Ce meh-7 & 1 r oO. 10 11 bo 13 14 15 16 17 18 O° 20 m — NO N Ro {2 24 ce — Federal Renorters, inc. 25 220 Classification and expansion or modification of facilities in an integrated fashion; components for organization and management of the system, for evaluation of the system, and then for expansion. It is really a very complete package that this first project 42 presents. Some comments about the individual components of the package: First, the organization, Dr. Dimick, a consultant for this review group, is project director. It is obvious that he has provided the very great impetus for the development of the entire program in Alabama. Planning for the entire program is in three phases. g | thore is a demonstration area in the Birmingham area, First, and then coordination of five contiguous cities, and then the cne he rr, aa arson County, and then finally CHP B agency area. That encompasses this county area and further. The component of comsumer education has the usual methods of consumer education and public information plus the innovation of being the first state 1 think to incecrporate bat their school system courses on first aid as part ef their secondary school educetion, 1 think. They nope te hire & full-time public information 4 . o PY pe te age om a uae et x, Pe oe ‘ ny py te os Tm ge dey es specialist. They have &@ tlurgve ancrease An pexsonnel for the AV ote « wn np pe eo ms eet Sp nel pt Dy “i - 14 oe spowy de yn ae ty Alan regional medheal vrogram, «nc we Ww Ji ge ante taal 7 mg ae Ye > hog . 4 . ey when 7 dise@uss budget if cust & mu mgavB ! t 10 11 @ 12 i3 14 15 16 17 18 19 20 e 2) 22 23 24 \ce ~ Federal Reporters, Inc. 25 221 Training, they hope to have seven rescue units in this first small area, training enough elements to staff them, and have a coordinative training program in the area. They have become very much interested in mobile primary care units, and give some interesting but usual statistics on the number of deaths from coronary disease prior to getting to the hospital, the length of time it takes to get to the hospital, the fact that emergency equipment like the local fire department 90 percent of those emergency vehicles reach the victim -- they use the term “victim" in this circumstance, rather than "patient" -- in less than three minutes. So, they want to move their entire mobile coronary care units in the direction of having them instantly available, staffed with good communications with physician monitors. They hope to provide eight mobile units with EMTs and equipment for them, as well as monitoring stations that are portable, with physicians monitoring them: DR. SCHERLIS: Is this telemetered monitoring? DR. BESSON: What do you mean by this? Two-way communication? DR. SCHERLIS: The physician will not be on the vehicle? DR. BESSON: What are the dedicated vehicles? DR. SCHERLIS: Purely for coronary care. 10 in @ 12 13 14 15 16 17 18 19 20 2) @ 22 23 24 ice ~ Federal Reporters, Inc. 25 LAL DR. BESSON: Yes. DR. SCHERLIS : Purely for coronary care? DR. BESSON: No, they are emergency rescue vehicles, but they are called coronary care unit vehicles and I suppose they are equipped for more than coronary care but I can't really answer your question. DR. SCHERLIS:- This is a critical question, at least in my mind. DR. BESSON: They are equipped for it. I don't know. DR. SCHERLIS:- Maybe I can dig that up. DR. BESSON: I get the impression that -- they are called coronary care unit vehicles but I think they are equipped for that plus other emergencies. They go into great detail giving plans for hospital coordination, for management, for intercommunity relations, for legislation, for description of existing systems, the accomplishments in the past, and go on for 247 pages of what is really a very well thought out program and for which Dr. Dimick certainly deserves high grades. Let's talk about bedget information a moment. The components of the budget which come to a total -- project 46, this first project -- 1.2 million for the first, 1.0 for the second year ,139 for the third year, and a total of 2.2 million for the three years are made up of central operations. I won't go into too mich detail, but central mea~1L0 10 i] @ 12 13 14 15 16 17 18 19 20 2) e 22 23 24 ace ~ Federal Reporters, inc. 25 223 operations requests 394,000, of which the bulk, 128,000, is made up of salaries for project director, executive officers, administrative officers, and so forth. And operations center equipment, equipment for coronary care, 54,000. Consultant fees, 87,000. The component of public information is going to be subcontracted. It just said subcontracted to a consultant firm experienced in the field. phey don't go any further than that except to say that that amounts to $107,000. Emergency medical training will be the Dunlop 18-houn course with three programs, 20 students each. Mobile CCU will have monitors and two medical residents, if you please, as riders on the mobile CCU vans, hoping to give EMTs training right on the spot, as well as providing medical care. The $30,000 that they have programmed for two second-year residents as monitors; two second-year residents as riders on these things, I have some question about that. I am not sure that this is the question raised here on our funding sheet, tuition charges should be disallowed for project 46. So, whether that refers to another one, I don't know. They speak of career Ladders moving there. People up in the junior college system from EMs to higher things, and thereby they hope to pay seme junior college salaries, which I have some aguestions about. But if it is okey with staff, fT mea-1ll° 10 Ni } 12 13 14 15 16 17 18 19 20 e 22 23 24 ce —Federal Reporters, lnc. 25 224 guess it is okay with me. They have a program for rescue training which I think is all right, communications. They have some 80,000 ~~ purchase and maintain system over a three-year period, that is going to come to approximately 80,000. Transportation, they want to buy eight ambulances for 112,000, and pay 48 EMTs, 75 percent of their salary while they were on a training basis and the ambulance people, will pay 20 percent of their salary, and that comes to a total of $82,000. So that while this is an extremely ambitious progran, it is very comprehensive, and it is very ambitious fiscally. I would grade the program as a 4.5 or a 5. I think it is a very comprehensive program. I will defer making a decision on numbers unless you force me to. DR. «©SCHERLIS: I won't force you to do anything. We will need numbers ~~ DR. BESSON: Do I need a secondary reviewer on that? DR, SCHERLIS: Let's have e secondary reviewer of that project, if we might, Dr. Roth. Do you have any comments? DR. ROTH: No, I have nothing to add. I have to admit that I did not have these with me. TI had 80 pounds of these things the day before I left to go to the west coast and back to Georgia, and then to Texas, and then here and I just couldn't earry them. OUT py mo, + _.. . a pr. SCHORLIS: There are certain questions maybe mea~-12 v > 1 t CR 6307 End #19 @ 3 10 1 @ 12 13 14 15 16 17 18 19 20 2) 22 we 23 | 24 4¢e— Federal Reporters, Inc. 25 DR. you can clarify. BESSON: We'll get to that, I guess. We can take them up separately. 225 CR 6307. 20 3 eak t 1 10 im 12 16 17 18 19 20 2) 22 23 24 ce - Federal Reporters, Inc. 25 tw ho n DR. SCHERLIS: hat is your funding recommendation on this, then? DR. BESSON: You want a funding recommendation? I will bring that up in context of the project 43. DR. SCHERLIS: Fine, however, you prefer doing that. DR. BESSON: Project 43 is an entirely different kettle of fish and it is a very elusive proposal. I spent several hours before I got the drift of it and I may not have it right yet. It apparently begins historically with a 1964 State Department of Health medical self-help training course which tried to improve training of individuals and also set up an ambulance training program. And then 1967, Birmingham developed an EMS committee which was chaired by Dimick. 1968, the State Health Department did a survey of EMS and recommended some legislation regarding ambulances. In 1970, apparently the Regional Medical Program discovered Dimick, following a study of cardiac resuscitation efforts by the University hospital that Allen became involved in. They became involved then, ARMP, in a study of cardiac deaths, and that lead to very deep involvement in EMS. They set up counciis in other areas and began to coordinate various EMS BACtivLtLles. influenced the passage of an act which created the authority for the Department of Public Health to develop standards LOL 10 1 12 13 14 15 16 18 19 20 2) e 23 24 ice ~ Federal Reporters, Inc. 25 227 ambulances. They said, well, if we have to develop standards for ambulances we'd better get some advisory committees so they appointed a statewide advisory committee which was also chaired by Dimick, and his impetus then led them to move from the development of ambulance regulations and standards as authority for this act to the establishment of an interest on a Statewide basis in training programs, communications, tran portation, and equipment. Now, this program, then, is to enable the State Department of Public Health, via this extended authority, which they really don't have, but nonetheless it is good that they are involved, to contract out these various aspects of their interest, a training program at 104,000, the development of a demonstration area at 125,000, to provide what they call a contingency fund for the development of local EMS councils , te provide training of emergency vehciles, to provide communi- cations and evaluation systems. tow, that is the meat of the program but there are a lot of fuzzy edges to it and if I were to read from the osal summary in our project says, ity pr f oO proposal summary, th "To creake through planning, training and development the regulations and standards a solid foundation uwoon which to EMS. To continue planning ana build an effective, statewid Bene am to ey ude Deed ded ~ yeaa Pama de cy oh Tye wpeeset ge dea pe a ete geet a tyeining activities, supplemented by acquisition or meceossr mere peu yyy ote Googe ee de ey ey red com ten eh Pegg a Ty ete des | ee race pad 2 pas at ecuiomenk and Materlei nected 1.oL etfective Ope raion Or 4b I ca ~ Fedeta 10 1 12 13 14 16 17 18 24 t Reporters, Inc. 25 228 EMS.” And they say that will be accomplished by staffing the Department of Public Health, beefing it up for creating their division of EMS. hey are developing some kind of statewide plan which they are not very explicit about to draft regulations which will implement this statewide act for ambu-~ lance standards, to train the general public in medical self-~- help, and American Red Cross, to extend the EMT training of the 81 | Dunlop programs throughcut the state, hopefully, and to contract with hospitals to develop courses for their emergency room personnel, to inform the public by creating what they call road shows, to coordinate various agencies involved in EMS, and to develop a demonstration area which will produce full scale EMS. Now, this effort is, in their words, to complement ing program is the previous project, 42. Tf think their budget very loose and totally unseparable, as far es I am concerned. T am paxticularly cenceined about their $256,000 slush fund which they say they will use for very worthy purposes. They have very loose contract statements for the subcontracting fox all of these compone ee ee Laey ane gol 9 to do et ate QOGUS not sure, although I asked Dr. Margulies said it yr et ae 4 a al. % oe pe got « 0% ye our authority to fund pubile agencies, and he was perfectly all right 2f 2% was en csGent Wak part of the syste. tT am not go sure this isn a bottomless pit to begin funding eak 4 4 10 im @ 12 13 14 15 16 17 18 19 20 21 oe 23 24 ce~ Federal Reporters, Inc. 25 229 state health departments for things that are rightly theixs. So while we have two programs that are said to be complementary, that I would be much more inclined to look to program No. 42 as being the nucleus for a statewide program, fund generously, and then let it spread. ‘ a = However, the area, statewide area, has had such a momentum that I would at the same time hate to discourage it by not providing some funds for 43. Sol would compromise by providing some funds for Project 43, the statewide program, as follows. SCHERLIS: Is 43 the same at 467 DR. DR. BESSON: the same as 47. DR. HINMAN: That is the same as 42. DR. HINMAN: Right. DR. BESSON: Right. DR. SCHERLIS: 46 is 42 and 47 is 43. DR. They request 640,000 for the eliminate of the salaries, project which I think is going contingency. them at a level of figures for fe oo % Spt we re te dat 150 ,C0G, providing they eak. 5 i 1 10 VW 12 13 14 15 16 17 18 19 20 21 eo 2 23 24 Ace — Federal Reporters, Inc. 25 230 program and an indication of how the EMT program is going to be cost-shared with the institutions and the ambulance services that are going to use these people. DR. SCHERLIS: Before you go into the figures, could I ask Dr. Rose, have you had some contact with the Alabama group? DR. ROSE: Yes. DR. SCHERLIS: Could you answer a question I had before, is this dedicated for pure coronary care? DR. ROSE: They do carry other equipment on the vehicle but it is specifically set up for such things as -~ DR. SCHERLIS: If somebody calls and they have chest pains, that ambulance goes out. DR. BESSON: Yes. DR. SCHERLIS: Suppose somebody else has call, the vehicle dees not go out for that? DR. BESSON: It does go out. DR. SCEERLIS: If is is coronary care =~ DR. GINRLE: 2I¢ is also carrying a medical vesident, . be * mn gy: aw St om ey o owt in times of digaster, number of emerganties, but qenerally it would not be o 3 a “3 used fox purposes othexs than suspected coronary patients. Z . a a wm ec ey wom co a ore yey ent oy yh eee PE fteny eve they olenning, how many i e a “ sere ye TST OGY . SCH RE A & ¢ rh DR © Yt one sy mw on 10 11 © 12 13 14 15 16 17 18 19 20 21 e 22 23 24 ace — Federal Reporters, Inc. 25 GI 4 DR. BESSON: Eight. DR. SCHERLIS: Is there any justification for that number of vehicles and the staff necessary for all those vehicles, any justification that they need and will have enough calls to make that item that can be justified in terms of costs? Most communities have moved away from this, the concept of dedicated vehicle. That was a2lexcellent concept at the time when there were materials being collated on 4 research basis but at this time most thinking is in terms of upgrading training to other people, not to have the physicians on board. It was very expensive to have this expensive a vehicle devoted purely to coronary care. I would be very much in favor of eliminating what feaction of this appears to be relate@ to that. I think they have eight Holter Avionics tape recorders present at the cost of $10,000. 2 think that is guilding it a bit. Where is enough information now from the supporting units to give us the information necessary, Dr. Nagle's group, You can go on and con. De. Warren's group, the Vincent group. fhere is plenty o£ LO2. DR, BESSON: They Are using this in an operational fashion, rather than a research fashion. I agree, having monitors om the ausulanees for 112,600, I as Yee ae ~ a pgm ey Peet set de by io, 4} ata ep ~~ oh eee, Eo Gontt kricil. Y would he that aown., I don't know how big Biwhangdscd remember the eak, 7 oOo 10 11 12 13 14 15 16 17 18 19 20 2) e 23 24 ice - Federal Reporters, Inc. 25 232 justification for that number, how they picked out that number. I think we can make an arbitrary cut of this whole program, I think, at 3.2 million, although it is an excellent program, that is far too much. DR. SCHERLIS: The nearest of eight mobile and coronary care ~~ DR. BESSON: The sequence of events that leads to th justification of this is that three minute time they go to great length to point out is the time that fire departments can get to a person, and they figure the number of lives that they can save if they can match that kind of distance. Whether it is cost effective or not, I have my doubt. DR. GIMBLE: That points out the basic flaw. Let's use the ambulance system performing well already. Why puild eight special ambulances? Why mimic it when you can use what you have? ZI think that is the basic flaw of the pro- 3 Qa an o end e DR. SCHEPLIS: Let the record show that I agree With Dx. Gimbie. DP, BESSON: =~ would make a condition for the ovard, then, to Gelete the mobile CCUs, therefoxe, perhaps, 2 ~ “p w ro a a ” 7 =“ fae 2 Celeting a@ Signiflcenl porvaon oO} the costs of the monLiors aan pl gud « ~, ~ ” — it totes RAITT A _ ; and viders and a portion of the BMT Lx ALNing » > My concern is that this really we ew be oro es eainde oye, oe] bed ga ve we oye, ke Va eee cp amy ays ‘ casts some Goubt on tne entire system taney nave dyvawn up woen Ww 10 11 12 13 14 15 16 17 18 19 20 2) e 22 23 24 \ce — Federat Reporters, Inc. 25 233 they have gone that route. DR. BESSON: I wnderstand what you are saying. DR. SCHERLIS: Because I think a few years ago this would have been something that would have been looked at with a great deal of interest but certainly for the last few years the emphasis has not been on the dedicated vehicle but an upgrading of existing emergency systems. And this is why that rosy glow that you imply pervades Alabama might be fading a bit. Dr. Joslyn? I was reviewing these two applications DR. JOSLYN: and I think I feel as Dr. Besson does, that they are two quite different applications, although they are complementary. I 4 share his concern about the fuzziness of the statewide, No. 43 and the beauty and completeness of the Birmingham, No. 42, e Lor to I guess I feel No. 42 was designed cemplete funding at the .5 million level and I thinkit was designed to be submitted in g : T cannot judge whether they really expected us, in BMPs, to fund thet, or whether they sant it to us te show you this dovetails with the other one they have ox what. suk Lt seems co me we could cob away at different parts of this beautiful large system, but 1 feel the system is designed to deteonstrate almost everything you can deo, short of cooplete helicopter services, 42 one aaa, ana Lt is not wees.ly aren) ray go pl bo e's . iw om pl a ye ed oy ft Gesilgned to spread owl ana eh ro] r be Ue = eak 3 lll saizk about this. It is designed for a complete system in 2 Birmingham and a few areas right next door. I think that is @ 3/1 the reason there are two applications, because the second Vay 4 application, as Dr. Besson pointed out, comes from a completely 5 @ifferent point of view. It is more of a grass roots, Oo broad based application that is having trouble knowing exactly 7\| where it is or what they need because they don't have the 8 expertise and the quality. And I just wondered whether RHPs 9} 35 in any position to fund the Birmingham one, since the 10) Birmingham application says right off, they have a superb 11! pms system right now, far better than most places in the © 1211 country. They just want to make it perfect and they 13] want toe answer some of the questions that people are asking 14] about, you know, what is the Girection we are going. 15 DR. SCHERLIS: 4 think -- 16 DR. JOSLYN: I don't know, If am throwing this out 17) in texms of the relationship of these two programs anc 18] wondering how the committee cat react to both of them and Look 19 uth them also in xelationship to wheat was said earlier about ty ne Tog AT be wy gery t. ey te ages he © att ot gabe py wpe eh bd ey yee Tr ees 20 using the RUP's money to Aire are the seedlings everywaerc 2) ‘ 22 Now, ZL am nob gaying tha i Birpmingnam can't make Good Pe “ 7 “A d : teeta 3 a oe oe ete Boonen eey 4 eens 23 use ang prcbably better use of a biock of Money 4 € we Were ee widayyge 1 he be wy eye 9 Ti pep ys Vide he pee yey aha my de wm te pyre 7 dey . 2 4 STO LTE at to ALGoana. f don't eriow Wi Lat the VeSGsi UL Lon ‘Ace ~ Federal Reporters, Inc. ” i foot Bela tgs en eepes tsi oF end 20 25 to this preblem is. CR 6307 Take 21 dw 1 10 11 12 13 14 15 16 17 18 19 20 2] oe » Zz 23 24 7a ~ Federal Reporters, Inc. 25 DR. SCHERLIS: What steps of the total program do they actually cover? We have heard a great deal about the transporta- tion system. You said it is a total emergency system? DR. JOSLYN: In Birmingham? DR. SCHERLIS: What else is incorporated? DR. BESSON: Employee training, public information and consumer education. DR. JOSLYN: Transportation. DR. BESSON: Transportation and ccmmunication. DR. JOSLYN: Rescue operations. They are talking about developing a career ladder. DR. SCHERLIS: When the ambulance is called, it is from the nearest hospital, is that correct? DR. BESSON: Not necessarily. DR. JOSLYN: They are going to look at all of Birmingham and decide where exactly ambulances need to be placed to give the best, shortest in time coverage, if I remember correctly. DR. SCHERLIS: Are emergency rooms part of the DR. JOSLYN: There wasn't that much emphasis on emergency rooms in this part. DR. ROSE: I had the impression, and maybe somebocy aw 2 10 1 12 13 14 15 16 17 18 19 20 2) @ 22 23 24 ‘ce ~Fedaral Reporters, Inc. 25 236 could help me with this. I had the impression most of these ambulances related to one emergency room. DR. SCHERLIS: This is what I was driving at. DR. ROTH: Since I did not have a chance to go into this in depth, I don't want to prolong this discussion, but this relates ina fascinating fashion to me to the opportunity that some of us had to go into depth in the Russian plan, with its dedicated vehicles of eight varieties. | I might say that I believe this is more coronary emergency units than supply the whole City of Moscow. But the figures that come out from the Russian system in terms of theri salvage rate, and so on, are fantastically good, if we can believe them, you know. We are involved in trying to get some knowledgeable people from this country who know our results, in taking the ambulance out and bringing the patient back to the source of expertise, as contrasted to the Russian system which is taking the expertise out with then. They have the physicians and the trained specialists on each one of these emergency types of ambulances And to me, this is an innovative feature of this thing, as a A a a demonstration project, that IT wouldn't want to slough of Lightly. 10 1 e 12 13 14 15 16 17 18 19 20 2) oe » 23 24 ce — Federal Reporters, Inc. 25 237 I think it would be awfully interesting to see this sort of thing done. DR. GIMBLE: It has been done 20 or 30 times in the last five years, there are similar projects of this nature, currently funded in this country. DR. SCHERLIS: This is the thing that troubles me. And that is, with the health dollar for emergency services available, the supply we have, I would rather they spoke to a transportation system where they upgrade the existing emergency staff to handle cardiovascular emergencies as well as otehrs rather than going into the dedicated group, because there are a lot of second thoughts, J think. The lives are saved, I grant that, but I don't thin they have to be saved by a dedicated vehicle. I think this is overkill, or oversave, I guess is a better word. DR. BESSON: May I make a motion? DR. SCHERLIS: My other concern is -- May I bring this up? DR. BESSON: Yes. DR. SCHERLIS: I am scanning this, you have gone . through it. I don't see where they relate to the problem of bringing this individual who is getting cardiopulmonary cesuscitation into the emergency room. What happens in the emergency room? DR. BESSON: They drop it from there. vy dw 4 10 1 12 13 14 15 16 17 18 19 20 2] e 23 24 ce ~Federal Reporters, inc. 25 238 DR. SCHERLIS: If the staff can't carry on the emergency service, if they aren't geared to handle it, this is why we are talking about a system of care under a regional medical program. We are looking at a system, not at this phase of transportation. You will frustrate every emergency technician unless you have a system built into it of a continuum of care. DR. BESSON: I don't pick up where they take over as soon as TER is mentioned. DR. ROSE: I think this might be part of the constraings of the contract program again. DR. SCHERLIS: Let them have their constraings. I don't think we have ours. Dr. Matory? DR. MATORY: So far as the emergency service is concerned, one of the problems they have is that a significant number of the 13 hospitals in Birmingham do not have emergency rooms. And I am not sure but what that may fortify that need for having better ambulance capabilities. DR. SCHERLIS: The point I would make that if they spoke of a system of having transportation -- decided they would have three or four emergency rooms in that system and seared to handle the catastrophe when it was brought there, I would subscribe to this as being a way of upgrading it. dw 5 1 10 1 @ 12 13 14 15 16 17 18 19 201; 21 22 23 24 sce — Federal Reporters, inc. 25 239 But if they are just isolating this and having an academic approach in one area and zero elsewhere, it isn't a system. DR. MATORY: I think they lean towards that because they speak of strengthening the categorization principle. One other thing, I was just wondering if perhaps, could I offer the alternative of instead of wiping out all of the coronary care units, perhaps there may be some proportion, one, two, that remain as part of that demonstration. DR. SCHERLIS: Dr. Besson? DR. BESSON: I think that is a reasonable approach. I share your concern about this degree of money on a program which doesn't need demonstration. But there is more than just the Birmingham area we are talking about, we are talking about a five-city area, and eventually a larger conglomeration of maybe three counties, is that correct, or five counties. DR. JOSLYN: Aren't these five cities suburbs? DR. SCHERLIS: It is Greater Birmingham we are talking about. DR. JOSLYN: The counties, as I got it to mean, are the counties in Birmingham proper, tapering off, the locale directly around it. dw 6 10 1 @ 12 13 14 15 16 17 18 19 20 21 e 23 24 ce ~ Federal Reporters, inc. 25 240 DR. BESSON: I don't know what the geographic area is that these mobile CCUs are going to address, but I would be personally happy to cut down both on the number, and maybe if we think in terms of two rather than eight, at least it is the equivalent of what Moscow has. That might be an approach. I don't know what else. DR. SCHERLIS: The Chair would vigorously oppose any support of a dedicated vehicle, even one, and I ama cardiologist, I would like the record to show that. But having just spoken of that, there was a film that came out which was supposedly for systems of care, to save a life, and having had the support of American Heart, re-shot in great measure so it.addresses a total system of care rather than a dedicated vehicle. I think to support a dedicated vehicle concept at this time is against the whole concept of making your emergency medical technicians be able to handle that typé of situation as well as others. This is the sort of training we are talking about. This is the course of training that is certainly recommended, the only one I think we should support. Furthermore, if we are going to talk here about transportation in bringing them to emergency rooms, which aren't able to handie the level of care necessary, you are going to have them just dying in the emergency room instead aw 7 10 11 12 e 13 14 15 16 17 18 19 20 21 e : 23 24 ce —Federal Reporters, Inc. 25 241 of in the street and I don't think that is commendable as an approach either... DR. BESSON: Okay. I will accede to the representative from the cardiology section, with greater wisdom. MR. MATORY: I was aware that we were fighting that battle all along. DR. HINMAN: Approximately 300, a little over 300 thousand tied up, as best I can estimate, in the dedicated ambulances. | If you use a figure of 112 thousand for ambulances, 43 thousand for equipment, 95 thousand direct costs for mobile coronary care training, half of the other -~- DR. BESSON: I will let you do the figuring but if that is one of the conditions for the award, I would certainly go along with that. DR. SCHERLIS: Another strong condition, they have to survey their emergency room,s and I think we can lay that down, can't we -- survey their emergency rooms and integrate that with their system of care, if any support is given. I couldn't support just transportation. DR. ROSE: That ig a rather massive effort in itself. DR. SCHERLIS: My own feeling is that this was put together for a contract and it doesn't fit our guidelines. 242 aw 8 1 This is the concern I really have. 2 DR. BESSON: But on the other hand, we are 3 asked to address ourselves to this project as it is 4 presented to us. 5 DR. SCHERLIS: Surely. b DR. BESSON: My recommendation, as I wrote it 7 down, is that we don't fund this at all and let HSMHA 8 play with it, bw that we can't do. 9 DR. SCHERLIS: Do you have a comment? 10 VOICE: I was at their RAG meeting when this was 11 discussed and it did come out, this was originally developed 12 e for the contract group, and there was some discussion between -the Birmingham proposal, the one down state, and during the 13 14 process of all this discussion, they agreed to submit them 15 both places but it originally was developed for the 16 contract. 7 DR. SCHERLIS: It really doesn't speak for the 18 total system of care. 19 DR. BESSON: Well, it has subsystems, and if we 20 ‘eliminate the subsystem of the mobile CCUs with all of the 2 additional funding that impinges on that without giving you @ 22 a number and have you work that out, with those conditions 23 for the award, A, elimination of CCUs and B, beefing up the a4 approach to the ER, and at least an inventory of ER facilities Ace ~ Federal Reporters, Inc. then I would accept that as ~~ 25 Ace ~ Federal Reporters, 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Inc. 25 243 DR. HINMAN: That would be approximately $900,000 for the first year. DR. SCHERLIS: Dr. Joslyn? — DR. JOSLYN: Another question is, it seems this -- although this is submitted by the state-wide RMP -- addresses only Birmingham, even in Phase II and III. IT wonder about -- in other words, it seems to me it was submitted as a contract proposal for Birmingham and doesn't address the state. I don't suppose it is my rule to put a condition on but I wonder if one of the things, that they be.more serious about the spread of this proposal to the whole state. I share Dr. Besson's concern that this one is more likely maybe to succeed and spread out across the whole state maybe than the other one because the other one is much younger and much less well formed, but I don't think in the form it is presented, it addresses a state-wide EMS system in the least, it addresses a city-wide system at a sophisticated level. DE. SCHERLIS: At this point you have suggested for Project 43 $150,000, isn't that right? DR. BESSON: Right. DR. HINMAN: One year funding only. DR. SCHERLIS: I have a feeling what you are trying dw 10 10 11 ) 12 13 14 15 16 17 18 19 20 ; 21 e 22 23 24 ce ~ Federal Reporters, Inc. 25 244 to do is come up with some sum of money for this other project and yet we find it hard to justify on any of the guidelines that we have followed to date. I would submit that if we support this, we are being rather inconsistent. DR. BESSON: You wanted a number. DR. SCHERLIS: Some of the numbers that I have at hand are very low. DR. SCHERLIS: You make your recommendation. I am only functioning as a moderator, with a vote. DR. BESSON: I think we have a meeting of the minds, and I think it is a double bind that we are in, and we are also constrained by time. So I think as a proposal, if it comes to nine hundred thousand, that seems like a lot of money for the first year for the City of Birmingham and we can just arbitrarily cut it from there. They are going to need less central operations, I suppose, if they are not going to have the CCUs to play with, less of the transportation. DR. SCHERLIS: My own feeling is let this go in as a contract proposal which is what they drafted it for because it doesn't fit our outlines. DR. BESSON: Can 't we defer action on this ana not give a figure? dw 11° 10 11 12 13 14 15 16 17 18 19 20 21 e 2» 23 24 ce — Federal Reporters, Inc. 25 245 DR. SCHERLIS: Let's not support it. DR. HINMAN: What do you mean by defer action? Re- fer it to the Council without recommendation? DR. BESSON: Without recommendation, to integrate it -- I think council can make a decision based on the conditions that we apply on the award, the conditions on the funding level for 43, and as far as 42 is concerned, if HSMHA is not going to fund it, then I think the Council can operate on the basis of the conditions that we have offered. DR. SCHERLIS: I don't think they are going to be able to. DR. ROSE: They won't know at the time that the council meets whether HSMHA is going to fund it or not. DR. SCHERLIS: Is any of that $150,000 available for general planning of an emergency medical system which is where I think they are at, as I read that. DR. BESSON: The 47? — DR. SCHERLIS: Yes. DR. BESSON: They talk about a demonstration area. I assume this can be the demonstration area, par excellence, and I have deleted that from the proposal. DR. HINMAN: The notes I have about 47 are one year at $150,000 with the advise to sharpen the EMT cost, local councils, public education, with no salaries and no demonstration project. ~ dw 12 ce —Federat Reporters, 10 1 12 13 14 15 16 17 18 19 20 2] 22 23 24 Inc. 25 246 DR. BESSON: Right. Okay, that we can set aside. Talking about 42, If the best we can do by eliminating the mobile CCUs is to cut it from 1.2 to $900,000, that still is -- DR. SCHERLIS: I don't see what we get with that. DR. BESSON: Let me just then arbitrarily give a figure of $300,000, which is 25 percent of their request. ‘That is hardly consistent with the sharpness of the whole proposal, but maybe I have been led astray by the rhetoric. DR. SCHERLIS: Dr. McPhedran, can I get an opinion from you on this? DR. McPHEDRAN: I don't know how you would decide ~- I don't know how one decides things like that. I don't see how we are going to decide it any better in council than we can decide it here. I think if we make an arbitrary award here, that council will probably be relieved that we made this arbitrary award and it will go in. DR. SCHERLIS: Dr. Joslyn? DR. JOSLYN: Checking back on.the demonstration area for Project 47 or the state-wide one, that is to be a rurp demonstration, which seems to me guite different from Birmingham. dw 13 . 10 11 @ 12 13 14 15 16 17 18 19 20 21 e 22 23 24 ce + Federal Reporters, inc. 25 247 I am just raising that point in which we are saying Birmingham can be the demonstration area for the state-wide one. I think they need coordination but I am not sure that was the point they had then they designed it. DR. SCHERLIS: My own suggestion is the hard one, and that is, it is a good grant request, but I don't know if they are requesting it from the right people in terms of what they are asking for. This is my view. DR. BESSON: I would like to defer action but apparently we are not going to do that. We are going to have action. DR. SCHERLIS: If we say no, that doesn't prevent them from coming in later? DR. BESSON: Later when, next cycle? Three months from now? DR. HINMAN: Four months, we are on a tri- annual basis now instead of quarterly. DR. BESSON: Defer it to HSMHA funding and if HSMHA Goesn't fund it and review it, next cycle. DR. SCHERLIS: With the limitationsthat we have placed on it. It must come in as a system. DR. BESSON: Number 47 with the recommendation that we made, 10 11 © 12 13 14 15 16 17 18 19 20 @ 21 22 23 24 Ace = Federal Reporters, Inc. 25 248 DR. SCHERLIS: Dr. Rose? MR. TOOMEY: I will second the motion. DR. SCHERLIS: Yes. DR. MATORY: Point of information. Your statement that it was not applicable to the guidelines was based upon what, area involved, or what? DR. SCHERLIS: I think if we are going to talk about an EMS, emergency medical system, that even though you can support one phase of it, it has to be tied in, as I view it, into the entire system. And this B specifies it is to the problem of one categorical area, essentially, coronary disease, without the total phases of emergency room on one end, coronary care unit on the other, a stratification of care in these areas, following recommended ICHD contracts, and so on. To me, it establishes a high priority on one limited aspect of the total emergency system, and the emphasis we have had right along is that it should not be categorization. This is one of the objections we have had to trauma as an isolated@ approach, and this, again, doesn't - go to coronary care and dedicated vehicles. DR. MATORY: I am sure those of you who read that --~ I didn't read it, but I say coronary care Was one of them, and I felt it was dealt to coronary care. _ * fi * dw 15 10 11 @ 12 13 14 15 16 17 18 19 20 21 sd 22 23 24 \ce - Federal Reporters, Inc. 25 249 DR. SCHERLIS: I think this was its major focus. DR. BESSON: It is not its major focus. DR. SCHERLIS: According to what you have mentioned it is. MR. TOOMEY: He is talking about the equipment. DR. BESSON: There are six or seven components, as far as equipment is concerned, yes. DR. HINMAN: I am uncomfortable. DR. SCHERLIS: We haven't made any motion yet. Would I accept separation -- DR. BESSON: I am going to move adjournment. DR. SCHERLIS: You recommended $300,000. DR. BESSON: I recommended deferring it to the next cycle if HSMHA doesn't fund. If HSMHA funds, we are off the hook, for Project 46. For 47, $150,000. 3.5 for 47. 4.0.° DR. ROSE: We are Likely not to have that. DR. HINMAN: It is possible. DR. BESSON: Okay. If I have to give a number, then, with all of the.commnents that we have had, and the blush taken off this rose, from 1.2, 25 percent is the figure that I suggested. DR. SCHERLIS: $300,000. DR. BESSON: Right. DR. SCHERLIS: Is there a second to that? 10 11 @ 12 13 14 15 16 17 18 19 20 2) oe 23 24 ce — Federal Reporters, inc. rt 25 250 DR. MC PHEDRAN: Second best one year funding. DR. SCHERLIS: Who would be in favor for Project 42, $300,00 with a rating of 4? (Chorus of ayes.) DR. SCHERLIS: All right, that passes. And a hundred and fifty thousand dollars for Project 43. DR. BESSON: Yes. DR. SCHERLIS: Was that for one year? DR. BESSON: Project 47, yes. DR. SCHERLIS: 42 was for what? DR. BESSON: One year. DR. SCHERLIS: All right. We now have the peculiar dilemma of having several more projects to review and time having run out. I wonder what -- I know we can finish in 45 minutes}, but that cuts out the plane travel. DR. HINMAN: The problem that we have is that we hafe to go to council two weeks from today, three weeks from today, whever it is, and we have to give them some sort of answers about these applications. DR. SCHERLIS: Yes. I have no problems DR, MC PHEDRAN: I can stay. DR. SCHERLIS: Who else has to leave? end 21 ice — Federal Reporters, 10 im 12 13 14 15 16 17 18 19 21 22 23 24 lac. 25 DR. ROTH: Only plane I have is 5:45. DR. SCHERLIS: Ali right. And you go where? DR. ROTH: Erie, Pennsylvania. The last plane I can get out is at 6:00. DR. HINMAN: With three, that still is some representation. DR. BESSON: How about you, Bob? MR. TOOMEY: My plane leaves at 9:00, so I am all right. DR. SCHERLIS: Well, Dr. Roth, you are primary reviewer for some of the remaining ones. DR. ROTH: Some of mine are real short. on oer, Ce ae / * W3--het- 4 inet a * * RA RR GD 14! 15 16 17 18 19 20 2) e 22 23 24 \ce — Federal Reporters, inc. 25 oo om ae DR. SCHEREIS We are going to do these by div ASLONS. The first is eastern branch, that will be Albany, and so on. DR. ROSE: That is the first section in Volume I of your book. DR. BESSON: Albany is asking for a six-month gre of $109 thousand, direct funding; and then for a two-year gr million, running from December of '72 at the wn request of i. < months to December "74, | tye end of s The general plan for Albany -- I will just read ant ant brief excerpts -- is, from the summary, I am reading, "A three year study to investigate the design and implementation of a ;PMS for the capitol district, consisting of what they describe to bo two major components, external to the hospital and internal. The external is basically the use of a rapid detection plan and preliminary care in a van. And then the internal svstem is the establishment of six beds, a four-bed .- trauma, intensive-care unit; located, Albany MNeagical Center; and a two-bed, similar unit; located in a community hospital. Let me just refer to budget, for a moment. There 1 s are -- for the six beds, they are requesting, there are sone 50 people that are being asked to be taken on as part Of the larger budget. Twenty-six of these are listed by name, wit a budget of 529,000; and 24 acditional neople, with a budge s sit ANVE'TV | | | ter~2 10 1 12 13 14 15 16 17 18 20 21 e 2 23 24 Ace - Federal Reporters, Inc. 25 They are also asking for the purchase of equipment which comes to 230,000. They are asking for computer funding in one form or another of 90,000. They are asking for the purchase of ambulance and communications, coming to 30,000, In addition to this, they are asking for 300,000 for what they referred to as a variety of incidental expenses. Basically, this is a request for funding a continuation of Dr. Samuel Power's research in trauma physiology. The general thesis is that the physiological -- meticulous physiological monitoring of massive injury has focused on the posttraumatic respiratory distress syndrome as a cause of death. The literature-morbidity rate of 40 to 80 percent in this situation has been reduced in this particular research, intensive care unit approach, of careful physiological monitor- ing, to one of the last ten patients with massive injuries, and the research unit says -~- and they make a categorical statement on page 21 of the application -- death from this cause has been virtually eliminated, although the basic cause of death is still unclear. This entire program in Albany is to continue that research effort. Now, in reading the application very carefully it is a magnificent piece of work, but I think that there are a variety of ruses used by Albany to trigger funding. 4 For example, this is called a demonstration unit -- it is hardly a demonstration unit, but a continuation of a 10 11 12 13 14 V5 16 17 18 N ~~ e 22 23 24 Ace -— Federal Reporters, inc. 25 24 physiological research program. It includes two trauma, inten- sive~care unit beds in a community hospital, therefore cloaking the entire project with a mantle of it being a community project, which it hardly is. It pays lip service to external hospital care by physician-communication with onsight ambulance personnel, but very cursorily mentioned. It also pays lip service to evalu= ating the cost, morbidity and mortality, with what are called "ordinary ICUs," presumably comparing them with what Dr. Powers can do when he is there. It pays lip service to outfitting a Winnebago Camper as a mobile ICU to demonstrate its values. It has one sentence in the entire proposal on community education. It proposes to establish a committee, and lists in one sentence, ten groups which can be triggered as “okay," groups, that will make up this committee. It talks about accident epidemiology as an extension of a package at Rensselaer Polytechnic Institute, which is said to analyze emergency events as predicted models, but I am not impressed with the detail in that predictive model, comment. The 129,000 which is modestly requested for the first six months of funding gives me the impression of being kind of a Gulf of Tonkin Resolution, with a $1.5 million request in the background. It seems to be only the beginning of a limitless ter-4 10 1] @ 12 13 14 15 16 17 18 19 20 @ 21 22 23 24 Ace ~ Federal Reporters, Inc. 25 25 and insatiable investment that is irrelevant to the problems that need solution in this area. When I talked to Dr. Scherlis, a week ago, about how this might be set up, he suggested maybe the best we could do is grade them "A" to "E" on the basis of what we have been told this morning, and from what I divined, I would grade this as "E," Incidentally, the technical review gives this pro- posal high marks, but it is with so much technology in its approach, it really does not address the right question. While this is, then, a remarkably, progressive approach to physiolog- ical monitoring of death from massive injuries, I think it is wide of the mark of what we intend to do with RMPs funding. So, I would recommend no funding for this project. DR. SCHERLIS: Secondary reviewer? MR. TOOMEY: I think that is me, and I could only agree with what Dr. Besson has said. [t looks to me as though it would be a great piece of research, and would be very interesting and very desirabie to be continued, but I just felt it was wide of the mark as far as the emergency medical services were concerned. DR. SCHERLTS: I guess the rating, according to our preview criteria -- DR. BESSON: I Gid not see these sheets. Maybe I will have to look at this sheet and see how we are doing this. 4 DR. SCEERLIS: Can I ask a question at this point? tex-5 10 1 12 13 14 15 16 17 18 19 20 2] e 22 23 24 Ace ~ Federal Reporters, Inc. 25 Bo on z Perhaps I am the only one confused on this. Albany is iisted as the primary reviewer, Dr. Besson, and Mr. Toomey, on this form. Tf I look at the other one, it is Dr. McPhedran and Dr. Besson. DR. MC PHEDRAN: For Albany? MR. TOOMEY: I had it done. I was secondary. DR. BESSON: I think I was primary. MR. TOOMEY: That is right. DR. ROSE: All of these were reviewed by these yeviewers. That is a mistake, q DR. SCHERLIS: I see. This is divided among the four, but this is the individual assignment. DR. BESSON: I would recommend, Mr. Chairman, that in accordance with this worksheet -- I assume that our final decisions will be on these sheets, is that right? DR. SCHERLIS: Yes. DR. BESSON: These white sheets? DR. SCHERLIS: Yes. What suggest is that the primary reviewer hand that sheet to Dr. Rose, and that he be responsible for the formulation of that sheet. Would that be satisfactory? DR. ROSE: Yes. DR. BESSON: Do we each fill out each sheet? The white sheet that comes in this book? ” 10 1] @ 12 13 14 15 16 17 18 19 - 20 2) e 22 23 24 Ace ~Fedeial Reporters, inc. 25 27 DR. SCHERLIS: I would suggest we not have indivi- dual votes but a committee vote, and only the primary reviewer fill it out, and that it recommend the concurrence of the secondary reviewer and of the committee, unless of course, we have another situation. But, I would suggest that you have the responsibility for filling this out, reflecting the committee decision. DR. BESSON: I would recommend, then, a, no recommended funding, no conditions for award, and rating five ~- or one, excuse me. DR. SCHERLIS: Rating one? DR. BESSON: Yes. DR. SCHERLIS: Does the secondary reviewer concur with that recommendation? MR. TOOMEY: Yes. DR. SCHERLIS: Any other comments from members of the review group? I will accept that as being a motion which has been seconded by the secondary reviewer. Any further discussion? Those in concurrence, signify by saying “aye.” (Chorus of aves.} DR. SCHERLIS: Opposed? That took care of Albany, I would guess. May I suggest this: If, for any reason, as part of the discussion, wat hg ty 10 1 @ 12 13 14 15 16 17 18 19 20 21 e 22 23 24 4ce - Federal Reporters, Inc. 25 if any of the task force of the staff which has been involved either in summarizing these, or as part of the DOD Branch, wishes to make any comment, I would appreciate that. -So Dr. Joslyn and Mr. Nash, if you would like to make any comment -- Dr. Joslyn? DR. JOSLYN: I concur. DR. SCHERLIS: We would like some facts presented, rather than a strong opponent or antagonistic point of view. distillate helpful to why I have if you are DR. JOSLYN: All right. DR. BESSON: One other question, Mr. Chairman. This will mean nothing to me after I am done. It may be the staff if it is legible. There is no reason to take this home with me. DR. ROSE: We would appreciate very much, having that not going to need it. XNEXXERM 7 10 11 @ 12 13 14 15 16 17 18 20 2] oe » 23 24 :@¢—Federal Reporters, Inc. 25 278 _DR. ROSE: Right,-severaltimes—ever . DR,-SCHERLIS:._Ali—right— Arizona. We are now on the western branch regions. The first one in that area is Arizona. Arizona has requested the sum of $116 thousand for one year for the organization and development of an EMS to provide accessible, adequate, and appropriate emergency care to all residents of Pima County. It proposes to adopt existing technology to produce a comprehensive plan for development of an integrated emergency medical service for Pima County, Arizona. The primary goal will be the development of a cost- acceptable organizationa. structure for the provision of EMS For the semi-rural communities, and adjacent, sparsely populated rural areas outside of the Tucson metropolitan area. The second goal will be developing methodology for the organization of specific alternatives, for the implement- ation in principal metropolitan areas. The staff recuest is approximately $85 thousand, for a breakdown of the budget. The dixect costs are S160 -yousand. The approach seems to be a reasonable one. It does build on existing needs and they intend as they go along, to even define these much more fully. I think they have indicated what their planning. VNOZTUV ter-5 10 1 @ 12 13 14 15 16 17 18 19 20 21 e 22 23 24 ce -- Federal Reporters, Inc. 25 process will be. It is a well organized program which will cover some 350,000 population area, of something like 90 to 100 square miles. The organization sponsoring it is the University of Arizona College of Medicine. They have the endorsement of the Comprehensive Planning B Agency and the Governor's Highway Safety Coordinator. It is a rather clearly stated project. I mention the figures that I did because I think, in terms of what they are talking about, they are asking for a somewhat higher sum of money than they might require in terms of what they are looking at. I suggested that they be rated at a level of three, that in terms of the funds which they are requesting, as I said, this is just for pima County, and a population of some 350,000 ~- I think they are asking for an excessive sum, but I would suggest that they be funded to the level of $65 thousand. This is essentially the planning phase at this time, one which I think will be a profitable use of the funds. Is there any member of staff, here, familiar -~ bee VOICE: I am her @ DR. SCHERLIS: The question I was going to ask you is a question in terms of the involvement of the people of Pina County. I went through this in some detail. My own feeling is that they look as if they can move it along but essentially bers Ge Edn #24 ce ~ Federal Reporters, 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Inc. 25 45u at a planning phase which is what they are looking at and I think with the help of the people they involve in the school and the act of involvement of their B Agency, they should be able to get this off the ground. are there any comments as far as other members of the review group are concerned, Then the motion I would make has been made in terms of funding at 65. Is there a second? DR. MCPHIDRAN: Second. Leeki4 - Ck 6247 yrbl | DR. SCHERLIS: Well, we are now going to have XEMKXX 2 Arkansas. Arkansas submitted a total of six projects, which Ij anc @ ° 4 Mr. Toomey have been asked to review, and these are $113,000, a varied 5\ group. ‘The gum totals of these, $5,000, $20 000, oi ~=$10,000, $33,000, $47,000 -- a total of some $307,000. 7 If I can try to put these in some semblance of 8 order -- actually if you will look in the back page you will see ? that it comes out to an excess of $1 million. 10 The first speaks to establish a cocrdinate education n system of emergency medical services for Arkansas, and this @ 12) te settled with the VA hospitals. I'm trying to get these 13 numbers in order. 14 The application to support the state-wide emercency 15 medical services system to include medical services council, 16 consumer education, transportation -- in other words, the 17 entire support. > a 18 It is designed to include some regional development. 5 e 9 A preliminary work schedule was presented to allow time phased 20 method and then present the entire methodology for this. ® 21 When you go through this, it is really very difficult to 22 determine exactly what is specifically requested. 23 This is a very ambitious program but the entire 24 request is really very poorly organized. As T went through le Federal Reporters, Ine. | 25 this I felt repeatedly the need for a more detailed budget jxb2 16 17 18 19 20 © 2] 22 23 24 e~ Federal Reporters, Inc. 25 bat ay 2 and more indication of exactly what was being planned. The application itself to me seems to be, ina word that I used for it, excessively padded. It emphasizes both planning and operational activi- ties. Funds are requested for developing of a pilot project as well as developing a state-wide emergency medical system and both of them are heavily oriented towards the purchase of hardware. The salaries are something like $75,000, consultants come to $76,000; the equipment to $40,000. They have asked for rennovation of part of the VA 7 2 facility. They have included replacement of medic supplies. As I went through this, I felt that part of it should be supported, namely that which emphasized essentially the training aspects more than anything else, and I'll come back to that as I review some of the other programs which were part of this. Project 42, which again is part of this overall Arkansas program, is asked for by the Arkansas Health Systems Foundation to improve emergency health services for a six- county area in Arkansas. The attempt is to uparade emergency services to the critically-ill or injured not only within this community but outside as well, and they discuss this as being achieved jrbs >—Federal Renortess, 10 1 12 14 15 16, 17 18 19 20 2) 22 23 24 Inc. 25 Lol by rural involvement through the establishment of a hospital~ based ambulance, regional communications system. They speak of ambulances being placed in each rural hospital staffed on a 24-hour basis, and this would be the responsibility of the rural communities. They emphasize that there is no communication transportation from the rural hospitals in the six-county area with the local regional hospital; Again, the request here is in terms of a great deal of funding for actual hospital personnel. Salaries come to something like $95,000, mostly for this, and the equipment to $60,000. It is a three-year operational request which is aimed at improving emergency room facilities, general emergency services, Major emergency services, upgrading emergency services. There is no really good description of just what is being planned, although they do ask specific support for emergency room personnel and eguipment. One problem here is that there is no real system of care which is discussed. As you go through the sheets -~ and I did this to again evaluate what specific items were present ~- you will find that they have really not directed themselves adequately to the criteria as outlined by the actual requests that they had received in terms of the JD 10 1 13 14 15 16 17 18 19 20 21 @ 22 23 24 2~ Federal Reporters, Inc. 25 162 outline which they should follow. My feeling on this was that it was a very poor request and I questioned whether any support should be given to it. The next one from Arkansas was again for a six- county area, the development of an emergency medical services system. It was for a one-year planning project. This particular instance, again, it was a very brief application. They only requested funds for planning this in the Little Rock area. The approach appeared to be a reasonable one, but they had asked again for what I thought was an excessive smount of funding and although they did follow the guidelines more carefully, I gave this a rating over the others, but again do not recommend full funding for it, and I'll give the numbers on that in a moment. The next request was again for Arkansas. As you gather as I go through this, this is not an overall, well organized project. There are bits and pieces applying to different parts of the State, rather than being a well-coordinated education program. This one was an in-depth study to determine the need and approach to emergency care and to establish such a program in a 10-county area. They asked for one-year support in order to plan jrb5 163 1 an emergency medical system for this 19~county area. This 2 was given in more detail, but again, there was a lack of @ 3 adequate information. 4 This was a rewrite of what appeared to be a grant - ° this was a rewrite of the whole guidelines, so at least they 6 did follow the guidelines more adequately than the others had 7 but, nevertheless, there were a great many omissions. 8 There was nothing new or innovative about it. 9 I felt there should be some support for the program because 10 it did address itself to planning, and I think they at least a defined what their needs were. @ 12 The next was, again, part of a program just for 13 Southeast Arkansas; in this particular one, they asked for 14 funding to establish a plan for an emergency medical service 15 system to involve the districts, 1l hospitals, establish 16 new ambulance services and upgrade those which were then in 17 operation. 18 Again, although there is evidence of a real need 19 as there is in all of these, one can't help but be impressed 20 with the fact that there is very little documentation, that 21 the application reports themselves are really very sparse. @ | 22 And if one funds this, again it would be a 23 priority which is rather low, and I would restrict the funds 24 here as well for the planning phase. ‘e~ Federal Reporters, Inc. 25 I think to move into any further step at the jrb6 >~ Federal Reporters, 10 1] 12 13 14 15 16 17 18 19 20 2) 22 23 24 Inc. 25 164 present time would be unjustified. In summary, looking at all of their applications -- MR. TOOMEY: I think you skipped one, Doctor. DR. SCHERLIS: Did I skip one? MR. TOOMEY: East Arkansas Planning and Deveicpment District? DR. SCHERLIS: That was omitted from mine. MR. 'TOOMEY: Okay. DR. SCHERLIS: Do you want to give that? MR. TOOMEY: It is a one-year planning grant for the Eastern Planning District, comprised of 12 counties, which is the second largest area in population of the State, with 371,000 people. Ambulance services in the area are operated by funeral homes and private concerns. The primary objective of this request is the development of a direct ambulance service linked with radio communication. The narrative speaks to the requirement of vehicles and communications equipment with no overall planning mechanism for the formation of development of a coordinative system within the district or with the state EMS plan. It shows little understanding of a total emergency medical services system. The monies are requested primarily for the purpose of equipment. Community needs and resources have not been assessed. jxb7 i 1] @ 12 13 14 16 17 18 19 20 21 e 23 24 @~ Federal Reporters,.inc. 25 There is no reference to linkages with the system other than radio communications. Of the $142,000 requested, $94,000 relates to vehicles purchased, and $33,000 for communications equipment, and $4,000 budgeted for training purposes. DR. SCHERLIS: All in all, I was extremely dissappointed with the Arkansas application. There were bits and pieces. Maybe they didn't have the time, but I don't think the program as finally put forth was one which really reflected an overall coordinated effort and I thought the funding requests were certainly -- what support might be given would be more for planning and hopefully on a more correlated basis. VOICE: Project 45 was omitted. It did not have Reg review, it was returned by the Reg for further revision. DR. SCHERLIS: That's why I don't have it. Is that to be considered by us or not? VOICE: We didn't get it. DR. SCHERLIS: The one just reviewed is really not part of our consideration; is that correct? All right. The part just discussed is not a part of our consideration, the last one reviewed, No. 45. So we have to consider then the other ones, No. 41, which had requested 3rpe 10 11 12 13 14 15 16 17 18 19 20 2) @ 22 23 24 2 —Federal Reporters, Inc. 25 Loo $300,000 for the first year -- is that correct? Yes. My recommendation on that was a funding only for planning at a rating of 2. The next one, No. 42 -- my recommendation was that only be funded for planning to a sum of $30,000 with a rating of 2. The next one, Item 42, I recommend action on that one, that there be no funding for that one. No. 43, I felt that should only be supported to the terms of planning. My recommendation was $25,000 there with a grade of 2. Project 44, for which $31,000 had been requested, I felt this one at least had some fuller data, and I thought it should be supported for the funds requested for planning, with a rating of 3. No. 45 is not subject to our consideration. No. 46 is. My rating on that was only for planning to a total of -- what they had here, $15,600, with a grade of 2. Secondary reviewer? We can be wide apart on these, given the funds requested, and the competency of draftsmanship. MR. TOOMEY: I was looking at something -- as you were going down the requests on the planning, I was in agreement, and I figured you were going to -- I don't know jrby 10 1 12 13 14 15 16 17 18 19 20 21 eo =» 23 24 :~ Federal Reporters, Inc. 25 where you were. DR. SCHERLIS: Project 41, I recommended $30,000 for the first year with a rating of 2. MR. TOOMEY: That is the $300,000? DR. SCHERLIS: Yes. Now, then, Project 42 I did not recommend being funded. Project 43, I recommended $25,000 with a rating of 2. MR. TOOMEY: That is the $45,000? DR. SCHERLIS: Yes. The request had been for 45. Project 44 had requested 31, and I thought that was an adequate figure for planning. I gave that a little higher rating of 3. No. 45 we have been asked not to consider. No. 46, I agree with $15,600, at a rating of 2. Are they about what you were going to suggest? Or what was your feeling? MR. TOOMEY: I didn't make the suggestion, but I would be in agreement. DR. SCHERLIS: Would that be all right? MR. TOOMEY: Yes. DR. MATORY: You have studied this a lot more closely than I, but I was a little concerned in that first one jrbL1.o o—~ Federal Reporters, 10 VW 12 13 14 15 16 17 18 1? 20 2] 22 24 Inc. 25 very little coordination and I would think the Staff comment 168 they indeed were setting about to begin to get some personnel trained. I was wondering if perhaps out of the $300,000, if -~ I am not satisfied with your justification for only a tenth funding. It seems they are about to get personnel training and organization. DR. SCHERLIS: What I was going to suggest was this as a follow-up-recommendation. All of this comes to over $100,000 for State, and whetI think should be done is that the State has to put together a thoroughly coordinated program to encompass emphasis on training in an overall plan. What we have been given is individual plans that have here would be that all of these should be coordinated into an overall view. Because a sum of $100,000 gets to be a very significant sum to work with in setting up, at this stage, planning and training. Would that answer your question? DR. MATORY: That answers it, but I just wonder what a State can do with $100,000? I am very much -~-- of course, now you have the 45, and I suppose given better consideration, that might be another plus. But I am impressed with their realization that thos | funeral ambulances have te go and I don't know how we are goin to do that unless they get gome funding and support. This is jEDiL 1 ae ‘e- Federal Reporters, 10 11 12 13 14 16 17 18 19 20 21 22 23 24 Inc. 25 L639 one of the big things we're all trying to get rid of. DR. SCHERLIS: That is a nation-wide program, isn't DR. MATORY: Yes. But Arkansas seems to have its share. DR. SCHERLIS: I am open to any suggestions. DR. HINMAN: I agree with you, Bill. I haven't seen the application. DR. SCHERLIS: Who is familiar with the Arkansas grant? VOICE: I was on the site visit. Is there a specific question that you would like to ask about this? DR. SCHERLIS: What do you think their ability is to mount this effort? What is their total funding at this time, in Arkansas? VOICE: 1.5. DR. SCHERLIS: $1.5 million? VOICE: As you know from the site visit, that was rather recent, they are one of the better regional medical programs, and seem to have the capability to plan a program. I suspect ~~ Mr. Says is the primary Staff person on this, but I suspect that the time constraint had its affect on the development of this. DR. SCHERLIS: This is one thing that bothered me, is that as you go through this, as apparently they are very jrb12 7 On 2a-— Federal Reporters, 10 1 12 13 14 15 16 17 18 19 20 2) 22 23 24 Inc. 25 170 thick brants, the requests that you deal with are very small proportions of them, and one of the problems that I had in goi through them is that these were in great measure, I assume, all prepared for other requests. Are they going to part of that $8 million? DR. ROSE: Yes. DR. SCHERLIS: These weren't really prepared under our guidelines, they were prepared for something else. While one can question however one can go by this sum, nevertheless, if we are going to buy the guidelines, we have to follow them. You are right what you can do for $100,000, you certainly can't replace all the hearses with adequately- staffed and equipped ambulances, but I would think. if they don't get their other fund, at least this is a good start in putting together an overall program. I know their coordinator who I think is one of the best I have ever had the opportunity of site visiting. I am sure he can use these funds very adequately at least as far as planning and coming in later for implementation. He can come in in the very near future for implementation. Any other comments? A motion has been made and I guess seconded. All iid those in favor, say “aye. (Chorus of "ayes.") jrb13 #14Lee CR 6307 :— Federal Reporters, 10 1 12 13 14 15 16 17 18 19 20 21 22 23 24 Inc. 25 171 DR. SCHERLIS: Opposed? DR. ROSE: Do you have an overall rating? DR. SCHERLIS: The overall rating comes to 3. DR. ROSE. 3. Okay. CR6307 #15-ter-1 oo 3 10 1 } 12 13 14 15 16 17 18 19 20 e 21 22 23 24 ce ~ Federal Reporters, Inc. 25 172 DR. SCHERLIS: All right, Bi+eState is the next one, Mr. Toomey. MR. TOOMEY: This is an application from Washington University in St. Louis. The funding is requested at $707 thousand for the first year, 293 for the second year, $314 thousand for the third year. I have a total of $1,316,000. The grant application covers an eight county region consisting of almost 50,000 square miles around and including St. Louis. The area population is about 2.5 million people, in 200 municipalities. Despite their separateness, their residences are linked to St. Louis through medical services patterns, There are many deficiencies in medical services because of the 200 independent, political jurisdictions. Concern over the eficiencies of an emergency medical service initiated this ww Gu grant request as mechanism for coordinating the emergency medi- cal services with governments cross-sectoring for management of the systems operation. The objectives stated were to establish an emergency yekem which is under, by, and . + ambulance central dispatching s readily accessible to the public served, to supply the area with a sufficient iamber of ambulances, to train the ambulance crews to the level of efficiency, sufficient to qualify them for reqistration as emergency medical technicians. supply ALVIS~1g tern2s 10 1 @ 12 13 14 15 16 17 18 19 20 } 2) © 22 23 24 ce ~ Federal Reporters, Inc. 25 173 essential equipment as defined by the American College of Surgeons, to categorize hospitals and designate receiving stations on the basis of emergency backup capabilities; and to establish communication links between all components of the emergency medical services system. The plan is to be implemented in two phases. The first phase of the system to become operational in the core. sector of St. Louis, in addition to gathering information to extend the system to the rest of the eight county metropolitan St. Louis area. ; Extension of the system to the rest of the area for a total emergency medical system will constitute Phase 2. The proposal is a three-year funding for phase one with imple- mentation of phase two, within the year following activation of Phase one. In the terms of my evaluation, the applicant demon- strated good knowledge of a total EMS System including hew the various phases would be integrated and has noted the deficiencies in the presystem which must be overcome. the specific geographic area was well described, and the proposal is community based, with broad representation of providers, oublic agencies, planning agencies, and community interests. Existing medical services have been taken into consideration with edification of facilities, equipment, and medical services available within the area, Additional ~ ter-3° 10 1 12 13 14 15 16 17 18 19 20 21 @ 22 23 24 ce — Federal Reporters, Inc. 25 L/4 resources have been identified and there is a clear assessment of needs and resources based on statistics. The plan makes reference to how the operating components will tie together and how additions to this system will be coordinated. The only weak area of the narrative relates to the improvement of quality care and linkages with local health care systems. The applicant only partially describes these linkages and briefly refers to followup of non-emergency patients, and community disaster planning. Techniques are described for utilizing financial resources, in addition to obtaining additional financial support at the expiration of this grant. While this is my -- this is my summary. While there are no outstanding or innovative approaches to the development of the EMS within this area, the application appears to be well conceived, a well conceived plan, a good organizational structure which will coordiante and administer the system. It reflects comprehensive planning for bringing together the key elements and a disaster and EMS system. However, a large portion of the grant is used for the purchase of ambulances and the equipment. Comments by the reviewer, Dr. Kaplan, "This basically is a well-thought out application." It has identified problems and has made an attempt to solve them. The one dereck that I would seo here is no mention of the Department of Transportation's support of ter-4. 10 11 © 12 13 14 15 16 17 18 19 20 @ 21 22 23 24 ce + Federal Reporters, inc. 25 175 ambulances. They appear to be coming 100 percent in support of ambulances in this application. In their defense, however, cutting back on ambu- lances support would greatly weaken the basic concept of this proposal. There is very little attention made to the emergency room's themselves and the followup area. I classified this application as a very good application. However, I am concerned about the amount of funding. I would like to hear the discussion before I make the recommendation. DR. MC PHEDRAN: So am I. This was one of the early ones that I read and I thought that what was described about the ambulance service was good, but that on reading it and rereading it, it really does not measure up to our notions about a system. I think it is a well designed ambulance service and the amount of money to be spent out of that first year budget, 707, 568, on ecuipment; including ecsuipping the ambulance for 16, 641 -- that is nearlv half a million dollars on the ambu- lances, and on the communications equipment, the emerge ney care equipment, and other things that have to go in the ambulances, in order to make them serve this function. And there is nearly 200,000 in personnel. Of course, the costs drop off sharply, the next year because of the initial -- in the proposal, the initial cost for the ambulances. 10 1 @ 12 13 14 15 16 17 18 19 20 ® 2) 22 23 24 Ace + Federal Reporters, Inc. 25 176 DR. SCHERLIS: Two ninety-three and 314 in the subsequent years. DR. MC PHEDRAN: When I think of this amount of money being requested for the first year and then put it beside the tri-state application, what was requested there, for the first year, it seems to me that -- now IT understand why I feel that way in the tri-state application, because so much is the development of planning, and linkages; whereas in this one, a portion of the system, I thought was well designed, but I really wonder if we ought to support it not because it is not a good part of the system, but because it is not really the whole system. That is the way I feel about it. I wonder whether we ought to support it at all because it is such a portion of the system. That is what I am concerned about. I mean it just is not the whole thing. We do not know whether the emer- gency rooms are going to be coordinated at all to prepare for what these ambulances will bring, for example. I guess they could be with the system as described, but we just do not know. DR. SCHERLIS: ALL right. MR. TOOMEY: I thought it was extremely well written. DR. MC PHEDRAN: I thought it was well written, but I thought it was just a piece, that is the trouble. DR. SCHERLIS: Is Dr. Caplan or Mr. Poster here? ter-6° 10 i © 12 13 14 15 16 17 18 19 20 @ 2] 22 23 24 ce — Federal Reporters, Inc. 25 177 DR. ROSE: Dr. Kaplan is not here. DR. SCHERLIS: I gather there are differences of opinion. Would you want to respond to this, Mr. Toomey? I do not think we have had a rating yet, really, for this. MR. TOOMEY: My rating of the application would he probably 3.5, between three and four. DR. SCHERLIS: How do vou feel about it? DR. MC PHEDRAN: I think for what it tries to do, it is a three, but I do not think it is a system, and I do not know that we ought to rate it as a system. That is my complaint about it. DR. SCHERLIS: How much of it is requested for planning in the overall, or isn't there any? DR. MC PHEDRAN: Well, I do not think there is very much. I can tell you in just a second. There is an evaluation of the project, $30 thousand. One of the field system planners, total supnport is requested for him. That is 17 thousand direct costs, or 19 thousand total, together; and secretarial help for the field systems planning. DR. SCHERLIS: Is what they ere going to do essentialpy set up the prehospital phase? Is that correct? DR. HC PHEDPAN: That is the way I view it. 178 ter-7 1] DR. SCHERLIS: If you are reading this summary, 9\| it certainly seems the emphasis is on that, without there being @ 3\| further involvement of the actual provider areas. 4 Do we have a motion? 5 We lie somewhere between $700 thousand and no dollars 6], at this point, if I read it correctly. 7 MR. TOOMEY: I remember now, the personnel involved gl in this for the first 12 months was $188 thousand. Then the 9], ambulances were 416 thousand. I do not see there was anything 10] specifically in the area of planning in terms of funds for withis. @ 12 DR. SCHERLIS: There is some training, is there not? 13 DR. MC PHEDRAN: Yes. 14 MR. TOOMEY: There is considerable. 15 DR. MC PHEDRAN: There is training equipment for the 16 ambulance -~ it seems to me there was some training for the 17 ambulance attendants but I am not even sure that that is true. 18 DR. SCHERLIS: They do have a duplicate-contract 19 request in, according to our worksheet, 20 DR. MC PHEDRAN: They do? 2] DR. MARGULIES: I think it will be visited. @ 22 DR. SCHERLIS: ft has not moved that far along. 23 DR. MARGULIES: Right. O4 DR. MC PHEDRAN: Yes. V7 DR. SCHERLIS: ; “Any other comments? 18 DR. BESSON: What is the motion? 19 DR. SCHERLIC: There is no motion. 20 “up. MC PHEDRAN: I wonder if there is some mechanism 3 that can ke suggested by RMPS that we could arrive at a figure @ 3 that would be realistic to help them, say, for example, get 53 the statewide consortium, since the application ability of the Now Haven model seems to be, what there is, the most 24 ce ~ Federal ay questionable part of it; what youl@ it cost them to get the 5 = sUGT CL » 10 i ® 12 13 14 15 16 17 18 19 20 e 21 23 24 ce ~Federal Reporters, inc. 25 22 statewide consortium that they described going for a year, and then as Dr. Besson suggests, maybe the experimental health services delivery people would find enough of their own money ta begin the demonstration model. | Could we say that we would approve it for that part of it which would put the statewide consortium into operation? DR. SCHERLIS: I think that is a reasonable request. DR. MC PHEDRAN: I don't know about the numkers, how to put a figure on that. DR. SCHERLIS: I. think we need a dollars figure on that, to know what kind of a staff they would need to implement that. DR. MARGULIES : The situation with the experimental health service delivery system is that it has only been recently appreved, to the best of my knowledge. So if it depends upon that, there is also a question of whether it might not be better to limit what they do until that develops into some ©.-: better relationship. Because it did go through with the Coordinating Review Committee just the last time. So nothing really has happened yet, although they have been working at it for a year. DR. BESSON: I second that motion. DR. SCHIERLIS: In other words the motion is to the effect, number cone, the rating is two-and-a-half or 3, somewhere; in that ball park, and that the support be limited to setting up mea-9 10 11 e 12 13 14 15 16 17 18 19 20 21 ®e 22 23 24 ce — Federal Reporters, inc. 25 a consortium as its majer effort. What was the other -- DR. BESSON: Not consortium, the statewide EMS. PDR. MC PHEDRAN: When they say consortium, that is what they are talking about. DR. BESSON: Consortium is used as the key word for the trauma unit, New Haven Health Care Incorporated, and Dunlop Associates. DR. SCHERLIS: Shall we say a total statewide EMS. DR. MC PHEDRAN: Planning, development and planning phase. DR. SCHERLIS: That would be limited to a planning, developmental phase for total statewide EMS. Is that correct? DR. BESSON: Yes. DR. SCHERLIS: What level of funding, just so we'll have a number here. They have been arbitrary in their request for funds, so we can be arbitrary here. DR. MC PHEDRAN: The total amount they asked for was 328. Do you think a half or a third of that is reasonable? DR. SCHERLIS: That is extremely generous for this developmental planning phase but that may speak of my own Monday morning feeling, as far as funding goes. DR. GIMBLE: I have a feeling it is going to lead to the same prohlem. Can you word it in such a way to preclude money falling back into the Yale Trauma -- mea~y Lu 10 1 @ , 12 13 14 15 16 17 18 19 20 ho 22 23 24 ice — Federal Reporters, Inc. 25 DR. BESSON: I thought that was part of the motion, that ‘the conditions were that these moneys only be used for these purposes. DR. MC PHEDRAN: Statewide planning. DR. SCHERLIS: Statewide planning development phase for total EMS. DR. MC PHEDRAN: Yes. DR. SCHERLIS: This is not limited by any means and in fact it should not be under to be trauma-based, but a total system base. Is that separated from the present orientation of the Yale funds? DR. GIMBLE: I'm not sure, if the people that are doing the planning are in this, in the Yale program. DR. SCHERLIS: Would you say that the planning be centered through the regional medical program core office? Would that give them ancthers loan? DR. MARGULIES: That it be done by the regional medical program. DR. SCHERLIS: It be done by the regional medical program and that ceiling be 50 to 100. DR. FAATZ: ke az Mea & * ve ~ Federal Reporters, 10 11 12 13 14 15 16 17 18 19 20 2) 22 23 24 Inc. 25 187 It would be the regional medical program itself, I think, that would do this, if I remember correctly. Here it is. There is a county in Utah which would be the first phase. and which would serve to some extent as a model for the others. That is called Wasatch Front, Emergency Medical System. That is in the first year. And the second year, the other comprehensive health planning district would be involved in the same kind of plan as had been set up for the Wasatch Front. And in the third year, it was hoped that the type of model that was developed in this one county would apply to all three. Mr. Toomey? MR. TOOMEY: Yes. The objectives that were derived that I took from this material, they include the establishment of a legal body with the authority and responsibility to plana and implement a statewide emergency medical system through a network of district EMS councils, and to establish a statewide communication system which will meet the needs of the area; to establish a rapid and safe emergency transportation system which will meet established standards; to upgrade the quality of hospital emergency departments; to establish a manpower training program which will provide an appropriate type of adequately trained personnel, to design and implement a standard data collection system which would provide information needed For 10 i @ “42 13 14 15 16 17 18 19 20 21 e 22 23 24 \ce — Federal Reporters, Inc. 25 L138 Management operation planning, evaluation and quality control, to assure high quality emergency care and to evaluate and compare emergency medical systems with other systems of emergency care, to provide a stable source of financial support for EMS, beginning after the third year, and as Dr. McPhedran said, it was planned in three staged phases. Phase one involves the development of a council to form the nucleus organization to employ a staff, and that was the Wasatch. Phase two involves the organization of the EMS network into an effective operational plan, to implement emergency services in each district. Phase three involves the formation of a statewide EMS authority to provide leadership for continuation of the program. My own evaluation was that the application: demonstrate knowledge of the total system and has identified deficiencies in the present operating system. It is a community-based program involving providers, public agencies, planning agencies, and community interests. Existing community needs and resources have been documented and we will define as to how each element will be coordinated with components already operational. Linkages with local health care systems are not well described; however, reference is made to enhancing preventive nitea-4- 10 1 @ 12 13 14 15 16 17 18 19 20 © -21 22 23 Z24 ce ~ Federal Reporters, inc. 25 189 medical services. Specific plans have been delineated for obtaining additional financial support and the prime area emphasis of this application is through the provision of various continuing educational training programs, limited to specific conditions. The population is sparsely settled; the terrain is mountainous. The approach for developing this system has been well thought out, has clearly defined objectives, and I think as I read it the thing that impressed me more than anything else was the potential for measuring the various accomplishments, methods of measuring whether or not they have accomplished the objec~ tives. DR. SCHERLIS: How did you rate this proposal? “MR. TOOMEY: I rated it as very good, good, which in my opinion would be a 3.5. I saw no reason, really, not to provide them with the funds that were requested. DR. BESSON: Second. DR. SCHERLIS:. Any further discussion? This then is for three years, 248, 222, 293. Both of you were impressed with this as a system of cace as well as the other points. You have heard the discussion; all those in favor say aye. (chorue of ogee) CR-6307 46 nb-1 XXX ~ Fedetat Reporters, 10 1 DR. SCHERLIS: All right. That is Connecticut. The next program is the Lakes Area. DR. MC PHEDRAN: Formerly Western New York. DR. SCHERLIS: Lakes Area, thank you. DR. MC PHEDRAN: This is formerly Western New York. ATS As a wroposal, the temesh is Hinds get AT YY \ half year period to document emergency medical needs and to develop appropriate emergency medical services in Erie County, New York, The proposal proposes a great deal of confidence in a man that has recently come on, an evaluator and planner, " 13 14 15 16 | 7| . | 19 20 2] 23 i 24) Inc. 25 by the name of pr, Geoffrey Gibson, Dr. Gibson did a Study in Chicago, where he was before, I gather, which I read in the course of doing other resource, it is a Study of Chicago emergency medical services needs, It certainly is a good piece of work, I thought. Io was very much interested in it. So, I can understand why the Lakes Area regional medical program is pleased to have him, The proposal that has been developed here is develope by an emergency medical cara committee, which advises the | Commissioner lof Health. The committee has fairly broad rep- resentation from hospital people and medical society and community leaders, The proposal includes one component for cammunications. VaaV SAAVI nb-2 10 im 12 13 14 15 16 17 18 19 20 2] eo 23 24}; ics ~ Federal Reporters, Inc. 25 an education component for training medical emergency techni-~ cians, and cf course, this research or this study into the effect of the whole program on emergency medical services. Now, the breakdown of the budget, for the first year there is really a very large expenditure on communications equipment. The total first year budget requested is $348,000. Of that, communications equipment eats up $207,000, M.E.T. training, the communications equipment is divided in budgetary breakdown among the several people, several groups, who would receive this communications equipment. That is roughly 60 percent of the total M.E.T. Training consumes $63,000 and the research and evaluation component just about the same, $63,000. The whole argument in presentation is that the communications scheme or the thing they want to develop is central to improving emergency medical services in this region. I think the argument is made with some effect. I find it difficult to quarrel with the figures that they ahve developed for the communications. If this is the central feature of developing this proposal, as they see it, I suppose that one would have to take the whole thing all together. The figures for communication equipment droppsc down sharply the second year, 78,000 against that figure of over 200,000 the first year, and the third year, 29,000. There apparently are other sources for funds for nb=3 ce — Federal Reporters, 10 11 12 13 14 15 16 17 18 19 20 Z4 inc. 25 62 keeping it up. and there are other -- there are other sources, large contributions, to communications component. Not as large as what RMP is asked to withstand, but nevertheless large, I think that as I say, the argument was made, at least to me, with good effect, that this would be an important direction for this regional medical program to take, and I would rate this proposal as a three and recommend it be funded if the funding can be found. That is my own feeling about it. | That is 348,744 for the first year. The figures that are shown here on the sheet -- I won't bother to read these -- they would be on the record on this sheet. DR. SCHERLIS: How many ambulances do they plan to putfit at the very onset? Do you have any == DR. BESSON: Forty-four. DR. MC PHEDRAN: Forty~four. DR. SCHERLIS: Hew many? DR. BESSON: Forty-four ambulances, participating hospitals. DR. MC PHEDRAN: Wait a minute. I am sorry, isn't it just 30? DR. BESSON: That is just the first year. DR. MG PHEDRAN: That is the first year. PR, SCHERLIS: Are these hospital-based ambulances? nb=-4 ce ~ Federal Reporters, 10 im 12 13 14 15 16 17 18 19 20 21 23 24 Inc. 5 63 DR. MC PHEDRAN: I think many of them are, DR. SCHERLIS: Do they coordinate one with the other or do they just service individual hospitals? I just happened to pick up a sheet that says -.. St. Francis Hospital and then lists -- DR. MC PHEDRAN: They would be coordinated through central dispatching, that is one of the points, of course, about all of this elaborate communications equipment. It is a central dispatching type of arrangement. DR. SCHERLIS: Right. DR. MC PHEDRAN: So that whether they -=- how they would be based seems not so important, they could work that out. DR. SCHERLIS: Have they already worked out the assignment of channels and expressed a willingness to cooper- ate one with the other? DR, MC PHEDRAN: They speak about that, that there would be an assigned frequency that would be used by all the cooperating parties. DR. MARGULIES: That is an area in which they are . rather expert. DR. MC PHEDRAN: Is that right? DR. MARGULIES: Yes. DR. MC PHEDRAN: You mean expert ~= who is expert, the oolice? nb-5 ce ~ Federal Reporters, 10 7 12 13 14 15 16 17 18 19 20 2] 22 23 24 Inc. 25 DR. MARGULIES: RMP has had a lot of experience with the use of radio communications. | DR. SCHERLIS: Dr. Besson? DR. BESSON: Yes, this program had its genesis in the appointment of the Blue Ribbon Committee, so-called, which was an advisory committee to the Commissioner of Health. As I have looked over the application and the minutes of the Blue Ribbon Committee, I see that the subcommitte on communications takes up the bulk of this application, And my only thinking is that some communications expert must have gotten to this subcommittee and really laid out a program for the development of a communications network that is maybe a little bit overkill, but I suppose that is what commun- ication gear costs, The details are just astounding for an application like this, and I think that has been the heavy emphasis, as Dr. McPhedran has already put, not only physical but so far as there interest is concerned. But I suppose I will have to live with the fact that we are equiping ten hospitals == participating hospitals, one regional hospital, and forty-four ambulances, for all this communications money of $270,0CG0, since the system just doesn't go unless you have that component part and if they are on the ball to lay out this kind of elaborate system, I suppose more power to then, They are linking that to a good training program ce ~ Federal Reporters, 10 11 12 13 14 16 17 18 19 20 21 22 23 24 tne. 25 O93 for technicians, training 5,000 over a three year period with 36 hours of formal training to be given throughout the region, hopefully. And they anticipate that this Blue Ribbon Committee will continve as a coordinating committee to expand the effort from this original area which is around in Erie County, around Buffalo.to the rest of Erie County and then throughout the Lakes Area Region, developing local committees as they go. I have difficulty in swallowing the whole thing, but I suppose that if that is money going to a gooa cause I would agree with the recommendation implied in Dr. McPhedran's presentation of a C rating and full funding, DR. MC PHEDRANs I want to just say, one of the concerns that I have is a concern I have about all of them, really, that evaluation has to do with whether or not they will be able to get the things equipped, whether or not they will be able to get the people on the same frequency by such and such a time. But again there isn't anything here that tells how they are going to decide whether or not coronary lives were saved, or accident victims were saved. I suppose they are hoping Dr. Gibson can design them a study. But that sure isn't in any of these applications that I have been able to tell, and it is not in this one, either. nb-7 10 im 12 13 14 15 16 17 18 19 20 21 ce ~ Federal Repoiters; 22 23 24 Inc, 25 66 DR. SCHERLIS: Do you think they are ready to start a system involving so. many ambulances, or do you think that we might not suggest -~ I am just asking this -- might not suggest they start with a small group, and feel their way -- DR. MC PHEDRAN: I think the idea wasn't they couldn't serve the whole region unless they tried to do this, and they want to try to make it a regional network from the beginning. DR. SCHERLIS: Something has to come first. DR. MC PHEDRAN: I guess, you know, if it is simply setting up central dispatching and then putting equip- ment into ambulances and having everybody use the same assigned frequency, there might not be much need to time phase that. DR. SCHERLIS: But the training would be a problem, In other words, what do they communicate? If it is just dispatching, that is a questionable facit of the total system, unless training is with it. DR. BESSONs Mr. Chairman, I think this is an example of an application which suggest to me that knowing about the so-called neglected disease, can be enhanced by getting involved in this. £ don't know ££ Dr. Dimick had Started out that way, but he sure became an expert from having become involved and getting them involved in communications is going to make it obvious to them that that is only one link in a chain, nb-8 ice ~ Federal Reporters, 10 VW 12 13 14 15 16 17 18 19 20 ho ~ 22 23 24 Inc. 7 25 67 And I think they will be self-corrective and the more they get to know about it, the more they will recognize that communications can't possibly function without having the other pieces of the puzzle, So while it is heavy in one area I think it is an entry point for this region to get involved. Now, we reviewed Maine, and there big handup is transportation. They are spending all their money on trans- portation but obviously they will have to get to the other parts as they recognize the state of the art and become more familiar with it. DR. SCHERLIS: Dr. Keller? DR. KELLER: It would seem in looking over and listening to a few of these, that the particular component that is stressed depends upon the enthusiasm of some individual or a small set of individuals on the particular site. The leap from that to deciding whether this is a legitimate priority for the region is another thing entirely, and I don‘t know whether anyone but someone on the scene who can really look over each of the components carefully and maybe acquire data not currently available, could possibly assess. What troubles me is not that particularly, because I think I would agree that almost any legitimate entry will bring along some of the other.components, but F ama little concerned about the relative position of the RMPs, nb+-9 ce — Federal Reporters, 10 1} 12 13 14 15 21 22 23 24 Inc. 25 68 Granting mechanisms as against Department of Transportation and other groups who have been very heavily hardware orientated g This is the sort -- I have also had an opportunity to review and look over a great many things that have come to the Department of Transportation. This is the sort of thing that ordinarily falls into their granting area, for vehicles and hardware associated with communications between the vehicles in various areas, I am wondering why this is directed to this. par- ticular group. I haven't been able to fathom, in the guidelines whether this group was that hardware oriented. DR. SCHERLIS: I think that is a facet of Sutton's law. S-u-t-t-o-n, | DR. KELLER: I am not that familiar with it. DR. SCHERLIS: That is why he robbed banks, because that. is where the money is. | | DR. MARGULIES: In defense of what they are doing, we talked before you came in about this problem of equipment. It reminds me of one of the earliest issues that I saw when I came to RuPs, in which there was an absolute standoff because the question was how can you hear the expert unless the equip- ment is there, and then they said, well, we can't get the equipment unless the expert is there. Now, at some point, you say, well, wea are going te train people. We don't have anything to use them in. nb-10 +~ Federal Reporters, 10 1] 12 13 14 15 16 17 18 19 20 21 22 23 24 Inc. 25 69 Or you Say you are going to have some equipment but nobody trained in them. There has to be a point of entry and some assurance that something will happen. Our problem, our responsibility, is to make sure that it does happen. One of the things we will clearly have to do very quickly after this exercise is to get out to those programs and carry to them the message you are talking about. We will be asking, among other things, members of the review committee to assist us with that kind of direct visit to these programs that are going to be granted funds. DR. BESSON: I wonder if Dr. Dimick can comment on that since he is one of the people that puts it all together with all the. component parts. How do you view the review committee's approach to maybe encouraging the thinking of emergency medical care as a total system by funding a little piece of it and hoping they will move the rest of the way? DR. DIMICK: I think, depending on the whole envir- onmental situation, where they are in the state of the art. And as you said, our emphasis has heen on training and then put in the hardware. Pecause if you put in the hardware first and they don't know how to use it they compound the injury, so tp speak, so depending on what is there right now, it sounds like from what I hear of the application, that is where the nb-11 1 10 11 12 13 14 15 16 17 19 20 2) oe =: 23 24 3~ Federal Reporters, inc. | 25 deficit is,.is communication. However, if they have good transportation, they can utilize this already. It would depend on what is existing in this area already. I wonder if someone could speak to that? DR. SCHERLIS: The comment was made they are going to train 5000 emergency technicians over a three year period and my concern there would be that certainly if they have that great a need, what are the untrained individuals going to do in a highly integrated system communicationwise unless they have been trained. We have to start somewhere but my feeling might be more of starting with both gradually instead of the budget beginning with all the hardware. | Perhaps we should phase’ this in over a stepwise period. I want to get your feedback on that. You have been through the grants in more detail than I have, DR. BESSON: Well, I think too the facinating thing about watching RMPs relate to the regions is a paradign of the way the center relates to the periphery, in that we are per- Inissive, we are unabling, we use the leverage of our funding, and our advice to encouraging a pluralistic response to a natural problen, It has to be pluralistic and I think RMPS is doing it as I would do it, and when you look at this region and see what there is about it that got them involved in communicetions, nb-12- ~ Federal Reporters, weet 10 ia 12 13 14 15 16 17 18 19 20 21 22 23 24 Inc. 25 71 this Blue Ribbon Committee decided that one of the problems that they had was people having to wait in emergency rooms. So they said how can we correct that, and they said well, we will devise a system of creating red, green, yellow alert. And well, how do we know what group is doing what? Well, we'll check with each emergency room. Well, they found when they did that by phone that they would get busy signals and they wouldn't be able to call, and they had 44 calls a day, and they found it was very complex, and along came this communications inne and said, I could solve it all for you. That is the genesis of their emphasis on communi- cations. And they say if communications is this vital, we had better put our money on this horse. So I can't fault them for that. That is their uniqueness. And I think with Gibson coming on board, who is really an expert, they will obviously look to the other four component parts within a year, I am sure. They will find they have all this hardware and they had better do it right. DR. MC PHEDRAN: Because that is certainly well brought out in the Chicago study, he lookds at all parts of it. It is a good study. DR, SCHERLIS: The requested funds were on the order nb-13 10 e~Federa! Reporters, 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Inc. 25 72 of 348,000, 231 and then 245, DR. BESSON: That is correct. DR. SCHERLIS: Would you like to make your recom- mendation in view of the discussion? What is your original recommendation? DR. MC. PHEDRAN: I recommended funding at the level, because I can't quibble with the figures, really. I don't know how to revise them downward. If I though that was nec- essary, that is. So I would recommedn it as requested. DR, BESSON: One year funding? | DR. MC PHEDRAN: One year funding? Well -=- DR. BESSON: Three years is 824, DR. GIMBLE: Can I raise a question? I have no doubt with the money you give them they will be able to set up ambulances and equip a communications system, I was unsure that they had looked into what they needed, I am sure they can tie them all together but after they tie them all together, is that going te. be adequate? Jt seems like they are putting a lot of money into something with- out having data to support it. DR. MC PHEDRAN: Yes, DR. SCHERLIS: My other concern is voiced by the training asvects of having the hardware and not the software to go with it. I do have concern on that point. nb~-14 1 10 11 12 13 14 15 16 17 18 20 21 e » 23 24 :— Federal Reporters, Inc. 25 73 MR. TOOMEY: How many counties were involved in this document? Was this the whole area? DR. BESSON: No, not by a long shot. DR. MC PHEDRAN: No, it is Erie County. MR, TOOMEY: Erie County? DR. BESSON: I believe it is just this county, and then during this period of time they are going to expand it beyond Erie County, presumably to the whole state. But I think for the time being, it is just Erie and: contiguous counties. Not even the whole county, the Buffalo area. MR. TOOMEY : They had a fellow named Dr. Sults, S-u-l-t-s, who has done a very complete analysis of the whole medical hospital emergency services. Do they mention that in application at all? DR. MC PHEDRAN: I don't recall. MR. TOOMEY: This is kind of in answer to your commint. This Dr. Suits has -= DR. GIMBLE: There was an initial survey done but they concluded from that, if I remember correctly, that they needed a more in-department study, which is why they request add larger amount for R&D. So the questions asked on the first survey were superficial and did not provide enough answers for a total system, nb-15 | 10 7 12 14 15 16 17 18 19 20 e 23 24 sce Federal Reporters, Inc. 25 14 Despite that they are spending a lot of money to put in equipment on a system they haven't analyzed thoroughly. That made me a little leary. DR. MC PHEDRAN: This is the region shown here and here is Erie County in there. This is -~ it includes Erie, Pennsylvania, and McKean County, Pennsylvania. The rest of them are New York counties. DR, JOSLYN: This project and the funds, the 800,000 is just for Erie County. Is that true? DR. BESSON: It is for less than that, primarily for the Buffalo area. And they speak about expanding it. DRe JOSLYN: That is not included in the funding at this point. DR. MC PHEDRAN: That is right. DR. BESSON: They speak of EMT training as being over a larger region and -- from their abstract, and they say, "Counties surrounding Erie, New York, have expressed interest in participating, and the Erie County Commissioner of Health has informed them that, "Courses would be open to individuals throught the region. But so far as the communications are concerned the ten participating hospitals are in the immediate area around Buffalo, one regional hospital, and the 44 ambu- lances serve just that area. DR. SCHERLIS: Mrs, Faatz, can you help us on this? DR. FAATZs + did not hear the last conment. nb-16 10 11 12 13 14 15 16 17 18 19 20 2) e 2 23 .~ Federal Reporters, Inc. 25 75 DR. SCHERLIS: Do you have any comment at all as far as the total application is concerned, their ability to carry this out or their degree of regionalization as far as the Lakes Areas are concerned? DR. FAATZ: I think the feeling on the Eastern branc is that they can probably do what they say they would like to do. With regard to Dr. Sults, I don't know his degree of involvement with this particular application, but I know he is still working with the RMP there and is quite involved in a number of their activities so I don't imagine he was shunted off to the corner. DR. SCHERLIS: I would like the record to show that Dr. Roth left the room because of his involvement with the Le area. Yes? DR. DIMICK: I would like to make one comment regarding project summary. As Dr. Besson indicated a moment ago the radio system is supposed to alleviate overcrowding of emergency room facilities. And I seriously question, as one who is in charge of a university busy emergency department and trying to coordinate 13 other hospitais in our city ~-- I am not so sure radio communications is going to alleviate overcrowding of facilities. The same question you are yaising, the radio system is no panacea for these types of problems. Tam sure it will help direct ambulances to less “nbe17 10 if 12 13 14 15 16 17 18 19 20 | 21 e 22 23 24 ‘é -— Federal Reporters, lac. 25 76 crowded facilities but not alleviate overcrowding. DR. BESSON: I agree with that, it doesn't address the basic question of what creates overcrowding. All they want to do is facilitate knowing what the green, yellow or red allert state of each emergency room is and direct people elsewhere, maybe. But that is in theory. DR. SCHERLIS: Is there any feeling from the reviewers as to how many emergency technicians are trained at this point who could man ambulances if they were fully equipped and put into that area? DR. MC PHEDRAN: I don't know. DR. SCHERLIS: My big concern remains the fact that all these ambulances will be equipped at a time when the technicians would not be trained. I think it is an over generous request in terms of what we know about that area and what organization is there, what still has to be done to get -a system of care into that area. DR. GIMBLE. I would.like to raise the question also of do they know how many ambulances they need? Are we going to equip 44 ambulances with communicatic when they only need 30? That would be an awful waste. Do they have data showing that they need 44 ambulances or are they just picking the number of ambulances they currently have to have operated. DR. SCHERLIS: My suggestion would be one way to UE nb-18 RO 10 im 12 13 14 15 16 17 18 19 20 21 e 23 24 ve — Federal Reporters, fac. 25 77 approach this might be with the first year being budgeted less, and iet's see where they get with a few ambulances and some training, and then make the second and third year contingent upon evidences of performance and having set up a system of care the first, year. I would be much more willing to vote on that favor- ably than on giving them what they have requested in view of the discussion of points that have been raised. Would that be acceptable? DR. MC PHEDRAN: I would go along with that. Maybe reducing it by half, to half of what it is, as a reasonable figure? Just reduce that part of it. DR. SCHERLIS: For’ the first year? DR. MC PHEDRAN: Right. And the second or third year -- DR. MC PHEDRAN: Make it just for the first year, if they can be equipped as Dr. Besson suggested, Perhaps that would be the best way. Because by the end of that time they should see if they can get enough people to run the ambulances. DR. SCHERLIS: What we are @iscussing is 150,000, but the conditions of the award, including the facts that beth the equipment and training would run hand in hand, and that the second or third year would be considered as based upon what they have accomplished and also upon evidence of setting up a true emergency medical system ~~ would that be more in nb-19 10 VW @ 12 13 14 15 16 17 18 19 20 2) eo , 23 24 > Federal Reporters, Inc. 25 line with some discussion? DR. MC PHEDRAN: For the first year you would want to cut the communications equipment in half? DR. SCHERLIS: Yes. DR. MC PHEDRAN: That would take it down to about 103 for that, communications, and then leave the others, which are the M.E.T. training and research and evaluation component, intact. DR. SCHERLIS: How much is that? DR. MC PHEDRAN: In round figures, 231. DR. BESSON: Plus another 14,000 for project personng DR. MC PHEDRAN: Okay. I'm sorry. DR, HINMAN: 245? DR. MC PHEDRAN: 245, DR. BESSON: 250. DR. HINMAN: I have a question for staff clari- fication. Po I understand you correctly that you feel that in all Liklihood, that the region could use the total amount requested over a three year period if they progress satis- factorily, and that you are limiting the first year recommended amount to 250,000, and the rest being contingent upon perfor~ mance during the first year? DR. MC PHEDRAN: Yes. DR. SCHERLIS: I think it has to be reviewed after the first year. - bi. nb~20 10 1 @ 12 13 14 15 16 17 18 19 20 21 e 22 23 24 ste ~ Federal Reporters, Inc. 25 79 DR. MC PHEDRAN: Yes. DR. HINMAN: One year approvai only? DR. BESSON: One year approval only, and re-review. DR. HINMAN: Okay. DR. SCHERLIS: When you say, could they use it, I don't think there is an area in the United States that can't come up with a paper plan of communications and the need to train emergency medical technicians. I think we have to show that there is a need and an ability to utilize these funds. And I think we have the feeling here that the area, at least probably can use it. We aren't quite satisfied with the total demonstration of need in terms of numbers of vehicles and so on. I think the recommendation made at least would move them towards justification of this. DR. MC PHEDRAN: Okay. DR. SCHERLIS: What was the rating? DR. MC PHEDRAN: Three. DR. SCHERLIS: Three. That has been seconded? DR. BESSON: Yes. DR. SCHERLIS: Any further comment, Mr. Toomey? MR, TOOMEY: No. DR. SCHERLIS: Is there concurrence on this, then? All in favor, say, aye. wm qQ 80 (Chorus of ayes.) DR. SCHERLIS: All right. I guess Dr. Roth can come back in the room. MR. TOOMEY: I had not read this material, but I was on a Site review there a year ago and I was impressed by Dr. Sults and I was also impressed with the lack of services in the innercity in Buffalo. These two things kind of stood out. 10 oT e 12 13 14 15 16 17 18 19 20 21 © 22 23 24 ce — Federal Reporters, inc. 25 (Chorus of ayes.) All right. ‘Louisiana, Dr. Besson. DR. BESSON: Louisiana is presenting a program for -- that involves four projects, with a total funding of 363,000 over a three-year period. The four projects are updating of an existing EMS system in the state, which was previously drawn up, a training proposal for ENTs, two-way communication systems, and a developmental study to determine feasibility of medical helicopter evaluation services in New Orleans. Apparently in 1969, the Highway Safety Commission of Louisiana, in an attempt to coordinate EMS programs statewise, asked the Gulf South Research Institute to do a study of the emergency medical services program in the state. They did submit the study and it is really an excellent study. It encompasses the entire statement of the problem with a good inventory of needs, resources, identifica- tion of shortcomings in the state, and a plan for correcting them. The study also suggests training, communications, and now with this RMPS program coming down the line they finally see a way of upgrading this 1969 study and beginning to implement it with specific projects. The first project they submit is that of updating, which will do just the things that I have suggested, inventory, VNVISINOT mea-~6 10 11 @ 12 13 14 15 16 17 18 19 20 2) @ 22 23 24 .ce ~ Federal Reporters, Inc. 25 191 develop workshops for the public and for personnel, establish EMS councils among B agencies, develop a program of priorities, and establish mechanisms for implementing the plan which will be updated. It is a one-year program and includes some evaluation and requests $54,000 in direct costs. I think it is a good program and I would grade this a 4 on that scale of five. Number 27 is a training program to train emergency room staff, ambulance personnel, and to produce a coordinated statewide training program and a register as well as developing standards for continuing education and recertification of EMTs. There is an evaluation included in their training program which is two years under the auspices of the state Department of Hospitals for a total of 72,148. The state Department of Hospitals has indicated that they will continue the program under their funding at the end of this two-year period. Also, it is a well put-together program and I would grade this on that same scale, and recommend full funding on that. The third program is that of communications, project 28. The objectives of this program I'll summarize, in reading this -- they have the notion that before hospital or ambulance be services spend the money for a conmunications system, they must mea~/ 10 :¢~Federal Reporters, 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Inc. 25 192 have information concerning advantages of the system, cost, effectiveness, capabilities, compatibility of equipment, and so On. These institutions must be shown through a variety of settings throughout the seven CHP areas that the communication system is a nececcity for good and efficient emergency medical services. It is anticipated that this demonstration project will stimulate and commit hospitals, ambulance services and governmental agencies to support a statewide emergency communication system. So, they are requesting 94,000 ~-- 122,000 for the second year -- 94 for the first year -- to approach the problem in this way, which involves purchasing some equipment, and getting the hospitals to all become aware at least of the need for communications and pick up the ball in two years. That is project nwnber 28, which I also think is well conceived, and gets us involved in cost-sharing with the hospitais, and although a critique of this by staff feit that the hospitals may not pick up the ball, at least it is a start. The fourth program, the helicopter evaluation program, has objectives to determine the need for air medical emergency patient transportation in the Greater New Orleans area establish feasibility of such a service, and determine its mechanism of operation and costs. T ‘mea-B 10 1 e 12 13 14 15 16 17 18 19 20 21 22 23 24 ice ~ Federal Reporters, Inc. 25 4195 They consider that since the medical helicopter service has been so successful in the military, this PMP study will aim to determine if this procedure will reduce mortality, and translated to the civilian role, provide a service for the State of Louisiana. ‘They are requesting a one-year study to do this for $46,000. So, in summary, we have four projects, 26 is an updating of an already existing comprehensive eysten and beginning implementation; 27 is a training program; 28 is a two-way communication system in a variety of hospital settings, 29 is the medical helicopter service. I would grade the program as maybe 4.0 and recommend full funding. And initially, in their introduction I am impressed with the figures that they quote, which may have been known to all of us, but I will just mention them gratuitously. Inspection of war figures to determine the value of transportation -- of the whole emergency care system, the war figures in 1969 that were done show that eight percent of casualties in World War II gigures ~- eight percent of the casualties dies. Four-point-five percent died in Korea and only 2.5 percent are dying in Vietnam, and the implications by these figures is that these casualty-to-death rates imply that we are gaining on it, and the things that we are doing in 10 11 @ ~ 12 13 14 15 16 17 18 19 20 ® 2) 22 23 24 || ce ~ Federal Reporters, Inc. 25 194 Vietnam that we weren't doing in World War JI should be replicated in civilian situations. The figures are impressive, and I think backed with that kind of approach, I liked the program. DR. ROTH: Jerry, why do they need to do a one-year study to establish the fact that nobody can afford the helicopter services except the federal government? DR. BESSON: I can't answer your question. DR. ROTH: There are plenty of cost figures on helicopters. DR. BESSON: I-am perfectly willing to scratch 37,000 from the program. I'd like..to hear from the secondary -reviewer. DR, SCHERLIS:: . The secondary reviewer, please? That is Dr. Roth. DR. ROTH: Well, I have not done any of my second area reviews. : | DR. SCHERLIS: Haven't you? All right. DR. BESSON: I would recommend that we grade them as 4 and fund them at 363, less 37,000. DR. HINMAN: Disapproval for 29. DR. SCHERLIS:. Disapproval for the helicopter study and the others, grant them at 4? Any other comments? DR. BESSON: — Federal Reporters, Inc. 25 125 facilities needs, transportation, data collection, and analysi and setting up a model for evaluation. Now, the phones -~ you can break this down several ways, but the first element that I talked about, the emergency care and communications, is $100,000 the first year, 43 and 30 the second and third, or a total of 173. The two phone referral services, putting them together, come to a grand total of about 270, and the planning and developmental comes to a grant totai of 132. Three-year request is 573 -- $573,000. Their relationship to each other and their relation ship to the rest of the program is difficuit to ascertain. It seems to me that individually, they have - ~ each one of them has moderate -- some merit. ; For example the emergency care and communications one is certainly no worse than the one that we have funded at a much higher level in Western New York, Lakes area. My feeling about them separately and individually is that they rate "C", that is, a "3" rating for -- I would rate a 3-rating for the planning and development, a 4 -~- excuse me; I'm going the wrong direction --~ A 2-rating for the telephone services, and a 3-rati again for the first element, that is the emergency care and communications. I wish that the telephone services could be ng Syrb5 10 1] 12 13 14 15 16 17 18 19 20 e 22 23 24 e ~ Federal Reporters, Inc. 25 LLO combined and somehow reduced and total expenditure, it seems to me, the total amount that is being asked is very high. And it seems to me it could be done on a more limited basis for much less money, and I would like to recom- mend that the funding be, instead of now totalling about 265, as I say, closer to $50,000 or $75,000 for the both of them. DR. SCHERLIS: Is that per year? Is that single years? DR. MC PHEDRAN: I was thinking about the total amount, but perhaps it would be more intelligent to say that for the first year, that is cutting them to about $10,000 for | each of them instead of their projected present level of $16,000 for one and $54,000 for the other. So I would -- I think I would recommend that the emergency care and communications, which I would say rates a "C" ~~ that that recommended funding be as is, a $173,787; but the telephone referral services be ~~ DR. SCHERLIS: Covld you give us the number? DR. MC PHEDRAN: 30B and 30C, that they be somehow combined into a single telephone referral system, and that their support be much reduced. DR. SCHERLIS: Was that $50,000? DR. BESSON: There is a little problem there becaug they are for different areas of the region. DR. MC PHEDRAN: I see what you mean. One is the ” yxrpo 10 1 12 13 14 15 16 17 18 19 20 21 @ 22 23 24 > Federal Reporters, Inc. 25 127 Southern Tier and the other is the Genesee County. DR. BESSON: They have nothing to do with each other as far as telephone linkages. DR. MC PHEDRAN: Yes. DR. BESSON: Maybe it would be helpful if before we get to funding, if I might give some comments on this. DR. MC PHEDRAN: Please do. DR. BESSON: Okay. As Dr. McPhedran has said, there are four parts to this application and at the risk of reiterating some, I'll say there are two general areas of this Rochester regional medical program that are included. One is the area of Monroe County, which is around Rochester, and the other is the Southern Tier Area which encompasses four counties. The first two projects, 30A and B, are -- first is the emergency care and communication net work for these three counties on a contractual basis with Southern Tier. The second is a health information referral and counseling service for the same area, contracting with the Southern Tier, again. If you'll look at the map of it -- in the applica- tion on pa ge 3, you will see how removed geographically these two areas are. So the Southern Tier is the southern portion of thi wa yrp/ #~ Federal Reporters, 10 1] 12 13 14 15 16 17 18 19 20 21 22 23 Z4 Inc. 25 L28 map, and then Project No. 3, community health information and crisis phone services for Monroe County and surrounding areas, is also on contract to what is called the Health Association o Rochester and Monroe County, which is a consortium of voluntee agencies. The fourth project is finally getting to the regional medical program of Rochester, planning and developmen component, for the ten-county region, the entire region. Now, as I read through the application -- and gear with me for a minute while I give you my sequential thinking to come to my conclusion -- I was impressed with the way the letters of endorsement all said the same thing: "Please accept the letter in evidence of our support." There are four letters which say the same thing. I said to myself, where do these letters originate? They were all addressed to Southern Tier Health Services, Inc. So I thought, this looks as though the Southern Tier Health Services, Inc., acts like some organized group and on page 12, I find that Southern Tier Health Services, Inc., is a not-for-profit corporation which was just approved by the Corporate Conmissioner with specific functions being listed on page 12, implementation of community health delivery system, physical management, administrative management, monitoring placement of patients, and initiation of needed + jrb-8 10 1 12 13 14 15 16 17 18 19 20 2) eo =. 23 24 2~ Federal Reporters, Inc. 25 129 experimental health delivery innovations; so I said this must be an experimental system, But then I looked at the next page, where it des- cribes Southern Tier Health Services Corporation, and it says, “Board of Directors of this corporation is made up of 12 peopl from the hospitals and 12 people from the community." And thereby is sprung the trap of who this corpora- tion is, which is a consortium of four hospitals interested in feathering the wrong nests, it seems to me, and they have the primary objective of developing and managing a comprehensi personal health services system ostensibly of the community, but it seems to me fortunately -- redounding to the ultimate benefit of the area encompassed by these four hospitals. Now, on this Board of Directors there are four administrators as you say, four board of directors, and four physicians -- they don't say who the physicians are, but presumably I would think they are with hospital orientations, so that this corporation really is not a community effort, although it happens to have 12 corporate members -~ community members on it. So the question that was raised in my mind about these two projects, 30A and 30B, which are going to be subcontracted to this corporation, is how representative can a four-hospital coalition be in speaking for the community with this kind of representation? © ve JE? a~ Federal Reporters, 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Inc. 25 Now, that deals with my paranoid nature about these first two projects. The Project 30C is also going to be subcontracted t a health association which is a consortium of voluntary agencies that is going to work with Strong Memorial Hospital to do something thathas already been on-going, which is the provision of a crisis-care phone and community health informa- tion coordinative functions, which has been on-going. And as they break down the number of calls and what they are about, and who they helped and how many people, it seems to be a useful kind of effort. I am also impressed that in their budgetary request for this, they are going to be on an extensive cost-sharing program with Strong Memorial Hospital in Rochester. Finally, the fourth program, 30D, planning and development, is to do what this group should have been doing right along, which is to lock at the entire ten-county region and say, what can we do to put together a coordinated syste? Putting that all together, suggests to me that I would be delighted to fund the planning and development and get them thinking in global terms. | I would be leary of funding a four-hospital information and communication network which I think is sone- what of a ruse for doing -~ having a hospital buy some equipme; jrbio 10 7 e 12 13 14 15 16 17 18 19 20 | 21 eo » 23 24 e- Federal Reporters, Inc. 25 for developing its own internal communications network and linking it with a very meritorious program, namely, inter-hospital communication. As far as the third program is concerned, I like it, but again, I wouldn't be interested in maybe buying a three year project, but maybe one-year. So I have somewhat of a different approach to this, Dr. McPhedran, and we'll put it up for grabs. DR. MC PHEDRAN: You think that the Southern Tier Health Services Corporation, that is the first one, that it is so unrepresentative as to just be unacceptable as an agency for doing this? DR. BESSON: As I view what is happening to the thrust of RMP nationally, or the experimental systems program, ox comprehensive health planning, I see that there are a varieity of consortia being developed to address community heaith problems. Now, all of these organizations exist in this area. Why should we fund a four-hospital coalition with a board that is made up of 12 people from the hospitals, and 12 from the community? I would dare say that the 12 from the community will never be there entirely but the 12 from the hospitals wil always be there, so that this is a hospital-directed effort. Now that wouldn't be bad if these were all cS ~~ (jrbl., 132 1 community hospitals, but they are not. 2 One is St. Joseph's Hospital, one is ~-- I don't @ 3 know which the others are. But it has a hospital crientation, 4] which I think is a different slant on what RMP is trying 5 to do in having a broad-based community representation. é Now, that falts them slightly, but I am a little 7 suspicious that this is not the vehicle we ought to be encoura- 8 ging. We should be encouraging RMP to be the vehicle, or ? COMP planning, or some kind of group to work together. 10 a DR. SCHERLIS: Yes? VW DR. JOSLYN: I don't know whether I should be raising ) 12 this, but I have not read this application, but just from what 13 we are talking about here, it struct me first that here is a 14 community, whether or not it be hospital-dominated -- and I 15 would like to know what the other hospitals are in this four- 16 county area, and whether or not they are involved, or maybe -- 17 I don't know if there are other hospitals -- but it strikes me 18 that here is an area that is active. 19 _ Now I would like it coordinated with, you know, 20 whatever programs are going on in the total RMP but it seems to 21 me one of the things we have been arguing for is that you e 22 cannot bring a plan, whether it is developed by the RMP or a 23 consultant, and drop it onto an area, 24 And I am wondering if, you know, maybe this group e ~ Federal Reporters, Inc. 25 that is growing up ought at least to be met halfway, in the jrbl2 2~ Federal Reporters, 10 11 12 13 14 15 16 17 18 19 20 2) 22 23 24 Inc. 25 133 sense that -- I just don't know -- I can't judge from here -- whether this is really a meritorious group or not. DR. MC PHEDRAN: It is just that there are a lot more people in the area, that is the point that Dr. Besson is making. There are other hospitals and -- DR. JOSLYN: In that four-county area? DR. BESSON: I don't know. All I know -- DR. MC PHEDRAN: There are. ‘DR. BESSON: This is a group of four hospitals that are opportunistic enough to create a non-profit corporation, and I think that we are creating a -- somthing that sheuld be aborted right now. That is not a community-representative group. It doesn't have the linkages that we are after. After all in the guidelines we say we should have provider, payer, public, and DR. MC PHEDRAN: All provider. DR. BESSON: But this is just a biased group. I don't think they can come up with any community answers. DR. SCHERLIS: I think we have to keep referring back to the EMS guidelines which were given to this group because these were the bases for which the various offers had been made. Dr. Gimble, you reviewed this project, I believe? DR. GIMBLE: The only comment I can make on this JxpLs e~Federal Reporters, 10 im 12 13 14 15 16 17 18 19 20 21 22 23 24 Inc. 25 134 particular point, I had mentioned that of 28 hospitals in the region, five are actively involved. DR. SCHERLIS: How nmiany hospitals? DR. GIMBLE: Twenty-eight in the region, and five are actively involved. And much emphasis is the University of Rochester, that's Strong. There appears to be active participation of the CHPB agency. DR. BESSON: In one project only.. . DR. GIMBLE: The other problem as. you have already mentioned, is the very poor interrelationship between the proposals. It is alluded to but I think they mention that the emergency care service will be linked to the telephone services and that is as far as the linkage is described in the text. I had lots of doubts about the entire project. DR. SCHERLIS: What sort of statement do we get from you two in this regard? DR. MC PHEDRAN: I guess what we agree on, on 30D, we would recommend it for funding as is. I gave it the A-ragi of 3. DR. BESSON: I will agree with that, full funding. DR. MC PHEDRAN: On 30C, I was mistaken about where that was, and I think that we -~ I would go along with Dr. Besson's recommendation for 01, and not 02 and 63, as is, for 54, “7 giving that a rating of C also. ng 10 11 12 13 14 15 16 17 18 19 20 21 eo : #1l Lee 23 CR6307 24 e- Federal Reporters, Inc. 25 Lj DR. BESSON: Okay. DR. MC PHEDRAN: Or 3. DR. BESSON: Okay. DR. MC PHEDRAN: For 30A and 30B, if it is not sufficiently representative of the community as a whole, the Southern Tier Health Services Corporation, perhaps the thing to do is simply not to recommend them for funding because they don't meet the EMS guidelines. DR. SCHERLIS: Do you concur in those recommenda- tions? DR. BESSON: I do. DR. SCHERLIS: Any other comments from members of the review group? All those in favor please say "aye." (Chorus of "“ayes.") DR. GIMBLE: "A" and “B" are disapproved because they don't meet the recommendations of the guidelines. DR. SCHERLIS: Yes. | DR. GIMBLE: Project "C" is a 3-rating for one yeanr and the next project for three years? DR. MC PHEDRAN: Three years. DR. SCHERLIS: I thought that was going to take much longer. _fearl® CR 6307 #19 ice ~ Federal Reporters, 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Inc 25 214 DR. SCHERLIS: All right. Any dissenting voice? Well, then, go ahead to South Dakota, Mr. Toomey, again. Following South Dakota, I assume Alabama. Is that the correct order? DR. HINMAN: Yes, sir. DR. SCHERLIS: Alabama will be next, so contain yourself. | MR. TOOMEY: The University of South Dakota is the applicant. The funding is requested for the first year, 470,000 and I. have none in the second and third year. Is that right? DR. MC PHEDRAN: That's right. MR. TOOMEY: South Dakota does not have an effective emergency health service; hence this grant will cover the entire state. The basic problems are those of small rural popula- tions with large geographic directions. There are very few trained ambulance drivers or emergency technician personnel manning the ambulances of the existing emergency transportation system. There is little public knowledge as to lifesaving technicues in the utilization of ambulance and training technioues. Generally South Dakota has few hospitals and they > ~” o aq | ba o a o a > mea~2 | 10 dd @ 12 13 14 15 16 17 18 19 20 2) oe 2 23 24 ice ~ Federal Reporters, inc. 25 215 have varying capabilities. It has a high tourist population in the summer months with a high incidence of traffic accidents. The state geographically encompasses an area the size of Delaware, Maryland, Virginia, and West Virginia, but has only 1/l7th the population. The specific objectives of this project include the establishment of medical technician and training programs, the establishment of hospital technician training programs, categorization of present hospital emergency services, establishy ment of health consumer education programs, and the purchase of medical equipment for ambulances. the planning process includes three phases of implementation: Phase one includes planning, demonstration and procurement; phase two, the implementation and utilization of the planning demonstration projects and procured resources; and phase three, the operational phase. All three phases encompass the total components of ar. EMS system including consumer education, ambulance purchase and equipment procurement, classification, categorization of emergency health services, emergency medical training, standardization of emergency services, communications develop~ ment, physicians’ assistants program, integration of emergency health services components into the current system. he narrative does not indicate how the. various phases will he integrated into the existing system. ¥ mea-3 | 10 1 @ 12 13 14 15 16 17 18 19 20 21 e 22 23 24 ce ~— Federal Reporters, Inc. 25 216 The geographic area has been described. However, there is only partial reference to involvement by providers, public agencies, planning agencies, and communities. The narrative does not define existing medical service areas in the region. However, it does partially speak to potential resources, and the assessment of needs and resources in the area. There are not adequate facts to document statements referred to in the narrative. There's inadequate information to determine how the operating components will be coordinated with already existing elements of an EMS system. The narrative does not describe the linkages with local health care systems nor is there adequate information to determine whether there's cooperation in community disaster planning or preventive medical systems. The application speaks briefly to the point of utilizing additional financial resources and for obtaining additional financial support after the expiration of this grant. | There is no general, overall innovative approach to the development of an EMS system in this area or any assurance as to the quality of care to be rendered. Once again, to turn to the staff evaluation ~~ while this application has many gocd ideas, as an application, as a plan and as a tool to achieve a total EMS system, it in my mea-4, 10 im «42 e 13 14 15 16 17 18 19 20 2} @ 22 23 24 ce — Federal Reporters, Inc. 25 217 opinion fails. There does not appear to be sufficient depth in the description of the problem of EMS in South Dakota. Statements are made but they aren't backed with facts. For example, they state many lives are lost, but don't state how many, where, why, when, and so on. The applicant talks about utilizing PERT, PPBS, management by objectives. They have demonstrated its use. The application needs better organization, a clearer definition of problems, needs and objectives and a clearer picture of a total EMS plan and a better interpretation of the EMS elements. DR. SCHERLIS: pr. McPhedran? DR. MC PHEDRAN: I agree essentially with the evaluation, that it is a portion of what we would want to have in an EMS put not the whole thing. Notice that the projected budget for year one is greater than the total annual budget for the South Dakota regional medical plan. Is that right? DR. HINMAN: Yes, sir, but I think there should be a comment made. South Dakota is in a planning phase, not an operational phase. They have just split from Nebraska last year) DR. MC PHEDRAN: I was going to bring this out, that mean * 10 11 @ 12 13 14 15 ie) 17 18 19 21 @ 22 23 24 ice ~ Federal Reporters, Inc. 1 25 218 this is really essentially a brand new region. I would not like to recommend that they get no funds; I just think that this is an enormous amount to expect them to spend sensibly at this time. pR, SCHERLIS: what would be the rating of this? MR. TOOMEY: I would say it would get 2 to 2.5. DR. MC PHEDRAN. I gave ita 2. DR. SCHERLIS:.. Would you agree on 2? Two is. the rating. MR. TOOMEY: I think they should be given # planning grant. DR. SCHERLIS:’ What sum would you think would be -- MR. TOOMEY: My estimate would be $50,000. DR. SCHERLIS: Dr. McPhedran, what would your feeling be on that? DR. MC PHEDRAN: Yes. DR. SCHERLIS: These are numbers from the air but at least they are based somewhat on the project itself. DR. MC PHEDRAN: On looking at the figures, that is sort of about half of what they had requested for personnel for the first year. I think that is a reasonable figure. DR. SCHERLIS: Do we have comments from the group on this? DR. HINMAN: Did you say 150? - mea-6 . ro 219 DR. MC PHEDRAN: rifty. DR. SCHERLIS: Fifty? DR. MC PHEDRAN: Fifty is what I said. DR. SCHERLIS: All right. * Sr Oe Git. 207 BUa-ter-1 MRKAMKA ~O 16 17 18 19 20 2) 23 24 ce- Federal Reportors, inc. 25 DR. SCHERLIS: Tri-State? DR. MC PHEDRAN: I think this is a very good proposal, and I would rate it as a four to five. I think it is one of the two or three best that I reviewed among the ones that I did as primary and secondary reviewer. The proposal is a large proposal. It is @ project number 18, and the requested funds are over about $650 thousand on the average for each of three years, or a total of $2.54 million, for the three state area in Massachusetts, Rhode Island, and New Nampshire. I found in going through the rating sheets, the yellow sheets here, that this proposal really addressed. most of the particular questions very well. It was a detailed proposal and took up virtually everv aspect of emergencies, responding ko emergencies, designing systems of educaticr he Toy emergencies. It was not innovative, but T do not really find that much to fault it, in any of these respects. It is a detailed proposel., I think all the pertinent factors were intelligently It has very strong Comorehensive Healtn Flanning & Agency support in Massachusetts, but also a strong working relationship with the state department of public health. It proposes planning and development activities to on fn oy t Lopate pees SE tan ny tee mm py ee “ nee pe . fey en agtnblish coordinated emergency mecical services in tnree im the differenk states. are ALVIS Tul | | | | | | | ter~2 10 1] @ 12 13 14 15 16 17 18 19 20 21 © 22 23 24 ‘ce ~ Federal Reporters, Inc. 25 137 different in Massachusetts, it is the Department of Public Health, and in Rhode Island, it is largely the Hospital Association of Rhode Island; and also, I think, the Medical Society. And in New Hampshire, beginnings have already been made in some emergency planning ~- actually in all three states they have, but in New Hampshire, some planning for emergency medical systems centering around a project in Hanover have already been begun. I. thought this was a very good proposal in nearly every respect, It is an awful lot of money. My word. And yet I really just do not know how to suggest that it would be pared down... I guess I would recommend that it be funded in each of three years, but it seems to me, inconceivable that we would have anything like the kind of money that could meet these demands for requested funds. I do not like to be in the position of suggesting just an arbitrary reduction, but I guess that is where I am. DR. SCHERLIS: I think we have been arbitrary all morning. MR. TOOMEY: Did not Dr. Margulies say, forget it. DR. MC PHEDRAN: ves. DR. SCHERLIS: My concern is the obvious cne, that even if this is rated highly, whether that amount should go to one region. Has this been submitted to contract funding? ~ tor-3 10 1 @ 12 13 14 16 17 18 19 20 21 e 22 23 24 sce — Federal Reporters, inc. 25 138 DR. BESSON: There has been a contract application from Boston. DR. SCHERLIS: It does not include this? MR. STOLOV: They are complimentary because they are not included in the projects. DR. SCHERLIS: All right. Secondary reviewer? DR. BESSON: Let us see. This is a complex and a very excellent application, and if I can make a crack at breaking it down, and see if we can come to grips with funding a little bit, I would say that it is composed of three major efforts. One is to subcontract to B Agencies in the Massachusetts Department of Public Health, its equivalent in New Hampshire, and its equivalent in Rhode Isiand, for indi- vidual project efforts in their areas. Two, is to attempt through RMP to provide a coor- dinative effort in the tri-state basis for looking to the tri- state areas as a single, glopal arca that has certain problems in common, and nerhaps develop coordinative activities. Three, to set up a program for planning and evalus- tion for the entire tri-state program, looking at it globally, again. Now, if we look at these three efforts, the first hh jot ty oo ans caown to eight individual regions ~~ B fort then bre Q agencies, each of whom have their own problems: Western 10 it e@ 12 13 14 15 16 17 18 19 20 21 e 22 23 24 ce~-Federal Reporters, Inc. 25 139 Massachusetts, Central Massachusetts, North Shore, Greater Boston, Middleborough, Amerrimac Valley, New Hampshire, and Rhode Island. Each of the B agencies in Massachusetts, as well as the Department of Public Health, are going’ to do a little piece of the problem, as they see it locally. Now, the sophistication of each of these groups varies from the sublime to the ridicu- lous. New Hampshire has had some work in the past and they are quite mature. Some B agencies in Massachusetts are just embryonic. And there is a great variation in the degree of competence in each of them. But yet, tri-state RMP is saving, let us let each locality set up its own program while we learn about what to do in viewing the entire tri-state area as a single region and we will encompass their activities eventually into an overall plan, which I think is a laudatory way of approaching the individual pieces without usurving locals' prerogatives. The Massachusetts Department of Public Health, on the other hand, has had its own little things they are doing, ambulance regulation and legislation, which they have been working with. They have produced passage of a House bill, or maybe it is pending, to set uo EMS Advisory Board for the state. Thev are involved in the development of licensure for emergency rooms in hospitals, and they will be involved in a number of things on a state-wide basis, that impinge on emergency nedical 10 11 @ 12 13 14 15 16 17 18 9 20 2] 22 23 24 Ace ~ Federal Reporters, Inc. 25 140 services, and do nto overlap with the B agencies, with what the B agencies are doing. So that, for this portion of the application, they will subcontract to these groups and hope fully in time, bring them all up to the same level of maturity. Now, they make some interesting comments about what the possible alternatives are so far as their funding is concerned. For example, they say, in their narrative, that if this program cannot be funded in toto, they would suggest that each state develop its free standing emergency medical services, which is one alternative for us to follow in trying to figure out how to get out of this dilemma. They also go on to say, in their narrative, that if no funding is available elsewhere, the state will be self-supporting within a three-year period, which is very encouraging at least, for them to say that they will mount this amount of money at the end of three years; both of which I think are very reasonable and mature statements So far as the other two programs are concerned, the central ccordination of training and the planning and evaluation both of them, I think, are meritorious. The planning and cyaluation, I think, is particularly so. They speak of evalua- tion as a function of tri-state regional medical program, inclu- a ding a rather sophisticated view of evaluation and evaluating the process and monitoring the process, itself, in evaluating fae EK a ter 5 10 im © 12 13 14 15 16 17 18 19 20 ® 2) 22 23 24 Ace Federal Reperters, Inc. 25 141i project achievement as a separate look, and then finally, doing what they call, impact evaluation. I think that this is meritorious enough as a meth- odology for looking at emergency medical care systens that if they can do what they say they will do in some detail, that it will provide a very nice model nationally. DR. MC PHEDRAN: Except they say about the impact, they do not “think they can manage it." This last part, which sounds like the thing that they have over everybody else, they say they do not "think they can do it with their pre- machinery," so it would have to come outside of this application DR. BESSON: I would at least encourage them by fully funding that portion of it, and I suppose -- I do not know how to reach a number with this, it is a difficult ques- tion to grapple with. If there is any merit to the notion that we ought to develop as large a deficit as we can by funding as many as we can, maybe we can turn off funds elsewhere in the federal establishment, and put them in here so we might as well buy the whole thing. DR. SCHERLIS: Yes. MR. STOLOV: Staff had an interesting observation when we were reviewing the community plan power development application from the tri-state region, and its ambitious nag oh ee py bo 7 ? A ~ aad? tomy he ok “ oe aot fon ay den budget, also. And we said, look to the program staff, which wag called "core." The core staff activities, and they dG tere / 10 11 @ 12 13 14 15 16 17 18 19 20 21 oe 2 23 24 ce -- Federal Reporters, inc. 25 142 have a sophisticated evaluator on this. And maybe this is where staff could aid. But, we looked also to the staff out in the Rhode Island area, the core staff out in the New Hampshire area, and we felt maybe, since they did assist, there could be some fine lines drawn. However, not being the technical budgetary person on this, I just threw this out as a methodology of how we were looking at the community base, manpower thing too; knowing the ambitious budget here. DR. BESSON: They are really approaching the both from the point of view of encouraging each locale to do their own thing, and yet saying to themselves, well we are going to coordinate the entire effort and at the end of a year or so, they all should have enough maturity, so that we can look to. the development of a tri-state-wide coordinated system, which, I think, is very nice. What did you recommend? DR. MC PHEDRAN: I find it impossible to recommend reduced funding in any intelligent way. I would go along with cortainly, fully supporting the evaluation parts. JI am inelined to recommend funding. I am sure they would not get full funding because there is not going to be that kind of money, ang I think we can recommend whatever kind of funding car be allotted to this. DR. SCHERLIS: What rating are you giving this?. 10 11 e 12 13 14 15 16 17 18 19 20 21 e : 23 24 \ce - Federal Reporters, inc. 25 143 DR. MC PHEDRAN: n four to five. I think it is very good. DR. SCHERLIS: Mr. Besson? DR. BESSON: I am going to give it, maybe a four. I am going to reserve “five” for Alabama. DR. SCHERLIS: The rating is four. I think it is unrealistic to think in terms of full funding for this. We might jeopardize a great deal by doing that. What is your feeling on this, Dr. Rose? DR. ROSE: Dr. Hinman might speak to this. DR. SCHERLIS: Yes. MR. STOLOV: I know we do not use a formula funding as other HEW programs have used, but as a yardstick, I would like to throw out a factor, Dr. Besson, who has always looked at things in a quantitative manner. Tri-state regional medical program ranks 31 out of 56 regions in terms of funding, per capita funding, per that three-state region. This is just a fact to supplement -- that may or may not help you with something. DR, SCHERLIS: That further obfuscates our entire problem. DR. BESSON: What do you mean by that remark? MR, STOLOV: I did not know whether or not you wanted some other fact to help you with vour decision, and this is one. I do not knew if it is out of place. _ fter~ 9. 10 mi @ 12 13 14 15 16 17 18 19 20 2) 22 23 24 Ace -- Federal Reporters, Inc. 25 144 DR. HINMAN: I have a concern. If you look at the breakdown of the budget as per year one, the very beginning of the application -- DR. SCHERLIS: Opposite page ten. DR. HINMAN: -- opposite page ten, you will see in the first year, $251 thousand for planning and organization, and almost $600 is allotted for things that might be considered partially implementation. I just wondered if we have a mixture here and are dealing with an attempt -- they have 119 thousand for data collection, and agencies; 251 thousand for planning and organization, and they are immediately going into education, some ecuipment -- DR. BESSON: Excuse me, Ed. They are Gealing with such a mixed bag here, they do not go from that to education. It is that they are allowing each region to submit their own budget for their particular needs, and I think what they have done is gotten everybody stimulated so that eight regions here - there are not eight -- six, plus New Hampshire, and Rhode Island, are submitting a separate budget. ui It happens to add up to 251,000, but that incluces -~ you know, they are accepting everyone's budget, and then on top of that, for coordinated training, and coordination, it is, they are submitting a separate budget. gk in ; TT x yan c - boo mye betyesyeechs Some ae fe TA : Dr. HINMAN: My question, though, 18 arc tney an one budget saving we are going to plan, and implement fron 10 11 @ 12 13 14 15 16 17 19 20 ) 21 22 23 24 ce ~Federat Reporters, Inc. 25 145 year one? DR. BESSON: Yes. DR. GIMBLE: The most encouraging part of the application is the small amount that has been allocated to equipment purchases, so it looks like they said, we are going to plan a lot and buy very little the first year, and it looks like they are doing it. DR. SCHERLIS: I just wonder if they asked for $10 million, if our support of $10 million would be realistic, and I question whether our recommending $850 thousand or $847 thousand is realistic. T think I would like to have a motion made for a sum, and if the recommendation includes that, if additional funds are available, they should be funded up to so and so, at a high priority. DR. ROSE: It might be easier for the committee to make a recommendation and let the amount of funds be handieed administratively, the judgment in terms of how much funds they are going to be able to get. DR. SCHERLIS: We never do that. DR. ROSE: Assuming the whole thing is meritorious. DR. SCHERLIS: Can I ask for a recommendation for a motion at this point? DR. BESSON: Let us just rate it and leave the fund- Ne wba ing gO open. ter-l1 10 1 @ 12 13 14 15 16 17 18 19 20 21 e 22 23 24 te ~ Federal Reporters, Inc. 25 146 DR. MC PHEDRAN: I feel so foolish recommending an arbitrary figure based on nothing. I have no way of basing it. All I can do is say, it is a meritorious program and maybe these things -- maybe they can consolidate some of this plan- ning, organizational activity. Maybe, it would not have to be so costly. DR. SCHERLIS: Are vou recommending full support as requested? With a rating of four? DR. MC PHEDRAN: I am rating it as. four and realizing that full support is just not going to happen, could not possibly happen. DR. SCHERLIS: Dr. Besson? DR. BESSON: I have a different view of this. I do not view this -~- it happens to be tri-state, but it would be like saying, well, what is the eastern operations branch, what kind of a program do they have? Thev do not have a single program, they have 27 programs. | We do not have single program here, we have ten programs, so that the number that I would use would be predi-~ cated on that as an underlying assumption. I think that the project is meritorious, the whole thing is meritorious, and if I were to be forced to give a figure, I would have to say the full thing and let the chips fall where they may. DR. SCHERLTS: I just wanted you to -~ this is with full knowledge and intent then, we are recommending that sum, ter-12 10 1 © 12 end #12 13 14 15 16 17 18 19 20 21 22 23 24 Sce ~Federat Reporters, Inc. 25 147 it is guite apparent. Any further discussion from members of the Review Group? All those in favor, say "ave." (Chorus of ayes.) DR. SCHERLIS: Opposed? DR. BESSON: I would also remind the Chairman that ~-- DR. SCHERLIS: I do not believe you recommended the whole thing. DR. BESSON: It is only one wing on a B52. DR. HINMAN: Unfortunately, we do not even have a motor on a B52, an engine. * yy CR 6307 #13 da-1 2 © 3 ~—a 10 i @ 12 13 14 15 16 18 19 20 @ 21 22 23 4 24 .ce ~ Federal Reporters, inc. 25 DR. SCHERLIS: Ail right. Virginia. DR. ROTH: That one is mine. DR. SCHERLIS: Dr. Roth on Virginia. DR. ROTH: I think the important thing to point out to begin with about Virginia is that we're talking about a total request of $30,250, It is a highly hypothetical application, on behalf of a council which says that it is in the early phases of initiating the organization of a ccmmunity emergency medical services council. And in the makings, it has covered that whole planning problem, if approved and funded, would be turned over to this council. It has not been approved by the RAG, and although we have only a request for this $30,250, it or a substantial operating grant of $244,415.90, for a total 3 year amount. It is distinctly a matter of building upon existing services. It is pretty sophisticated in the use of, for example helicopter service is available in the area. But it is my feeling that it is such a relatively small amount that if the ~~ only matter before us now is the approval of the $30,250, f would give the programa 3~ 1/2 to 4, because it has built on a base of accomplishment, and recommend full funding. DR. HINMAN: I would like to add one point, Dr, Roth. The planning portions of this have been reviewed by CHP and the ‘RAG, and have been approved. DR. SCHERLIS: the logging sheet has a check mark * VINIOULIA ah-2 wwe ~ Federal Reporters, 10 1 12 13 14 15 16 17 18 19 20 2) 22 23 24 Inc. 25 "ves." Is that correct? DR. HINMAN: The earlier ones didn't. The first log- ing sheet didn't. DR. SCHERLIS: But that is a subsequent change in the operating data that we received. The present log sheets state that they have been reviewed by RAG. DR. SILSBEE: It is the planning portion only. DR. SCHERLIS: That is all we are talking about, planning, at this time. I am secondary reviewer on this and I also review it as essentially a planning phase, since they state they want to evaluate, categorize, and coordinate their existing > emergency: services, and I think in view of the fact that this is a planning phase, and they have devoted considerable thought on how to go about it, I would concur with the feeling of the primary reviewer on this and would also recommend support for the sum requested which is for one year, a total of $30,250. I would concur with that recommendation. DR. ROTH: ‘This I would assume makes no commitments on oux part for anything but those operations. DR. SCHERLIS: This is purely for one year. Any cther comments on Virginia? f£ thought it was 3. DR. ROTH: 3. That's good. DR. SCHERLIS: Any other comments? All those in favor say aye, ( home of oye) 10 VW 12 e 16 17| 18 19 20 | 21 eo : 23 24 ce ~ Federal Reporters, inc. 25 150 (Gherus—_of—ayes ) All right. Next is West Virginia, Dr. Roth. That is a series of 3 projects. DR. ROTH: West Virginia is a series of 3 very sketchy requests, the first for a rural, multi-county -- and it is actually 4 counties -- in Northern West Virginia, and the second cne is for actually a single county building within a single hospital, primarily, have access to taking care of emer- 4 gency cases. And the final third one is a state wide program, or it would have state wide application ability, to train emerge cy medical technicians, The problem here, it-isn't fair to poke fun at a grant request, but I would say that the grantsmanship illustra- ted here was unsophisticated in the extreme. Dr. Besson pointed out that he had « series of letters which were like filling in blanks, and that has clearly been the operation here in West Virginia. Somebody, a coordinator, wrote a letter and said "I think it would be nice if you all sent back something along this lins," so they all copied the letter, and just changed the rr at iLgnatures and put in the names, ‘DR. SCHERLIS: A lot of these are from voluntary fire departments, too. DR. ROTH: Yes. This is almost pathetic, There are 20 “= ET haven't tallied them -«- 2] letters VINIOUIA LSaMh dh-4 ] 10 1 @ 12 13 14 15 16 17 18 19 20 21 22 23 24 \ce ~ Federal Reporters, Inc. 25 152 from individual members of a newly formed Dodridge County emer- gency squad. The letters go something like this: "We have this emergency squad formed, and it would be nice if we just had a radio that we could find out where it is we are supposed to be going, and if we could see that we ‘could have a doctor or somebody in the hospital when we got back," There is one delightful one where the young lad says, "We hope to finish our class soon on heart de-fibulation, in the care of heart patients. And as a member of the class, I realize the great need for communications." This is the heart of this request. So you‘are given a situation in which you have virtually no medical personnel to provide the care, and once you can herd it in, you have prac- tically nothing except hearses available to be the mechanisms of transportation. You have bad roads, you have a relatively small population <- I'm sure you don't have an awful Lot of transient travel, so you're not worring so much about automobile accidents and 7 on as you may be about myocardial infractions and indus- trial accidents, and things of that sort. But it is a testimony to abject need in an area which lacks resources of all kinds, and the request, even though mod-~ est, translates into a fairly high ratio in terms of dollars to population. But if need is one of the qualifications for eli-~ gibilitv, I would say this ranges 4 plus in need, ang very Low dh=5 1 10 in 12 e 16 17 18 19 20 21 ® 22 23 24 ice ~ Federal Reporters, Inc. 25 Lo2 in terms of the resources. to work with which tempers your en- thusiasm, or at least your predictions, about how much will coma of it. But I think for an application with a strongly Appala- chian flabor, that it deserves our consideration. The 3 are somewhat complimentary. The one for a Single county, Jackson County, and a single hospital, really, to my way of thinking, there is scant use in correcting all these emergencies unless you have somewhere to take them with some kind of care to give. And they certainly need the instruction: of the emergency medical technicians. So I would lump them all to- gether as being, to a degree, somewhere related, tending towards systematisation. By taking a figure of practically zero for the state of the art but a figure of 4 for the degree of the need I would come out averaging that off with about a 2 and recommend fund- ing. DR. SCHERLIS: For all 3? DR, ROTH: For all 3. DR, SCHERLTS: I am secondary reviewer. I also arrived at a grade of 2. I was very concerned about the ini- tial 2 requests for funding first of all in terms of who is to do the training. The first one, for example, was to be done by, as I anterpret it, a local staff in the hospital of Stonewai Jackson. re dh-6 1 10 11 @ 12 13 14 15 16 17 18 19 20 2) 22 23 24 \ce'— Federal Reporters, Inc. 25 153 I agree, some training should be done. I felt more and more as I read.it that they should have one training center, that was the Davis and Elkins College, for a sum of $28,000, rather than dispersing this in 3 different areas with different leveis of ability and I would concur with 2, but I thought the total funding should be about $30,000, because I didn't have some concern about dispersing the training into the other areas. What was your reaction about the action of Stonewall Tackson Hospital as far as being able to carry out the program? DR. ROTH: It was apparent to me throughout the thing that they're going to have to import talent to do <«~ they just don't have the capacity there. And this Davis Elkins Col- lege thing seemed to me to be by far the best. DR. SCHERLIS: I was concerned -- for example, in the first one under training, they stated -= the 4 physicians in Louis County, the lone physician in bodridge County, and the national health corps physician in Gilmer County, which is the total medical compliment, have :agreed to conduct training cour~ ses for these men. They're going to deliver the 82 hour course. This requires, I think more ability than they can muster.for.that- sort of a training effort. DR. BESSON: ¢ wonder whether it’ might not be worth- while in the advice to this region to work jointly with the state of Maine on their problem which is very similar, and their ch=7 ] 10 1 @ 12 13 14 15 16 17 18 19 20 21 e 22 23 24 tce — Federal Reporters, Inc. 25 154 solution, which is perhaps ideal for this kind of area. If they are production video tapes, there is no reason why the vided tapes can't be used in West Virginia in these rural counties. just as well.as they're used in Maine. DR. SCHERLIS: The second one, they say “"Upon fund- ing of this application the hospital will recruit and immediatei train 80 emergency technicians" and again I question their ability, without the sort of help that you referred to, My suggestion would be that we go along with the thiy regional training center, which is the Davison-Elkins Group, and maybe expand their program somewhat so they can incorporate training the others. I have a certain reluctance as far as the amount of funds they have requested for the first 2 hospitals, concerning what might come out of it when they are done. DR. ROTH: I'll agree with this, completely. It has always been a problem to me to ~~ i think Serry Besson spoke about our issuing the seédlings, or water: ing them. There isn't even a seedling here to nourish, you havd to start doing some planting. DR, SCHERLIS: Is anyone here from the West Virginia ut area who could comment? pr. Henderson, do you want to comment on the problem: of this project? DR, HENDERSON: I think the generations that have been made are accurate. I have been scanning this application Y a dh=-8 } 10 1 @ 12 13 14 15 16 17 18 19 20 2) e 22 23 24 ice ~ Federal Reporters, Inc. 25 here for a few minutes. The fact that they have submitted 3 proposals that are very similar in nature and have essentially all the same working necessities brings me again to Dr. Roth's consideration of the need. Now actually, the heart of all this is employment of former military types to function as emergency medical service technicians. This may give this thing a bit more rooting than if they were to be starting at scratch and wandering around looking. for people to train. In the light of that and in view of the need, would it be practical to fund just one of the 3 proposals? Number 18, the first one, goes in the direction of trying to provide priority health care services for rural com= munities that have none, or counties. Theiprice tag on this one is said to be $6,000. And even though there is spotty support for doing it, if they can in fact apply it, previous military corpsman, and if they can find a physician who will work at running the project, to me it would be worth doing. Because then it might provide the impetus to energize activi ties in the re- gions of the other proposals. MR. TOOMEY: The thing that bothers me, and it is not on my list to read and I haven't read it <= the thing that both~ ers me is that knowing that West Virginia has a state wide healt planning organization fundea under the Appalachian Regional Development Act, and from what I hear, it seems quite apparent ae dh=9 ] 10 i @ 12 13 14 15 16 17 18 19 20 ® 2] 22 23 24 ace = Federal Reporters, Inc. 25 that there has been, as I would read it, little contact between this project and the Appalachia Project, or the Applachian program. And with the fifth or sixth years of expenses under the Appalachian Health Program, which is a specific section of the Appalachina Region National Development Act, it seems that they should have been farther down the road than what apparently has come cut from this RMP. My point is that I think that they ought to look at each other. DR. SCHERLIS: Any comment from staff on that? Yes? VOICE: The application as it is does not reflect the true working relationship that exists between RMPs and the Appalachian TCHPA.Agency. ‘The application does reflect the cooperation between the RMP and the local B Agency, which is the -- the liaison man working with the advisecry group to the B Agency in determining the local needs and priorities. Someone made a comment about why do we have 3 similar proposals from 3 separate areas. Well, when West Virginia uses field staff very effectively, and there is a field man assigned to these areas, he has quite a bit of knowledge in EMS. So therefore this is one reason these particular proposals come from that particular area. And one other thing, too, The West Virginia regional medical program has just recentll: restated their objectives, and one of their proposed area-object dh-10 ice ~ Fedeial Reporters, 10 1 12 13 14 15 16 17 18 19 20 2] 22 23 24 Inc. 25 157 ives is the emergency medical service, DR. HINMAN: Norm, are you saying that there are accountive working relationships between the Applachian Health Program Planning Council and the West Virginia RMP? VOICE: Have definitely. DR. ROTH: Beyond how much virtue it is, but that fir project , the 4 county project, serving a population of 103,000 people, working out at about 73 center per capita in an area where, as far as. I know, there is very little overall support given. The second one works out somewhere inbetween $3 and $4 per capita and I would be willing to drop that one out completely. But somehow or cther I would like to do something to get those radio sets into these pseudo ambulances, to get something into that 4 couty area of West Virginia, DR. SCHERLIS: I really think in terms of the 4 count) area, that is as far as there being adequate information or they're really having paid attention to the good lines in having at the time all system care, there are serious shortcominas,. And yet, perhaps they should have enough funds te c et least make a start of this. They're talking about 6 full tim q u § patchers, 2 paramedics. It is a budget which, while it adds up to $76,000, I question whether or not they might better spend some of those funds for planning. DR. ROTH: They could do a great deal with less than st “e 10 VW @ 12 13 14 15 16 17 18 19 end #13 CR 6307 90 2) 22 23 24 dace ~ Federal Reporters, Inc. 25 half of that. DR. SCHERLIS: This what I feel and I think if we could talk in terms of putting more into planning and getting a small course started, than perhaps a reasonable sum instead of $76,000 might be something like $35,000. But for quality of training I still think that Davison Elkins looks good. DR. ROTH: Yes. DR. SCHERLIS: Ana the first one would be for $35,000 and the second is zero, the third for $28,000 and crossing out the second. I'til put that on as a motion. $35,000 for the first one, zero for the second phase, the third phase, $26,009 as requested and that rating was 2, 2 for each of those. Any further suggestions? (No response.) All right, all in favor ~~ (Chorus of ayes.) Opposed? We now move out of the eastern branch regions into the south central branch region, and the irrepressible Dr. Basson. 24 ° = Federay Reporters, Ine, i, Q 25) 15 excell, 25 | LS ¢ Selle i | | I have ls | 8 PLOY rar: that x have Tead, The epPlicakion, ‘s) ~ 2 : ~ ee ats + 8 7 Well Prepared, “@s¢ribes al] Cloments Of an. MR, TOOMEY . We are Still » south central, DR, SCHERLTS; SOF | Wisconsin, Mr, - Pooney , MR, TOOMEY : This Pr Oposal is Submitted by ty It has and theo firsts v@ar, a ny = my 4 2765 4 Nousang t! *© thirg Year, Cather 4N eit ens] ve review, Do voy Bea; Want me Cause actually I owilty jump to the SONClusiony 1 “ d JIaS C 10 1 @ 12 | 13 14 15 16 17 18 19 20 21 ® 22 23 24 ce ~ Federal Reporters, inc. 25 276 emergency medical services system. It is factual, has clearly defined objectives and methods for evaluating the effective- ness of a total, comprehensive operating system. Tt includes in its formulation -~ it includes efforts by the people in the Highway Safety Program, Comprehensive tealth Planning Agency, the Hospital Association, Medical Society, Governor's task force, a health program and policy council, greater Milwaukee agencies and Milwaukee County Medical Society. The applicant represents the -- the application represents the efforts of key groups of health providers in the devélopment of this program over the past five years. I think it is the best one I have read. I give it a rating of five and would recommend full funding. DR. SCHERLIS: Dr. McPhedran? DR. MC PIHEDRAN: I concur. It is one of the two best that I read. : DR. SCHERLDIS: What was the other one? DR, MC PHEDRAN: I thought tri-state was very, very good. This is terribiy good, too, and it has been long in 4 preparation. And it shows it. tT cannot remember what rating I gave tri-state. I m afraid LT would be inconsistent. I do not think I gave it a five. f would give this at least a four. Maybe it is a dittie bit bekter than tri-state. 2 do remember the body of the. 10 HW @ 12 13 14 15 16 17 18 19 20 21 @ 22 23 24 ce ~ Federal Reporters, Inc. 25 277 application, where the argument is built up about how the thing is to be time-phased, and what the methods are, what are the assumptions on which each step is based, and how these assumptions can be validated. It is really very good. MR. TOOMEY: It provides for an organizational structure to carry it out from the start to the finish. DR. SCHERLIS: What about the money recommendation? MR. TOOMEY: I concur with the funding. It seems for the project, in relationship to some of the requests for other funding, this is quite reasonable. DR. SCHERLIS: All right. The record should show that they will be funded as requested, for three years? MR. TOOMEY: Yes, sir. DR. SCHERLIS: All right. DR. HINMAN: What is the rating? MR. TOOMEY: Did we submit it? DR. SCHERLIS: Between four and five. DR. MC PHEDRAN: I would say 4.5, and you are going to say five, right? DR. SCHERLIS: let us make that five, then. DR. HINMAN: Five? DR. SCIERLIS: The staff has suggest we use the number five, since they provided us -- we have been given a quota system. We have a certain number of fives. Have we used up all of our twos and threes? DR. ROSE: Right, several times over.