liability
Healthcare services
may be redirected
HCWs have limited
liability protections
Penalizes any person who
knowingly and willfully fails to
comply with government orders
Nonconforming HC
services may lead to
sanctions
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Maryland Emergency Declarations
Declaration of State of Emergency
What the Declaration Authorizes
Potential Impact on
Hospitals:
Governmental use/distribution of supplies,
equipment, facilities
Distribution meds may be
dictated by state policy
Suspension of laws that impede emergency
responses
Normal rules for HC delivery
change
Evacuation of the population from threatened HCWs/patients/staff may be
areas
diverted
Control movement of populations; closure of
facilities
Availability of HCWs may be
curtailed
Use of private property subject to
compensation for governmental purposes
Taking of meds/ supplies may
diminish available supplies
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Legal Environment During Declared
Emergencies - 2
Unlike many existing MOUs, our Model MOU
recognizes and embraces these changes in the
legal environment. Specifically, the provisions
of the MOU shall be applied consistent with
changing legal norms.
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Transferring Patients in Emergencies - 1
• Transferring existing and prospective patients
between hospitals may be essential during
emergencies, but is subject to legal challenges:
•
•
•
•
•
EMTALA
Resource availability
Appropriate processes
Benefits and burdens
Health information privacy
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Transferring Patients in Emergencies - 1
• The Model MOU addresses these issues:
• Anticipates and recognizes the effect of EMTALA waivers
• Requires hospitals to pre-determine “resourced beds”
• Acute trauma care
• Pediatric care
• ICU
• Implements a process for hospitals seeking to transfer
existing patients:
• Determination of a lack of adequate care
• Seek patient consent
• Notification of transfer
• Safe transportation
• Assurances of health information privacy
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Liability Concerns - 1
Who may potentially face civil
liability?
 Hospital employees, contractors,
and volunteers
 Health care entities that transfer
patients, resources, & personnel
 Health care entities that receive
patients, resources, & personnel
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Liability Concerns - 2
Mitigating liability risks via the Model MOU
 Recognition of changing standards of care
 Use of volunteer health practitioners
 Transferred employees/contractors
 Lending hospitals
 Failure to respond
 Workers’ compensation
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Next Steps
• Circulate the Model MOU nationally for potential
consideration and use by hospitals
• Scholarship to introduce and explain the Model
MOU
• Present the Model MOU at various national or
regional conferences
• Study its actual use in real-time emergencies to
assess its utility
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Conclusion
• Questions, comments, thoughts?
• For more information about legal preparedness issues,
including real-time information related to legal responses
to the 2009 H1N1 outbreak, please contact us or visit our
website at: www.publichealthlaw.net
• James G. Hodge, Jr., [email protected]
• Stephen P. Teret, [email protected]
• Evan Anderson, [email protected]
• Thank you!
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