Fiddling as Rome Burns: The State of Disaster Preparedness for Clinical Environments

By Kevin D. Burton, Founder and CEO, Burton Asset Management, Inc.

Disaster Recovery and Business Continuity is a top of mind challenge for Hospital and other clinical environments across the nation. With most American hospitals and clinics operating at near capacity and a nation-wide nursing shortage, it is difficult to find the needed time and resources to contemplate disasters striking the cornerstones of our nations capability to provide relief to the traumatized and injured victims of such calamities within the communities our hospitals serve- let alone be certain that the hospitals and clinics themselves are prepared.

Meanwhile, America’s current financial crisis creates more patients whom cannot afford regular healthcare and are prime to become medical emergencies as they miss appointments, skip key treatments, or ignore their course of care all together. This dynamic, of healthcare being turned into urgent care and emergency medicine as patients mindfully (or not so mindfully) ignore their health, has create a sense of angst and anger within the healthcare industry.

Finally, as there is a push for new digital demands (such as the potential for an IDC-10 migration on hospitals), the business of disaster recovery is often relegated to the very vendors who sell such automation, and rarely include an ‘all hazards’ approach that includes the recovery of data and systems, as well as the human capital needed to run a hospital – let alone one under duress. While most Medical Executives would like to have the business continuity and disaster recovery challenge well under control, few have the visibility into such programs they need to feel confident that they are indeed under ready for a community-scale disaster, let alone one that impacted a large region and the hospital itself.

Putting out Fires – Hospital capacity limits and their impact on disaster planning:
Many health care policy options are designed to increase access to care – for example, by increasing the number of individuals who have health insurance. But access to care is also determined by the availability of health care resources. Having too few resources (under capacity) or having too many resources (over capacity) stresses hospital administrators, physicians, nurses, and ultimately their patients. Under capacity can strain resources, leading to a shift in priorities as administrators wrangle with the ambiguous mathematical models for dealing with capacity while being unable or unavailable for the development of a plan for dealing with disaster- both in the hospital and the presumed surge of patients that come from a regional disaster.

Overcapacity can lead to unnecessary use of health services, which is inefficient and increases patients' exposure to medical error (a core of concern for administrators) and a lack of focus on the creative foresight and consensus needed to build a plan for disaster – both within the Information Systems arena and the Business Continuity arena.

Measuring Capacity: The key dimensions of overall capacity include the number of health care resources, their distribution across geographic areas, and their projected future capacity. Here are the basic facts about the number of physicians, registered nurses, and hospital beds in the United States:

Physicians. There were 921,900 physicians in the United States in 2006 (American Medical Association, 2008). Physician capacity varied widely between counties: 460 counties had 20 or more physicians per 10,000 population, whereas 672 counties had less than 5 physicians per 10,000 population.

Registered Nurses. There were 2.4 million RNs in the United States in 2007, an average of about 800 per 100,000 population. Of these, approximately 70 % were full time RNs, and 30 % were part time (Biviano et al., 2004). The current vacancy rate for hospital nursing positions is 8.5 % (Levi, Vinter, Segal, 2007).

Between 1970 and 2000, the number of primary care and specialist physicians increased relative to the general population. The ratio of physicians to population is expected to flatten in 2005-2020 compared with that earlier period. The number of specialists is expected to decrease relative to the general population between 2015 and 2020.

Hospital Beds: In 2006, there were 947,412 total hospital beds in the United States, an average of 3.2 per 1,000 population (American Hospital Association, 2008).

Managing risk in overcapacity environments is highly challenging. A lack of administrative insight, consensus and direction based on capacity demands as opposed to clarity, involvement and the mindful execution of creating a business continuity and disaster recovery program is one of the biggest challenges facing hospitals and critical care facilities today. In short, it is hard to plan for fires when you are busy putting out fires.

Recommendation: Involving an agnostic team of business continuity and disaster recovery professionals to assist with your planning efforts while lowering the impact on your key decision makers is crucial. However, beware: the cardiology team that does not know what to do with, or has not been included in the creation of their own disaster recovery and business continuity plan is a unit that will be confused at best, and not functional at best, during an actual event.

Paying it Forward – Patient Means and their impact on disaster planning:
Dr. George F. Burton, M.D. is the Founding President of NAMDRC and servers at the Kettering Medical Center in Dayton, OH. His concern, like many others in the field of hospital administration and healthcare is that patient care during the current “recession” has caused outpatient practice to experience a new and disturbing wrinkle: patient non-compliance for financial reasons. As observed by healthcare providers nationwide, the symptoms of financial non-compliance are such that reliable patients are:
1. Failing to appear for scheduled office visits
2. Failing to have ordered diagnostic tests performed
3. Failing to pick up medications from their pharmacy
4. Stretching out their medications

“I believe that the pubic health effect of this all may be catastrophic.” Dr. Burton says, “Like the shore that is fairly calm when the tide rushes out before a tsunami, there will be the devil to pay when the inevitable wave of previously underserved patients rushes back in.” The potential for a “wave of patients” is only heightened as H1N1 starts to rear its head and looks as if it may become a full-blown pandemic.

Without a Means Test to determine the financial viability of a patient’s ability to comply with a doctors orders, the tide continues to rush out- preparing to stress an already stressed system. The additive nature of hospitals already operating at or near capacity and the looming threat of a potential wave of patients overwhelming a hospitals ability to provide care is only exasperated by the ever-present potential for disaster.

Recommendation: Understanding that a myriad of compounded issues and risks give real rise to the possibility of systemic failure eliminates the use of software vendors and so-called “hotsites” as viable options for hospitals. The challenge of a Disaster Recovery and Business Continuity plan is to have ongoing care available in the hospital or at a nearby facility and to continue to serve the community- not to take your data offsite to a remote location and recover patient records.

When the challenges stack up, and the cracks in the ice appear, as they are with hospitals across the U.S. one can only wonder if the pending result is not similar to the systemic failure of banks that started late last year and has now turned into a deep, ongoing mess. Here, it is not an issue of a loss of credit, funds, or access to ATMs. It is the potential loss of life that looms as hospitals struggle with the near term challenges and do not look up to see the wave coming ashore.

Involving business analyst and systems integrators equally to meet the challenge of disaster recovery and business continuity in the hospital environment is a must do – lest the disaster arrives ahead of the plan.

The Rush to Electronic Medical Records Keeping – and the Temptation to “Kill two Birds with one Stone.”

The rush to the modernization of medical record keeping will do nothing to ameliorate the problem of understanding what puts the hospital at risk and how to deal with that risk from a patient-care point of view. Dr. Anne Armstrong-Cohn, in a recent op-ed piece for the New York Times argues that the computer de-personalizes medicine – it ignores nuances that we do not measure but that clearly influence care. The notion of moving from ICD9 to ICD-10, while a hot political potato and a potential boom for the makers of such systems ignores all together the need for sound planning for disasters and hospital surges.

In a special report in Business Week, John Halamaka, M.D. M.S., CIO of Harvard Medical School and Beth Israel Deaconess Medical Center writes; “healthcare CIO’s need to implement applications that filter data so that it becomes information, that transforms information into knowledge.”  It’s hard to gauge that ICD-10 would yield any more knowledge than a system that was designed to create more meaningful means tests, and generate event driven medicine models.

Either way, the ‘fox is in the hen house’ when it comes to trying to use the same vendor that is responsible for implementing new systems to create the disaster recovery and business continuity plans required to keep a hospital running in the absence of those systems.

Worrying about the ICD-9/ICD-10 issue along with the Disaster Recovery and business continuity issue is like trying to kill two birds with one stone. The problem here, is that the stone is a hardware/software vendor that will take a systems approach to a patient care problem. According to Dr. Burton, “I can tell you that spending much time on that (ICD-9/ICD10) is like fiddling while Rome burns.

Recommendation: Understanding that automation challenges and health care electronic records management are not the sole components of a sound business continuity and disaster recovery plan is key. Do not let the vendors of new systems, hardware or software components assure you with false promises and unspecified service level agreements. The real litmus test of a sound business continuity and disaster recovery plan is what will happen to our patients during a crisis? How will we spring forth from adversity with determination and will?

Final Thought: The devil is in the details and finding a vendor that will put your patient needs first is key. Look to sound business analysis, strong systems acumen, and an agnostic approach to the challenge of disaster recovery and business continuity before the additive impacts of capacity, patient non-compliance, and increased systems complexity before beginning the journey towards improving on existing plans, are starting your planning effort for the first time.