DRIGI i Transcript of Proceedings ENT OF HEALTH, EDUCA @DEPA@RTM TION, AND WELFARE -OIFIT @,U (@"O l@@' ti y,, 15 I- 72 ACE FEDERAL REPORTERS, INC. Official Reporters 415 Second Street, N,E. Telephone: Washington, D. C. 20002 (Code 202) 547-6222 NATION@WIDE COVERAGE LEE: rs CR 6307 DEPARTMENT OF HEALTH, EDUCATION AND WELFARE 2 3 JOINT SUBCOMMITTEE 4 FOR REVIEW OF 5 EMERGENCY MEDICAL SERVICES 6 7 Conference Room A Parklawn Building 8 5600 Fisher Lane Rockville, Maryland 9 Monday, 15 May 1972 10 The conference was convened, pursuant to notice, at 9:00 a.m., Dr. Leonard Scherlis, Chairman. 12 PRESENT: Drs. Margulies, Scherlis, Dimick, Rose, 13 Gimble, Joslyn, Besson, Silsbee, Faatz, Roth, Matory, Keller, Hinman and McPhedran and Messrs Toomey and, @tolov. 1 4 15 16 17 18 19 20 21 22 23 24 Ace -Federal Reporters, Inc. 25 2 C 0 N T E N T S 2 REGION: PAGE 3 Albany 22 4 Central New York 29 Connecticut 40 5 Lakes Area (Western New York) 60 Maine 80 6 Metro Washington, D. C. @. f@ New York Metro Area 104 7 Northern New England 118 Rochester 122 8 Tri State 1 3 6 Virginia 148 LJ @ @o. 9 Arkansas 159 Bi-State 172 10 Intermountain 186 Louisiana 190 11 Missouri 196 New Mexico 205 12 Oklahoma 209 South Dakota 214 13 Alabama 219 Florida 252 14 Northlands 253 Ohio Valley 254 15 Memphis 256 Northeast Ohio 260 1 6 Georgia.,. 2 6 1 Illinois 267 17 Wisconsin 275 Arizona 278 18 California 281 Hawaii 293 19 Mountain States 299 Oregon 303 20 21 22 23 24 Ace-Federal Reporters, Inc. 25 3 CR-6307 P R 0 C E E D I N G S ,@#1 DR. MARGULIES: Come to order, please. 2 nb-1 May 15, 192'@. our purpose in being here is fairly obvious by the amount of material which is piled up on the front table, but 4 5 I would like to at least introduce members of the committee 6 who are functioning here and talk about some of the purposes 7 which we hope to have in going through this review process'? 8 explaining some of the things which we have had to do. 9 Has everyone at the front table met one another? 10 Dr. Russell Roth, Mr. Toomey, Dr. McPhedran, 11 Dr. Beason, Dr. Scherlis, Dr. Hendryson,, over here from 12 New Mexico. 13 Let me just give you all a common background on 14 this, and then review any kinds of issues which require some 15 clarification before the review process begins. 16 The effort to have some explicit emergency medical activities in the RMP is not new. RMPvs have been involved 1 7 18 in emergency activities for a long time, but they have for the 19 most part been fairly scattered. 20 They have often concentrated on specific aspects 21 of emergency care, such as training or ambulance standards and 22 so forth, and at the meeting in January, the coordinator of 23 the national conference, by direction of the stearing committee 24 which had prepared for that meeting, including emergency medical Ace -Federal Reporters, Inc. services,, because this had become an issue of general importance 25 4 nb-2 1 And there was, even before the January meeting, a 2 consensus that there had to be a more organized systematic 3 approach to emergency services and that the RMPs should be involved. This was even prior to the statement by the Presi- 4 5 dent during his State of the Union message that he was con- 6 cerned with elevating the management of emergency medical 7 services to a higher Point. 8 Immediately after the meeting in January there was 9 also an agreement that whatever we did in the RMP should be 10 as effectively correlated as possible with the separate contract 11 activities which are being conducted as major demonstrations 12 through HSMHA. 13 Now, just to keep those clearly in mind let me speak 14 of them once more, but I think several of you are already 15 familiar with them. There is at the present time a review going on to prepare for the award of contracts to not more 16 17 than five applicants to establish emergency or emergency medical 18 system activities which will be supported over a period, probably 19 not to exceed three years in selected settings. 20 The purpose will be to demonstrate on a large scale 21 basis the way in which a systematic approach to emergency 22 medical services can be carried out. 23 one of our purposes in having a special meeting at 24 this time and reviewing emergency activities is to develop Ace - Federal Reporters, Inc. a more fertile field for effective emergency care than would 25 5 nb-3 1 occur under other circumstances. 2 There have been too many experiences with demon- 3 strations which are in isolation and which produce no general 4 change. We felt that if we develop a common approach, one 5 through contracts which are separate and the other through the 6 RMPS, which are similar in scope but not necessarily tied with, 7 but certainly sympathetic with, the contract approach the 8 chances of success of both would be much greater. 9 The particular reason for doing this out of phase, 10 @has more to do with our physical situation than anything else, 11 and the timing of it. Had we had the time, and had we known 12 what our funds would be at the end of the year -- let me 13 add parenthetically, we still don't know -- we could have 14 initiated this earlier, had it go through the review committee, 15 careful analysis, and then on to the council for their action. 16 There was not the time for that kind of process. 17 This will not occur again,.to the best of my knowledge. 18 The difficulty has been produced by two major events, 19 physically. one of them has been the late release of funds 20 which were appropriated for RMP in the last fiscal year, but 21 which became available only quite late during this fiscal 22 year. The other has been the uncertainty of availability of 23 funds from two sources, one of them the money which was set 24 aside for area health education centers and the other the money Ace -Federal Reporters, Inc. which has been set aside for HMOs. 25 6 1 So that even as you review these activities, these nb-4 2 proposals, I cannot tell you any sum of money against which 3 they are being set because at this moment we still don't know 4 whether those funds have been released. I doubt that we will 5 know the total amount of money available until, at the very 6 earliest, the first week in June, and very likely the second 7 week in June. 8 So what we will ask you to do is what has been the 9 custom of both review committee and council, and that is to 10 review the request for grant support on the basis of their 11 merit, without tryin- to determine whether or not they get 12 supported because you have X amount of money available. 13 There is a distinction in the RMP type of grant 14 request, as compared with the contract activity. Contract 15 activity is very carefully defined around the emergency episodes, 16 it is time related, and it looks at the action necessity from 17 the time that an emergency is declared by somebody until the 18 resolution of that emergency occurs as an emergency. 19 So it may end in the emergency room, it may end 20 before the emergency room. But it is that specific kind of a 21 phase of activity. 0 22 Dr. Matory? 23 There you are, we did not have a chance to intto- 24 duce you. You are also one of the consultants back there. Ace-Federal Reporters, Inc. Dr. Matory is from Washington, D.C. 25 7 nb-5 1 So we are in a position in looking at the activities 2 in the RMP to act on what is available in these proposals and 3 to recognice that the RMP will continue to have an interest 4 in emergency medical systems over a period of time, and to 5 recognize also the special charges of RMP as a-@mechanism 6 for developing EMS. 7 we will be particularly interested in the EMS reviews 8 here in how well they relate to other factors in the delivery 9 system. 10 We are not going to be that restricted and will be 11 concerned with any expression of ways in which this particular 12 activity can be brought in conjunction with the associated 13 services of an ambulatory or nonambulatory kind so that it is 14 part of a larger systemt which clearly is our responsibility 15 because ours will hot be a discreet time limited activity 16 ending in a demonstration but will be part of an ongoing 17 regional medical program. 18 We hope that the designation "emergency" will be 19 patient defined. We don't want to have systems that respond 20 to a specific kind of crisis, like a categorical crisis. 21 We are looking at something that will meet whatever 22 demand there is on the system. 23 I think some of the other issues which we might 24 have raised are not necessary, with an expert group like this, Ace-Federal Reporters, Inc. 25 such as the fact that we are not going to give a very high I 8 1 priority, I would hope to activities which seem to be dumped nb-6 2 on the community without the community being involved. 3 I think we understand the importance of general involvement which is essential to the success of an effective 4 5 emergency medical system. 6 The staff comments you will receive, are really 7 provided only to assist the resources They don't represent consensus opinions, but we do hope they have been designed 8 9 in such a way that they can focus the resoursels effort. It 10 is a pretty formidable task. 11 Any of the people in the professional technical 12 division or the ditision of operational development,whether 13 or not needed for the review during the course of the day, 14 can be made available to you, so don't hesitate to look to 15 them. 16 We hope that the consultants will feel free to 17 provide at any time, either on response or spontaneously, 18 opinions regarding the technical merits of the proposals. They 19 have not seen the proposals, they are not reviewing them in 20 the RMP sense. 21 We are asking them to comment on them in the technical 22 sense,, as people who are particularly experienced and expert 23 in the field of emergency medical services. 24 We would like to have you develop, if you feel Ace-Federal Reporters, Inc. comfortable with it, some kind of ranking order for funding 25 9 nb-7 1 purposes because this will in the final analysis have consid- 2 erable importance for us. 3 A simple kind of score of one to five, with one 4 being the worst, and five being the best, may be very useful 5 with a primary and secondary reviewer selected by the sub 6 committee, 7 We are particularly interested in local coordination 8 and the integration with the total delivery system, and the 9 description of methods by which the applicants selected 10 priority areas for implementation because this is reflective 11 of RMP activities. 12 Again,, we will be less interested in applications which reflect funding for only a part of an emergency system, 1 3 14 much more concerned with applications which represent either 15 initial or over a period of planning, the total delivery 16 system. 17 With those few comments, a few more than I think 18 you have time for, I would like to turn the meeting over to 19 Dr. Scherlis, who will chair it for you, and who will, I am 20 sure, be fair, impartial, and demanding. 21 DR. SCHERLIS.O Those are three interesting criteriat none of which I feel up to at the moment. Perhaps I could 22 23 ask a question. I think you have concisely defined our pro- blem. 24 Ace - Federal Reporters, Inc. I know what you would like to see the committee 25 10 I accomplish. Having reviewed, as everyone else here has, a nb-8 2 good number of the project requests, there are.certain 3 problems which I have, and I am surl- these problems are shared by other members of the committee. 4 5 Perhaps I can voice them so@they can be discussed at 6 this point. I have no trouble ranking them, I guess, as far 7 as whether they are awfully good or awfully bad. Then I get 8 into the problem of compared to what. 9 I think your statement that you have no idea about 10 what funds are available represents an administrative dil@mma, 11 As far as we are concerned, some of the projects, one I am 12 sure can rate of being worthy of some support, unless the 13 funds are unlimited and then you sayt 4ell, it is:worth a 14 trial, let's see what they can do it with, sort of attitude. 15 Although we don't know hom many dollars are avail- 16 able when we sit in a review conunittee,for RMP, we have a 17 pretty good idea, not to@the dollar but at least to the hundred 18 thousand dollar, roughly where we sit, certainly in terms of 19 what the national allotment is to RMP. 20 We have a grasp to that. What do these sums add 21 up to that are requested? of 1 22 DR. ROSE: Just about $14 million. 23 24 Ace -Federal Reporters, Inc. 25 CR 6307 1 DR. SCHERLIS: The requests come to some $14 Take 2 2 million. Are we talking about that as a rough, ballpark le w 1 3 number? 4 Do we feel that, well, let's give them some brownie 5 points because they are trying and reach close to that 6 sum, or are we talking about just a small fraction of that3 7 I think in evaluating this, it is nice to know 8 how tough it will be. 9 DR. MARGULIES: I think that is fair enough. 10 DR. ROTH: Where did I get the figure $8 million? 11 DR. MARGULIES: The $8 million figure represents 12 the money which is specifically designated for emergency 13 medical systems which has been moved into the office of the 14 administrator or for contract activities and is a one-time 15 funding which will be increased next year, but it won't be 16 part of RMP. 17 That is a separate issue. 18 DR. SCHERLIS: That has nothing to do with us. 19 DR. MARGULIES: Just to give you some sense -- 0 and this could be well off -- if you are thinking in terms 21 of three to four million total, you would be somewhere near 22 correct. 23 Let me explain to you what the difficulty is. We at this point -- this came up during review 24 Ace -Federal Reporters, Inc. committee. I do not know whether we will get anywhere from 25 12 dw 2 1 zero to seven million dollars of the funds set aside for 2 HMO available for this year, so we are really in a very 0 3 uncertain range. 4 But we will clearly have an amount of 5 money available which will be in that general range. 6 That gives you some kind of an idea. 7 DR. BESSON: Is there another degree of Uncertainty 8 added to it by the Council's consideration for this funding 9 cycle of the relative priority in making grants for emergency 10 medical services compared to other RMP grants that can be 11 made? 12 DR. MARGULIES: No, what we are going to have to 13 do is to keep this it a somewhat separate area. 14 There is another reason for it which may help you. 15 And, if we receive a portion of the HMO funds, 16 that is those that were set for that purpose, released this 17 year, we Will have to manage them in such a way -- and I 18 should make some comment about this anyway -- that they will 19 not become a part of the level of commitment to regional 20 medical programs in the subsequent three years. 21 So whenever possible, we may be asked to fund 22 what you approve here for the total lifetime of that 23 proposal, say it is two years or three years, whatever it 24 may be. Ace-Federal Reporters, Inc. So this is carried as a kind of separate budgetary 25 13 dw 3 1 channel. 2 At the end of that period of time that funding 3 will disappear and the reginal medical program will be 4 wherever it may have reached in levels of full commitment. 5 So that we have to look at it as a function of the 6 separate budgetary item not competing with other RMP funds, 7 so we will give that some protection. 8 You talk about three to four million that will 9 really be protected for that purpose. 10 DR. BESSON: Another question I would like to ask: 11 Of the $14 million that represents the total of these 12 programs that we are going to review here requested, what 13 amount of that $14 million represents a duplicate application 14 which is also being offered to HSMHA. 15 DR.ROSE: I don't have that figure in terms of 16 amount. 17 DR. MARGULIES: I think we can identify those, 18 however, which come to H8MHA for contract request, so that 19 you know when it has gone in both directions, because some 20 have.- 21 DR. BESSON: Okay, perhaps we can do that as we 22 go along. 23 DR. MARGULIES: Yes. 24 DR. BESSON: But a corollary question is in not Ace - Federal Reporters, Inc. 25 knowing which the applications to HSMHA are, can you give us I 14 dw 4 an idea of what their total amount is requested? How many 2 applications? 3 DR. HINMAN: There were 51 responses to the 4 request for proposal. I don't have the total dollars, but 5 each one on a per year basis exceed a million dollar average, 6 I would assume. 7 As the review proceeds, they are keeping us 8 informed of the review process, so that when it comes time 9 for awards to be made, there will not be any duplicate 10 funding. 11 There are some duplicate applications, some that 12 are, except for the face page, identical applications, upstairE 13 and here. We have kept them informed and they are keeping 14 us informed as they go along so that we will not duplicate or 15 compete in the same area to attempt to solve the problems. 16 DR. BESSON: I would understand that, Ed, but 17 my question is, how do we, in our approach towards an 18 application, for example, Alabama has an application that 19 is being submitted both ways -- how do we approach it? Just 20 from approval, or indicating or suggesting level of funding 21 and that the decision be made in a@coo@dinative fashion. 22 DR. MARGULIES: I think you should review it, 23 ignoring during your review the fact that there is a 24 duplicate contract activity but letting us inform you what Ace-Federal Reporters, Inc. 25 action may occur, because what is going to have to happen up 15 dw 5 1 there, and I am part of that review process, also, is that 2 they must have quickly and tentatively narrow down the 3 applications to the view they can site visit. 4 So even though there is something up there, the 5 chances of it being in the final review process get very 6 low. 7 I should introduce Dr. Dimick, who is from Alabama 8 and who is one of our other consultant%revidwers.- 9 DR. SCHERLIS: From the point of view of review 10 processes, you will want a person who comes from that state 11 to leave the room during the discussion. No reference 12 specifically to Alabama. 13 Or there any other questions or comments by the 14 members of the review group? 15 Dr. Hinman, do you have any fatherly advice? 16 DR. HINMAN: Good luck. 17 DR. SCHERLIS: Thank you. 18 Dr. Rose, I know you have been heavily involved 19 with the staffing of this. Are there any suggestions or 20 problems you think we might have that should be discussed 21 at this point before we get down to specific cases? 22 DR. ROSE: Would you mention the confidentiality 23 of the proceedings here just as a general reminder. 24 DR. SCHERLIS: You have heard, as a reminders that Ace - Federal Reporters, Inc. 25 all the proceedings here are confidential. These are I CR6307 16 #2-ter-1 folg DW5 1 These are privileged documents, and in terms of the review 2 process, as I mentioned before, to avoid any conflict of 3 interest, anyone who is resident of the state involved will be 4 asked to leave the room. 5 There are some 35 individuals -- 6 DR. BESSON: I have a couple of questions that I 7 would like to Ask about. 8 DR. SCHERLIS: Surely. 9 DR. BESSON: I have five pages but I will just 10 restrict them to three questions. 11 one is a question of support. As I read the infor- 12 mation that was sent to us, we can make either organizational, 13 developmental, one-year grants, or three-years, operations. 1 4Is that correct? 15 So, we can specify, even though a particular 16 application does not specify, the direction that it is going, 17 it will be obvious on reading it? We are not precluded from 18 specifying one year for even an operational request? 1 9 DR. IIINMAN: Yes. 20 DR. BESSON: The second question is the eligibility of subcomponent systems for support. I also read that any 21 0 29 public institution can be an applicant. There is no constraint 23 on us funding a state health department, let us say, or any 24 other public institution that derives its funds from elsewhere, Ace-Federal Reporters, Inc. is there? 25 ter-2 17 DR. @IARGULIES: Not if it has made an application. 2 But, I think all of these represent PPIP applications. 3 DR. HINMAN: They are through the RMP. Some of 4 them, the sponsor may be a state Department of Public Health, 5 through the RMP. 6 DR. BESSON: State Department of Public Health, to 7 give you an example, that may request funds for support of 8 personnel? 9 DR. P4ARGULIES: Yes. 10 DR. BESSON: That ordinarily would be supported bv 11 the State Department of Public Health. But, now that is asking 12 for M4Ps to supplement state support? That is perfectly 13 reasonable for us to fund? 14 DR. MARGULIES: We can if we wish to make a grant 15 through the 910 process to a non-FnIP, nonprofit in structure. 16 DR. BESSON: Okay. The third uestion, about equip 17 ment. While purchase of equipment is indicated as reasonable, 18 there are innuendos throughout the guidelines that we would ig rather not do that. Can I get a little better feel as to what 20 the attitude is about Purchase of equipment, some of which 21 becomes quite substantial, as we all know. 22 DR. P4ARGULIES: We made a big issue about it because 23 there is always a temptation in these circumstances to use this 24 as an opportunity to buy equipment and do little else. Very Ace-Federal Reporters, Inc. clearly, Jerry, if a plan is well developed, and the equipment 25 ter-3 18 1 purchase is reasonable and critical to the success of that 2 plan, then that is supportable. 3 But, if it looks like a wav of getting equipment 4 and that is all, then we clearly would be disinterested. 5 DR. BESSON: One final question that you alluded to 6 this morning, when you said the applications given the highest 7 consideration would be those in which there is broad community 8 support. 9 Several of the applications that I had on occasion 10 to review indicated in their letters of endorsement, a great 11 deal of -- more than hesitations, but outright opposition, 12 much of it because of the obvious precipitous nature of the 13 application submission, but some of it because P,14Ps is moving 14 into a field of health delivery that impinges on the preroga- 15 tives of the private sector, or that is'just now becoming 16 manifest in this request for letters of endorsement. 17 I wonder if we may have a more clear expression 18 of our constraints in funding if there is this kind of lack 19 of community support. 20 DR. MARGULIES:: I think it pretty much depends upon 21 whether it represents, in your judgment, a barrier to the 22 effective development of the emergency medical system. 23 If it merely represents some concern over whether this is where RMP ought to be but nevertheless evidences that 24 Ace-Federal Reporters, Inc. 25 it will be acceptable, and will be effective -- I think once I ter-4 19 1 you get into it -- just the existence of some anxiety should 2 not be a basis for turning it off. 3 But the presence of real objection which would 4 interfere with it should. It just means that the time is not 5 right. 6 DR. SCHERLIS: Any other questions? 7 There are some 35 regions, some of which have as 8 many as six projects. If we can give ten minutes to each, 9 that is five or so hours, and I do not know how we are going 10 to get through this, except to suggest that it will be apparent, 11 I am sure that the first few are going to take much longer 12 than the subsequent one. And therefore, as Chairman, I will 13 not cut short the discussion early on, for those of you who 14 are trying to keep time. 15 So, do not just pro-rate 35 minutes for the discussion 16 for Alabama -- I am sure the time will become less as we move 17 on. I think the issues which will be raised in some of the 18 earlier ones will be related to the later ones, and we will not 19 have to discuss principles as much. 20 DR. BESSON: Is there any possibility of us having lunch here? 21 22 DR. SCHERLIS: I had suggested this to Dr. Rose, 23 that this could very well be a marathon session from that 24 point of view, and I would think the wisest thing to do would Ace-Fedetal Reporters, Inc. be to have sandwiches and a beverage here, if that could be 25 ter-5 2 0 1 arranged. 2 DR. ROSE: Do you have choides? Shall we circulate 3 a list around of the sandwiches @ available and have you check 4 that off? 5 DR. SCHERLIS: Would that be satisfactory to the 6 members of the Review Committee? I do not see how we are 7 possibly going to get through it any other way. 8 DR. MARGULIES: It is against the building rules 9 but as long as the meeting is confidential, I suspect you 10 could do it. 11 DR. SCHERLIS: Also in opposition to the building 10 12 rules are smoking, but this is a confidential meeting. All 13 right, if we could do that. Even doing that, I am not convinced 14 we will get through all of this with the feeling of having 15 done justice to them, but we will define justice relatively, 16 as we go along, too. 17 DR. ROSE: Dr. Scherlis. 18 DR. SCIIERLIS: Yes. 19 DR. ROSE: You will notice, as you go through the 20 applications that there are several budget figures written. 21 The figure on the budget sheet, which is the white page at the 0 22 end of each region's set of forms, is what we are calling the 23 right figure. That is as carefully calculated as we can come 24 up with. Ace -Federal Reporters, Inc. DR. SCHERLIS: Where is that listed? 25 ter-6 21 1 DR. ROSE: For example, in Alabama, the last page 2 under the Alabama application is a budget worksheet and the 3 budget figure on that one does not match those on, for 4 example, the log-in sheet, or some other parts of the 5 application, but this is a more carefully calculated and 6 apparently, correct, figure. I would hope you would work from 7 those numbers. 8 DR. SCHERLIS: As far as the method of review, we 9 have a primary reviewer and a secondary reviewer. I would hope 10 that the first would summarize the project, recommend both a 11 funding and a rating level, -- let me do it this way, if this 12 is satisfactory. 13 Have the primary reviewer first discuss the project 14 as his general feeling before discussing funding, then have a 15 secondary reviewer, then return to the primary reviewer for 16 funding and rating. 17 Let us see how it goes. 18 Would you like to begin, Dr. Besson? 19 DR. BESSON: What is our order going to be? 20 DR. SCHERLIS: We have a list here -- there is a list 21 enclosed which goes through the states in alphabetical order. 22 Would that be a satisfactory wav to do it? or do you want to 23 do it by division? End #2 24 DR. ROSE: By division, it would be a little easier Ace-Federal Reporters, Inc. for some of the staff. 25 22 .CR6307 E3-ter-1 I DR. SCIIERLIS: We are going to do these by divisions. 2 The first is eastern branch, that will be Albany, and so on. xxxxxx 3 DR. ROSE: That is the first section in Volume I 4 of your book. 5 DR. BESSON: Albany is asking for a six-month grant 6 of $109 thousand, direct funding; and then for a two-year grant 7 request of 1.5 million, running from December of '72 at the 8 end of six months to December '74. 9 The general plan for Albany -- I will just read 10 brief excerpts -- is, from the summary, I am reading, "A three 11 year study to investigate the design and implementation of a 12 PMS for the capitol district, consisting of what they describe 13 to be two major components, external to the hospital and 1 4 internal. 15 The external is basically the use of a rapid 16 detection plan and preliminary care in a van. And then the 17 internal system is the establishment of six beds, a four-bed, 18 trauma, intensive-care unit; located, Albany Medical Center; 19 and a two-bed, similar unit; located in a community hospital. 20 Let me just refer to budget, for a moment. There 21 are -- for the six beds, they are requesting, there are some 22 50 people that are being asked to be taken on as part of their 23 larger budget. Twenty-six of these are listed by name, with 24 a budget of 529,000; and 24 additional people, with a budget Ace-Federal Reporters, Inc. 25 of 584,000. ter-2 23 1 They are also asking for the purchase of equipment 2 which comes to 230,000. They are asking for computer funding 3 in one form or another of 90,000. They are asking for the 4 purchase of ambulance and communications, coming to 30,000. 5 In addition to this, they are asking for 300,000 6 for what they referred to as a variety of incidental expenses. 7 Basicallv, this is a request for funding a continuation of Dr. 8 Samuel Pol,.@er's research in trauma physiology. The general 9 thesis is that the physiological -- meticulous physiological 10 monitoring of massive injury has focused on the posttraumatic 11 respiratory distress syndrome as a cause of deat . 12 The literature-morbiditv rate of 40 to 80 percent 13 in this situation has been reduced in this particular research, 14 intensive care unit approach, of careful physiological monitor- 15 ing, to one of the last ten patients with massive in3'uries, 16 and the research unit says -- and they make a categorical 17 statement on page 21 of the application -- death from this 18 cause has been virtually eliminated, although the basic cause 19 of death is still unclear. 20 This entire program in Albany is to continue that research effort. 14ow, in reading the application very carefully, 21 0 22 it is a magnificent piece of work, but I think that there are 23 a variety of ruses used by Albany to trigger funding. 24 For example, this is called a demonstration unit -- Ace - Federal Reporters, Inc. it is hardly a demonstration unit, but a continuation of a 25 ter-3 2 4 1 physiological research program. It includes two trauma,'inten- 2 sive-care unit beds in a community hospital, therefore cloaking 3 the entire project with a mantle of it being a community 4 project, which it hardly is. 5 It pays lip service to external hospital care by 6 physician-communication with onsight ambulance personnel, but 7 very cursorily mentioned. It also pays lip service to evalu@ 8 ating the cost, morbidity and mortality, with what are called 9 "ordinary ICUS," presumably comparing them with what Dri Powers 10 can do when he is there. 11 It pays lip service to outfitting a Winnebago Camper 12 as a mobile ICU to demonstrate its values. It has one sentence in the entire proposal on community education. It proposes 1 3 14 to establish a committee, and lists in one sentence, ten groups 15 which can be triggered as "okay," groups, that will make up this committee. 16 17 It talks about accident epidemiology as an extension 18 of a package at Rensselaer Polytechnic Institute, which is said 19 to analyze emergency events as predicted models, but I am not 20 impressed with the detail in that predictive model comment. 21 The 129,000 which is modestly requested for the first six 22 months of funding gives me the impression of being kind of a 23 Gulf of Tonkin Resolution, with a $1.5 million request in the 24 background. Ace - Fpderal Reporters, Inc. It seems to be only the beginning of a limitless 25 ter-4 25 1 and insatiable investment that is irrelevant to the problems 2 that need solution in this area. When I talked to Dr. Scherlis, 3 a week ago, about how this might be set up, he suggested 4 maybe the best we could do is grade them "A" to "E" on the 5 basis of what we have been told this morning, and from what I 6 divined, I would grade this as "E." 7 Incidentally, the technical review gives this pro- 8 posal high marks, but it is with so much technology in its 9 approach, it really does not address the right question. While 10 this is, then, a remarkably, progressive approach to physiolog- 11 ical monitoring of death from massive injuries, I think it is 12 wide of the mark of what we intend to do with RMPs funding. So, I would recommend no funding for this project. 1 3 14 DR. SCIIERLIS: Secondary reviewer? 15 MR. TOOMEY: I think that is me, and I could only 16 agree with what Dr. Besson has said. It looks to me as though 17 it would be a great piece of research, and would be very 18 interesting and very desirable to be continued, but I just 19 felt it was wide of the mark as far as the emergency medical services were concerned. 20 21 DR. SCHERLIS: I guess the rating, according to our 22 preview criteria 23 DR. BESSON: I did not see these sheets. Maybe I 24 will have to look at this sheet and see how we are doing this. Ace -Federal Reporters, Inc. DR. SCHERLIS: Can I ask a question at this point? 25 26 ter-5 1 Perhaps I am the only one confused on this. Albanv is listed 2 as the primarv reviewer, Dr. Besson, and Mr. Toomey, on this 3 form. 4 If I look at the other one, it is Dr. T4cPhedran and 5 Dr. Besson. 0 DR. i4C PHEDRAN: For Albany? 7 MR. TOOMEY: I had it done. I was secondary. 8 DR. BESSON: I think I was primary. 9 @IR. TOOMEY: That is right. 10 DR. ROSE: All of these were reviewed bv these 11 reviewers. That is a mistake. 12 DR. SCHERLIS: I see. This is divided among the 13 four, but this is the individual assignment. 14 DR. BESSON: I would recommend, Mr. Chairman, 15 that in accordance with this worksheet -- I assume that our 16 final decisions will be on these sheets, is that right? 17 DR. SCHERLIS: Yes. 18 DR. BESSON: These white sheets? 19 DR. SCHERLIS: Yes. What I suggest is that the 20 primary reviewer hand that sheet to Dr. Rose, and that he be 21 responsible for the formulation of that sheet. Would that 22 be satisfact6rv? 23 DR. ROSE: Yes. 24 DR. BESSON: Do we each fill out each sheet? The Ace -Federal Reporters, Inc. 25 white sheet that comes in this book? I ter-6 27 I DR. SCHERLIS: I would suggest we not have indivi- 2 dual votes but a committee vote, and onlv the primary reviewer 3 fill it out, and that it recommend the concurrence of the 4 secondary reviewer and of the committee, unless of course, 5 we have another situation. 6 But, I would suggest that you have the responsibility 7 for filling this out, reflecting the committee decision. 8 DR. BESSON: I would recommend, then, a, no 9 recommended funding, no conditions for award, and rating five 10 or one, excuse me. DR. 8CHERLIS: Rating one? 12 DR. BESSON: es. 13 DR. SCHERLIS: Does the secondary reviewer concur 1 4with that recommendation? 15 MR. TOOMEY: Yes. DR. SCHERLIS: Any other comments from members Of 16 the review group? 17 18 I will accept that as being a motion which has been ig seconded by the secondary reviewer. 20 Any further discussion? Those in concurrence, signify bv saying ifaye.11 21 0 22 (Chorus of ayes.) 23 DR. SCHERLIS: Opposed? 24 That took care of Albany, I would guess. May I Ace'-Fedefat Reportefs, Inc. suggest this: If, for any reason, as part of the discussion, 25 2 8 ter-7 I if any of the task force of the staff which has been involved 2 either in summarizing these, or as part of the DOD Branch, 3 wishes to make any comment, I would appreciate that. 'So Dr. 4 Joslyn and @4r. Nash, if vou would like to make any comment 5 Dr. Joslyn? 6 DR. JOSLYN: I concur. 7 DR. SCHERLIS: We would like some facts presented, 8 rather than a strong opponent or antagonistic point of view. 9 DR. TOSLYN: All right. DR. BESSON: One other question, @ir. Chairman. This 10 11 distillate will mean nothing to me after I am done. It may be 12 helpful to the staff if it is legible. There is no reason 13 why I have to take this home with me. 14 DR. ROSE: We would appreciate very much, having that 15 if you are not going to need it. 16 17 18 19 20 21 22 23 24 Ace-Federal Reporters, Inc. 25 CR 6307 29 4 eak 1 1 DR. SCHERLIS: Central New York? Besson and Toomey, 2 again, 3 If any of the consultants would like to enter the 4 discussion as far as any of the technical aspects of this, we would appreciate their patience, if you have any familiarity 5 or help you can give us with this. 6 DR. BESSON: Okay. Six projects for this application 7 0 requesting funding from July 172 to July 173 of 306,000. The 8 9 six projects are: 1. The development of a regional council for EMS. 10 11 2. The development of council components in B 12 agency areas. 13 3. The development of a communidatibns.,systems. 14 4. Advanced MET training. 15 5. Public education through the American Red Cross. 16 6. Public education through the American Heart 17 Association. 18 The total objectives are as is indicated here, plus 19 a few other subcomponent parts, inventorying ambu ances, evaluating EMS components, public education, first aid, general 20 21 courses in first aid education, improvement of detection, 22 notification and feasibility of an air-raedic evaluation 23 program. There are seven counties involved in this central 24 New York area with a population of two million. The specific Ace - Federat Repotters, Inc. components, first the regional council that they propose to 25 eak 2 30 1 develop is -- this will be the group that develops and doordi- 2 nates the model program in the Syracuse-Cortland-Binghamton 3 area for training, communications, equipment standards, system 4 of detection notification and dispatch. All of these will be 5 to test the program components, evaluate them, and if and when 6 that is done, expand them. 7 There is a relative poor history of regionalization 8 in this area and a history of a Jack of general coordination. 9 But this is a proposed effort at $40,000. This is probably 10 worthwhile. Second is they hope to expand this to develop area 11 12 councils, as well as a regional council to inventory the local 13 needs and resources and relate to the regional council for 14 meeting these needs. They want to develop a plan for the 15 locals to do what the regional will do regarding detection, 16 notification, and so forth. They are going to split costs here 17 with Comp planning and RMP's bill will come to $57,000 for 18 a year. 19 The third component is advanced MET training. They 20 have had one group, a RMP group, talk about the training of 21 MET, but there are very scant details. It is only referred to 22 in one small aspect of this application. They request 29,000 23 for one year. This includes stipends for two students at 24 17,500. Are stipendsdisallowed in this program? There is Ace - Federal Reporters, Inc. 25 some comment made in the guidelines about that. I am not sure I 31 eak 3 1 where we stand. 2 DR. 14ARGULIES: I think we could allow them if they 3 are essential to the program, yes. 4 DR. BESSON: A fourth program is developing a radio 5 communications system in this Syracuse-Cortland-Binghamton 6 area, so that a physician may be directed -- "Physician may 7 direct care at the scene and enroute." 8 Now, this includes the purchase of 11 base stations 9 at $4600 a piece, 17 mobile stations at $1600 a piece, six 10 tape recorders at $900 a piece for hospitals, branches and 11 so forth, for a total cost of $99,000, all of which is very 12 laudable, but there are endless costs involved in hardware 13 purchase for private institutions. 14 Nonetheless, I assume that is okay with this commit- 15 tee. It is essential to the development of a funcioning 16 program. So in that light, I think that is probably reasonable 17 Then, there are two major public education programs 18 in first aid. That is Red Cross first aid. There are 25 chapters of Red Cross. Is Red Cross right? I feel as though I 19 20 should be saying Blue Cross. Between June 1970 and 1971, 21 they trained 3,000 peoplei and there are many more informally 22 trained, perhaps an equal number. So if we guess there are 23 6,000 people trained in this effort at first aid, they are 24 requesting $6,000, so at a dollar a piece, that is a bargain. Ace - Federal Reporters, Inc. The Heart Association also is mounting a public 25 eak 4 32 1 education campaign on cardiopulmonary resuscitation. They have) 2 had 30 classes between 1970 and 171 and 453 certified CPR 3 people. They want 50 additional courses at 29 -- at 20,000. 4 In general, this is an attempt in central New York to produce 5 a coordinate education program. It is very sketchy and very 6 slapdash but it is far better than nothing and though it is 7 inadequate on a grade of one to five, I would grade this three. 8 And I would recommend full funding. It is of interest to note 9 that the hectic pace that was engendered by the submission 10 of this application between April 19 and the time of the 11 February 24th letter sent the coordinator to a hospital with 12 what was described as nervous exhaustion. 13 And then by 4-26 when the application finally came 14 in, there was an addendum saying, "P.S., he is much better, 15 thank you." And somebody finished the application and sent it 16 in. 17 DR. SCHERLIS: That is for one-year funding? 18 DR. BESSON: Right. The emergency medical services 19 through integration of its components into a total working 20 system through a 17 county area. The plan, I think, has been 21 developed as an evaluation. Perhaps the most essential element 22 of this system is a development of a radio communication net- 23 work with an interhospital and ambulance communication on a 24 regional basis, which accounts for one-third of the funding Ace-Federal Repo@rs, Inc. requested. The review indicates the program description is 25 eak 5 33 1 weak in the area of quality assurance and evaluation. There 2 is a need for local and regional organization which will 3 spend approximately two-thirds of the money requested. 4 Potential resources not documented, however, the model 5 program area and services are adequately listed. The 6 application centered around two major components, an advanced 7 emergency medical technician training program and a communica- 8 tions system. 9 The application appears to be innovative in the 10 area of EMT training due to the lack of physicians and 11 emergency room facilities in the north country. Applicant 12 stresses the priority of training over equipment for proper implementation and coordination of the total system. It 13 14 appears that a total communication system in this region is 15 needed and the applicant has planned for an effective 16 implementation. 17 However, applicant refers to how the areas should 18 develop a communication program but little emphasis is placed 19 on the funding mechaniIsms for future expansion into rural 20 areas and appropriate training of personnel prior to the 21 implementation of the equipment facet. The application is 22 a --it lacks in department planning, identification of resource-,, 23 utilization of present resources, methods of future financing 24 for rural areas, and a plan of action for the total implementa- Ace-Federal Reporters, Inc. tion based on the results from the model program. I think on 25 eak 6 34 1 this basis, that I would agree with the three rating. 2 DR. SCHERLIS: Would you suggest full funding? Do 3 you think they can utilize that effectively from some of the 4 points that you have made? 5 MR. TOOMEY: Yes. 6 DR. SCHERLIS: Who would be in charge of this over- 7 all plan, the RMP itself? 8 DR. BESSOII: They will develop a regional council. 9 DR. SCHERLIS: That will be it? 10 MR. TOOMEY: And then subcouncils* 11 DR. BESSON; And then subcouncils, in coordination 12 with the Comp planning, local areas. 13 DR. SCHERLIS: Dr. Joslyn? 14 DR. JOSLYN: I just wondered whether the committee 15 has the right or the intention in any of these where there are 16 multiple facets that are clearly separated, to make any dis- 17 tinction As to which programs warrant funding and which do 18 not? In other words, this has a total budget of a little over 19 200,000 but it is clearly broken down into six projects in 20 four areas. 21 Now, you know, does the committee have any intention 22 as they go along in different regions to say that certain 23 projects warrant funding, others do not? 24 DR. SCHERLIS: I would assume we do. Am I correct Ace-Federal Reporters, Inc. 25 in this? I would have no hesitation in supporting a I 35 eak 7 1 recommendation that a certain project not be funded or another 2 project be cut significantly. I think in this type of review, 3 we would have that ability. 4 DR. BESSON: Mr. Chairman -- 5 DR. SCHERLIS: Not necessarily the wisdom but the 6 ability. 7 DR. BESSON: I think Dr. Joslyn's point is well- 8 taken in that as I went through the six components, I made a 9 comment about the individual funding request for each. To 10 reiterate, the regional council should be funded, the local 11 councils should be funded, particularly since we are splitting 12 costs with Comp planning, the advanced training for technicians, 13 if stipends are okay, and I think they are, should be funded. 14 Radio communications, I have some hesitation about 15 the purchase of all this equipment, but I think that it is an 16 integral part of their system. Public education, I think that 17 is where I mention a bargain at a dollar a piece for Red 18 Cross training and 20,000 for American Heart Association 19 program also. 20 One of the problems with central New York is the 21 fact that they need something to get their teeth into, to 22 things on a cooperative basis. This is the first indication 23 that they might be able to mount such an effort. I think they 24 should be encouraged. And in passing, too, I might make Ace-Federal Reporters, Inc. 25 another comment. I eak 8 36 1 As I have reviewed all of these applications and 2 wondered about how RMPs can assist in this national neglected 3 disease, I thought our function would probably be best served 4 by our acting as a catalytic agent and be generous in our 5 funding of seedlings, rather than single, massive programs. In 6 that sense, if there is a program that I encountered which had 7 any merit at all which wasn't just a ruse for getting some 8 bucks out of the Peds, and would produce an opportunity to do 9 just what RmPs started to do many years ago in planning and 10 developing an organization for creating regional concepts, then 11 I thought it was meritorious enough to get at least some 12 monies, rather than turning them off completely. 13 In that light then, I think central New York needs 14 help. This may be an indication of how we might do it. 15 DR. SCHERLIS: This speaks more of a system of care 16 certainly as compared to the -- 17 DR. BESSON: Yes. It addresses components parts 18 and integrates them. 19 DR. SC8ERLIS: The recommendation is a rating of 20 three with full funding. Any conditions for the award? 21 Obviously the question of stipends for training you wish to 22 look into. DR. BESSON: I don't think that is conditioned. 23 DR. SCHERLIS: As far as you are concerned, this is 24 Ace - Federal Reporters, Inc. 25 a one-year 37 eak 9 I DR. BESSON: It is a one-year request. They have a 2 three-year request -- no, it is all one-year. The only 3 conditions would be to do a good job. 4 DR. SCHERLIS: Any other comments from members of 5 the committee? I will accept this as a motion and a second. 6 Any further discussion? 7 All those in favor say "aye." 8 (Chorus of ayes.) 9 DR. SCHERLIS: All right. 10 Do you have any comment at this point? 11 DR. MARGULIES: The only comment I would make here, 12 now that your action has been completed, is that I think that 13 the reasons for doing it make very good sense. It is a region 14 which has had problems in the past. It is under new leader- 15 ship and this will give them something they can bite into. We 16 will have to talk with them about what they intend to do in 17 the future, whether this is a part of the future program develol- 18 ment. But for this region, it is just as well they don't go 19 beyond a year. 20 MR. STOLOV: The reason they are asking for one- year funding is that the regaional advisory group and executive 21 22 committee asks they only come in for one-year funding due to 23 the nature that there is no appointed full-time coordinator. 24 However, I believe that since they actively Ace-Federal Reporters, Inc. 25 recruited a consultant to help them with their EMS planning, eak 10 38 1 and their plans for their application which is due in here July 2 lst, that they may, in all likelihood, continue this as a major 3 part of their overall program, should they have a three-year 4 plan. But that was it. 5 DR. SCHERLIS: Next is Connecticut. 6 DR. BESSON: One other comment I would like to 7 make in this connection that struck me about this application 8 and one other application, Illinois, when we come to it, is 9 that as RmPs has moved into -- since the St. Louis meeting, 10 and I don't know what has been happening in the past year -- 11 new areas of focus, and if our area is health delivery, 12 throughout the country we are seeing perhaps a reaction to that 13 movement on the one hand in the turbulence in the core staff, 14 with people who originally came on to RMP in a categorical 15 fashion now having to look at a much broader view of health 16 deliveryi and also, on the other hand, on the private sector, 17 where there are groups that we thought were very strong who 18 are now beginning to question whether RMP has a role in health 19 delivery. Witness some of the telegrams we got, in at least the application that I have, California and Rutgers, where the 20 21 private sector is perhaps stiffening their resistance to RMP's 0 22 intrusion. 23 Now, emergency medical services, I think of all of 24 the areas that RmPs is moving into, that is one less highly Ace-Federal Reporters, Inc. 25 charged, I think, than some of the other potentials, like HMO I eak 11 39 1 and quality of care. Therefore, I think wherever we have an 2 opportunity to develop linkages with the providers, particu- 3 larly, which are very weak in many parts of the country, in 4 this non-threatening area, for example, we should encourage 5 it. 6 Now, for an area like central New York that can mean 7 a great deal. So whatever encouragement we can give them in 8 dollars, even though we don't give them encouragement in dollar5 9 for other programs that may be just as meritorious, I think 10 we should. 11 DR. MARGULIES: I would like to recognize Dr. 12 X61ley from Ohio State has arrived, one of our c6nsu tants. red 4 13 DR. KELLEY: Thank you. 14 15 16 17 18 19 20 21 22 23 24 Ace -Federal Reporters, Inc. 25 4 0 arl I DR. SCHERLIS: All right. Connecticut, Dr. 2 McPhedran. 3 DR. MC PHEDRAN: The Connecticut request is for 4 one year, total funds, 328095, and it is mainly organizational 5 and exploratory. I'll sav at the beginning that I rated 6 this at three, perhaps lower than the staff review, and I'll 7 state at the outset the reasons for this are, I have some 8 questions about why no interrelationship between this and 9 another program, another project I reviewed, that is, Tristate. I am not sure I reallv understand that. And also there are 10 11 some intrinsic problems within the region itself. 0 The intent of the project is to, as stated on the 12 13 Form 15, organize statewide EMS systems -- develop and 14 organize, through regional regulatory and management mechanisms, 15 and to launch an operational EMS demonstration in the south 16 central region, that is, metropolitan New Haven, and surround- 17 ing regions. And they intend to work through the Ya e trauma 18 program, which is a going concern. This is for a one-year organizational periodt 1 9 20 expected to provide the framework for a statewide analysis 21 of EMS delivery. And, then, of course, the demonstration 22 in the New Haven area. it is stated that -- it is hoped that the experience 23 in New Haven, the demonstration there, will be such that it 24 Ace-Federal Reporters, Inc. can be -- what is learned there can be extended to the rest 25 41 ar2 of the state through this EMS consortium. The consortium 2 which is proposed will build on the one which is now working 3 and which is centered around the Yale trauma program. 4 Now, some of the problems, questions that I had 5 about this, are now well -- what can be learned -- how much 6 one can expect to learn from the New Haven area to extend to 7 the rest of the state. I wonder whether this is a realistic 8 idea. 9 I don't really understand also why, if they could 10 propose this activity for one year -- I don't really under- 11 stand what is going to happen after the one year. It seems a 12 little strange to me that these monies are requested for one- 13 year activities. I don't really see exactly what is going 14 to happen after that. There are plans for funding from other 15 sources spoken about on the application, but that part of it 16 didn't seem definite or detailed enough for me to understand 17 exactly where they are going from there. 18 So this is essentially a planning and organizational 19 period for which funds are requested. Some general plans for 20 the state as a whole, some specific plans, and a demonstra- 21 tion project for part of the state are included. I have 22 already given the amount, I think. I recommend its funding 23 with reservation. 24 I hope that we can discuss this matter of inter- Ace-Federal Reporters, Inc. regional planning and cooperation. It is difficult for me as 25 42 ar3 I someone who was born and bred in the northeast to understand 2 why there isn't evidence in these two applications, Tristate 3 and Connecticut, of more conversation between the two of 4 them. I would have thought there would be some pertinent 5 issues they should discuss together. But I don't see any 6 evidence of that. Maybe it would just make the application 7 too big. 8 DR. SCHERLIS: Let's have the secondary reviewer 9 and then we'll throw this open for discussion. Dr. Besson. 10 DR. BESSON: To reiterate some of what Dr. ii McPhedran has already presented, they do want to organize a 12 statewide EMS program through what they describe as regional regulation and management, and then create a single demongtra- 1 3 tion program in the south central portion of New Haven. 14 15 Number three is to develop an EMT training program an :..,Len 16 create what they call a consortium between the Yale trauma 17 organization, New Haven Health Care, Incorporated, which is a newly funded experimental health services elivery system, 18 19 apparently, and Dunlop Associates, who are now nationally 20 famous, to organize, train, and produce and implement an 21 action program regionally. 22 And then the final program is to have a year to organize an analysis on the content of this demonstration 23 24 program. Ace-Federal Reporters, Inc. Now, as I looked at the budgetary breakdown for 25 4 3 ar3 1 this $300,000 - $328,000 they request, pages 14 to 16 of the 2 application, are the only places where a budget is mentioned, 3 and it is extremely sketchy and no breakdown. 4 The New Haven Health Care, Incorporated, program 5 is also described in a very sketchy fashion. They merely 6 mention it, that they will consider it with the newly funded 7 experimental health services delivery system, and they describe it, but it is apDarentlv a new organization that has 8 9 a very fussy goal. While I haven't seen the EHSDS, I am not 10 sure how much they can cut the mustard. They have very sketchy information, as Dr. McPhedran has pointed out, on the 11 12 development of either statewide, regional or interregional 13 program. 14 Their information on their EMT training, which they 15 describe as one of their component parts, is described in one 16 line, practically. They speak of the implementation of an EMS system component to facilitate, organize and direct EMT 17 18 training throughout the state, although Dunlop Associates, 19 of course, has a good track record, and presumably will help 20 them in their developmental portion. 21 They have no information on how they will relate 22 to the Yale Trauma Program. And then they very poignantly 23 state they want funds because the Department of Transportation 24 may phase out their funding. And they say besides the Ace-Federal Reporters, Inc. Department of TransDortation funds probably should better be 25 44 ar4 I used for highway accidents and purchase of related equipment, 2 and "we have a broader mission." 3 1 think the entire application is very limited in 4 description, and I would be interested in funding them only 5 on conditions that they provided more details on how they 6 expect -- there has to be some more meat on these bones they 7 present. 8 But again I can be charitable and say the applica- 9 tion was just put together in the usual case for this whole I 0 series. 11 DR. SCHERLIS: May I ask a question? As I view 12 the document, apparently this was really put together for the Department of Transportation in May of 171, with some 1 3 14 introductory statements at the front. Is that correct? 15 Because I was looking for the budget, I was curious how they 16 were going to spend this in a year and not tie up people who 17 entered the program, wondering about the second or third vear. 18 And again I could find no budget here at all 19 except for the sheets which are surprisingly specific about 20 salary and wages, $172,312, but yet nothing that in any 21 indicates how they arrived at that figure. 22 DR. BESSON: They had an ongoing program with the 23 Department of Transportation, and the Yale Trauma Program, 24 and this is an extension of that, basically. Ace-Federal Reporters, Inc. DR. SCHERLIS: Dr. Gimble? Do you have any concept 25 45 ar5 I of how those numbers were arrived at? 2 DR. GIMBLE: I found the whole application was very 3 scant in detail and though their general motives looked like 4 they were in agreement with RPS goals, most of it lacked 5 detail of any sort, including the budget. 6 DR4 BESSON: The other thing, Mr. Chairman, that 7 might be appropriate with this application is that since -- 8 the bulk of this application involves a continuation of the 9 Department of Transportation program with the Yale Trauma 10 program, and since this is just a tentative exploration of 11 the development of an EMS system on a statewide basis with a 12 demonstration program, with the experimental system, it might 13 be that in asking for more details on how they expect to go 14 about it, that we might ask them to use other funds for this, 15 for the year, and see whether they are really going to add 16 to what has already been done with the Yale Trauma program of 17 the past. 18 DR. SCHERLIS: Is all this trauma-oriented, if we are going to speak about a system of care? 1 9 20 DR. GIMBLE: The current Yale Trauma system is, but I was a little hesitant about how applicable what they are 21 22 going to do in the Yale-New Haven area, not being very, 23 familiar with Connecticut in general. But I am sure the rest 24 of Connecticut doesn't resemble the New Haven area and this Ace-Federal Reporters, Inc. system is going to be modeled very strongly on the New Haven 25 4 6 follows ar mea-1 CR 6307 #5-B I area. T was hesitant about how applicable it would be to the 2 rest of the region? 3 DR. SCHERLIS: Dr. Rose? 4 DR. ROSE: Would you like comments from the branchi 5 the general terms, about RMP? Might that be helpful, how this 6 might tie in? HEMIS-., I think it might be helpful if we 7 DR. SC 8 had some general background. My concern has been voiced by both 9 reviewers. 10 The budget, and is this going to be essentially 11 trauma with the Yale-New Haven area as a model, with less over- 12 all system involvement? 13 DR. FAATZ: I think generally for years and years 14 New Haven has been probably the most heavily studied town on 15 the east coast, and I think RMP is probably following that same 16 tradition. 17 The New Haven south central area of Connecticut is 18 being set up as a demonstration for the rest of the state 19 because Yale is there, and it is the easiest to get to. 20 DR. MARGULIES-. I am curious, in this application, 21 about the fact Connecticut has in its RMP this general design 22 of linkages between hospitals which cover the entire state and 23 from what you have described to me, it seems to me they have 24 ignored their basic structure and have set up something quite Ace-Federal Reporters, Inc. different. I don't understand that. 25 mea-2 47 1 I would have thought that that hospital system that 2 they are trying to design would have been quite a good vehicle 3for statewide emergency medical systems. 4 DR. MC PHEDRAN: It is not clear that they have set 5up something so much different but they have set up something 6just with no relationship to that. It doesn't have enough 7specific details to tell if it is different, really. 8 DR. BESSON: That is the impression that I get. I 9am very restless about the fact that again -- and I may say this ]Oia few more times,Len, over the next eight hours -- that now 11 that RMPS is moving out into the area of health delivery, we 12 are really going to be testing whether the linkages that we 13 speak of in such glowing terms in RMPS are really there. 14 Now, if they are really there, Dr. Clark should have 15 just fallen right into the skeleton that we talk about that is 16 going to be so useful. If they are a sham, which I personally 17 believe they have been in Connecticut for some time -- I think 18 they have been a ruse for the medical schools to buy some 19 additional salaried people -- then the linkages don't really 20 exist for putting this kind of delivery system onto that 21 skeleton. 22 Now, I don't know how else to look at Connecticut. 23 Clark is a pretty bright guy and I think that they are just not 24 equipped to move out into a broad-based community organization Ace -Federal Reporters, Inc. 25 and get into health delivery. 4 8 mea- 3 1 so they flounder around and look for an organization 2 that is not even funded, and want to contract with them to do it. 3 Well, all I can say is, this is what core staff, if the linkages 4 are there, should be able to just move right into. 5 So the fact they are not makes me a little bit leary 6 that they do have the linkages competence. 7 DR. SCHERLIS:. Yes? 8 DR. FAATZ: I think the Connecticut regional 9 medical program was only peripherally involved in developing 10 this project, if at all. I think it was developed by Yale 11 trauma and other people. 12 The RMP is being used as a vehicle to get funding, and Dr. Clark and the Dean of Yale and those people signed off 1 3 14 on the request, and it came in. But RMP I believe was not 15 involved in the development of the program. 16 DR. SCH@l$@:. I ask this only for information. 17 Is my interpretation of the indirect costs, 18 66 percent at Yale -- DR. BESSON: Yes. 1 9 20 DR. SCHERLIS.*. Is that right? DR. BESSON: That is correct. 2 1 22 D@ S'CHERLIS: I guess I hesitate over this one to get more direction for myself and the members of the Committee. 23 Is this a system of care? I would think that with 24 Ace-Federal Reporters, Inc. all the studies that have gone on in that area -- those of you 25 mea-4 49 who can see, this is a thick document filled with questionnaires, but no data. Isn't that correct? 2 DR. MC PHEDRAN: That is correct. 3 DR. ROSE: Can I comment for just a moment? 4 DR. SCHERLIS. Yes. 5 DR. ROSE: Actually the questionnaires represent a 6 statewide survey. I tried very hard to get some results from 7 the survey figuring that you all would need this. 8 DR. SCHERLIS*. Yes. 9 DR. ROSE: It turns out they will not be available 10 until next month. So, the questionnaires have been used. 11 DR. SCHERLIS: I was curious how they arrived at 12 need in terms of this request for funds. 13 DR. BESSON: They have some preliminary idea. They 14 have a preliminary analysis of this survey which is the thing 15 that has been ongoing between the -- funded by the Department 16 of Transportation. 17 This was submitted May 1, 1971 -- submitted by the 18 Yale Trauma Program to the Department of Transportation, this, 19 entire thing. But they do have a preliminary analysis 41 and I 20 just can't -- 21 22 DR. SCHERLIS@-. You have all agreed on a grade 3. DR. BESSON: Oh, here, excuse me, Mr. Chairman. 23 The preliminary analysis of all of this data has pinpointed 24 Ace-Federal Reporters, Inc. five areas: Lack of trained @kRS.Personnel, lack of community 25 mea-5 50 organization, uninformed public, no linkages, and no objective 2 standards to evaluate. Now, if they were to address, even on that 3 preliminary basis, some of these objectives, they would have an 4 5 entirely different program. DR. SCHE@RLIS@i. I have some concern at this point, 6 7 in that while you have recommended a rating: of 3, you have 8 also recommended full funding.-- would there want to be some reconsideration of whether or not if you are going to make a 9 recommendation we might not restrict this to 'ust some seed 10 11 money to begin to set up some developmental 12 DR. MC PHEDRAN: That was my recommendation. I don't know whether Dr. Besson concurs on a rating of 3. 13 14 DR. BESSON: I concur on a ratings of 3, or maybe one 15 as low -- maybe two-and-a-half, but my suggestion was to approve 16 the application but request that RMPS have no new funding and fund it out of core. 17 18 DR.,SCHERLISl., In other words, you are saying it is 19 a pretty good application but you aren't recommending any new 20 funding? 21 DR. BESSON: They have plenty of money. As I 22 remember that Connecticut application, it was in the seven 23 figures. 24 DR. scHERLIS,:. Are the niceties of that recotamenda- Ace-Federal Reporters, Inc. tion appreciated by the primary reviewer? 25 mea- 6 !) J. I DR. MC PHEDRAN: Yes. I don't know whether -- can we 2do that? I am not sure we can. 3 DR. H-ARGULIES: That actually would pose a problem because if there is anything that that program needs, it is a 4 5stronger program staff. That is one place where they don't have any fat; they are very weak. And we have been pushing 0 7them hard to strengthen that program staff. 8 So, you might look for other sources of funding than 9that, if you want to. I think that would not help that program. 10 DR. MC PHEDRAN: Maybe that program -- maybe t e 11 Connecticut regional medical program shouldn't have let this come in under their name if they weren't going to have more 12 input into it. Maybe they can be faulted for that. 13 14 But as'stated in the@note from the eastern operations 15 branch, they apparently -- this is not something that has been 16 central to their interests, this kind of activity, in the past. 17 And maybe -- I don't know, if it hasn't been central to their 18 interests, it perhaps would be a disservice to them to say it is 19 a good thing to do, go ahead and do it, with your present moneys and present staff. That might just injure the rest of 2 0 21 the program, or they might feel it would injure the rest of the 22 program. Perhaps it would be better to approve it with some 23 funding that would seem enough to enable them to get started 2 4 Ace-Federal Reporters, Inc. With part of it at any rate. I don't know what that would be, 2 5 52 mea-7 really DR. SCHERLIS-. There isn't enough? 2 3 DR. MC PHEDRAN: There isn't enough data to tell. 4 -DR. SCHERLIS@: - If they had a gross figure here of 5 120,000 or450,000 I think we would be just as lost as to how 6 they were going to spend the money. DR. BESSON: They don't tell us what they are going 7 8 to do with the money. They don't have any budgetary breakdown; 9 it will be all going into the Yale slush fund. Excuse me. And I 0besides, the EHSDE-S Program, if it has been funded -- and I 11 assume it has been -- that is what this experimental system management board is supposed to do anyhow, so what is RMP 12 1 3putting money into that pot. 14 DR. MC PHEDRAN: Experimental health services 15 delivery? 1 DR. BESSON: Yes. 17 DR. SCHERLIS-. Any other comments? DR. BESSON: What is the motion? 18 DR. SCHERLI,S4- There is no motion. 1 9 MR. MC PHEDRAN: I wonder if there is some mechanism 20 21 that can be suggested by RMPS that we could arrive at a figure 22 that would be realistic to help them, say, for example, get 23 the statewide consortium, since the application ability of the 24 New Haven model seems to be, what there is, the most Ace-Federal Reporters, Inc. questionable part of it; what would it cost them to get the 25 mean ii I statewide consortium that they described going for a year, and 2 then as Dr. Besson suggests, maybe the experimental'health services delivery 3 . people would find enough of their own money tc 4 begin the demonstration model. Could we say that we would approve it for that part 5 6 of it which would put the statewide consortium into operation? DR. SCHERLIS: I think that is a reasonable request. 7 DR. MC PHEDRAN: I don't know about the numbersi how 8 9 to put a figure on that. DR. SCHERLIS: I think we need a dollars figure on 10 that, to know what kind of a staff they would need to implement 11 that. 12 DR. MARGULIES: The situation with the experimental 13 health service delivery system is that it has onlv been recently 14 approved, to the best of my knowledge. So if it depends upon 15 that, there is also a question of whether it might not be 16 better to limit what they do until that develops into some 17 better relationship. Because it did go through with the 18 Coordinating Review Committee just the last time. 19 So nothing really has happened yet, although they 20 have been working at it for a year. 21 22 DR. BESSON: I second that motion. DR. SCHERLIS: In other words the motion is to the 23 effect, number one, the rating is two-and-a-half or 3, somewhere 24 Ace-FederaiRepotters,inc. in that ball park, and that the support be limited to setting up 25 54 mea-9 a consortium as its major effort. What was the other -- 2 DR. BESSON: Not consortium, the statewide EMS. DR. MC PHEDRAN: When they say consortium, that is 4 what they are talking about. 5 DR. BESSON: Consortium is used as the key word for 6 the trauma unit, New Haven Health Care Incorporated, and Dunlop 7 Associates. 8 DR. SCHERLIS: Shall we say a total statewide EMS. 9 DR. MC PHEDRAN: Planning, development and planning 10 phase. DR. SCHERLIS: That would be limited to a planning, 12 developmental phase for total statewide EMS. Is that correct? 1 3 DR. BESSON: Yes. 14 DR. SCHERLIS: What level of funding, just so we'll 15 have a number here. They have been arbitrary in their request 16 for funds, so we can be arbitrary here. 17 DR. MC PHEDRAN: The total amount they asked or was 18 328* Do you think a half or a third of that is reasonable? 19 DR. SCHERLIS: That is extremely generous for this 20 developmental planning phase but that may speak of my own 21 22 Monday morning feeling, as far as funding goes. DR. GIMBLE: I have a feeling it is going to lead to 23 the same problem. Can you word it in such a way to preclude 24 Ace-Federa[Reportefs,lnc. money falling back into the Yale Trauma -- 25 mea-.Lu I DR. BESSON: I thought that was part of the motion, 2 that the conditions were that these moneys only be used for 3 these purposes. 4 DR. MC PHEDRAN: Statewide planning. 5 DR. SCHERLIS: Statewide planning development phase 6 for total EMS. 7 DR. MC PHEDRAN: Yes. 8 DR. SCHERLIS: This is not limited by any means and 9 in fact it should not be under to be trauma-based# but a total 10 system base. 11 Is that separated from the present orientation of the Yale funds? 12 13 DR. GIMBLE: I'm not sure, if the people that ate doing the planning are in this, in the Yale program. 14 15 DR. SCHERLIS: Would you say that the planning be 16 centered through the regional medical program core office? 17 Would that give them another loan? 181 DR. MARGULIES: That it be done by the regional I 9medical program. 20 DR. SCHERLIS: It be done by the regional medical 21 program and that ceiling be 50 to 100. 22 DR. FAATZ: I have a feeling in the discussion, 23 maybe I have something nobody else has -- 24 DR. BESSON: You have the only extant copy, I think. Ace - Federal Reporters, Inc. If that is a breakdown of the programs, I have never seen one. 25 Tnea-11 I DR. SCHERLIS: I have that front sheet but that is 2 all. Is that why you've had that knowledgeable look on your 3 face? DR. BESSON: They come up with 19,000; I guess that 4 5 is their component. 6 What is this Connecticut State Deparpment of Health? 7 Is that their statewide program? 8 DR. MC PHEDRAN: I think that is the statewide -- wait a minute; that is the EMT part of it. 9 10 DR. BESSON: The EMT had been previously put together. 11 DR. MC PHEDRAN: It will be continued through the 12 Connecticut State Department of Health. 13 DR. BESSON: Connecticut Regional Medical Program is requesting 19,QUU. You were about ten times too generous. 14 15 OR4 MC PHEDRAN: Right. 16 DR. HINMAN: We can put a ceiling of 100,000 and ask 17 staff to negotiate the actual figure necessary to do it. I 18 think that would be a fairly clear directive. 19 DR. SCHERLIS: Is that an adequate directive for staff? 20 DR. MARGULIES: Yes. 21 22 DR. BESSON: I think 100,000 is too much in the 23 light of this budgetary breakdown. 24 DR. SCHERLIS: We do not have those copies. Ace-Federal Reporters, Inc. DR. BESSON: Here, organization and development of 25 mea-12 state and local. 2 DR. MC PHEDRAN: EMS. 3 DR. BESSON: EMS. DR. MC PHEDRAN: This is also Connecticut State 4 5 Department. DR. JOSLYN: How much were they asking for tho 0 organization? Is that still 19? 7 8 DR. MC PHEDRAN: No -- 9 DR. BE8SON: They speak of this as components butL,,. they don't tie the components to what we have had here. 10 11 DR. SCHERLIS: I suggest you look at that, and the 12 rest of us will help ourselves to coffee. Perhaps you can come up with a figure. Apparently 13 14 you have the only copy extant here of that document. 15 (Recess.) 16 DR. SCRERLIS: Let's get started. 17 Dr. Besson and Dr. McPhedran, have you worked out a 18 joint resolution? 19 DR. MC PHEDRAN: The figure we found from sheets 20 which were supplied, the direct cost figure was 19,000. This 21 was a figure specifically for the statewide planning for EMS 22 through the Connecticut Regional Medical Program. That is the 23 institution affiliation which is listed. 24 It is component 5, Roman Numeral 5, of th s bu get Ace-Federal Reporters, Inc. breakdown. That is the figure thereo 19,000 direct cost. 25 58 mea-13 I DR. SCHERLIS: The recommendation is for -- 2 DR. MC PHEDRAN: Funding of that. 3 DR. SCHERLIS: Funding for that? 4 DR. MC PHEDRAN: Yes. 5 DR. SCHERLIS: The funding would be restricted to 6that item as specified in the budget? We don't have to have excessive working on that. That has been seconded by the 7 8secondary reviewer. 9 DR. GIMBLE: Nineteen thousand? 10 DR. SCHERLIS: Yes, direct. We have lost two of 11 our reviewers. While we ate waiting, will each of you please 12 fill out your lunch requests. Restrict your items to those 13 listed on the form. The motion has been made, reviewing the budget, that 14 15 they be funded for that item which is in terms of helping to 16 plan their total EMS Program which came to 19,000. 17 That was seconded by the secondary reviewer. 18 Any further discussion? 19 All those in f avor say aye. 20 (Chorus of ayes.) 21 DR. SCHERLIS: Opposed? 22 MR. TOOMEY: What was the rating? 23 DR. MC PHEDRAN: Three. 24 DR. SCHERLIS: The rank was what? Ace -Federal Reporters, Inc. DR. MC PHEDRAN: We said two-and-a-half. 25 mea-14 I DR. SCHERLIS: Two-and-a-half. 2 DR. ROSE: Is that for the approval as presently set 3up? 4 DR. SCHERLIS: I don't know. Is that for the total 5program or as presently set up? 6 In other words -- 7 DR. MARGULIES-. It was for the total. 8 MR. MC PHEDRAN: For the total. 9 DR. SCHERLIS: What range would you attach to that 10 present, limited,restricted recommendation? 11 DR. MC PHEDRAN: I think that was satisfactory. I 12 would give that 3 to 4, that part of it, myself. DR. SCHERLIS: Would that be satisfactory, then? CR 6307 13 14 DR. BESSON: Three. I would agree to three. 15 16 17 18 19 20 21 22 23 24 Ace-Federal Reporters, Inc. 25 60 CR-6307 DR. SCHERLIS: All right. That is Connecticut. #6 1 nb-1 2@ The next program is the Lakes Area. xxx 3 DR. MC PHEDRAN: Formerly Western New York. 4 DR. SCHERLIS: Lakes Area, thank you. 5 DR. MC PHEDRAN: This is formerly Western New York. This is a proposal, the request is funds over a three and a 6 7 half year period to document emergency medical needs and to 8 develop appropriate emergency medical services in Erie Countyo New York. 9 10 The proposal proposes a great deal of confidence 11 in a man that has recently come on,, an evaluator and planner, 12 by the name of Dr. Geoffrey Gibson. 13 Dr. Gibson did a study in Chicago, where he was before, I gather, which I read in the course of doing other 14 resource, it is a study of Chicago emergency medical services 15 needs. It certainly is a good piece of work, I thought. 16 1 was very much interested in it. 17 So. I can understand why the Lakes Area regional 18 medical program is pleased to have him. > 19 The proposal that has been developed here is develops( 20 by an emergency medical care committee, which advises the 21 22 Commissioner.'of Health. The committee has fairly broad rep- resentation from hospital people and medical society and 23 community leaders. 24 Ace-Federal Reporters, Inc. The proposal includes one component for communications, 25 K) L 1 an.education component for training medical emergency techni- nb-2 2 clans, and of course, this research or this study into the 3 effect of the whole program on emergency medical services. Now, the breakdown of the budget, for the first 4 5 year there is really a very large expenditure on communications equipment. The total first year budget requested is $348,000. 6 7 of that, communications equipment eats up $207,000. M.E.T. 8 training, the communications equipment is divided in budgetary 9 breakdown among the several people, several groups, who would 10 receive this communications equipment. 11 That is roughly 60 percent of the total M.E.T. 12 Training consumes $63,000 and the research and evaluation 13 component just about the same, $63,000. 14 The whole argument in presentation is that the communications scheme or the thing they want to develop is 15 16 central to improving emergency medical services in this region. 17 I think the argument is made with some effect. 1 18 find it difficult to quarrel with the figures that they ahve 19 developed for the communications. If this is the central 20 feature of developing this proposal, as they see it, I suppose 21 that one w6uld have to take the whole thing all together. 22 The figures for communication equipment dropped 23 down sharply the second year, 78,000 against that figure of 24 over 200,000 the first year, and the third year, 290000. Ace -Federal Reporters, Inc. There apparently are other sources for funds for 25 6 2 1 keeping it up. and there are other -- there are other sourcesp nb-3 2 large contributions, to communications component. Not as 3 large as what RMP is asked to withstands but nevertheless large. 4 5 I think that as I say, the argument was made# at 6 least to me, with good effect, that this would be an important 7 direction for this regional medical program to take, and I 8 would rate this proposal as a three and recommend it be 9 funded if the funding can be found. That is my own feeling 10 about it. 11 That is 348,744 for the first year. The figures 12 that are shown here on the sheet -- I won't bother to read 13 these -- they would be on the record on this sheet. 14 DR. SCHERLIS: How many ambulances do they plan 15 to putfit at the very onset? Do you have any 16 DR. BESSON: Forty-four. 17 DR. MC PHEDRAN: Forty-four. 18 DR. SCHERLIS: How many? 19 DR. BESSON: Forty-four ambulances, participating 20 hospitals. 21 DR. MC PHEDRAN: Wait a minute. I am sorry, isn't 22 it just 30? 23 DR. BESSON: That is just the first year. 24 DR. MC PHEDRM: That is the first year. Ace -Federal Reporters, Inc. DR. SCHERLIS: Are these hospital-based ambulances? 25 63 1 DR. MC PHEDRAN: I think many of them are. nb-4 2@ DR. SCHERLIS: Do they coordinate one with the 3 other or do they just service individual hospitals? 4 1 just happened to pick up a sheet that says St. Francis Hospital and then lists -- 5 DR. MC PHEDRAN: They would be coordinated through 6 central dispatching, that is one of the points, of course, 7 about all of this elaborate communications equipment. 8 It is a central dispatching type of arrangement, 9 DR. SCHERLIS: Right. 10 DR. MC PHEDRAN: So that whether they -- how they would be based seems not so important, they could work that 12 out. 13 DR. SCHERLIS: Have they already worked but the 14 assignment of channels and expressed a willingness to cooper- 15 ate one with the other? 16 DR. MC PHEDRAN: They speak about that, that there 17 would be an assigned frequency that would be used by all the 18 cooperating parties. 1 9 DR. MARGULIES: That is an area in which they are 20 rather expert4 21 22 DR. MC PHEDRAN: Is that right? DR. MARGULIES: Yes. 23 DR. MC PHEDRAN: You mean expert -- who is expert,, 24 Ace -Federal Reporters, Inc. the pGlice? 25 6 4 1 DR. MARGULIES: RMP has had a lot of experience with nb-5 2 the use of radio communications. 3 DR. SCHERLIS: Dr. Besson? DR. BESSON: Yes, this program had its genesis in 4 5 the appointment of the Blue Ribbon Committee, so-called, which 6 was an advisory committee to the Commissioner of Health. 7 As I have looked over the application and the 8 minutes of the Blue Ribbon Committee, I see that the subcommittee 9 on communications takes up the bulk of this application. And 10 my only thinking is that some communications expert must have 11 gotten to this subcommittee and really laid out a program 12 for the development of a communications network that is 13 maybe a little bit overkill'# but I suppose that is what commun- 14 ication gear costs. The details are just astounding for an 15 application like this, and I think that has been the heavy 16 emphasis as Dr. McPhddran@.has already put, not only physical 17 but so far as there interest is concerned. 18 But I suppose I will have to live with the fact 19 that we are equipinq ten hospitals -- participating hospitals, 20 one regional hospital, and forty-four ambulances, for all this 21 communications money of $270,,000, since the system just 22 doesn't go unless you have that component part and if they are 23 on the ball to lay out this kind of elaborate system, I suppose 24 more power to them. Ace - Federal Reporters, Inc. They are linking that to a good training program 25 b.5 for technicians, training 5,000 over a three year period with nb-6 2 36 hours of formal training to be given throughout the region, 3 hopefully. And they anticipate that this Blue Ribbon Committee 4 will continue as a coordinating committee to expand the effort 5 from this original area which is around in Erie County, 6 around BUffalo,to the rest of Erie County and then throughout 7 the Lakes Area Region, developing local committees as they 8 go* 9 1 have difficulty in swallowing the whole thing, but 10 I suppose that if that is money going to a good cause I would 11 agree with the recommendation implied in Dr. McPhedran's 12 presentation of a C rating and full funding, 13 DR. Mc PHEDRAN: I want to just say, one of the 14 concerns that I have is a concern I have about all of them, 15 really, that evaluation has to do with whether or not they will 16 be able to get the things equipped, whether or not they will be able to get the peo0le on the same frequency by such and 17 18 such a time. 19 But again there isn't Anything here that tells how 20 they are going to decide whether or not coronary lives were 21 saved, or accident victims were saved. 22 I suppose they are hoping Dr. Gibson can design 23 them a study. But that sure isn't in any of these applications 24 that I have been able to tell, and it is not in this one, Ace - Federal Reporters, inc- either. 25 6 6 DR. SCHERLIS: Do you think they are ready to start 2 a system involving so.many ambulances, or do you think that nb-7 3 we might not suggest -- I am just asking this -- might not suggest they start with a small group, and feel their way -- 4 5 DR. MC PHEDRAN: I think the idea wasn't they 6 couldn't serve the whole region unless they tried to do this, 7 and they want to try to make it a regional network from the 8 beginning. 9 DR. SCHERLIS: Something has to come first. 10 DR. MC PHEDRAN: I guess, you know, if it is 11 simply setting up central dispatching and then putting equip- 12 ment into ambulances and having everybody use the same assigned frequency, there might not be much need to time phase that. 13 14 DR. SCHERLIS: But the training would be a problem. 15 In other words, what do they communicate? If it is just 16 dispatching, that is a questionable facit of the total system, unless training is with it. 1 7 DR. BESSON: Mr. Chairman, I think this is an 18 example of an application which suggest to me that knowing 1 9 about the so-called neglected disease, can be enhanced by 20 getting involved in this. I don't know if Dr., Dimick had 21 22 started out that way, but he sure became an expert from having become involved and getting them involved in communications is 23 24 going to make it obvious to them that that is only one link Ace - Federa I Repof ters, Inc. in a chain. 25 67 1 And I think they will be self-corrective and the nb-8 2 more they get to know about iti the more they will recognize 3 that communications can't possibly function without having the other pieces of the puzzle. So while it is heavy in one area 4 5 I think it is an entry point for this region to get involved. 6 Now, we reviewed Maine, and there big handup is 7 transportation. They are spending all their money on trans- 8 portation but obviously they will'have to get to the other 9 parts as they recognize the state of the art and become more 10 Ifamiliar with it. 11 DR, SCHERLIS: Dr. Keller? 12 DR. KELLER: It would seem in looking over and 13 listening to a few of these, that the particular component 14 that is stressed depends upon the enthusiasm of some individual 15 or a small set of individuals on the particular site. 16 The leap from that to deciding whether this is a 17 legitimate priority for the region is another thing entirely, 18 and I don't know whether anyone but someone on the scene who 19 can really look over each of the components carefully and 20 maybe acquire data not currently Available, could possibly assess, 21 22 What troubles me is not that particularly, because 23 I think I would agree that almost any legitimate entry will 24 bring along some of the other components, but I am a little Ace-Federal Reporters, Inc. concerned about the relative position of the RmPsi, 25 68 nb-9 I Granting mechanisms as against Department of Transportation 2 and other groups who have been very heavily. hardware@orientated. 3 This is the sort -- I have also had an opportunity to review an@ 4 look over a great many things that have come to the Department 5 of Transportation. This is the sort of thing that ordinarily 0 falls into their granting area, for vehicles and hardware 7 associated with communications between the vehicles in various 8 areas. 9 I am wondering why this is directed to this.-par- 10 ticular group. I haven't been able to fathom, in the guidelines, 11 whether this group was that hardware oriented. 12 DR. SCHERLIS: I think that is a facet of Sutton's 13 law. S-u-t-t-o-n. 14 DR. KELLER: I am not that familiar with it. 15 DR. SCHERLIS: That is why he robbed banks, because 16 that is where the money is. 17 DR. MARGULIES: In defense of what they are doing, 18 we talked before you came in about this problem of equipment. 19 It reminds me of one of the earliest issues that I saw when I 20 came to kMPso In which there was an absolute stando:Bf because 21 the question was how can you hear the expert unless the equip- 22 ment is there, and then they said, well, we can't get the 23 equipment unless the expert is there. 24 Now, at some point, you say,, we-11, we are going to Ace -Federal Reporters, Inc. 25 train people. We don't have anything to use them in4 I 69 nb-10 I or you say you are going to have some equipment but nobody 2@ trained in them. 3 There has to be a point of entry and some assurance 4 that something will happen. Our problem, our responsibility 5 is to make sure that it does happen. 6 One of the things we will clearly have to do very 7 quickly after this exercise is to get out to those programs 8 and carry to them the message you are talking about. 9 We will be asking, among other things, members of 10 the review committee to assist us with that kind of direct 11 Ivisit to these programs that are going to be granted funds. 12 DR. BESSON: I wonder if Dr. Dimick can comment on 13 that since he is one of the people that puts it all together 14 with all the@comppnent parts. 15 How do you view the review committee's approach to 16 maybe encouraging the thinking of emergency medical care 17 as a total system by funding a little piece of it and hoping 18 they will move the rest of the way? 19 DR. DIMICK: I think, depending on the whole envir- 20 onmental situation, where they are in the state of the art. 21 And as you said, our emphasis has been on training and then 22 put in the hardware. Because if you put in the hardware first 23 and they don't know how to use it they compound the injury, 24 so tp speak, so depending on what is there right now, it sounds kce -Federal Reporters, Inc. 25 like from what I hear of the application, that is where the 70 deficit is,.i§ communication. nb-11 I However, if they have good transportation, they can 2@ utilize this already. It would depend on what is existing 3 in this area already. I wonder if someone could speak to 4 that? 5 DR. SCHERLIS: The comment was made they are going 6 to train 5000 emergency technicians over a three year period 7 and my concern there would be that certainly if they have 8 that great a need, what are the untrained individuals going to 9 do in a highly integrated system communicationwise unless 10 they have been trained. We have to start somewhere but my feeling might be 12 more of starting with both gradually instead of the budget 13 beginning with all the hardware. 14 Perhaps we should Phaselthis'in,@over a stepwise 15 period. I want to get your feedback on that. You have been 16 through the grants in more detail than I have. 17 DR. BESSON: Well, I think too the facinatihg thing 18 about watching RMPs relate to the regions is a paradigm of the 19 way the center relates to the periphery, in that we are per- 20 missive, we are unablinq, we use the leverage of our funding, 21 and our advice to encouraging a pluralistic response to a 22 natural problem. 23 It has to be pluralistic and I think RMPS is doing 24 it as I would do it, and when you look at this region and see @ce - Federal Reporters, Inc. 25 what there is about it that got them involved in communications, I 71 nb-12' this Blue Ribbon Committee decided that one of the problems 2 that they had was people having to wait in emergency rooms. 3 So they said how can we correct that, and they said well, we will devise a system of creating red, green, yellow aldrt'@, 4 5 And well, how do we know what group is doing what? Well, 6 we'll check with each emergency room. 7 Well, they found when they did that by phone that 8 they would get busy signals and they wouldn't be able to call, 9 and they had 44 calls a day, and they found it was very 10 complex, and along came this communications expert and said, 11 I could solve it all for you. 12 That is the genesis of their emphasis on communi- 13 cations. And they say if communications is this vital, we 14 had better put our money on this horse. So I can't fault them 15 for that. That is their uniqueness. 16 And I think with Gibson coming on board, who is 17 really an expert, they will obviously look to the other four 18 component parts within a year, I am sure. 19 They will find they have all this hardware and they 20 had better do it right. 21 DR. MC PIIEDRAN: Because that is certainly well 22 brought out in the Chicago study, he lookds at all parts of it. 23 24 It is a good study. kce -Federal Reporters, Inc. Dgs SCHERLIS: The requested funds were on the order 25 72 nb-13 I of 348,000,@. 231 and then 245. 2@ DR. BESSON: That is correct. 3 DR. SCHERLIS: Would you like to make your recom- mendation in view of the discussion? 4 5 What is your original recommendation? 6 DR. MC,PHEDRIOI: I recommended funding at the level, 7 because I can't quibble with the figures, really. I don't 8 know how to revise them downward. If I though that was nec- 9 essary,, that is. So I would recommedn it as requested. 10 DR. BESSON: One year funding? 11 DR. MC PHEDRAN: One year funding? Well -- 12 DR. BE8SON: Three years is 824. 13 DR. GIMBLE: Can I raise a question? 14 I have no doubt with the money you give them they 15 will be able to set up ambulances and equip a communications 16 system. 17 I was unsure that they had looked into what they 18 needed. I am sure they can tie them all together but after 19 they tie them all together, is that going tobe adequate? It 20 seems like they are putting a lot of money into something with- 21 out having data to support it. 22 DR. MC PHEDRAN: Yes. 23 DR. SCHERLIS: My other concern is voiced by the 24 training aspects of having the hardware and not the software kce -Federal Reporters, Inc. to go with it. I do have concern on that point. 25 7 3 nb-14 I MR. TOOMEY: How many counties were involved in 2 @ this document? 3 Was this the whole area? DR. BESSON: No, not by a long shot. 4 5 DR. MC PHEDRAN: No, it is Erie County. 6 MR. TOOMEY: Erie County? 7 DR. BESSON: I believe it is just this county, and 8 then during this period of time they are going to expand it 9 beyond Erie County, presumably to the whole state. 10 But I think for the time being, it is just Erie 11 And contiguous counties. Not even the whole county, the 12 Buffalo area. 13 MR. TOOMEY: They had a fellow named Dr. Sults, 14 S-u-1-t-s, who has done a very complete analysis of the whole 15 medical hospital emergency services. 16 Do they mention that in application at all? 17 DR. MC PHEDRAN: I don't recall. 18 MR. TOOMEY: This is kind of in answer to your commint. This Dr. Sults has -- 19 20 DR. GIMBLE: There was an initial survey done but 21 they concluded from that, if I remember correctly, that they 22 needed a more in-department study, which is why they request 23 add larger amount for R & D. So the questions asked on the 24 first survey were superficial and did not provide enough @ce- Federal Reporters, Inc. answers for a total system. 25 74 nb-15 Despite that they are spending a lot of money to put in equipment on a system they haven't analyzed thoroughly. 2 3 That made me a little leary. DR4 MC PHEDRAN: This is the region shown here and 4 5 here is Erie County in there. This is -- it includes Erie, 6 Pennsylvania, and McKean County, Pennsylvania. 7 The rest of them are New York counties. 8 DR. JOSLYN: This project and the funds, the 9 800tooo is just for Erie County. Is that true? 10 DR. BESSON: It is for less than that, primarily 11 for the Buffalo area. And they speak about expanding it. 12 DR. JOSLYN: That is not included in the funding 13 at this point. 14 DR. MC PHEDRAN: That is right. 15 DR. BESSON: They speak of EMT training as being 16 over a larger region and -- from their abstract, and they say, 17 "Counties surrounding Erie, New York, have expressed interest 18 in participating, and the Erie County Commissioner of Health 19 has informed them that,, "Courses would be open to individuals 20 throught the region. But so far as the communications are 21 concerned the ten participating hospitals are in the immediate 22 area around Buffalo,, one regional hospital, and the 44 ambu- 23 lances serve just that area. 24 DR. SCHERLIS: Mrs.; Faatz, can you help us on this? kce- Federal Reporters, Inc. DR. FAATZ: I did not hear the last comment. 25 75 1 DR. SCIIERLIS: Do you have any comment at all as nb-16 2 far as the total application is concerned, their ability to 3 carry this out or their degree of regionalization as far as the Lakes Areas are concerned? 4 5 DR. FAATZ: I think the feeling on the Eastern branct is that they can probably do what they say they would like 6 7 to do. With regard to Dr. Sults, I don't know his degree of 8 involvement with this particular application, but I know he 9 is still working with the RMP there and is quite involved in 10 a number of their activities so I don't imagine he was shunted 11 off to the corner. 12 DR. SCHERLIS: I would like the record to show that 13 Dr. Roth left the room because of his involvement with the 14 area, 15 Yes? 16 DR. DIMICK: I would like to make one comment 17 regarding pro3ect summary. As Dr. Besson indicated a moment 18 ago the radio system is supposed to alleviate overcrowding of 19 emergency room facilities. And I seriously question, as one 20 who is in charge of a university busy emergency department 21 and trying to coordinate 13 other hospitals in our city -- I 22 am not so sure radio communications is going to alleviate 23 overcrowding of facilities. The same question you are rais'11)9,, 24 the radio system is no panacea for these types of problems. kce -Federal Reporters, Inc. I am sure it will help direct ambulances to less 25 76 1 crowded facilities but not alleviate overcrowding. nb-17 2 DR. BESSON: I agree with that, it doesn't address 3 the basic question of what creates overcrowding. All they want to do is facilitate knowing what the green, yellow or 4 5 red Allert state of each emergency room is and direct people 6 elsewhere, maybe. But that is in theory. 7 DR. SCHERLIS: Is there any feeling from the reviewers as to how many emergency technicians are trained 8 9 at this point who could man ambulances if they were fully 10 equipped and put into that area? 11 DR. MC PHEDRAN: I don't know. 12 DR. SCHERLIS: My big concern remains the fact 13 that all these ambulances will be equipped at a time when the 14 technicians would not be trained. I think it is an over 15 generous request in terms of what we know about that area and 16 what organization is there, what still has to be done to get 17 a system of care into that area. 18 DR. GIMBLE. I would..,.like to raise the question also 19 of do they know how many ambulances they need? 20 Are we going to equip 44 ambulances with communications 21 when they only nee ? 22 That would be an awful waste. Do they have data 23 showing that they need 44 ambulances or are they just picking 24 the number of ambulances they currently have to have operated. \ce- Federal Reporters, Inc. DR. SCHERLIS: My suggestion would be one way to 25 77 1 approach this might be with the first year being budgeted less, nb-18 2 and let's see where they get with a few ambulances and some 3 training, and then make the second and third year contingent upon evidences of performance and having set up a system of 4 5 care the first, year. 6 I would be much more willing to vote on that favor- 7 ably than on giving them what they have requested in view 8 of the discussion of points that have been raised. 9 Would that be acceptable? 10 DR. MC PHEDRAN: I would go along with that. Maybe 11 reducing it by half, to half of what it is, as a reasonable- 12 figure? Just reduce that part of it. 13 DR. SCHERLIS: F6r'.the first year? 14 DR. MC PHEDRAN: Right. And the second or third 15 year -- 16 DR. MC PHEDRAN: Make it just for the first year, 17 if they can be equipped as Dr. Besson suggested. Perhaps that 18 would be the best way. Because by the end of that time they 19 should see if they can get enough people to run the @ ulances. 20 DR. SCHERLIS: What we are discussing is 150,000, 21 but the conditions of the award, including the facts that both 22 the equipment and training would run hand in hand, and that 23 the second or third year would be considered as based upon 24 what they have accomplished and also upon evidence of setting \ce -Federal Reporters, Inc. up a true emergency medical system -- would that be more in 25 line with some discussion? nb-19 DR. MC PHEDRAN: For the first year you would want 3 to out the communications equipment in half? 4 DR. SCHERLIS: Yes. 5 DR. MC PHEDRAN: That would take it down to about 103 for that, communications, and then leave the others, which 0 7 are the M.E.T. training and research and evaluation component, 8 intact. 9@ DR. SCHERLIS: How much is that? 101 DR. MC PHEDRAN: In round figures, 231. 11 DR. BESSON: Plus another 14,000 for project personn(.,l. 12 DR. MC PHEDRAN: Okay-,' I'm sorry. 13 DR. HINMAN: 245? 14 DR. MC PHEORAN: 245. 15 DR. BESSON: 250. 16 DR. HINMAN: I have a question for staff clari- 17 fication. Do I understand you correctly that you feel that 18 in all liklihood, that the region could use the total amount 19 requested over a three year period if they progress satis- 20 factorily, and that you are limiting the first year recommended 21 amount to 250,000, and the rest being contingent upon perfor- 22 mance during the first year? 23 DR. MC PHEDRAN: Yes. 24 DR. SCHERLIS: I think it has to be reviewed after Ace-Federal Reporters, Inc. the first year. 25 79 1 DR. MC PIIEDRAN: Yes. nb-20 2 DR. HINMAN: One year approval only? 3 DR. BESSON: One year approval only, and re-review. 4 DR. HINMAN: Okay. 5 DR. SCHERLIS: When you say, could they use it, I don't think there is an area in the United States that 6 7 can't come up with a paper plan of communications and the need 8 to train emergency medical technicians. 9 I think we have to show that there is a need and 10 an ability to utilize these funds. 11 And I think we have the feeling here that the area, 12 at least probably can use it. We aren't quite satisfied with 13 the total demonstration of need in terms of numbers of 14 vehicles and so on. 15 I think the recommendation made at least would 16 move them towards justification of this. 17 DR. MC PHEDRAN: Okay. 18 DR. SCHERLIS: What was the rating? DR. MC PHEDRAN: Three. 19 DR. SCHERLIS: Three. That has been seconded? 20 DR. BESSON: Yes. 21 22 DR. SCHERLIS: Any further comment, Mr. Toomey? MR. TOOMEY: No. 23 24 DR. SCHERLIS: Is there concurrence on this,, then? ikce- Federal Reporters, Inc. All in favor, say, aye. 25 80 nb-21 1 (Chorus of ayes.) 2 DR. SCHERLIS: All right. 3 I guess Dr. Roth can come back in the room. MR. TOOMEY: I had not read this material, but I 4 5 was on a site review there a year ago and I was impressed 6 by Dr. Sults and I was also impressed with the lack of services in the innercity in Buffalo. These two things kind 7 8 of stood out. xxx 9 DR. SCHERLIS: Maine. Dr. McPhedran? 10 DR. MC PHEDRAN: This is part of an EMS system. 11 The application indicates that in the Department of Health in 12 the state, there is already some interest and ferment about 0 13 emergency medical dare system, and this proposal here is for 14 An ambulance attendant and other medical -- emergency medical 15 personnel training system, and also as Dr. Bess6n indicated 16 previously, a design for an emergency transportation system 17 to be developed as part of the establishment of coordinated 18 medical care systems. 19 The wish is to develop a packaged standardized 20 hospital based training course for use throughout the state. 21 And the funds requested in the first year, a total of 123,000i 0 That is broken down -- the equipment part of that, since we can't help but be interested in that, includes some videotape 23 equipment, training aids and so forth, totaling about $50,000. 24 @ce- Federal Reporters, Inc. About 40 percent of the total that is requested for 25 81 1 first year and in the second year and third year of this requested nb-22 2 three year program, there are no more equipment requests and 3 the budget drops considerably. It also drops because in the 4 first year they propose to do a transportation study using 5 a consultant whose name I have forgotten, now. 6 DR. BESSON: Chi Systems. 7 DR. MC PHEDRAN: Chi Systems, thank you. 8 The transportation study for the state of Maine 9 is proposed for the first year at a cost of $22,000. 10 Now, I thought that the proposed course of instruc- 11 tion was worthy, and it was probably something that would be 12 quite useful in the state, around the state. I really didn t 13 get the feel at all of the transportation study. 14 Maybe Dr. Besson has another view of it. But it 15 seemed to me that ih the terms that they described it in 16 this application, the terms were so very general that I 17 really didn't get much of a feel as to what they would do, how 18 they would go about it. And I didn't get much of a feel that 19 i wanted to support it. 20 Really what we are being asked to do here is to 21 give money for support of two fragments of a system, and the 22 total system we really don't see in the application or didn't 23 see, in the application. 24 And the one fragment seems to me worthy of support, Ace - Federa I Repof ters, Inc. 25 But I am not -- I guess I don't know enough about the Chi Systems ii z I study, and their presentation doesn't give me enough of a feel nb-23 2 for it in any specific terms. 3 It is all so general. I don't know whether I want to support it or not. I would like to have help from 4 5 Dr. Besson about this. 6 I would have rated this fragment, that is the emer- 7 gency medical training, as a three, And recommended support 8 for it. But the other I feel very doubtful about. 9 DR. SCHERLIS: Dr. Besson? 10 DR. BESSON: I had occasion to review Maine previously 11 and I am impressed with Dr. Chattogee's approach to the entire region and the term used by an individual is in the operations 12 branch is frugality. 1 3 14 I think that is a very applicable term. T e average income per capita in the state of Maine is something like 15 16 3400, and one-third of the population has an income of under 17 5900,, with over 5 percent of the people over 65 living at 18 the poverty level. 19 The distribution of its population is extremely 20 rural, 5 percent of the people in Maine living outside of the urban areas. 21 22 Now, the emphasis in this application is certainly 23 on transportation. They have developed a communications net- 24 work whith has been vital to keep in touch in that very rural Ace -Federal Reporters, Inc. state. A rural and inaccessible state -- they use the term of 25 83 1 a trip that would ordinarily take a half hour in the summer 2 time and it might ordinarily take four hours in the winter nb-24 3 time and that is applicable to rural Maine. So they have had a communications in the past which 4 5 has been developed and it is very functional, They have also 6 developed a use of video physicians, let me just say, use of 7 videotape for physician training which has been excellent in 8 utilizing the,scarce time of physicians in being involved 9 in this kind of a program. 10 they are developing a whole medical school, I under- 11 stand, from having read an application previously, on this basis, 12 And it is an extremely innovative approach to the 13 use of scarce teacher manpower. They recognize the short comings in their pretraining program for EMTSO and speak about 14 15 adding to their training by the incremental approach of block 16 training in extrication, various aspects of EMT training, in 17 house training, AOS hospital base, Red Cross, so forth, with a 18 good systematic training for EMT. 19 The critique of the application mentions that the 20 emphasis is upon transportation and Dr. McPhedran certainly 21 implies that and I don't disagree. 22 But I am also impressed by the fact that recognizing 23 that they might get some help in creating a transportation system, they apparently put out to bid among systems groups 24 Ace-Fedefal Repofters, Inc. throughout the country what their problem is,, and Chi Systems 25 8 4 1 of Ann'Arbor, Michigan, whom I had never heard of before, nb-25 2 submitted a proposal for solving their transportation problem. 3 I am interested in Chi System's approach to this 4 whole thing, approaching it as a very astute systems firm. 5 And I think that their submission of their study approach I 6 am impressed@w'ith,, and the dollars involved, the $140000. 7 I think that is money well spent. That will buy 8 the wheels on an ambulance, but it will be very well spent if 9 the entire transportation system is studied. Then they speak 10 of implementing the system for individual counties, for 11 individual region&, as being an additional 7000, applying this 12 methodology to other regions, and then each additional region 13 is 4000, and so forth. 14 I like this approach of RMP recognizing that.,@hey ha%e 15 limited expense, and buying expertise. I think that $14,000 16 is money well spent. 17 Their emergency room problem is also mentioned in 18 the critique as hot being addressed and I agree that that is 19 the probldm, that is a very significant problem. 20 But in contrast to many more blessed areas in the 21 country where they have people who can staff emergency rooms 22 and have a plethora,6f professional physician; personnel, Maine 23 has a problem in that they have physician shortage. 24 The best they can do is get a physician out of his Ace -Federal Reporters, Inc. busy office to answer an emergency room call which is relatively 25 8 5 nb-26 1 impossible. They have a problem in staffing emergency rooms. 2 So I see reason for not addressing that particular problem, 3 but this time I think a region of this maturity will. 4 So in general I agree that the proposal is a good 5 one and I wouldn't be reticent about funding the transportation 6 subcontract, and I would recommedn with Dr. McPhedran that it 7 be fully funded. 8 DR. MC PHEDRAN: I go along with you about the trans- portation subcontract. I just don't have a good feeling for 9 10 this kind of systems approach. It isn't something that means 1 1 a great deal to me. 12 It would mean an awful lot more to me if somebody 13 had written down -- had taken examples from Ptestique Isle, 14 or Aroostook, or some place like that, you know. 15 Then I could understand it, begause I know the 16 state and I could understand it. To address it this way it is hard for me to appreciate. But if you think it is okay, 17 18 I will go along with it. 19 You knows we have said that it is mostly transpor- 20 tation. It really isn't though, most of the budget has to do 21 with training, and it is a small part of it that addresses 22 this transportation study. Those are the two items. 23 24 DR. SCHERLIS: How do you rate this? Ace-Federal Reporters, Inc. DR. MC PHEDRAN: I rated the transportation -- I 25 86 I didn't know how to rate the transportation part. The other 2@ part I would rate as a four. nb-27 3 I thought the training was good, the training program was good. 4 5 DR. SCHERLIS: You are n6dding your head to show 6 concurrence, Mr. Besson. 7 DR. BESSON: I would rate the whole program as 8 four. 9 DR. SCHERLIS: You are recommending full funding? 10 DR. MC PHEDRAN: Full funding. 11 DR. SCHERLIS: For three years? 12 DR. MC PHEDRAN: Yes. 13 DR. SCKERLIS: Any considerations or recommendations 14 that go along with the award? 15 DR* BESSON: Spend it frugally. 16 DR4 MC PHEDRAN: Which they will. 17 DR. SCIFERLIS: Any other comments? 18 All those in favor say, aye? 19 (Chorus of ayes.) 20 DR. SCHERLIS: Opposed? 21 (No response.) nd of#6 22 DR. SCHERLIS: All right. 23 24 Ace -Federal Reporters, Inc. 25 87 CR 6307 dh-1 Next area is Metropolitan Washington. The report 7 2 will show that Dr. Matoty left during this discussion. 3 DR. BESSON: Mr. Chairman, I feel that since Dr. 4 McPhedran and I are the only ones who have done any work for 5 this committee meeting, that we be given special recognition. 6 DR. SCHERLIS: I would like that expunged from the 7 record. xxxx 8 DR. BESSON: Metro Washington. This is an applica- 9 tion for $95,000 for a 6 month period of time. 10 DR. SCHERLIS: A question on that. Our white sheets 11 show $79,000. Would someone explain? 12 DR. BESSON: I suppose the white sheets take prece- 1 3dence. 14 DR. HINMAN: 94 is direct, or indirect, and 79 is 15 the direct funding. 16 DR. BESSON: Thank you. 17 DR. SCHERLIS: Thank you. 18 DR. BESSON: They're going to contract with an RMP- 19 EMS coordinating committee, which is going to contract for ser- 20 vices of resources and data information establishment of needs 21 and development of a plan for the Metropolitan Washington area, 40 22 Their application is to a great extent a reiteration 23 of the wording of the guidelines that they have previously sub- 24 mitted to them. It is clearly a planning and developmental Ace -Federal Reporters, Inc. 25 request. They have no apparent, intrinsic core competency in I 88 dh-2 I the field, and they have asked for the subcontracting organiza- 2 tions that they may work with, particularly Block McGibney, and 3 I forget the other one, whatever it is, who are management con- 4 sultants for health systems of one sort or another -- to put 5 together a program. 6 And having worked with applications that were put 7 together by Block McGibneyp I think this application was written 8 by Block McGibney as a potential subcontract, to taking it on 9 a contingency basis. That may not be a fair statement but I 10 think it is the best method. 11 C. Can do at the moment. 12 The staff summary critiques this as lacking a com- munity base for information to be implemented, and it suggests 1 3 14 revealing this community base first, and I certainly agree with 15 that. But method C. has problems. 16 Beyond their soluble problems, but I intend to be 17 very charitable towards Method C in spite of the fact that we 18 have some negative comments by associated department of health 19 in Prince George's County, and the District of Columbia Medical 20 Society, which I would like to read to you indicating the tenuous 21 nature of the effort by the sobcontractor to put together a 0 22 system. 23 In letters of support received by the program coor- 24 dinator of Method C.-RMP, the medical society of the District Ace - Federal Reporters, Inc. of Columbia says, "Thoroughly in agreement with one concept ofthe 25 89 dh-3 1 plan. Heartily I endorse it." However, I am somewhat distressed 2 by the fact that that group will furnish the major amounts of 3the emergency services are not included in much of the earlier 4planning, namely, the physicians in the area. 5 They go on to say that, "If this prominent,omission 6can be corrected,uthat is,@the medical community is not enmeshed 7in their planning effort, they would be pleased to lend their 8full endorsement to the program. Now, even the county department 9of health of Prince George Is County says that, "The emergency 10 medical services system coordinating committee is packed with 11 health planners who plan on a technical basis, but have no ,emergency 12i medical service procedures. 13 I do hot mean to reflect adversly on the members 1 4chosen for the comm ittee since I know many of them and they Ire 15 all capable people," as Caesar was, "But the committee has no 16 physicians who are active in the practice of medicine. The 17 committee has no emergency room physicians, no members from plaiL8 18 or rescue squads, no members from hospitals. 19 The only MDs taken are from Government servic4@@ll,.@@ 20 and I think that is a very touching statement of what is happen- 21 ing in asking the nation to respond in 6 weeks to a problem 22 that has awsome implications. 23 Beyond what to do with the dilemma any more than the 24 rest of us do, and I am not faulting RMPS. That is the nature Ace - Federal Reporters, Inc. of the exigencies of funding. 25 90 dh-4 I So if I put all of these rambling comments together, 2 I say that this application . written by a sub contractor for a 3 RMP that has probably one of the worst management histories, is 4 a planning grant for 6 months. And though I would grade this 5 on the basis of 1 to 5, maybe 2, and I would note the reserva- 6 tions, I would still fund them fully because they need all the 7 help@ they can get and this is a tremendous problem for the 8 area. 9 DR. SCHERLIS: Would you state whether or not you 10 have any conditions on that? In other words, would you go a ong 11 with some of the letters that have,been written, or do you just 12 give it without condition? 13 DR. BESSON: Well, I suppose the conditions@are in- 14 herent- in what our leverage is. All we can do is 2 things, 15 provide moneys and assistance, advice, resource ass.istancei 16 The money we can do easily. We can say yes or no, 17 'The advice is a little harder. Yet, we have been 18 trying to do this for how many years now, Judy, and it is like 19 trying to get blood out of a.turnip. There are no conditions 20 that I would specify on these monies except do a good job, 21 fellows. 22 DR. SCHERLIS: Second area reviewer, Mr. Toomey? 23 MR. TOOMEY: My comments actually followed pretty 24 closelywhdt Dr4 Besson said. The coordinating committee on Ace-Federal Reporters, Inc. emergency @ services including representatives from Maryland.,,, 25 1 i -'? Virginia# and the 9 1 dh-5 I District of Columbia, to contract with a independent health plan- 2 ning organization for the development of the plan. It is an 3 application for a planning grant rather than a program grant. 4 According to page 9 of the application, the EMS 5 programs have a history of being unsatisfactory and are not 6 effective. This proposal plans to eliminate the causes for 7 these unsatisfactory systems by revealing a plan which will 8 provide the philosophy, guidelines, and methodologies to be 9 followed to insure the development of a regional council on 1 0 EMS. 11 DR. SCHERLIS: Philosophy. identification of rules 12 particularly current and future requirements, maximum effective 13 utilization of anexses to current resources, medical profession 14 and community patience, coordination and control, identification 15 of linkages with non-EMS health care agencies, linkages with 16 supportive agencies, specifications of standards. 17 I won't go on. The fact is that they apparently are 18 greatly in need of an organized and coordinated program and the 19 indications are that the first step necessary would be.@such a 20 study as they're talking about. And I frankly don't know where 21 I would rate it but I think that it is the kind of thing that 22 we probably would justified in providing funds for, for this 23 study to be done. 24 DR. SCHERLIS: I 'Was just looking at the list of mem- Ace-Federal Reporters, Inc. bers of their coordinating committee. And whether you reviewed 25 9 2 dh-'6 I it, do you share the concerns of those letters? I do, to a 2great degree. 3 DR. BESSON: Sure. I think it is the best we have 4in method C., though, and I suppose I mentioned my feelings 5earlier, that we are either going to rewar t e strong or 6nurture the week. And I think if it is a seedling that we are 7interested in, my personal approach is to fund all the seedlings 8and nurture all the saplings, and straighten out the weak ones. 9 I think we have to be most cost-effective with our 10 money, and rather than saying no to method C, I think for $79 11 grand, whether we by an ambulance for Albany, or wherever at the 12 same amount of money, that this is money well spent. DR. SCHERLIS: Would you accept as one of the condi- 13 14 tions that they restructure their coordinating committee to make 15 it a much more representative group? 16 DR. BESSON: Sure. 17 DR. SCHERLIS: As I look at it, it is a governmental 18 agency that has been transposed'to Metto and operating an-emerg- 19 ency system. Would that be acceptable? 20 DR. BESSON: Absolutely. We'll accept this as a 2 1motion. 22 Mr. Chairman, rather than reiterating this, I think 23 that in advice that would go with each of these funding awards, 24 I think that is an opportunity for us to tell them and tell Ace - Federat Reportets, Inc. them and tell them again. 25 9 3 dh-;7 I DR. SCHERLIS: Yes. 2 DR: BESSON: All of them. 3 DR. SCHERLIS: There are no apparent consumers on 4this. 5 DR. BESSON: Don't you agree, Judy'? 6 DR. SILSBEE: I haven't had a chance to rea e 7application, but who is going to be -- 8 DR. BESSON: Block McGibney. 9 DR. SILSBEE: The subcontractor? 10 DR. BESSON: Yes. 11 They are going to put together a plan and come back 12 after the $79 grand are spent with a plan. 13 DR. HINMAN: .,Doesn't it bother you a little bit 14 that a professional grant writing group doesn't know to get the 15 right group involved.7 16 DR. BESSON: I have worked with Block, McGibney 17 before, I think they're idiots. But they're the best we have, 18 I suppose. I would like maybe for Kai Systems to have gotten 19 involved in this, or some other more astute organization. 20 DR. SCHERLIS: If I recall your comments with Kai 21 Systems, you were impressed with their documentation but you 22 don't have any personal experince with that group, is that 23 correct? 24 DR. BESSON: I don't work with them. Ace-Fedefal Reporters, Inc. DR. SCHERLIS:@ Do you know anything about them? 25 9 4 dh-8 1 DR. BESSON: This is the first time I have ever en- 2 countered Kai Systems. 3 DR. SCHERLIS: I didn't want this to be construed on 4 the record as a personal recommendation based on experience, 5 It is just a personal recommendation, right? 6 DR. BESSON: We'll expunge that one, too. 7 DR. SCHERLIS: Expunged. 8 There is a problem with an area like Metro. I think 9 we all know from personal experiences of the tremendous need 10 and we're pleased the're going to do something about it. We 11 are concerned about this frankly being developmental money And 12 we don't know what will come of it but at least it is an attempt. 13 I would assume.that RMP is close enough to the scene 14 that hopefully, there would be careful monitoring of what goes 15 on in the area. That hasn't been the history of M'etro,,: 1 6 has it? 17 DR. SILSBEE: That has not been the history of the 18 region. 19 DR-. HINMAN: Their acceptance of previous staff advice 20 has not been high. 21 DR. SCHERLIS: I would hope that these funds would bE 22 supplemented quite definitely as a new funding mechanism, at 23 the least, new funds. 24 Any other comments? Ace -Federal Reporters, Inc. (No response.) 25 !I @ dh-9 1 This known as a negative halo effect, it comes out 2 favorably. All those in favor say aye. 3 (Chorus of ayes) 4 opposed? 5 DR. FAATZ: What is it ranging? 6 DR. SCHERLIS: Two. 7 DR. JOSLYN: And full funding? 8 DR. SCHERLIS: Yes. 9 DR. BESSON: One year, that is all I requested. end #7 10 DR. JOSLYN: Yes. CR 6307 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Ace - Fedetat Reportefs, Inc. 25 9 6 ii6307 I DR. SCliERLIS: Next is New Jersey. Lee (8) 5/15172 2 DR. MC PHEDRAli: There are two pieces here. one is 1 3according to their numbering system, 028 Emergency medical 4Service System Plan, 029 is a Computerized Shock and 5Assessment of Treatment. 6 I would say in summary that these are either 7rated -- I will rate them as one or "can't rate them," and 8would not recommend them for any funding. 9 In the Emergency Medical System Plan, there is 10 simply not enough information really to tell anything about 11 needs or resources, let alone to relate the different resources 12 one to another. 13 It is a proposal to evaluate these things, but it 14 seems that like the other regions, they might have accumulated 15 enough information sort of to give us a feeling that they had 16 some faint idea what the problems might be, other than that 17 there are serious problems of deprived people in urban centers. 18 1 really -- I couldn't tell much of anything about ig a state that I really know a lot about, from having been there 20 many times. I just don't think there is enough information, 21 enought detail here, to warrant funding the System Plan. That 22 is the part of it that I think would be -- might be appropriate 23 for RMP's funding. 24 The other is a study as Dr. Gimble correctly -- I Ace-Federal Reporters, Inc. think it was Dr. Gimble that reviewed this,--@stated. No, 25 9 7 jr 2 sombody else, I'm sorry. A study of a method of evaluating 2 patients in shock and using a computer system for deciding on 4D 3 the effective treatment, and it is a clinical study, and I 4 think not appropriate for RMP funding. 5 So in summary, I wouldn't recommend any funding for 6 either one and rate them both as one. 7 What they have produced here stands in contrast to 8 what I gather -- eastern operations said this is a region that 9 has had good management capability in the past. And it doesn't 1 0 come through. 11 DR. SCHERLIS: Dr. Besson? 0 12 DR. BESSON: Yes. I agree with the physiological 13 monitoring. 14 This is a reflection of the kind of thing Albany 15 wanted to do and I think it is inappropriate for RMP, and 16 nothing further need be said about that. 17 The other program, the integrated program, so 18 called,, means to survey transportation by an interagency 19 council, develop a plan for EMT training, assess emergency 20 rooms, and identify the needs of the poor working with mo e 21 cities and community development cities, 20 in all, to improve 22 the emergency care rendered to the poor. 23 I view this as a developmental grant, this proportion 24 of it, and I agree with Dr4 McPhedran and the reviewer, Ace - Federal Reporters, Inc. 25 Dr. Gimble, that the entire program is extremely sketchy and I 9 8 jr 3 1 scant, although New Jersey does have a good program coordinator 2 @and in general has been a relatively mature region. 3 Again I am charitable in saying that this was the 4 result of the precipitous nature of the proposal submission, 5and I am a little bit more charitable in not faulting the 6region as Dr. McPhedran might be in not giving them any funding. 7 I think the fact that they do have a model cities 8program that is working, that is interested in becoming 9attached to this kind of effort, I think the fact that they are 10 using the model cities in their community development program 11 as an entry point for not only providing emergency services 12 f or the poor, but addressing the nation-wide utilization o 13 emergency services as an access point, which is an entirely 14 different question, and one which has to be answered -- we 15 can't overlook it by talking just at the lofty level of pro- 16 viding emergency medical services. 17 Many people use it as an access point. So, while 18 there is no recognition of that aspect of it in their proposal, 19 and the whole thing is very sketchy.. I think it is interesting 20 that RMP is talking to consumers who will rapidly bring this 21 to their attention. And with their maturity 22 @, I would be inclined to maybe 23 rather than not giving them any funding, to give them one-third 24 Or so funding of the second component only. Ace - Federal Reporters, Inc. DR. SCHERLIS: How much would that be? 2 5 99 jr 4 DR. MC PHEDRAN: About $40,000. 2 DR. BESS014: $40,000, yes. 3 DR. GIMBLE: Are you, talking about 28 now? Proposal 4 028? 5 DR. BESS014: Yes. Fund nothing for 29. 6 DR. SCLIERLIS: The agreement is zero funding level 7 for the shock study. 8 DR. MC PHEDRAN: Okay. 9 DR. SCHERLIS: And now you are talking in terms of 10 getting this off the ground, the general proposal; and you are 11 recommending how much? 12 DR. BESSON: We have two motions. 13 DR. MC PHEDRAN: I agree with you, I think that is 14 an important part of it. I think that is an important oppor- 15 tunity that they have. This is a problem everybody has an 16 they did address that as a specific objective more than many 17 of the other plans did, I guess. 18 Okay, I'll wnend mine. I'll go along with that. 19 still, it is hard to recommend anything for something which 20 I still find I can't rate. 21 I find sort of an internal inconsistency with 22 recommending any funds at all for something that I would rate 23 so low. 24 DR. HINMAli: You could rate 29 separately from 28. Ace-Federal Reporters, Inc. 25 DR. MC PHEDRAN: Yes. I've done that. I 100 jr 5 1 DR. SCHERLIS: I think the rating we should have is 2 purely on that fragment of the approved project. 3 DR. MC PHEDRAN: Yes.. Okay - 4 DR. GIMBLE: I would like to comment. They mention 5 a specific problem in New Jersey: The independence of the 0 volunteer emergency squads. And most of their application 7 appears to be directed at improving the quality of service 8 rendered by these squads. 9 The thing I find unfortunate, though I think it is 10 a good opportunity to get all the squads together in terms of 11 getting cooperation., this isn't very strongly put forth in the 12 application. I think that is the most important part of the 1 3 application. 14 if they could use this as a vehicle for cooperation 15 between squads and between emergency rooms and hospitals, it 1 6 would be important. 17 I get the feeling it is overlooked in this applica- 18 tion and I think a recommendation to that effect, rather than 19 just support the squads on an X amount of money for each squad 20 to improve their education. 21 But somehow they should be hooked into getting them 22 together for a cooperative venture, more than just a training 23 amount. 24 DR. BESSON: I agree with that. I see the only Ace - Federal Reporters, Inc. 25 virtue of this application, $40,000, will be to help them get I 101 jr 6 off the ground, and also to sit down and talk with some urban 2 poor. Once they sit down and talk with them, I'm sure they 3 will get the answer, "Gee, where have you been? we're glad 4 you asked." And from then they will submit a much more rele- 5 vant application next year. 6 DR. SCHERLIS: Do,you have any comments about the 7 New Jersey area, Mrs. Faatz? 8 DR. FAATZ: No. 9 DR. SCHERLIS: What is the rating then, the two of 10 you? 11 DR. MC PHEDRAN: Well, as part of a system, I guess 12 I might rate these parts as a 2 or 3. But as the whole, -- 13 028 is this whole plan, that is the number altogether. 14 DR. SCHERLIS: Yes. 15 DR. MC PHEDRAN: As a whole, I don't think you 16 could give it that high a rating. But these portions of it, 17 where they talk about identifying and trying to do something 18 about problems of urban poor, to correct this abuse of emer-- 19 gency room systems, to do something to devise some system to 20 do that, to get away from that, we could rate that as 2. 21 DR. SCIIERLIS: Do you accept that as a 2 rating? 22 DR. BESSON: Sure. 23 DR. SCHERLIS: Dr. Rose? 24 DR. ROSE: May I ask whether you would like to con- Ace-Federal Reporters, Inc. 25 sider breaking down 028? You are able to break that down if I jr 7 1 you would like. 2 DR. BESSON: You would rate the physiological moni- 3 toring as one? As zero? What is the'least? 4 DR. MC PHEDRAN: Zero. 5 DR. SCHERLIS: Zero. 6 DR. MC PHEDRAN: It is inappropriate. 7 DR. SCHERLIS: I think we could accept zero. 8 DR. BESSON: The other is 2.5. I would go along 9 with that. 10 DR. SCHERLIS: Is that satisfactory? 11 DR. ROSE: That is for the whole 028 project? You 12 don't want to place any restrictions as to what kind of activi- 13 ties they will be doing in that project? 14 DR. BESSON: No. 15 DR. GIMBLE: I didn't find enough material to break 16 down, unfortunately. 17 DR. SCHERLIS: We are talking about making a start 18 on a system of dare, and trying to get into the ambulance 19 problem and hoping the training might be the wedge to Make them 20 less independent. 21 DR. BESSON: I don't know that it would be appropriate 22 for us to say, "You can only work on component 4." 23 I think we have to give them this amount of money 24 with the advice. Ace-Federal Reporters, Inc. DR. SCHERLIS: That they try to set up a system of 25 10 3 ir 8 1 care 2 DR. BESSON: Yes, and let them do the best they can. 3 DR. SCHERLIS: Right. Any further discussion? 4 All those in favor, say aye. 5 (Chorus of ayes.) 6 DR. SCIIERLIS: All right. That is New Jersey. 7Next is New York Metro. 8 9 10 I I 1 2 1 3 14 15 1 6 17 18 1 9 20 2 1 0 22 23 24 Ace-Federal Reporters, Inc. 25 # 104 Mil-1 DR. SCHERLIS: Dr. Besson, metropolitan New York. 2 DR. BESSON: Let the record show that I can leave 3 at 1:00 as soon as I am through. 4 DR. SCHERLIS: I give that a reading of one. 5 DR. HINMAN: Zero. 6 DR. BESSON: Metropolitan New York is asking for 7 two years funding from July, '72, to July, '74, $225,000 8 for a problem which may be stated thusly: that 70 percent of 9 visits at the Bronx Municipal Hospital Center, or nationally 10 -- Bronx Municipal Hospital Center is what we are talking 11 about -- 70 percent of visits are to the emergency room. 12 Primary care in the emergency room, we all know, is far 13 greater, up to 10 times as great as costs otherwise, and it 14 ties up facilities. 15 The alternative I have proposed in this application 16 is to develop what is called a triage M.D., an R.N., or @ 17 medical coreman or technician and with three months' training, 18 to triag6@into one of.Ithree categories: immediate emergency, 19 the late emergency, or non-emergency. The principal investi- 20 gator or who has been doing this kind of thing, social work 21 type, says that 1970 at the Bronx Municipal Hospital Center, 22 there were 83,000 patients seen in the emergency roomand in 23 the non-appointment clinic, which are the walk-insi there 24 were 40,000 patients. Ace-Federal Reporters, Inc. When this system was instituted, a ttiage, the 25 105 mil-2 I emergency room census fell uniquely throughout the country 2 from 83,000 to 66,000, and the non-appointment clinic 3 appointments rose to 54,000. She says there is a great deal 4 of value in developing this notion of triaging prior to 5 utilization of emergency room facilities. 6 Now this is a national problem as we all know, 7 and it is nice that somebody is going to do something about it. 8 She proposes to prepare an operational manual, devise a train- 9 ing curriculum for doing triage, do a program analysis, and 10 she describes this in some sketchy detail. A methodology 11 I think, is self-evident. But I think that the development 12 of a triage methodology in a manual at one hospital for 13 $225,000 is just totally inconsonant with the request for 14 proposal that was sent out February 25. It is a piece of the 15 action, no question about it, but it is a very expensive 16 piece. 17 I would consider that of one to five, I would rate 18 this three on merit, but suggest they write a nice letter o 19 the National Center for Health Services Research and 20 Development, and ask them for some funds. Because it would be much more appropriately funded by that organization than by 21 22 this. 23 So even though I like it, I won't eat it. 24 DR. SCHERLIS: Mr. Toomey? Ace-Federal Reporters, Inc. MR. TOOMEY: I liked it, too, and unlike you, I thiik 25 106 mil-3 I I would have at least some bites on it and either part of it. 2 It is an important part of the total system. The utilization 3 of emergency rooms not only in terms of their being brought 4 by plans, but also in terms of the utilization within the 5 emergency room itself, is so frequently inappropriate that 6 any effort in analysis of a subsystem of the total system, 7 it seems to me would be desirable. 8 I think there is an overriding concern on the part 9 of too many people about the use of the emergency room and 10 the problem is not the use of the emergency room, but its 11 inappropriate use. I think whether it is triage or an analysis 12 of the utilization of the emergency room, that is a desirable 13 facet of the RMP's concern. 14 Too many of the applications,as I have read and heard 15 them, have concerned themselves with the transportation 16 and communications and not enough of them with what goes on 17 inside the emergency room to take care of the people who do 18 arrive at that room, at that department. 19 I don't believe there is enough study of the way 20 in which the facility is designed and I don't think there is 21 enough study yet in terms of the services that are provided 22 therein. I felt this was rather sketchy. I felt it was, 23 if you will, typically New York, in that they were going to 24 assign some Ph.D.Is to do in-depth kinds of studies, and I felt Ace -Federal Reporters, Inc' that the amount of money requested for the program was too 25 107 mil-4 I much. 2 But I felt it was something that should be looked 3 at, should be studied and analyzed and consequently I would 4 rate it a little higher and recommend that it receive some 5 funding. I don't know it needs all that was proposed. 6 DR. BESSON: The salary -- here is one hospital, onE 7 emergency room, and they want to have $15,000 for project 8 director to watch the people come in and out and what happens 9 to them, $15,000 for research associate, $3,500 for a 10 technical writer, $9,000 for a secretary, a physician- 11 consultantl,at $100 a day, for $15,000 -- heck, you can provide 12 all the services for everybody for that amount. 13 If you would give me a reasonable kind of figure, 14 Roger, I'll take a small bite. They are asking for two 15 hundred -- 16 DR. SCHERLIS: May I ask a question on this point? 17 When they come up with a manual, will that have any relevance 18 in any place except this hospital? 19 DR. MATORY: I think as all of you have very well 20 stated, there is a desirability of such a study. It is 21 desirable not only so far as the patients are concerned, but 22 also so far as the professionals are concerned. We all feel there is some other way of doing it. We are not all sure 23 24 that it is safe or desirable to have someone else triage. Ace -Federal Reporteis, Inc. The whole idea of triage,we have talked about for a long time 25 10 8 CR6307 Lolg r,,iil-4 I but we are not convinced that triage is worthwhile. We are not 2 convinced that a patient, who comes to the emergency room indeed, 3 should be sent a@,7a,,! bv anybody but the physician. 4 But, this question needs to be answered. one of 5 the reasons why it is difficult to answer is because we are 6 not sure that there is a bod@i of knowledge which vou could 7 entrust, a body of criteria that @iou can trust to a person 8 other than a physician, and feel confident that this has been 9 done. 10 This is a medical--al-)ility thing attached to this. 11 If he is sent away by a nurse or corpmari, and something happens, 12 we all are liable. So certainly, I think that your criticism 13 of the amount of dollars to be placed, certainly that I)ears 14 merit. Ilowever, I wonder if there is not a need to search the 15 budget to see certain things. 16 The most important of these is the evaluation of the effect of the triage, in terms of what really does happen 17 L 18 to the patient, in terms of propatient disposition, patient 19 satisfaction. The evaluation needs to be done over a signifi- cant -)eriod of time and in a significant volume. If, within 20 that budget, a significant amount of this mone,,7 is targeted 21 22 for evaluation, I would lean closer to one hundred twenty-five. 23 But, I would be concerned about such a program being 24 supported. The data which is collected, if properly supported Ace-Federal Reporters, lnc- by re-evaluation, would certainly be of practical value to 25 ter-,2 109 1 others throughout the country. 2 DR. SCIIERLIS: Yes. 3 !4R. TOO@-@IEY: What you are suggesting then, is a 4 redirection of the study in terms of the net results subsequent 0 L 5 t the triage, rather than the mechanisms 'or triage? 6 DR. ,,IATORY: I have not read enough to see how much 7 evaluation is in this, but I think evaluation is a key point 8 in this. 9 MR. TOOMEY: No, it says that, "This project is not intended to evaluate the triage svstem as it operates at the I 0 11 Bronx 'Aunicipal hospital Center, in comparison to no system 12 or to other triage. Rather the goal is to document and codify 13 operating procedures of an ongoing system and specify the training program for the triage professionals staffing that 14 15 system." 16 Pnd then it says, "Evaluation is not appropriate. Monitoring is anpropriate." 17 18 DR. BESSON: That is a significant point because what they reallv are doing is developing a manual, and on page 19 20 nine is an example of the proposed branching-logic-disposition 21 chart, where they have on the top, "Symptom -- Vaginal Bleeding; 22 and they break it up. 23 If it is child bearing -- they go down in this fashion 24 for a medical corpman or somebody to make a decision. That Ace -Federal Reporters, inc- is fine, it is no question that it is going to be useful and 25 ter-.j 110 1 the number of dollars they are going to save nationally, will 2 be all right. If it was not for $225 thousand, I would say 3 all right. 4 I am questioning whether TZ!@!Ps is the vehicle for 5 funding something like this, though, whether we have the power 6 to be generous if it is needed, whether we suggest they apply 7 for the national Center for funding -- these are the nature 8 of my questions, Dr. Matory. 9 Otherwise, I agree with you. 10 DR. Tlz%TORY: If vou say there is not a significant 11 evaluation of this and they set out stating they are not going 12 to evaluate it; to me, it weakens the whole program. It is 13 very desirable but to me, it has no value unless there is a 14 significant amount of evaluation to it. 15 DR. BESSON: This is a health services delivery 16 experimental program that has great merit, but lies out of the 17 purview of -- if you read our guidelines, and look at this, 18 they are two different universes. 19 DR. SCHERLIS: I have some problem with this. 20 DR. BESSON: ilow about a hundred thousand? 21 DR. SCHERLIS: As I read the background of the 22 project director, essentially, it is in the area of statistics 23 operations, research. This is not an accident room or emergency 24 room pnysician, this is someone looking at the system from Ace -Federal Reporters, Inc. 25 the outside. I t(--r-4 I DR. BESSON: But she is going to use physician con- 2 sultants to create the branching manual. 3 DR. SCHERLIS: All medicine is a branching manual. 4 I do not want to be involved with that beyond the point, but 5 I do not know if a simple program is going to be the answer. 6 I was wondering if you might exnound on that a bit? I do not 7 know what you have when you are done with this, even if the 8 success is achieved by her definition. 9 ;Ihat do you have at the end of the $200,000 plus? 10 .'Ns I read it, the proposal seeks funds which will enable us to 11 develo-) a manual of procedures, to develop a syllabus for 12 training triage professionals, and to asses the triage system. 13 DR. t4ATORY: The problem with that, of course, 14 this is available, and particularly the Chicago group have done 15 this. And they have outlines on just what was done. So, 16 again, it would have value if this is developed and utilized and 17 evaluated. 18 It does not disturb me that she is not a part of 19 the system. Indeed, I think that --, 20 DR. SCIIERLIS: That is probably a beneficial effect 2 1at this time. DR. BESSON: TIhat are we payincT her fifteen grand 22 23 for? 24 DR. @@TATORY: I thought I understood his question as Ace - Federal Reporters, Inc. to the value of having a person who is not really a part of 25 112 ter-5 1 the ,)hysician-care system. But to me, this is a plus. It 2 gives her a better opportunity to make a good overview and if 3 she is going to use consultants liberally, she can perhaps, 4 get the whole program together with less prejudice. 5 MR. TOOMEY: The thing that impresses me is the 6 fact that this studv is not applicable to all emergency rooms. 7 It would seem to me it is very applicable to those public 8 hospitals in the large cities in this country, or the large 9 oublic hospitals in the larger cities. 10 I would agree that the monitoring and follo@vup is 11 something that would be desirable. But, while all emergency 12 rooms have problems, I do not think there are an@7 that have 13 as great T)roblems as the municipal and the citv-county 1 4hospitals that do exist. 15 I can see this has a value in those areas. Specific- 16 ally in terms of a manual, itself, and secondly, as far as the ability of -- and I agree with you on the evaluation I very 17 18 much agree. Because, even in the small cities where you have 19 relatively active emergency rooms, and you do have shortages of T-)hvsicians, there is a great reluctance to rely on people 20 other than Physicians to do the triage. 21 And thev are not always available. Consequently, 22 23 I think if this were looked upon as being of value, particularly 24 to those governmental hospitals in the large cities, and added Ace-Federal Reporters, Inc. a bit more stress on the evaluation of the triage, that then 25 113 ter-6 I it would have value to many other organizations. But I am 2 in agreement, I do not think this kind of study should cost 3 anywhere from $200,000 to $250 thousand. I think you should 4 be able to get it done for somewhere in the neighborhood of 5 twentv, fifty, and one hundred thousand. 6 DR. MC PIIEDRAN: Mr. Chairman, we could spend a lot 7 more time with this. In the interests of expediting,, I would 8 defer to the secondary reviewers figure, and if you said fifty 9 to a hundred thousand dollars, I would accept fifty, which is 10 one-third of the requested amount, of 156 for two years. 11 DR. IIINMAN: I have a 'ooint, I am concerned about 12 something. 13 What I hear you saying is that this is information 14 that could be useful in the long run. But, I do not see 15 how this fits our guidelines after attempting to have an P@IP 16 work with provider groups to improve care to patients. We 17 are not in the business of funding R&D.. I thought. 18 I just wonder if you all feel there is merit to 19 proposals or other mechanisms and you could request it be 20 considered for a developmental contract in R&D, or someone 21 else to get the information. But I am just concerned as to 22 how this is going to move Metro New York, -TUIP to improving 23 Datient care for the residents of New York City? 24 DR. SCIIERLIS: This is part of what you have suggested Ace-Federal Reporters, Inc. in the first place, that you refer it to the other agency. 25 114 ter-7 I Perhaps this would be the legitimate answer. 2 DR. BESSOL@: But we are the fat cats, R&D maybe 3 does not have as many bucks as we can, and maybe as long as we 4 have a bird in the hand, we ought to take it that is what 5 I gather his comments are, that the implications are great 6 enough so that if we could fund a little piece of some program 7 in 'Llew Jersey because they are a "red ink," a poor program, we 8 could fund this, even though it is far from the guidelines. 9 DR. HINMAti: Except with New Jersey, I heard you 10 saying that you were attempting to see to it that that RMP 11 talked more with the usual and the poor and their problems of 12 access to emergency services with the espectations that change 13 would occur as a result of it. 14 That is quite different from developing a manual 15 that will give you a method of doing triage. I do not see 16 how that fits what RMPs has talked about in the two or three 17 publications that have gone out on EMS. 18 DR. BESSON: If this is inconsistent with the 19 guidelines, maybe we are just -- 20 DR. SCHERLIS: Let us not prolong the discussion. 21 DR. NIATORY: I think if you go by the guidelines, 0 22 that you are definitely right. On the other hand, if the 23 author would have indicated that this is the type of development 24 which would indeed, effect the other major metropolitan hospital.@ Ace -Federal Reporters, Inc. in this area, if so coordinated through RMP, it would have that 25 115 1 type of value. But, I do not know that this is made clear. 2 DR. BESSON: Besides, I think'as I read the guide- 3 lines, I see -- and as I specifically ask that question, this 4 morning -- that we can fund a component of a system. 5 Ilow, we did not argue too much -- some -- about 6 transportation in l@laine, but communications in western l@ew 7 York, Lakes area. Here is another problem which maybe does 8 not have the same degree of advisability but is a component. 9 DR. SCHERLIS: I think the difference is, though, 10 that while this is a component, the question of whether this 11 is really R&D has to be seriously considered. 12 DR. BESSON: I move we fund them at fifty thousand, 1 3and we give them a rating of three. 14 DR. SCIIERLIS: Mrs. Faatz? 15 DR. FAATZ BEfore you make your final decision, I 16 would like to draw your attention to the eastern branch comments 17 which are to the effect, I think, that metro ilew York is experiencing rather troublesome organizational and management 18 19 Droblems, and they have in fact, projected quite a surplus of 20 unexpended funds over the next sometime. DR. BESSON: I correct mv motion and approve it, 21 1 22 but no funding. Thank you very much, Anne. 23 DR. SCHERLIS: Approve it to what? 24 DR. BESSON: Approve it with a recommendation that Ace - Federal Reporters, Inc. it be funded out of projected surplus of funds. 25 ter-9 116 1 DR. SCHERLIS: what amount? Is that within our 2 legal capability? 3 DR. SILSBEE: You would approve it to $50 thousand, 4 and the decision as to funding -- 5 DR. BESSON: No additional funds. This is a 6 supplemental application. 7 DR. SCHERLIS: I gather as far as EMS is concerned, 8 we should make that a request for funding and not specify 9 where it comes from, and staff will work it out. I do not 10 think part of our consideration should be that we have monev 11 therefore, we should fund it, it should be, does this -compara- 12 tively merit funding. There should be inked into this, the 13 comments made that there has to be an evaluation to a more 14 adequate degree. 15 DR. IIINMAN: Fifty for the two years, twenty-five 16 a year. 17 DR. BESSON: Right. 18 DR. SCHERLIS: A rating of three. Any other comments? 19 MR. TOOMEY: I would like to make one other comment 20 because it bothers me a little bit. 21 It is hard to, in light of the guidelines, looking 22 at the total emergency medical system, to then focus down on 23 one institution and say, this institution meets these guide- 24 lines. If you relate the number of people they serve to the Ace-Federat Reportefs, Inc. 25 number of people that are served in some of the larger systems, I 117 1 I think once again, in terms of population, which probably is 2 several million people, utilizing, or in that area, I think 3 you have -- and if I understood correctly, somewhere in the 4 neighborhood of 150,000 to 200,000 emer(-iei-icv room visits in 5 the course of a year, which is probably as much as some of the 6 smaller states have -- I think you can justify it, even though 7 it is A one-hospital problem. 8 DR. SCHERLIS: One type of hospital problem. 9 jIR. TOOMEY: Yes. 10 DR. SCliERLIS: Perhaps we should try to finish one 11 more region before we have our lunch break. End @9 12 Lunch will be no more than half an hour. 13 1 4 15 1 6 17 18 1 9 20 2 1 22 23 24 Ace-Fedefat Repofters, Inc. 25 118 CR6307 #10-ter-1 1 DR. BESSON: Northern New England. They are xxxxxxx 2 requesting a one-year funding of -- 3 DR. SCHERLIS: Direct and indirect is '74, the 4 other is 172. 5 DR. BESSON: Now, this has been an ongoing program 6 in northern New England, and they have had three superb studies 7 of ambulance services in Vermont, hospital emergency room 8 services in Vermont, and then an up-to-date study of the entire 9 emergency health system in 1971, as an ongoing program in 10 northern New England in the past; done by the University of 11 Vermont and one particular fellow, whose name, I forget. 12 In an investigation Of the status of ambulance 13 services, they conclude that ambulance services are very 14 meagerly coordinated and prepared in the State of Vermont, 15 lnd need a great deal of help. Their studv of the hospital 16 emergency rooms, all but two of the hospital emergency rooms 17 have problems of coverage, operation, and evaluation of 18 their entire -program. 19 The effects of both of these shortcomings, ambulance 20 and emergency room is -- culminates in a state which they 21 mention, that 23 percent of their injuries, survivable injuries, 22 die in prehospital or hospital care, which is a facet of what 23 the national figure is. 24 This happens to be what they come up with in Ace -Federal Reporters, Inc. Vermont. The past activities that I have mentioned of; 25 119 ter-2 I progress in Vermont is that there have been attempts to 2 coordinate and develop standards for personnel, equipment, 3 operation, attempts at standards for training programs, commun- 4 ications, and so forth, and what this proposal is to do, 5 purports to do, is to involve itself in four so-called high- 6 priority areas: improvement of the capability of individual 7 ambulance districts to carry out regional coordination, 8 establish ambulance regulation, emergency room regulations, 9 and improvement of existing training programs. 10 They hope to establish formal health services 11 advisory committees to replace the informally established 12 committees, to establish a central dispatch communications 13 pattern throughout the state, and to increase public knowledge 14 about handling of emergencies. 15 All of this really is a relatively complete pac age. 16 Their proposal for training include as package in the first 17 year, for nurse refresher training for enliqhteninq physicians 18 to accept surrogates doing work in the absence of the physician, 19 or on his own, to improve the Dunlop EMT Course, and then 20 to evaluate their training in coordinative functions. 21 They need funds for the emergency room nurse teaching 22 package for coordination and for teaching aids. As far as 23 their second major activities, the state planning activities, 24 they want to use these funds to devise state plans, to set Ace-Federal Reporters, Inc. goals for each district, and to further -- and this is a 25 ter-3 1 comment that you made in relation to the tri-state area 2 interstate coordination. 3 This is one of the few applications where one 4 particular region will look to contiguous regions and use some 5 of its funds for interregional cooperation, which is very 6 laudable. As I have looked over their budgetary use of monies 7 for personnel, I am impressed by the training of the people 8 and their past experience. It is quite impressive. Their 9 general budget figures are in keeping with the frugality of 10 Nbw England Region. 11 They are asking for 72,000 for a project which I 12 grade as, at least, a "B," if not a "B+." Four, four and a 13 half. Four point five. I would recommend full funding. 14 DR. SCHERLIS: All right. 15 DR. BESSON: And it is cheap at twice the price. 1 6 DR. SCHERLIS: Mr. Toomey? 17 MR. TOOMEY: I had only two areas of concern. One 18 was the imposition of emergency room operation regulations by 19 agencies from outside the hospital itself, and the other one 20 was the concern of the Physicians for nonmedical personnel 21 taking care of patients who do arrive in the emergency room. 0 22 Other than that, I agree, this is a good application 23 for what it is aiming to do. 24 DR. SCHERLIS: What would your recommendation be? Ace-Federal Reporters, Inc. MR.. TOOMEY: I would say, at $74 thousand, it would 25 121 ter-4 I be a bargain. I recommend it and I would give it a four. 2 DR. SCHERLIS: Any other comments? 3 Dr. Joslyn, any comments on this? 4 DR. JOSLYN: No. 5 DR. P@IATORY: I would like to agree with the comment 6 about the professional capability of the group doing this. 7 They are very fine people. 8 DR. SCHERLIS: Thank you very much. 9 All those in favor, please indicate by saying, "aye." 10 (Chorus of ayes.) 11 DR. SCIIERLIS: Opposed? 12 DR. JOSLYN: What is the final rating? 13 DR. SCHERLIS: Four. 14 DR. BESSON: Four point twenty-five. 15 DR. SCHERLIS: There are so few above two, that this 16 will stand out whether it is four or 4.25, if my memory serves 17 me correctly. 18 At this time, unless anyone objects seriously, 19 sup egin at quarter ,pose we adjourn for lunch and maybe we can b 20 of one. 21 (Whereupon the hearing was recessed, to reconvene 22 at 1:45 p.m., this same day.) 23 24 Ace-Federal Reporters, lhc. 25 CR 6307 122 Lee #11 jrbl AFTERNOON SESSION (I-.00 P.M.) 2 DR. SCHERLIS: We will move right along as best 3 we can. xxxxx 4 Rochester is next for consideration. 5 DR. McPHEDRAN: Yes. 6 DR. SCHERLIS: Rochester, Dr. McPhedran. 7 DR. McPHEDRAN: This is a set of four projects for 8 which support is being asked, each project for three years. 9 I think it may be of interest that the total annual RMP Budget 10 in this region is given on the left, a figure that we haven't 11 referred to before. 858, 806. 12 If you take Year One, these four projects would 13 add a total of about -- not quite $250,000. This would be a 14 big increase in total funding. 15 A good deal of this is on a contract basis for various kinds of activities. The activities are in really 16 17 three spheres. There are four projects in three kinds of activity. 18 19 One is to develop an emergency care and communication system using some modern communication technology. And there is a 20 21 fair-sized proportion of the first year expenditure which is 22 devoted to that, $30,000 in equipment out of the $100,000 23 first-year request for that portion. That emergency care communication network hopes to m 24 t3l @ce- Federal Reporters, Inc. set up two-way communications linking hospitals, emergency 25 123 1 rooms, and attendants, and to develop a manpower training Vrogran 2 for continuing the in-service education of emergency personnel, 3 and to develop standard procedures for handling emergencies 4 both outside of the hospital and to some extent inside the 5 hospital. 6 This proposal lacks details of such important things 7 as how the training program is to be actually constructed, and 8 the assistance in sharp contrast to some of the other programs 9 that I've reviewed in which there was sufficient detail to 10, really tell what it is they intended to do with the training I I money. 12 Then, the second kind of activity -- excuse me, 13 that first activity is to be contracted out to an organiza- 14 tion which is called the Southern Tier Health Services Corpora- 15 tion, which is largely -- it consists largely of the directors 16 of several hospitals, about five hospitals. But that, again, 17 doesn't seem to really represent the whole region, because 18 that is only about a fifth or a fourth of the total number of 19 hospitals that are in the region. 20 So that it seems as if there is some doubt that 21 the Southern Tier Health Services Corporation really represents 22 even the hospitals fairly, or proportionately, in the region. 23 The Southern Tier Health Services Corporation is alr0 24 a subcontractor for one of two telephone referral services, kce - Federal Reporters, Inc. 25 and for this element, for the first year, $61,000, this is a I - jrb3 124 1 general referral service to be provided by this health services 2 corporation, and part of it will be to assemble the necessary 3 data so that an appropriate referral can be made, but the 4 main purpose is a telephone center which would respond to any 5 kind of health information at any time. 6 The training of the kinds of operators who would 7 perform this service is mentioned but again not described in 8 sufficient detail for me to be able to get much of a feeling fDr 9 it. 10 The third of the four projects is another telephone 11 answering system. This is to unify and refplace several crisis 12 phone services, one a poison control center, but also a teen- 13 hot-line and I think a suicide prevention -- I have forgotten 14 if this is in this one or not. 15 But this is a crisis phone service. It is hard to 16 see from the application why this crisis phone service could 17 not somehow have been unified with the general information and 18 referral services, whether there oughtn't to be some inter- 19 relationship. 20 This brings up the general point about the whole 21 application, that it is hard to see interrelationships between 22 the several kinds -- the several projects. 23 The last element in the request is a planning and 24 developmental element, and it concerns itself with developing kce- Federal Reporters, Inc. 25 comprehensive programs for determinations of manpower needs, I jrb 4 125 1 facilities needs, transportation, data collection, and analysis; 2 and setting up a model for evaluation. 3 Now, the phones -- you can break this down several 4 ways, but the first element that I talked about, the 5 emergency care and communications, is $100,000 the first year, 6 43 and 30 the second and third, or a total of 173. 7 The two phone referral services, putting them 8 together, come to a grand total of about 270, and the planning 9 and developmental comes to a grant total of 132. Three-year 10 request is 573 -- $573,000. 11 Their relationship to each other and their relatior- 12 ship to the rest of the program is difficult to ascertain. It 13 seems to me that individually, they have each one of 14 them has moderate -- some merit. 15 For example the emergency care and communications 16 one is certainly no worse than the one that we have funded at 17 a much higher level in Western New York, Lakes area. My 18 feeling about them separately and individually is that they 19 rate "C", that is, a "3" rating for -- I would rate a 3-rating 20 for the planning and development, a 4 -- excuse me; I'm going 21 the wrong direction -- 22 A 2-rating for the telephone services, and a 3-rating 23 again for the first element, that is the emergency care and 24 communications. \ce -Federal Reporters, Inc. 25 I wish that the telephone services could be 126 jrb5 I combined and somehow reduced and total expenditure, it seems 2 to me, the total amount that is being asked is very high. 3 And it seems to me it could be done on a more 4 limited basis for much less money, and I would like to recom- 5 mend that the funding be, instead of now totalling about 265, 6 as I say, closer to $50,000 or $75,000 for the both of them. 7 DR. SCHERLIS: Is that per year? Is that single 8 years? 9 DR. MC PHEDRAN: I was thinking about the total 10 amount, but perhaps it would be more intelligent to say that 11 for the first year, that is cutting them to about $10,000 for 12 each of them instead of their projected present level of 13 $16,000 for one and $54,000 for the other. 14 So I would -" I think I would recommend that the 15 emergency care and communications, which I would say rates 16 a "C" -- that that recommended funding be as is, a $173,787; 17 but the telephone referral services be -- 18 DR. SCHERLIS: Could you give us the number? 19 DR. MC PHEDRAN: 30B and 30C, that they be somehow 20 combined into a single telephone referral system, and that 21 their support be much reduced. 22 DR. SCIIERLIS: Was that $50,000? 23 DR. BESSON: There is a little problem there becaule 24 they are for different areas of the region. kce- Federal Reporters, Inc. 25 DR. MC PHEDRAN: I see what you mean. One is the jrb6 127 Southern Tier and the other is the Genesee County. 2@ DR. BESSON: They have nothing to do with each 3 other as far as telephone linkages. 4 DR. MC PHEDRAN: Yes. 5 DR. BESSON: Maybe it would be helpful if before 6 we get to funding, if I might give some comments on this. 7 DR. MC PHEDRAN: Please do. 8 DR4 BESSON: Okay. 9 As Dr. McPhedran has said, there are four parts 10 to this application and at the risk of reiterating some, I'll 11 say there are two general areas of this Rochester regional 12 medical program that are included. 13 one is the area of Monroe County, which is around 14 Rochester, and the other is the Southern Tier Area which 15 encompasses four counties. The first two projects, 30A and B, 16 are -- first is the emergency care and communication net work 17 for these three counties on a contractual basis with Southern 18 Tier. 19 The second is a health information referral and 20 counseling service for the same area, contracting with the 21 Southern Tier, again. 22 If you'll look at the map of it -- in the applica" 23 tion on pa ge 3, you will see how removed geographically these 24 two areas are. @ce- Federal Reporters, Inc. 25 So the Southern Tier is the southern portion of thig I j rb7 128 1 map, and then Project No. 3, community health information and 2 crisis phone services for Monroe County and surrounding areas, 3 is also on contract to what is called the Health Association of 4 Rochester and Monroe County, which is a consortium of volunteer 5 agencies. 6 The fourth project is finally getting to the 7 regional medical program of Rochester, planning and development 8 component, for the ten-county region, the entire region. 9 Now, as I read through the application -- and gear 10 with me for a minute while I give you my sequential thinking 11 to come to my conclusion -- I was impressed with the way the 12 letters of endorsement all said the same thing: 13 "Please accept the letter in evidence of our 14 support." 15 There are four letters which say the same thing. 16 I said to myself, where do these letters originate? They were 17 all addressed to Southern Tier Health Services, Inc. 18 So I thought, this looks as though the Southern 19 Tier Health Services, Inc., acts like some organized group 20 and on page 12, I find that Southern Tier Health Services, 21 Inc., is a not-for-profit corporation which was just approved 22 by the Corporate Commissioner with specific functions being 23 listed on page 12, implementation of community health delivery 24 system, physical management, administrative management, kce -Federal Reporters, Inc. 25 monitoring placement of patients, and initiation of needed I 129 jrb 8 1 experimental health delivery innovations; so I said this must 2 be an experimental system. 3 But then I looked at the next page, where it des- 4 cribes Southern Tier Health Services Corporation, and it says, 5 "Board of Directors of this corporation is made up of 12 people 6 from the hospitals and 12 people from the community." 7 And thereby is sprung the trap of who this corpora- 8 tion is, which is a consortium of four hospitals interested 9 in feathering the wrong nests, it seems to me, and they have 10 the primary objective of developing and managing a comprehensive 11 personal health services system ostensibly of the community, 12 but it seems to me fortunately -- redounding to the ultimate 13 benefit of the area encompassed by these four hospitals. 14 Now, on this Board of Directors there are four 15 administrators as you say, four board of directors,@and four 16 physicians -- they don't say who the physicians are, but 17 presumably I would think they are with hospital orientations, 18 so that this corporation really is not a community effort, 19 although it happens to have 12 corporate members -- community 20 members on it. 21 So the question that was raised in my mind about 0 22 these two projects, 30A and 30B, which are going to be 23 subcontracted to this corporation, is how representative can a 24 four-hospital coalition be in speaking for the community with kce -Federal Reporters, Inc. 25 this kind of representation? I jrb9 130 1 Now, that deals with my paranoid nature about these 2@ first two projects. 3 The Project 30C is also going to be subcontracted tD 4 a health association which is a consortium of voluntary 5 agencies that is going to work with Strong Memorial Hospital 6 to do something thathas already been on-going, which is the 7 provision of a crisis-care phone and community health informa- 8 tion coordinative functions, which has been on-going. 9 And as they break down the number of calls and 10 what they ate about, and who they helped and how many people, 11 it seems to be a useful kind of effort. 12 I am also impressed that in their budgetary request 13 for this, they are going to be on an extensive cost-sharing 14 program with Strong Memorial Hospital in Rochester. 15 Finally, the fourth program, 30D, planning and 16 development, is to do what this groupl@should have been 17 doing,right along, which is to look at the entire ten-county region and say, what can we do to put together a coordinated 18 1 9 system? 20 Putting that all together, suggests to me that I 21 would be delighted to fund the planning and development and 22 get them thinking in global terms. 23 I would be leary of funding a four-hospital 24 information and communication network which I think is some- kce -Federal Reporters, Inc. what of a ruse for doing -- having a hospital buy some equipment 25 jrblo L .3 -L I for developing its own internal communications network 2 and linking it-with a very meritorious program, namely, 3 inter-hospital communication. 4 As far as the third program is concerned, I like 5 it, but again, I wouldn't be interested in maybe buying a thre@- 6 year project, but maybe one-year. So I have somewhat of a 7 different approach to this, Dr. McPhedran, and we'll put 8 it up for grabs. 9 DR. MC PHTDRAN: You think that the Southern Tier 10 Health Services Corporation, that is the first one, that it 11 is so unrepresentative as to just be unacceptable as an agency 12 for doing this? 13 DR. BESSON: As I view what is happening to the 14 thrust of RMP nationally, or the experimental systems program, 15 or comprehensive health planning, I see that there are a 16 varieity of consortia being developed to address community 17 health problems. 18 Now, all of these organizations exist in this area. 19 Why should we fund a four-hospital coalition with a board that 20 is made up of 12 people from the hospitals, and 12 from the 21 community? 22 I would dare say that the 12 from the community 23 will never be there entirely but the 12 from the hospitals wi I1 24 always be there, so that this is a hospital-directed effort. kce- Federal Reporters, Inc. 25 Now that wouldn't be bad if these were all I I rbll. . 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 orientation, 4 which I think is a different slant on what RMP is trying 5 to do in having a broad-based community representation. 6 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 9 COMP planning, or some kind of group to work together. 10 DR. SCHERLIS: Yes? 11 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 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 kce -Federal Reporters, Inc. 25 that is growing up ought at least to be met halfway, in the I jrbl2 133 sense that -- I just don't know -- I can't judge from here -- 2 whether this is really a,meritorious group or not. 3 DR. MC PHEDRAN: It is just that there are a lot 4 more people in the area, that is the point that Dr. Besson is 5 making. 6 There are other hospitals and -- 7 DR. JOSLYN: In that four-dounty area? 8 DR. BESSON: I don't know. All I know -- 9 DR. MC PHEDRAN: There are. 10 DR. BESSON: This is a group of four hospitals that 11 are opportunistic enough to create a non-profit corporation, 12 and I think that we are creating a -- somthing that should be 13 aborted tight now. 14 That is not a comunity-representative group. It 15 doesn't have the linkages that we are after., After all in the 16 guidelines we say we should have provider, payer, public, and 17 DR. MC PHEDRAN: All provider. 18 DR. BESSON: But this is just a biased group. 19 I don't think they can come up with any community answers. 20 DR. SCHERLIS: Ithink we have to keep referring 21 back to the EMS guidelines which were given to this group 22 because these were the bases for which the various offers had 23 been made. 24 Dr. Gimble, you reviewed this projects, I bel3eve? kce - Federal Reporters, Inc. 25 DR. GIMBLE: The only comment I can make on this jrbl3 134 1 particular point, I had mentioned that of 28 hospitals in 2 the region, five are actively involved. 3 DR. SCHERLIS: How many hospitals? 4 DR. GIMBLE: Twenty-eight in the region, and five 5 are actively involved. And much emphasis is the University 6 of Rochester, that's Strong. There appears to be active 7 participation of the CHPB agency. 8 DR. BESSON: In one project only., 9 DR. GIMBLE: The other problem as you have already 10 ti nship,@between the mentioned is the very poor interrela o 11 proposals. It is alluded to but I think they mention,that 12 the emergency care service will be linked to the telephone 13 services and that is as far as the linkage is described in the 14 text. 15 I had lots of doubts about the entire project. 16 DR. SCHERLIS: What sort of statement do we get 17 from you two in this rdgard? 18 DR. MC PHEDRAN: I guess what we agree on, on 30D, 19 we would recommend it for funding as is. I gave it the A-raging 20 of 3. 21 DR. BESSON: agree with that, full funding. 22 DR. MC PHEDRAN: On 30C, I was mistaken about where 23 that-was, and I think that we -- I would go along with Dr. 24 Bessongs recommendation for 01, and not 02 and 03, As is, for kce - Fedefa I Repoi ters, Inc. 25 54. -- giving that a rating of C also. jrbl4 135 1 DR. BESSON: Okay. I DR. MC PHEDRAN: Or 3. 3 DR. BESSON: Okay. 4 DR. MC PHEDRAN: For 30A and 30BO, if it is not 5 sufficiently representative of the community as a whole, the 0 Southern Tier Health Services Corporation, perhaps the thing 7 to do is simply not to recommend them for funding because 8 they don't meet the EMS guidelines. 9 DR. SCHERLIS: Do you concur in those recommenda- 10 tions? 11 DR. BESSON: I do. 12 DR. SCHERLIS: Any other comments from members of 13 the review group? 14 All those in favor please say 'aye." 15 (Chorus of "ayes.") 16 DR. GIMBLE: "A" and "B" are disapproved 17 because they don't meet the recommendations of the guidelines. 18 DR. SCHERLIS: Yes. 19 DR. GIMBLE: Project "C" is a 3-rating for one@,year 20 and the next project for three years? 21 DR. MC PHEDRAN: Three years. 22 DR. SCHERLIS: I thought that was going to take #11 Lee 23 much longer. CR6307 24 kce - Federal Reporters, Inc. 25 136 CR6307 #12-ter-1 DR. SCIIERLIS: Tri-State? 2 DR. 14C PHEDRAN: I think this is a very good 3 pronosal, and I would rate it as a four to five. I think it xxxxxxx 4 is one of the two or three best that I reviewed among the 5 ones that I did as primary and secondary reviewer. The proposal is a large proposal. It is a project 6 7 number 18, and the requested funds are over about $850 thousand 8 on the average for each of three years, or a total of $2.54 9 million, for the three state area in Massachusetts, Rhode I 0Island, and New Hampshire. 11 I found in going through the rating sheets, the 12 yellow sheets here, that this proposal really addressed most 13 of the particular questions very well. It was a detailed 14 proposal and took up virtually every aspect of emergencies, 15 responding to emergencies, designing systems of education for emergencies. 1 6 17 It was not innovative, but I do not really find that 18 much to fault it, in any of these respects. It is a detailed 19 proposal. I think all the pertinent factors were intelligently 20 outlined. It has very strong Comprehensive Health Planning B 21 Agency support in Massachusetts, but also a strong working 22 relationship with the state department of public health. 23 It proposes planning and development activities to 24 establish coordinated emergency medical services in three Ace-Federal Reporters, Inc. states. The vehicles, or agencies in the different states are 25 ter-2 137 1 different in Massachusetts, it is the Department of Public 2 Health, and in Rhode Island, it is largely the Hospital 3 Association of Rhode Island, and also, I think, the Medical 4 Society. 5 And in New Hampshire, beginnings have already been 6 made in some emergency planning -- actually in all three states 7 they have, but in New Hampshire, some planning for emergency 8 medical systems centering around a project in Hanover have 9 already been begun. 10 I thought this was a very good proposal in nearly I 1every respect. It is an awful lot of money. My word. And 12 yet I really just do not know how to suggest that it would e 13 pared down. I guess I would recommend that it be funded in 14 each of three years, but it seems to me, inconceivable that 15 we would have anything like the kind of money that could 16 meet these demands for requested funds. 17 I do not like to be in the position of suggesting 18 just an arbitrary reduction, but I guess that is where I am. 19 DR. SCHERLIS: I think we have been arbitrary all 20 morning. 21 MR. TOOMEY: Did not Dr. Margulies say, forget it. 22 DR. MC PHEDRAN: yes. 23 DR. SCHERLIS: My concern is the obvious one, that 24 even if this is rated highly, whether that amount should go to Ace -Federal Reporters, Inc. one region. Has this been submitted to contract funding? 25 ter-3 138 1 DR. BESSON: There has been a contract application 2from Boston. 3 DR. SCEIERLIS: It does not include this? 4 MR. STOLOV: They are complimentary because they 5are not included in the projects. 6 DR. SCHERLIS: All right. Secondary reviewer? 7 DR. BESSON: Let us see. 8 This is a complex and a very excellent application, 9and if I can make a crack at breaking it down, and see if 10 we can come to grips with funding a little bit, I would say 11 that it is composed of three major efforts. 12 one is to subcontract to B Agencies in the 13 Massachusetts Department of Public Health, its equivalent in 14 New Hampshire, and its equivalent in Rhode Island, for indi- 15 vidual project efforts in their areas. 16 Two, is to attempt through RMP to provide a coor- dinative effort in the tri-state basis for looking to the tri- 17 18 state areas as a single, global area that has certain problems 19 in common, and perhaps develop coordinative activities. 20 Three, to set up a program for planning and evalua- 21 tion for the entire tri-state program, looking at it globally, 22 again. 23 Now, if we look at these three efforts, the first 24 effort then breaks down into eight individual regions -- B Ace - Federal Reporters, Inc. agencies, each of whom have their own problems: Western 25 ter-4 139 1 Massachusetts, Central Massachusetts, North Shore, Greater 2 Boston, Middleborough, Amerrimac Valley, New Hampshire, and 3Rhode Island. 4 Each of the B agencies in Massachusetts, as well as 5the Department of Public Health, are going'to do a little piece 6of the problem, as they see it locally. Now, the sophistication 7of each of these groups varies from the sublime to the ridicu- 8lous- New Hampshire has had some work in the past and they 9are (Tuite mature. 10 Some B agencies in Massachusetts are just embryonic. 11 And there is a great variation in the degree of competence in 12 each of them. But yet, tri-state PJ4P is saying, let us let 13 each locality set up its own program while we learn about 14 what to do in viewing the entire tri-state area as a single 15 region and we will encompass their activities eventually into 16 an overall plan, which I think is a laudatory way of approaching 17 the individual pieces without usutning locals' prerogatives. 18 The Massachusetts Department of Public Health, on 19 the other hand, has had its own little things they are doing, 2 0ambulance regulation and legislation, which they have been 21 working with. They have produced passage of a House bill, or 0 22 maybe it is pending, to set up EMS Advisory Board for the state. 23 They are involved in the development of licensure for emergency rooms in hospitals, and they will be involved in a number of 24 Ace - Fede ra I Repor te rs, Inc. things on a state-wide basis, that impinge on emergency medical 25 ter-5 140 1 services, and do nto overlap with the B agencies, with what 2 the B agencies are doing. 3 So that, for this portion of the application, they 4 will subcontract to these groups and hope fully in time, bring 5 them all up to the same level of maturity. Now, they make some 6 interesting comments about what the possible alternatives are 7 so far as their funding is concerned. 8 For example, they say, in their narrative, that if 9 this program cannot be funded in toto, they would suggest that 10 each state develop its free standing emergency medical services, 11 which is one alternative for us to follow in trying to figure 12 out how to get out of this dilemma. They also go on to say, 13 in their narrative, that if no funding is available elsewhere, 14 the state will be self-supporting within a three-year period, 15 which is very encouraging at least, for them to say that they 16 will mount this amount of money at the end of three years; both of which I think are verv reasonable and mature statements 17 18 to make. 19 So far as the other two programs are concerned, the 20 central coordination of training and the planning and evaluation 21 both of them, I think, are meritorious. The planning and 22 evaluation, I think, is particularly so. They speak of evalua- 23 tion as a function of tri-state regional medical program, inclu- 24 ding a rather sophisticated view of evaluation and evaluating Ace-Federal Reporters, Inc. the process and monitoring the process, itself, in evaluating 25 141 ter-6 I project achievement as a separate look, and then finally, doing 2 lwhat they call, impact evaluation. 3 I think that this is meritorious enough as a meth- 4 odology for looking at emergency medical care svstems that if 5 thev can do what thev say they will do in some detail, that 6 it will provide a very nice model nationally. 7 DR. PIC PHEDRAII: Except they say about the impact, 8 they do not "think they can manage it." This last part, which 9 sounds like the thing that thev have over everybody else, 10 they sav thev do not "think ttie@7 can do it with their pre- 11 machinery," so it would have to come outside of this application. 12 DR. BESSON: I would at least encourage them by 13 fully funding that portion of it, and I suppose -- I do not 14 know how to reach a number with this, it is a difficult ques- 15 tion to grapple with. If there is anv merit to the notion 16 that we ought to develop as large a deficit as we can by funding 17 as many as we can, maybe we can turn off funds elsewhere in 18 the federal establishment, and put them in here so we might 19 as well buv the whole thing. 20 DR. SCHERLIS: Yes. 21 MR. STOLOV: Staff had an interesting observation 22 when we were reviewing the community plan power development 23 application from the tri-state region, and its ambitious 24 budget, also. And we said, look to the program staff, which Ace -Federal Reporters, Inc. was called "core." The core staff activities, and they do 25 ter-7 142 1 have a sophisticated evaluator on this. And maybe this is where 2 staff could aid. 3 But, we looked also to the staff out in the Rhode 4 Island area, the core staff out in the New Hampshire area, 5 and we felt maybe, since they did assist, there could be some 6 fine lines drawn. However, not being the technical budgetary 7 person on this, I just threw this out as a methodology of how 8 we were looking at the community base, manpower thing too; 9 knowing the ambitious budget here. 10 DR. BESSON: They are really approaching the both from the Doint of view of encouraging each locale to do their 12 own thing, and yet saying to themselves, well we are going to 13 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, 14 15 the development of a tri-state-wide coordinated system, which, I think, is verv nice. 16 17 What did you recommend? 18 DR. MC PHEDRAN: I find it impossible to recommend reduced funding in any intelligent way. I would go along with 1 9 20 certainly, fully supporting the evaluation parts. I am 21 inclined to recommend funding. I am sure they would not get 22 full funding because there is not going to be that kind of 23 money, and I think we can recommend whatever kind of funding 24 can be allotted to this. Ace Federal Reporters, Inc. DR. SCHERLIS: What rating are you giving this? 25 14 3 ter-8 1 DR. MC PHEDRAN: A four to five. I think it is 2 very good. 3 DR. SCHERLIS: Mr. Besson? 4 DR. BESSON: I am going to give it, maybe a four. 5 I am going to reserve "five" for Alabama. 6 DR. SCHERLIS: The rating is four. I think it is 7 unrealistic to think in terms of full funding for this. 8 We might jeopardize a great deal by doing that. 9 What is your feeling on this, Dr. Rose? 10 DR. ROSE: Dr. Hinman might speak to this. 11 DR. SCHERLIS: Yes. 12 MR. STOLOV: I know we do not use a formula funding 13 as other HEW programs have used, but as a yardstick, I would 14 like to throw out a factor, Dr. Besson, who has always looked 15 at things in a quantitative manner. Tri-state regional medical 16 program ranks 31 out of 56 regions in terms of funding, per 17 capita funding, per that three-state region. 18 This is just a fact to supplement -- t at may or 19 may not help you with something. 20 DR. SCHERLIS: That further obfuscates our entire 21 problem. 0 22 DR. BESSON: What do you mean by that remark? 23 MR. STOLOV: I did not know whether or not you wanted 24 some other fact to help you with your decision, and this is one. Ace-Federal Reporters, Inc. I do not know if it is out of place. 25 144 ter-9 I DR. IIIN.14AN: I have a concern. If you look at the 2 breakdown of the budget as per vear one, the very beginning 3 of the application 4 DR. SCHERLIS: opposite page ten. 5 DR. IIIN@IM;: -- opposite page ten, you will see 6in the first year, $251 thousand for planning and organization, 7and almost $600 is allotted for things that might be considered 8partially implementation. I just wondered if we have a mixture 9here and are dealing with an attempt -- they have 119 thousand 10 for data collection, and agencies; 251 thousand for planning 11 and organization, and they are immediately going into education, 12 some equipment -- 13 DR. BESSON: Excuse me, Ed. They are dealing with 14 such a mixed bag here, they do not go from that to education. 15 It is that they are allowing each region to submit their own 16 budget for their particular needs, and I think what they have 17 done is gotten everybody stimulated so that eight regions here 18 there are not eight -- six, plus New Hampshire, and Rhode 19 Island, are submitting a separate budget. 20 It happens to add up to 251,000, but that includes 21 you know, they are accepting everyone's budget, and then on 0 22 top of that, for coordinated training, and coordination, it is, 23 they are submitting a separate budget. 24 DR. HINMAN: my question, though, is are they in the Ace-Federal Repofters, Inc. 25 one budget saying we are going to plan, and implement from I 145 ter-10 I year one? 2@ DR. BESSON: Yes. 3 DR. GIMBLE: The most encouraging part of the 4 application is the small amount that has been allocated to 5 equipment purchases, so it looks like they said, we are going 6 to plan a lot and buy very little the first year, and it looks 7 like they are doing it. 8 DR. SCEIERLIS: I just wonder if they asked for 9 $10 million, if our sup ,port of $10 million would be realistic, 10 and I question whether our recommending $350 thousand or $847 11 thousand is realistic. 12 I think I would like to have a motion made for a 1 3 sum, and if the recommendation includes that, if additional 14 funds are available, they should be funded up to so and so, 15 at a high priority. 16 DR. ROSE: It might be easier for the committee 17 to make a recommendation and let the amount of funds be handleed 18 administratively, the judgment in terms of how much fun s 19 they are going to be able to get. 20 DR. SCIIERLIS: We never do thati 21 DR. ROSE: Assuming the whole thing is meritorious. 22 DR. SCHERLIS: Can I ask for a recommendation for 23 a motion at this point? 24 DR. BESSON: Let us just rate it and leave the fund- Ace-Federal Reporters, Inc.. 25 ing go open. I 146 ter-11 1 DR. MC PIIEDRAN: I feel so foolish recommending an 2 arbitrary figure based on nothing. I have no way of basing it. 3 All I can do is say, it is a meritorious program and maybe 4 these things -- maybe they can consolidate some of this plan- 5 ninq, organizational activity. Maybe, it would not have to 6be so costly. 7 DR. SCHERLIS: Are vou recommending full support 8as requested? With a rating of four? 9 DR. ",IC PIIEDRAN: I am rating it as four and realizing 10 that full support is just not going to happen, could not 11 possibly happen. 12 DR. SCHERLIS: Dr. Besson? 13 DR. BESSON: I have a different view of this. I 14 do not view this -" it happens to be tri-state, but it would 15 be like saying, well, what is the eastern operations branch, 16 what kind of a program do they have? Thev do not have a single 17 program, they have 27 programs. 18 We do not have single program here, we have ten I 9programs, so that the number that I would use would be predi- 20 cated on that as an underlying assumption. I think that the 21 project is meritorious, the whole thing is meritorious, and if 22 I were to be forced to give a figure, I would have to say 23 the full thing and let the chips fall where they may. DR. SCHERLIS: I just wanted you to -- this is with- 24 Ace-Federal Reporters, Inc. full knowledge and intent then, we are recommending that sum, 25 ter-12 147 1 it is quite apparent. 2 Any further discussion from members of the Review 3 Group? 4 All those in favor, say flaye.ft 5 (Chorus of alzes.) 6 DR. SCHERLIS: Opposed? 7 DR. BESSON: I would also remind the Chairman 8 that -- 9 DR. SCHERLIS: I do not believe you recommended 10 the whole thing. 11 DR. BESSON: It is only one wing on a B52. 12 DR. IIINMAN: Unfortunately, we do not even have a end #12 13 motor on a B52, an engine. 14 15 16 17 18 19 20 21 22 23 24 Ace -Federal Reporters, Inc' 25 148 CR 6307 1 DR. SCHERLIS: All right. Virginia. #13 dh-1 2 DR. ROTH: That one is mine. 3 DR. SCHERLIS: Dr. Roth on Virginia. 4 DR. ROTH: I think the-impottant thing to point out 5 to begin with about Virginia is that we're talking about a total request of $30,250, It is a highly hypothetical application, 0 on behalf of a council which says that it is in the early 7 8 phases of initiating the organization of a community emergency 9 medical services council. And in the,makin'gs.,, it has covered io that whole planning problem, if approved and funded, would be turned over to this council. I 1 12 it has not been approved by the RAG, and although 13 We ave only a request for this $30,250, it rates a substantial 14 operating grant of $244,415.90, for a total 3 year amount. 15 It is distinctly a matter of building upon existing services. It is pretty sophisticated in the use of, for example, 16 17 helicopter service is available in the area. But it is my 1 8feeling that it is such a relatively small amount that if the 19 only matter before us now is the approval of the $30,250, I 20 would give the program a .3, - 1/2 @ to 4, because it has,, built@:on 21 a base of accomplishment, and recommend full funding. 22 DR. HINMAN: I would like to add one point, Dr. Roth. 23 The planning portions of this have been reviewed by CHP and the 24 and have been approved. Ace -Federal Reporters, Inc. DR. SCHERLIS: The logging sheet has a check mark 25 149 dh-2 I flyes."' Is that correct? 2 DR. HINMAN: The earlier ones didn't. The first log- 3 ing sheet didn't. 4 DR. SCHERLIS: But that is a subsequent change in th 5 operating'data that we received. The present log sheets state 6 that they have been reviewed by RAG. 7 DR. SILSBEE: It is the planning portion only. 8 DR. SCHERLIS: That is all we are talking about, 9 planning, at this time. I am secondary reviewer on this and I 10 also review it as essentially a planning phase, since they state 11 they want to evaluate, categorize, and coordinate their existing 12 emergency. services, and I think in view of the fact that this 13 is a planning phase, and they have devoted Considerable thought 14 on how to go about it, I would concur with the feeling of the 15 primary reviewer on this and would also recommend support for 16 the sum requested which is for one year, a total of $30,250. 17 I would concur with that recommendation. 18 DR. ROTH: This I would assume makes no commitments 19 on our part for anything but those operations. 20 DR. SCHERLIS-. This is purely for one year. 21 Any other comments on Virginia? 22 I thought it was 3. 23 DR. ROTH: 3. That's good. 24 DR. SCHERLIS: Any other comments? Ace - Federal Reporters, Inc. All those in favor say aye. 25 150 dh-3 (Chorus of ayes.) 2 All right. Next is West Virginia, Dr. Roth. That is 3 a series of 3 projects. 4 DR. ROTH: West Virginia is a series of 3 very 5 sketchy requests, the first for a rural, multi-county -- and it 0 is actually 4 counties -- in Northern West Virginia, and the 7 second one is for actually a single county building within a 8 single hospital, primarily, have access to taking care of emer- 9 gency cases. And the final third one is a state wide program, 10 or it would have state wide application ability, to train emergen 11 Cy medical technicians. 12 The problem here, it isn't fait to poke fun at A 13 grant request, but I would say that the grantsmanship illustra- 14 ted here was unsophisticated in the extreme. Dr. Besson pointed 15 out that he had a series of letters which were like filling in 16 blanks, and that has clearly been the operation here in West 17 Virginia. 18 Somebody, a coordinator, wrote a letter and said "I 19 think it would be nice if you all sent back something along this 20 line," so they all copied the letter, and just Changed the 21 signatures and put in the names. 22 DR. SCHERLIS: A lot of these are from voluntary 23 fire departments, too. 24 DR. ROTH: Yes. This is almost pathetic. Ace -Federal Reporters, Inc. 25 There are 20 -- I haven't tallied them 21 letters 151 dh-4 I from individual members of a newly formed Dodridge County emer- 2 gency squad. The letters go something like this: 3 "We have this emergency squad formed, and it would 4 be nice if we just had a radio that we could find out where it 5 is we are supposed to be going, and if we could see that we 6 could have a doctor or somebody in the hospital when we got 7 back." 8 There is one delightful one where the young lad says, 9 "We hope to finish our class soon on heart de-fibulation, in the 10 care of heart patients. And as a member of the class, I realize 11 the great need for communications." 12 This is the heart of this request. So youare given 13 A situation in which you have virtually no medical personnel to 14 provide the care, and once you can herd it in, you have prac- 15 tically nothing except hearses available to be the mechani ms of 16 transportation. You have bad roads, you have a relatively small 17 population -- I'm sure you don't have an awful lot of transient 18 travel, so you're hot worring so much about automobile accidents 19 and so on as you may be about myocardial infractions and indus- 20 trial accidents, and things of that sort. 21 But it is a testimony to abject need in an area which 22 lacks resources of all kinds, and the request, even though mod- 23 estt translates into a fairly high ratio in terms of dollars to 24 population. But if need is one of the qualifications for eli- Ace -Federal Reporters, Inc. gi.b-ility, I would say this ranges 4 plus in need, and very low 25 152 dh-5 I in terms of the resources to work with which tempers your en- 2 thusiasm, or at least your predictions, about how much will come 3 of it. But I think for an application with a strongly Appala- 4 chian flabor, that it deserves our consideration. 5 The 3 are somewhat complimentary. The one or a 6 single county, Jackson County, and a single hospital, really, 7 to my way of thinking, there is scant use in correcting all 8 these emergencies unless you have somewhere to take them with 9 some kind of care to give. 10 And they certainly need the instructional of the 11 emergency medical technicians. So I would lump them all to- 12 gether as being, to a degree, somewhere related, tending towards 1 3systematisation. 14 By taking a figure of practically zero for the state 15 of the art but a figure of 4 for the degree of the need I would 16 come out averaging that off with about a 2 and recommend fund- 17 ing. 18 DR. SCHERLIS: For all 3? 19 DR. ROTH: For all 3. 20 DR. SCHERLIS: I am secondary reviewer. I also 21 arrived at a grade of 2. I was very,concerned@about the ini- 22 tial 2 requests for funding first of all in terms of who is to 23 do the training. The first one, for example, was to be done by, as I interpret it, a local staff in the hospital of StonewalL 24 Ace-Federal Reporters, Inc. Jadkson, 25 153 dh-6 agree, some training should be done. I felt more 2 and more as I read it that they should have one training center, 3 that was the Davis and Elkins College, for a sum of $28,000, 4 rather than dispersing this in 3 different areas with different 5 levels of ability and I would concur with 2, but I thought the 6 total funding should be about $30,000, because I didn't have 7 some concern about dispersing the training into the other areas. 8 What was your reaction about the action of Stonewall 9 Jackson Hospital as far as being able to carry out the program? 10 DR. ROTH: It was apparent to me throughout the 11 thing that they're going to have to import talent to do -- they 12 just don't have the capacity there. And this Davis Elkins Col- 13 lege thing seemed to me to be by far the best. 14 DR. SCHERLIS:, I was concerned for example, in 15 the first one under training, they stated the 4 physicians 16 in Louis County, the lone @hysician in Dodridge County, and the 17 national health corps physician in Gilmer County, which is the 18 total medical compliment,, have @lagreed to conduct training cour- 1 9ses for these men. 20 They're going to deliver the 82 hour course. This requires, I think more ability than they can muster.-for,that 21 22 sort of a training effort. 23 DR. BESSON: I wonder whether it'miqht not be worth- 24 while in the advice to this region to work jointly with the Ace -Federal Reporters, Inc. state of Maine on their problem which is very similar, and their 25 154 dh-7 I solution, which is perhaps ideal for this kind of area. If they 2 are production video tapes, there is no reason why the videc 3 tapes can't be used in West Virginia in these rural counties, 4 just as well as they're used in Maine. 5 DR. SCHERLIS: The second one, they say ';"Upon fund- 6 ing of this application the hospital will recruit and immediately 7 train 80 emergency technicians" and again I question their 8 ability, without the sort of help that you referred to. 9 My suggestion would be that we go along with the third 10 regional training center, which is the Davis6n-Elkins Group, an6 11 maybe ekpand their program §omewhat so they can incorporate 12 training the others, I have a certain reluctance As far as the 13 amount of funds they have requested for the first 2 hospitals, concerning what might come out of it when they are done. 14 15 DR. ROTH: I'll agree:with this, completely. 16 it has always been a problem to me to -- I think 17 Jerry Besson spoke about our issuing the se6dlings, or water- 18 ing them. There isn't even a seedling here to nourish, you havE 19 to start doing some planting. 20 DR. SCHERLIS: Is anyone here from the West Virginia 21 area who could comment? 22 Dr. Henderson, do you want to comment on the problemE 23 of this projedt? 24 DR. HENDERSON: I think the qenerations,that have Ace-Federal Reporters, inc- been made are accurate. I have been scanning this application 25 155 dh-8 I here for a few minutes. The fact that they have submitted 3 2 proposals that are very similar in nature and have essentially 3all the same working necessities brings me again to Dr. Roth's 4consideration of the need. 5 Now actually, the heart of all this is employment of 6former military types to function as emergency medical service 7technicians. This may give this thing a bit more rooting than 8if they were to be starting at scratch and wandering Around 9looking for people to train. In the light of that and in view 10 of the need, would it be practical to fund just one of the 3 11 proposals? 12 Number 18, the first one, goes in the direction of 13 trying to provide priority health care services for rural com- 14 munities that have none, or counties. Thi?@price tag on this one 15 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 1 6 17 corpsman, and if they can find a physician who will work at 18 running the project, to me it would be worth doing. Because then 1 9it might provide,..Ithe.,. impetus to energize active ties in the re- 20 gions of the other proposals. 21 MR. TOOMEY: The thing that bothers me, and it is not 22 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 23 24 planning organization funded under the Appalachian Regional Ace - Federal Reporters, Inc. Development Act, and from what I hear, it seems quite apparent 25 156 dh-9 I that there has been, as I would read it, little contact between 2this project and the Appalachia Project, or the Applachian 3program. And with the fifth or sixth years of expenses under 4the Appalachian Health Proqraml which is a specific section of 6the Appalachina Region National Development Act, it seems that 6they should have been farther down the road than what apparently has come out from this RMP. 7 8 My point is that I think that they ought to look at 9each other. 101 DR. SCHERLIS: Any comment from staff on that? 11 Yes? 12 VOICE: The application as it is does not reflect the true working relationship that exists between RMPs and the 1 3 14 Appalachian TCHPA.Agency. The application does reflect the 15 cooperation between the RMP and the local B Agency, which is 16 the -- the liaison man working with the advisory group to the 17 @B Agency in determining the local needs and priorities. 18 Someone made a comment about why do we have 3 similar proposals from 3 separate areas. Well, when West@.Vir'ginia uses 19 20 field staff very effectively, and there is a field man assigned 21 to these areas, he has quite a bit of knowledge in EMS. 22 So therefore this is one reason these particular 23 proposals come from that particular area. And one other thing, too. The West Virginia regional medical program has just recentIly 24 Ace -Federal Reporters, Inc. restated their objectives, and one of their proposed area object- 25 157 dh-10 I ives is the emergency medical service. 2 DR. HINMAN: Normi,are you saying that there are 3 accountive working relationships between the Applachian Health 4 Program Planning Council and the West Virginia RMP? 5 VOICE: Have definitely. 6 DR. ROTH: Beyond how much Virtue it-is, but that first 7 project , the 4 county project, serving a population of 103,000 8 people, working out at about 73 center per capita in an area 9 where, as far as I know, there is very little overall support 10 given. 11 The second one works out somewhere inbetween $3 and 12 $4 per capita and I would be willing to drop that one out 13 completely. But somehow or other I would like to do something 14 to get those radio sets into these pseudo ambulances, to get 15 something into that 4 couty area of West Virginia. 16 DR. SCHERLIS: I really think in terms of the 4 county 17 area, that is As far as there being adequate information or 18 they're really having paid attention to the good lines in having 19 at the time all system care, there are serious shortcomings. 20 And yet, perhaps they should have enough funds to 21 at least make a start of this. They're talking about 6 full time 22 patchers, 2 paramedics. It is a budget which, while it adds up 23 to $76,1000, I question whether or not they might better spend 24 some of those funds for planning. Ace-Federal Reporters, Inc. DR. ROTH: They could do a great deal with less than 25 dh-11 I half of that. 2 DR. SCHERLIS: This what I feel and I think if we 3 could talk in terms of putting more into planning and getting 4 a small course started, than perhaps a reasonable sum instead 5 of $76,000 might be something like 1$35,000. But for quality 6 of training I still think that Davison Elkins looks good. 7 DR. ROTII: Yes. 8 DR. SCHERLIS: And the first one would be for $35,000, 9 and the second is zero, the third for $28,000 and crossing out 10 the second. I'll put that on as a motion. $35,000 for the 11 first one, zero for the second phase, the third phase, $28,000 12 as requested and that rating was 2, 2 for each of those. 13 Any further suggestions? 14 (No response.) 15 All right, all in favor -- 16 (Chorus of ayes.) 17 Opposed? 18 We now move out of the eastern branch regions into 19 the south central branch region, and the irrepressible Dr. end #13 CR 6307 20 Besson. 21 0 22 23 24 Ace -Federal Reporters, Inc. 25 Lee#14 159 CR 6307 jrbl I DR. SCHERLIS: Well, we are now going to have xxxxxx 2 Arkansas. 3 Arkansas submitted a total of six projects, which I and 4 Mr. Toomey have been asked to review, and these are a varied 5 group. The sum totals of these, $5,000, $20,000, $113,000, 6 $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 9 that it comes out to an excess of $1 million. 10 The first speaks to establish a coordinate education 11 system of emergency medical services for Arkansas, and this 12 is settled with the VA hospitals. I'm trying to get these 13 numbers in order. 14 The application to support the state-wide emergenc@ 15 medical services system to include medical services council, 16 consumer education, transportation -- in other words, the 17 entire support. > 18 It is designed to include some regional development. 19 A preliminary work schedule was presented to allow time phasec 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 I went through kce- Federal Reporters, Inc. 25 this I felt repeatedly the need for a more detailed budget I jrb2 160 1 and more indication of exactly what was being planned. 2 The application itself to me seems to be, in a 3 word that I used for it, excessively padded. 4 It emphasizes both planning and operational activi- 5 ties. Funds are requested for developing of a pilot project 6 as well as developing a state-wide emergency medical system 7 and both of them are heavily oriented towards the purchase 8 of hardware. 9 The salaries are something like $75,000, 10 consultants come to $76,000; the equipment to $40,000. 11 They have asked for rennovation of part of the VA 12 facility. They have included replacement of medical 1 3 supplies. 14 As I went through this, I felt that part of it 15 should be supported, namely that which emphasized essentially 16 the training aspects more than anything else, and I'll come 17 back to that as I review some of the other programs which were 18 part of this. 19 Project 42, which again is part of this overall 20 Arkansas program, is asked for by the Arkansas Health Systems 21 Foundation to improve emergency health services for a six- 22 county area in Arkansas. 23 The attempt is to upgrade emergency services to 24 the critically-ill or injured not only within this community Ace-Federal Reporters, Inc. 25 but outside as well, and they discuss this as being achieved I jrb3 161 1 by rural involvement through the establishment of a hospital- 2 based ambulance, regional communications system. 3 They speak of ambulances being placed in each 4 rural hospital staffed on a 24-hour basis, and this would be 5 the responsibility of the rural communities. They emphasize 0 that there is no communication transportation from the 7 rural hospitals in the six-county area with the local regional 8 hospital. 9 Again, the request here is in terms of a great 10 deal of funding for actual hospital personnel. Salaries come 11 to something like $95,000, mostly for this, And the equipment 12 to $60,000. 13 It is a three-year operational request which is 14 aimed at improving emergency room facilities, general 15 emergency services, major emergency services, upgrading 16 emergency services. 17 There is no really good description of just what 18 is being planned, although they do ask specific support for 19 emergency room personnel and equipment. 20 one problem here is that there is no real system 21 of care which is discussed. As you go through the sheets -- 22 and I did this to again evaluate what specific items were 23 present -- you will find that they have really not directed 24 themselves adequately to the criteria as outlined by the kce- Federal Reporters, Inc. 25 actual requests that they had received in terms of the I jrb4 162 1 outline which they should follow. 2 My feeling on this was that it was a very poor 3 request and I questioned whether any support should be given 4 to it. 5 The next one from Arkansas was again for a six- 6 county area, the development of an emergency medical services 7 system. It was for a one-year planning project. 8 This particular instance, again, it was a very 9 brief application. They only requested funds for planning 10 this in the Little Rock area. 11 The approach appeared to be a reasonable one, but 12 they had asked again for what I thought was an excessive 13 smount of funding and although they did follow the gu delines 14 more carefully, I gave this a rating over the others, but 15 again do not recommend full funding for it, and I'll give 16 the numbers on that in a moment. 17 The next request was again for Arkansas. 18 As you gather as I go through this, this is not 19 an overall, well organized project. There are bits and pieces 20 applying to different parts of the State, rather than being 21 a well-coordinated education program. 22 This one was an in-depth study to determine the 23 need and approach to emergency care and to establish such a 24 program in a 10-county area. \ce-Fedefat Repofters, Inc. 25 They asked for one-year support in order to plan j rb5 16 3 1 an emergency medical system for this 10-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 5 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 11 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, 11 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. kce -Federal Reporters, Inc. 25 I think to move into any further step at the I jrb6 164 1 present time would be unjustified. 2 In summary, looking at all of their applications -- 3 MR. TOOMEY: I think you skipped one, Doctor. 4 DR. SCHERLIS: Did I skip one? 5 MR. TOOMEY: East Arkansas Planning and Development 6 District? 7 DR. SCHERLIS: That was omitted from mine. 8 MR. TOOMEY: Okay. 9 DR. SCHERLIS: Do you want to give that? 10 MR. TOOMEY: It is a one-year planning grant for 11 the Eastern Planning District, comprised of 12 counties, 12 which is the second largest area in population of the State, 13 with 371,000 people. 14 Ambulance services in the area are operated by 15 funeral homes and private concerns. The primary objective of 16 this request is the development of a direct ambulance service 17 linked with radio communication. 18 The narrative speaks to the requirement of vehicle.- 19 and communications equipment with no overall planning 20 mechanism for the formation of development of a coordinative 21 system within the district or with the state EMS plan. 22 It shows little understanding of a total emergency 23 medical services system. The monies are requested primarily 24 for the purpose of equipment. Community needs and resour es kce-Federal Reporters, Inc' 25 have not been assessed. I j rb7 165 1 There is no reference to linkages with the system 2 other than radio communications. 3 of the!a42,000 requested, $94,000 relates to 4 vehicles purchased, and $33,000 for communications equipment, 5 and $4,000 budgeted for training purposes. 6 DR. SCHERLIS: All in all, I was extremely 7 dissappointed with the Arkansas application. There were bits 8 and pieces. Maybe they didn't have the time, but I don't think 9 the program as finally put forth was one which really reflecte 10 an overall coordinated effort and I thought the funding 11 requests were certainly -- what support might be given would he 12 more for planning and hopefully on a more correlated basis. 13 Yes? 14 VOICE: Project 45 was omitted. It did not 15 have Reg review, it was returned by the Reg for urt er 1 6 revision. 17 DR. SCHERLIS: That's why I don't have it. Is that 18 to be considered by us or not? 19 VOICE: We didn't get it. 20 DR. SCHERLIS: The one just reviewed is really not 21 part of our consideration; is that correct? 22 All right. 23 The part just discussed is not a part of our 24 consideration, the last one reviewed, No. 45. So we have to \ce -Federal Reporters, Inc. 25 consider then the other ones, No. 41, which had requested jrb8 166 1 $300,000 for the first year -- is that correct? I Yes. my recommendation on that was a funding only 3 for planning at a rating of 2. 4 The next one, No. 42 -- my recommendation was that 5 only be funded for planning to a sum of $3OiOOO with a rating f 0 of 2. 7 The next one, Item 42t I recommend action on that 8 one, that there be no funding for that one. 9 No. 43, I felt that should only be supported to 10 the terms of planning. My recommendation was $25,000 there 11 with a grade of 2. 12 Project 44, for which $31,000 had been requested, 13 I felt this one at least had some fuller data, and I thought 14 it should be supported for the funds requested for plann ng" 15 with a rating of 3. 16 No. 45 is not subject to our consideration. 17 No. 46 is. My rating on that was only for planning, 18 to a total of -- what they had here, $15,600, with a grade 19 of 2. 20 Secondary reviewer? 21 We can be wide apart on these, given the funds 22 requested, and the competency of draftsmanship. 23 MR. TOOMEY: I was looking at something -- as you 24 were going down the requests on the planning, I was in @ce- Federal Reporters, Inc. 25 agreement, and I figured you were going to -- I don't know jrb9 16 7 1 where you were. 2 DR. SCHERLIS: Project 41, I recommended $30,000 3 for the first year with a rating of 2. 4 MR. TOOMEY: That is the $300,000? 5 DR. SCHERLIS: Yes. 6 Now,'thenl Project 42 I did not recommend being 7 funded. 8 Project 43, I recommended $25,000 with a rating 9 of 2. 10 MR. TOOMEY: That is the $45,000? 1 1 DR. SCHERLIS: Yes. 12 The request had been for 45. 13 Project 44 had requested 31, and I thought that 14 was an adequate figure for planning. I gave that a little 15 higher rating of 3. 16 No. 45 we have been asked not to consider. 17 No. 46, I agree with $15,600, at a rating of 2. 18 Are they about what you were going to suggest? Or 19 what was your feeling? 20 MR. TOOMEY: I didn't make the suggestion, but I 21 would be in agreement. 22 DR. SCHERLIS: Would that be all right? 23 MR. TOOMEY: Yes. 24 DR. MATORY: You have studied this a lot more Ace-Fedefal Repofters, Inc. 25 closely than I. but I was a little concerned in that first one* jrblo 168 1 they indeed were setting about to begin to get some personnel 2@ trained. 3 I was wondering if perhaps out of the $300,000), if 4 I am not satisfied with your justification for 5 only a tenth funding. It seems they are about to get 6 personnel training and organization. 7 DR. SCHERLIS: What I was going to suggest was 8 this as a follow-up-reconmiendation. All of this comes to over 9 $100,000 for State, and whati think should be done is that 10 the State has to put together a thoroughly coordinated program 11 to encompass emphasis on training in an overall plan. 12 What we have been given is individual plans that have 13 very little coordination And I would think the Sta comment 14 here would be that all of these should be coordinated into 15 an overall view. Because a sum of $100,000 gets to be a very 16 significant sum to work with in setting up, at this stage, 17 planning and training. 18 Would that answer your question? 19 DR. MATORY: That answers it, but I just wonder 20 what a State can do with $100,000? I am very much -- of 21 course, now you have the 45, and I suppose given better 22 consideration, that might be another plus. 23 But I am impressed with their realization that those 24 funeral ambulances have to go and I don't know how we are going kce- Federal Reporters, Inc. 25 to do that unless they get some funding and support. This is jrbll 169 1 one of the big things we're all trying to get rid of. 2 DR. SCHERLIS: That is a nation-wide program, isn't 3 it? 4 DR. MATORY: Yes. But Arkansas seems to have its 5 share. 6 DR. SCHERLIS: I am open to any suggestions. 7 DR. HINMAN: I agree with you, Bill, I haven't 8 seen the application. 9 DR. SCHERLIS: Who is familiar with the Arkansas 1 0 grant? 11 VOICE: I was oh the site visit. Is there a 12 specific question that you would like to ask about this? 13 DR. SCHERLIS: What do you think their ability 14 is to mount this effort? What is their total funding at 1 5 this time, in Arkansas? 16 VOICE: 1.5. 17 DR. SCHERLIS: $1.5 million? 18 VOICE: As you know from the site visit, that was 19 rather recent, they are one of the better regional medical 20 programs, and seem to have the capability to plan a program. 21 I suspect -- Mr. Says is the primary Staff person 22 on this, but I suspect that the time constraint had its affect 23 on the development of this. 24 DR. SCHERLIS: This is one thing that bothered me, kce-Federat Repofters, Inc. 25 is that as you go through this, as apparently they are very jrbl2 170 1 thick brants, the requests that you deal with are very small 2@ proportions of them, and one of the problems that I had in goilg 3 through them is that these were in great measure, I assume, 4 all prepared for other requests. 5 Are they going to part of that $8 million? 6 DR. ROSE: Yes. 7 DR. SCHERLIS: These weren't really prepared under 8 our guidelines, they were prepared for something else. While 9 one can question however one can go by this sum, nevertheless, 10 if we are going to buy the guidelines, we have to follow them. 11 YOU are right what you can do for $100,000, you 12 certainly can't replace all the hearses with adequately- 13 staffed and equipped ambulances, but I would think if they 14 don't get their other fund, at least this is a good start 15 in putting together an overall program. 16 I know their coordinator who I think is one of the 17 best I have ever had the opportunity of site visiting. 18 1 am sure he can use these funds ver adequately at least as far y 19 as planning and coming in later for implementation. 20 He can come in in the very near future for 21 implementation. 22 Any other comments? 23 A motion has been made and I guess seconded. All 24 those in favor, say "aye.11 kce- Federal Reporters, Inc. 25 (Chorus of "ayes 171 jrbl3 1 DR. SCHERLIS: Opposed? 2 DR. ROSE: Do you have an overall rating? 3 DR. SCHERLIS: The overall rating comes to 3. #14Lee 4 DR,.ROSE. 3. okay. CR 6307 5 6 7 8 9 10 I I 12 1 3 14 15 16 17 18 1 9 20 21 22 23 24 kce- Federal Reporters, Inc. 25 172 CR6307 #15-ter-I 1 DR. SCHERLIS: All right, Bi-State is the next one, 2 Mr. Toomey. xxxxxxx 3 ?@IR. TOOP4EY: This is an application from Washington 4 University in St. Louis. 5 The funding is requested at $707 thousand for the 6 first year, 293 for the second year, $314 thousand for the 7 third year. I have a total of $1,316,000. 8 The grant application covers an eight county region 9 consisting of almost 50,000 square miles around and including 10 St. Louis. The area population is about 2.5 million people, in 11 200 municipalities. 12 Despite their separateness, their residences are 13 linked to St. Louis through medical services patterns. There 14 are many deficiencies in medical services because of the 15 200 independent, political jurisdictions. Concern over the 16 deficiencies of an emergency medical service initiated this 17 grant request as mechanism for coordinating the emergency medi- 18 cal services with governments cross-sectoring for management 19 of the systems operation. 20 The objectives stated were to establish an emergency 21 ambulance central dispatching system which is under, by,, and 22 readily accessible to the public served, to supply the area 23 with a sufficient number of ambulances, to train the ambulance crews to the level of efficiency, sufficient to qualify 24 FA Ace-Federal Reporters, Inc. them f or registration as emergency medical technicians . supply 25 ter-2 173 1 essential equipment as defined by the American College of 2 Surgeons, to categorize hospitals and designate receiving 3 stations on the basis of emergency backup capabilities; and to 4 establish communication links between all components of the 5 emergency medical services system. 6 The plan is to be implemented in two phases. The 7 first phase of the system to become operational in the core. 8 sector of St. Louis, in addition to gathering information to 9 extend the svstem to the rest of the eight countv metropolitan I 0 St. Louis area. 11 Extension of the system to the rest of the area 12 for a total emergency medical system will constitute Phase 2. 13 The proposal is a three-year funding for phase one with imple- 14 mentation of phase two, within the year following activation 15 of Phase one. 16 In the terms of my evaluation, the applicant demon- 17 strated good knowledge of a total EMS System including how 18 the various phases would be integrated and has noted the 19 deficiencies in the presystem which must be overcome. The 20 specific geographic area was well described, and the proposal is community based, with broad representation of T 3 21 -)rov ders, 22 public agencies, planning agencies, and community interests. 23 Existing medical services have been taken into 24 consideration with edification.6f facilities, equipment, and Ace-Federal Reporters, Inc. medical services available within the area. Additional 25 174 ter-3 I resources have been identified and there is a clear assessment 2 @of needs and resources based on statistics. 3 The plan makes reference to how the operating 4 components will tie together and how additions to this system 5 will be coordinated. The only weal-, area of the narrative 6 relates to the improvement of quality care and linkages with 7 local health care systems. The applicant onlv partially 8 describes these linkages and briefly refers to followu-o of 9 non-emergency patients, and community disaster planning. 10 Techniques are described for utilizing financial 11 resources, in addition to obtaining additional financial support 12 at the expiration of this grant. While this is my -- this is 13 my summary. While there are no outstanding or innovative 14 approaches to the development of the EMS within this area, 15 the application appears to be well conceived, a well conceived 16 plan, a good organizational structure which will coordiante 17 and administer the system. It reflects comprehensive planning 18 for bringing together the key elements and a disaster and EMS I 9 system. 20 However, a large portion of the grant is used for 21 the purchase of ambulances and the equipment. Comments by the 0 22 reviewer, Dr. Kaplan, "This basically is a well-thought out 23 aoplication." It has identified problems and has made an 24 attempt to solve them. The one defect that I would see here is Ace-Federal Reporters, Inc. 25 no mention of the Department of Transportation's support of ter-4 175 1 ambulances. They appear to be coming 100 percent in support 2 of ambulances in this application. 3 In their defense, however, cutting back on ambu- 4 lances support would greatly weaken the basic concept of this 5 proposal. There is very little attention made to the emergency 6 room's themselves and the followup area. I classified this 7 application as a very good application. 8 However, I am concerned about the amount of funding. 9 I would like to hear the discussion before I make the I 0recommendation. 11 DR. MC PHEDRAN: So am I. This was one of the early 12 ones that I read and I thought that what was described about 13 the ambulance service was good, but that on reading it and 14 rereading it, it really.does not measure up to our notions 15 about a svstem. 16 I think it is a well designed ambulance service and 17 the amount of money to be spent out of that first year budget, 18 707, 568, on equipment; including equipping the ambulance for 19 16, 641 -- that is nearly half a million dollars on the ambu- 20 lances, and on the communications equipment, the emergency care 21 equipment, and other things that have to go in the ambulances, 22 in order to make them serve this function. 23 And there is nearly 200,000 in personnel. of course, 24 the costs drop off sharply, the next year because of the Ace - Federal Reporters, Inc. 25 initial -- in the proposal, the initial cost for the ambulances. I 176 ter-5 I DR. SCFIERLIS: Two ninety-three and 314 in the 2 subsequent years. 40 3 DR. MC PHEDRAN: @@7hen I think of this amount of 4 money being requested for the first year and then put it beside 5 the tri-state ap for the .placation, what was requested there, 6 first year, it seems to me that -- now I understand why I 7 feel that way in the tri-state application, because so much is 8 the development of planning, and linkages; whereas in this one, 9 a portion of the system, I thought was well designed, but I 10 really wonder if we ought to support it not because it is not 11 a good part of the system, but because it is not really the 12 whole system. 13 That is the way I feel about it. I wonder whether 14 we ought to support it at all because it is such a portion of 15 the system. That is what I am concerned about., I mean it 16 just is not the whole thing. We do not know whether the emer- 17 gencv rooms are going to be coordinated at all to prepare for 18 what these ambulances will bring, for example. 19 I guess they could be with the system as described, 20 but we just do not know. 21 DR. SCHERLIS: All right. 22 MR. T0014EY: I thought it was extremely well written. 23 DR. MC PHEDRAN: I thought it was well written, but 24 I thought it was just a piece, that is the trouble. Ace -Federal Reporters, Inc. DR. SCHERLIS: Is Dr. Caplan or Mr. Poster here? 25 ter-6 177 1 DR. ROSE: Dr. Kaplan is not here. 2 DR. SCIIERLIS: I gather there are differences of 3 opinion. Would you want to respond to this, Mr. Toomey? 4 I do not think we have had a rating yet, really, 5 for this. 6 MR. TOOMEY: .!4y rating of the application would be 7 probably 3.5, between three and four. 8 DR. SCHERLIS: How do you feel about it@ 9 DR. MC PHEDRAN: I think for what it tries to do, 10 it is a three, but I do not think it is a system, and I do 11 not know that we ought to rate it as a system. That is my 12 complaint about it. 13 DR. SCHERLIS: How much of it is requested for 14 planning in the overall, or isn't;there any? 15 DR. MC PHEDRAN: Well, I do not think there is 16 very much. I can tell you in just a second. There is an 17 evaluation of the project, $30 thousand. one of the field 18 system planners, total support is requested for him. 19 That is 17 thousand direct costs, or 19 thousand 20 total, together; and secretarial help for the field systems 2 1 planning. 22 DR. SCIIERLIS: Is what they are going to do essentially 23 set up the prehospital phase? Is that correct? 24 DR. MC PHEDRAN: That is the way I view it. Ace -Federal Reporters, Inc. 25 MR. TOOMEY: Yes. I 178 ter-7 I DR. SCHERLIS: If you are reading this summary, 2it certainly seems the emphasis is on that, without there being 3further involvement of the actual provider areas. 4 Do we have a motion? 5 lie lie somewhere between $700 thousand and no dollars 6at this point, if I read it correctly. 7 TOOMEY: I remember now, the personnel involved 8in this for the first 12 months was $188 thousand. Then the 9ambulances were 416 thousand. I do not see there was anything 10 specifically in the area of planning in terms of funds for I Ithis. 12 DR. SCHERLIS: There is some training, is there not? 13 DR. MC PHEDRAN: Yes. 14 MR. TOOMEY: There is considerable. 15 DR. MC PI,IEDRAN: 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-conttact 19 request in, according to our worksheet. 20 DR. !,IC PHEDRAN: They do? 21 DR. MARGULIES: I think it will be visited. 22 DR. SCHERLIS: It has not moved that far along. 23 DR. MARGULIES: Right. 24 DR. MC PHEDRAN: I feel this is not enough of a Ace - Federal Reporters, Inc. svstem.Ithought it was a good proposal as far as it went, but 25 ter-8 179 1 that it is reallv not a EMS. 2 DR. SCHERLIS: I can understand that. 3 DR. BESSON: On the sight-'Visit, I am wondering 4 under what circumstances -- 5 DR. SCIIERLIS: Contract. 6 DR. BESSON: For a contract? 7 DRt MARGULIES: Yes. 8 DR. BESSON: Is there going to be any sight-visiting 9 of these proposals separately? 10 DR. MARGULIES: No, we would not have time for it. 11 DR. SCHERLIS: I think what we are finding is that 12 some of the programs we fault, on the basis of not being a 13 system have been submitted under different guidelines for a 14 contract. I think this is what hung us up on Arkansas, to 15 a certain degree. 16 We sort of try to see what in that program is RMPs 17 guideline material, rather than being part of a system that 18 might, for example, fit into the contract mechanisms. 19 DR. MARGULIES: of course the contracts are all 20 supposed to be total systems. 21 DR. BESSON: Much more than ours. 22 DR. MARGULIES: So the criticisms I just heard 23 would be applicable to the contract. 24 VOICE: I do not know that much about the total Ace-Federal Reporters, Inc. system that is proposed in the application, but they have 25 ter-9 180 1 gotten a large number -- practically every group possible, 2 together. The mayors of the different muncipalities, the 3 different civic groups, they have done some planning. As I say, I cannot speak for what shows up in the ap lication, but 4 @p 5 they have been working on this, and the experimental health system application for planning for St. Louis has been approved, 0 7 and there is some tieup between the two applicant agencies of 8 these two. 9 DR. IIENDRYSON: May I ask one question about this? 10 DR. SCHERLIS: Yes. 11 DR. IIENDRYSON: Is there any evidence of any community 12 funding, 'oint funding, local funding, to go with this plan? 3 DR. SCHERLIS: Does anybody have a comment? 1 3 14 DR. @IC PHEDRAN: No, I did not see any evidence of 1 5that. DR. SCHERLIS: Okay. 1 6 17 DR. PIC PHEDRAN: And as it was pointed out in Dr. 18 Caplan's note, there might be other possible sources for getting the ambulances. It was looked into, but not spoken of in the 19 20 application. 21 DR. SCHERLIS: I think our criteria have to include 22 the guidelines, certainly. 23 Yes? 24 DR. IIINRIAN: In answer to Dr. Hendryson's question -- Ace-Federal Reporters, Inc. according to Dr. Caplan's review, he checked "yes" under the 25 ter-10 181 1 first three questions of financial support, which had to do with 2 utilization of other potential funds. 3 DR. SCHERLIS: Yes? 4 DR. ROSE: I do not have anything. 5 DR. SCHERLIS: Do we have a recommendation from one 6 of the reviewers so we can move ahead on this? 7 TIP,. TOOMEY: All right. I am a little bit hungup 8 on the fact that despite what you said, Dr. Margulies, as far 9 as total systems are concerned, we have also looked at, and 10 it says in the guidelines, to look at svstems and subsystems, 11 and I look upon this as part of the subsystem. 12 I also remembered being concerned with the amount 13 of money being put in for the ambulances. I also did check 14 back, and there is provision for training people for a period 15 of somewhere in the neighborhood of five or six hundred people during the course of the three vears for this particular 1 6 17 program. And my probl-em is the same thing that was opened up earlier, and that is, that the program is dependent upon the 18 19 ambulances and to have the people without the ambulances really 20 would ruin the project. 21 I do not know how you cut it back in terms of the 22 fact that this is a total subsystem within the whole system. 23 I do not see how you cam pick a piece of it. This is mv 24 Problem in recommending funding. I have no hesitation in Ace-Federal Reporters, Inc. recommending a gradin for it interms of 3-1/2 or 4, somewhere 25 9 1 82 ter-11 I in that range, as a project. But I do not know how to pick 2 @out the dollars for it. 3 DR. MC PIIEDRAN: Could we not recommend that they 4 try to get support for some of this equipment elsewhere? 5 I mean, at least that would help out some, if they could get 6 some from the Department of Transportation? Could they not 7 do that? Is that not conceivable? 8 DR. SCHERLIS: And then what recommendations would 9 you make? Let us assume if they could get the equipment else- 10 where, what would you say? 11 DR. MC PHED-RAN: It still is not an emergency 12 medical system. That is what you are trying to tell me? 13 DR. SCHERLIS: No, I am not. 14 DR. MC PHEDRAN: But I feel that way about it, it is 15 a real problem. 16 MR. TOOMEY: I recommend approval of funding on -- 17 with the contingency that they secure the funds for ambulances 18 elsewhere. 19 DR. SCHERLIS: My concern is if we talk about the 20 700 and we talk about the 800, that is one point five, and 21 that is a good fraction of the total available, and if they 22 go by our strict ranking, that is it. 23 And that would exhaust most of the funds. 24 DRi MC PHEDRAN: Let us say, we support the people Ace-Federal Reporters, Inc. 25 for the first year if they can get the ambulances and then I 18 3 ter-12 I they can come back and see about the second or third year. 2 DR. SCHERLIS: I doubt if they would have time to 3 gear up to get the equipment in that period of time. 4 DR. MC PHEDRAII: You do not think so? 5 DR. r4ARGULIES: It just depends on how far they 6 have gone with DOT, what the potentialities are. If they 7 can get it here, like all these situations, they are not going 8 to get there. I think we can easily find out how far they 9 could go in the other direction. 10 DR. SCHERLIS: Well, the recommendation -- 11 DR. MC PHEDRAN: I would favor supporting it for 12 just a year to support the personnel costs. Maybe they -- I 13 do not know whether all of the kinds of personnel they described 14 would really be useable under these circumstances if they did 15 not have the equipment, but supposing, for example, they had -- 16 they wanted to get the project director and secretarial support, 17 who would -- or the planner, whoever would be required; to see 18 what sources of funds could be tapped for getting the 19 equipment. 20 I would support that for a year, and see where they 21 go after that. This is the kind of approach I would favor. 22 MR. TOOMEY: I think within the context of the 23 resources that they have, that there are steps that can be 24 taken to make a smoother emergency system out of it. And I Ace-Federal Reporters, Inc. 25 would agree with Dr. DlcPhedran's recommendation. I ter-13 184 1 DR. SCHERLIS: You mean -- we still do not have a 2 number on that, though. This is one of the problems that I 3 have. 4 DR. MC PHEDRAN: Okay. 5 MR. TOODIEY: You have 188,000? 6 DR. MC PIIEDRA@L: That is their total personnel 7 request, which includes a project director at a total of forty 8 grand, a jeep dispatcher for 15 and a half, ten dispatchers, 9 for a total of 100 -- they cannot use them all. We do not 10 have the ambulances. The dispatchers, we cannot use. The 11 secretary, he can use. 12 DR. SCHERLIS: I share the concern about putting all 13 this amount of money into one aspect of a system of care with- 14 out putting significant funds into the total planning, and what 15 happens when these patients hit the emergency room, and hit 16 the rest of the medical echelons of care. 17 Now, really, -- 18 DR. MC PHEDRAN: How about supporting the project 19 director and secretarial help, that is 48,000, and a field 20 system planner, 20,000, that would be about $70 thousand, 21 all together. 22 DR. SCHERLIS: Even if you raised 100,000, in terms 23 of at least working on a system of care, this, I think would 24 be a more viable use than buying all the ambulances. Ace-Federal Reporters, Inc. What about some funds for training? 25 185 ter-14 MR. TOOP@IEY: I think they have 52,000 down here, as 2 I read it. 3 DR. SCHERLIS: That comes to about 150. 4 DR. BESSON: A procedural question, @Ir- Chairman. 5 If we are arguing about hiring secretaries and 6 dispatchers for each application, we would not get anywhere. 7 DR. SCHERLIS: I agree. I am trying to say that 8 700,000 seems like an inordinate number. 9 DR. MRGULIES: If I understand what you are saying, 10 what you are talking about -- giving them whatever is necessary 11 to extend their planning and develop a fuller system; and if 12 they can amplify it in some other way, fine, but if you want 13 to talk in those terms, and give us freedom to negotiate at 1 4a reasonable level -- 15 DR. SCHERLIS: We are talking about a sum of 150 16 thousand to 200 thousand, at a rating of three? 17 Is that satisfactory? 18 DR. D-IC PHEDRAN: Yes. 19 DR. SCHERLIS: All those in favor, say ilaye.it 20 (Chorus of ayes.) 21 DR. SCHERLIS: All right. 22 !4ow, intermountain areas, Mr. Toomev and Dr. end #15 23 "4cPhedran. 24 Ace - Federal Reporters, Inc. 25 186 mea- CR 6307 #16 0 intermountain. Time is getting tight- @ DR. SCHERLIS-@ z @ > 2 Mr. Toomey? 3 MR. TOOMEY: I had that but I canlt find my summary. 4 I am sorry. will you give me a moment? 5 DR. SCHERLIS:@ Will the secondary@, reviewer like 6 to begin on that one, for variety? 7 DR. MC PHEDRAN: I will say that I thought this was 8 a good proposal. Indeed it was a system. It is for a portion 9 of the region, the State of Utah. 10 In going through the check list, the yellow,check 11 list, I felt that it met most of our requirements for a,,system 12 quite satisfactorily. The numbers that we are talking about are 13 shown in the back. 14 The first year, 250. The second, 226. The third 15 year, $193,000. I thought there was at least evidence of some 16 satisfactory performance in virtually every category in 17 assessing needs and resources, and in community organization. 18 The representation of consumers as such is not any 19 more in evidence here than in perhaps just one or two others, 20 but I thought that it was at least as good as most. 1 21 So, to be brief about it, I thought it was a good 22 proposal for a system, really, in Utah: a health emergency 23 care system for manpower training, communication systems, which are now operating, and a formal 24 coordination of the ones Ace - Fede ra I Reportets, Inc. organization for coordinating the subsystems. 25 mea-2 187 1 It would be the regional medical program itself, I 2think, that would do this, if I remember correctly. Here it is. 3There is a county in Utah which would be the first phase and which would serve to some extent as a model for the others. 4 That is called Wasatch Front, Emergency Medical System. That is 5 6in the first year. 7 And the second year, the other comprehensive health 8planning district would be involved in the same kind of plan as 9had been set up for the Wasatch Front. 10 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. 12 Mr. Toomey? 1 3 MR. TOOMEY: Yes. The objectives that were derived 14 that I took from this material, they include the establishment 15 of a legal body with the authority and responsibility to plan a 16 and implement a statewide emergency medical system through a 17 network of district EMS councils, and to establish a statewide 18 communication system which will meet the needs of the area; to 19 establish a rapid and safe emergency transportation system which 20 will meet established standards; to upgrade the quality of 21 22 hospital emergency departments; to establish a manpower training program which will provide an appropriate type of adequately 23 trained personnel, to design and implement a standard data 24 Ace-Federal Reporters, Inc. collection system which would provide information needed for 25 188 management operation planning, evaluation and. quality control, 2 to assure high quality emergency care and to evaluate and 3 compare emergency medical systems with other systems of 4 emergency care, to provide a stable source of financial support 5 for EMS, beginning after the third year, and as Dr. McPhedran 6 said, it was planned in three staged p ases. 7 Phase one involves the development of a council to 8 form the nucleus organization to employ a staff, and that was 9 the Wasdtch. 10 Phase two involves the organization of the EMS 11 network into an effective operational plan, to implement emergency services in each district. 12 13 Phase three involves the formation of a statewide 14 EMS authority to provide leadership for continuation of the 15 program. 16 @ My own evaluation was that the application@demonstratds 17 knowledge of the total system and has identified deficiencies in 18 the present operating system. 19 It is a comnunity-based program involving providers, 20 public agencies,, planning agencies, and community interests. 21 Existing community needs and resources have been 22 documented and we will define as to how each element will be 23 coordinated with components already operational. 24 Linkages with local health care systems are not well Ace - Federal Reporters, Inc. described; however, reference is made to enhancing preventive 25 189 mea-4 1 medical services. Specific plans have been delineated for 2 obtaining additional financial support and the prime area 3 emphasis of this application is through the provision of 4 various continuing educational training programs, limited to 5 specific conditions. 6 The population is sparsely settled; the terrain is 7 mountainous. 8 The approach for developing this system has been well thought out, has clearly defined objectives, and I think as I 9 10 read it the thing that impressed me more than anything else was the potential for measuring the various accomplishments,,methods 1 1 12 of measuring whether or not they have accomplished thelobjec- 13 tives. DR. SC-HERLIS: How did you rate this proposal? 14 MR. TOOMEY: I rated it as very good, good, which 15 16 in my opinion would be a 3.5. 17 I saw no reason, really, not to provide them with 18 the funds that were requested. 19 DR. BESSON: Second. 20 DR. S;CK.E,RLIS:., Any further discussion? 21 This then is for three years, 248, 222, 293. 0 22 Both of you were impressed with this as a system of 23 care as well as the other points. 24 You have heard the discussion; all those in favor say Ace-Federal Reporters, Inc. aye. 25 190 mea-5 (Chorus of ayes.) All right. @Louisiana, Dr. Besson. DR. BESSON: Louisiana is presenting a program 3 4 for -- that involves four projects, with a total funding of 5 163,000 over a three-year period. The four projects are updating of an existing EMS 6 system in the state, which was previously drawn up, a training 7 8 proposal for EMTS, two-way communication systems, and a 9 developmental study to determine feasibility of medical 10 helicopter evaluation services in New Orleans. 11 Apparently in 1969, the Highway Safety Commission of 12 Louisiana, in an attempt to coordinate EMS programs statewise, asked the Gulf South Research Institute to do a study of the 13 14 emergency medical services program in the state. 15 They did submit the study and it is really an 16 excellent study. It encompasses the entire statement of the 17 problem with a good inventory of needs, resources, identifica- 18 tion of shortcomings in the state, and a plan for correcting 19 them. 20 The study also suggests training, communications, 21 and now with this RMPS program coming down the line they finall 22 see a way of upgrading this 1969 study and beginning to 23 implement it with specific projects. 24 The first project they submit is that of updating, Ace - Federal Reporters, Inc. which will do just the things that I have suggested, inventory, 25 mea-6 191 develop workshops for the public and for personnel, establish 2 EMS councils among B agencies, develop a program of priorities, 0 3 and establish mechanisms for implementing the plan which will 4 be updated. 5 It is a one-year program and includes some evaluation 6 and requests $54,000 in direct costs. 7 I think it is a good program and I would grade this 8 a 4 on that scale of five. 9 Number 27 is a training program to train emergency 10 room staff, ambulance personnel, and to produce a coordinated 11 statewide training program and a register as well as developing 12 standards for continuing education and recertification 0 EMTS. 13 There is an evaluation included in their training 14 program which is two years under the auspices of the state 15 Department of Hospitals for a total of 72,148. 16 The state Department of Hospitals has indicated that 17 they will continue the program under their funding at the end 18 of this two-year period. 19 Also, it is a well put-together program and I would 20 grade this on that same scale, and recommend full funding on 21 that. 22 The third program is that of communications, project 23 28. The objectives of this program I'll surmarize, in reading 24 this -- they have the notion that before hospital or ambulance Ace -Federal Reporters, Inc. services spend the money for a communications system, they must 25 mea-7 192 have information concerning advantages of the system, cost, 2 ,2ffectiveness, capabilities, compatibility of equipment, and so on. 3 4 These institutions must be shown through a variety of settings throughout the seven CHP areas that the communication 5 6 system is a nececcity for good and efficient emergency medical services. 7 8 It is anticipated that this demonstration project 9 will stimulate and commit hospitals, ambulance services and governmental agencies to support a statewide emergency 10 I Icommunication system. 12 Soi they are requesting 94,000 --- 122,000 for the 1 3second year -- 94 for the first year -- to approach the 14 problem in this way, which involves purchasing some equipment, 15 and getting the hospitals to all become aware at least of the need for communications and pick up the ball in two years. 16 That is project number 28, which I also think is well- 17 conceived, and gets us involved in cost-sharing with the 18 hospitals, and although a critique of this by staff felt that 19 the hospitals may not pick up the ball, at least it is a start. 20 The fourth program, the helicopter evaluation 21 22 prograir., has objectives to determine the need for air medical emergency patient transportation in the Greater New Orleans area, 23 establish feasibility of such a service, and determine its 24 Ace-Federal Reportets, Inc. mechanism of operation and costs. 25 193 mea-8 I They consider that since the medical helicopter service has been so successful in the military, this RMP study 2 3will aim to determine if this procedure will reduce mortality, and translated to the civilian role, provide a service for the 4 State of Louisiana. 5 They are requesting a one-year study to do this for 6 $46,000. 7 8 So, in summary, we have four projects, 26 is an 9updating of an already existing comprehensive system and 10 beginning implementation; 27 is a training program; 28 is a 11 two-way communication system in a variety of hospital settings, 29 is the medical helicopter service. 12 I would grade the program as maybe 4.0 and recommend 13 full funding. 14 And initially, in their introduction I am impressed 15 with the figures that they quote, which may have been known to 16 all of us, but I will just mention them gratuitously. 17 Inspection of war figures to determine the value of 18 transportation -- of the whole emergency care system, the war 19 figures in 1969 that were done show that eight percent of 20 casualties in World War II figures -- eight percent of the 21 22 casualties dies. Four-point-five percent died in Korea and only 2.5 percent are dying in Vietnam, and the implications by 23 these figures is that these casualty-to-death rates imply that 24 Ace-Federa[Reporters,inc. we are gaining on it, and the things that we are doing in 25 194 Vietnam that we weren't doing in World War II should be 2 @ replicated in civilian situations. 3 The figures are impressive, and I think backed with 4 that kind of approach, I liked the program. 5 DR. ROTH: Jerry, why do they need to do a one-year study to establish the fact that nobody can afford the 6 7 helicopter services except the federal government? 8 DR. BESSON: I can't answer your question. DR. ROTH: There are plenty of cost figures on 9 10 helicopters. 11 DR. BESSON: I am perfectly willing to scratch 12 37,000 from the program. 1 3 14 DR. SCH.ERL S@ The secondar-Y reviewer, please? 15 That is Dr. Roth. DR. ROTH: Well, 1 have not done any of my second 16 area reviews. 17 18 DR. S.CHERLIS- Haven't you? All right. 19 DR. BESSON: I would recommend that we grade,them as 20 4 and.fund them at 363, less 37,000. 21 DR. HINMAN: Disapproval for 29. 22 DR. SCNBRLIS@I: Disapproval for the helicopter study 23 and the others, grant them at 4? Any other comments? DR. BESSON: I might add that as the B agency or 24 Ace -Federal Reporters, Inc. other endorsing groups were asked to comment on these four 25 195 1 proposals, they considered that this helicopter program was last 2 in priority. 3 DR. SCHER@ISI All right. 4 All in concurrence? 5 (Chorus of ayes.) 6 DR. SCHEPLT$@: Opposed.) 7 DR. HIMIAN: $225,615 the first year, and then CR 6307 End #16 8 $100,325 the second year. 9 1 0 1 1 12 1 3 14 15 1 6 17 18 1 9 20 21 22 23 24 Ace-Federal Reporters, Inc. 25 196 CR6307 #17-ter-1 DR. SCHERLIS: All right. 2 The next area is that of Missouri and I want to 3 than)-, Dr. Besson. Missouri submits two projects, Project 4 No. 85, centers around Kansas City General Hospital Medical 5 center. Its purpose is as stated to provide a comprehensive xxxxxxx 6 emergency service for Kansas City, and a centralized trauma 7 service for Kansas City. 8 The Kansas City General Hospital would be designated 9 as a major emergency facility capable of treating,,-immediately 10 upon arrival, any patient of a life, or limb threatening 11 condition at any time. The emphasis on this, both in their 12 brief summary and in the grant itself, is highly on trauma. C) 13 The hospital is operating as a major emergency 14 facility, giving care and definitive treatment for all emergencies. Early screening fcr emergency room patients with 15 appropriate specialized treatment in trauma, drug abuse, etc. 16 17 Early screening, establishing an overnight observation ward 18 adjacent to the emergency room, and conducting a computerized 19 trauma registry for proper recording and feedback. 20 The sum of money requested for project 85 is 300,000 21 the first year, 285,000, the second, and 300,000 for the third 22 year. 23 Reviewing the project, it is centered not on the 24 community basically, but very much about the Kansas City Ace -Federal Reporters, Inc. Hospital, itself. As far as I can determine, there is very 25 197 1 little in the way of community involvement. The linkages, 2 themselves are only partial, as best I could determine from the 3 reviexi. Some 250 thousand is requested for salaries for the 4 emergency room and trauma center, which significant sum is 5 obviously for the in-service area of the hospital. 6 There is very little evidence to me of regionaliz- 7 ation in this. It does not speak to a system of total emergency 8 care, but much more to trauma, itself. There is some indication 9 of problems in handling the ambulatory patients which come 10 to the emergency room. But basically, this is oriented almost 11 completely towards the Kansas City Hospital in the in-trauma; 12 and the support of the staff of the emergency area and the 13 trauma center, as I have indicated, comes to most of the sum. 14 I did not give that any recommendation as ar as 15 rating. I do not thing it speaks to a system of care, and I 16 think it is all for the Kansas City General Hospital without 17 being part of what our guidelines would recomment. 18 The second project is one which centers around the xxxxxxx 19 Lester E. Cox Medical Center. This project requests a sum 20 of $1 million for the first year, 1.4 for the second, 900,1000 21 for the third, for a total then of $3.3 million. It speaks to 22 developing, and this is Project No. 87 -- hierarchy of emergency 23 medical service facilities, an integrated emergency transpor- 24 tation system, and to train necessary personnel. Ace-Federal Reporters, Inc. This would be to provide a comprehensive system 25 ter-3 198 1 for 33 counties in rural southwestern 14issouri, which would 2 include an emergency transportation network plus emergency 3 medical facilities. 4 It would include six equipped ambulances, three 5 equipped busses, md one helicopter, and they want to establish 6 at least one major medical facility, and several satellite 7 emergency facilities, train 25 nurses in emergency treatment, 8 as well as other associated paramedical personnel, and to 9 develop a communications system, in addition. 10 In reviewing this, something like $500 thousand for 11 salaries, 376,000 for equipment, includes 30 ambu ance atten- dants, 25 nurses, and individuals to man the helicopters, 12 13 as well. There will be three phases in terms of mobile units. 14 Family health care is discussed as well, and actuallv 15 when you read about the bus system, this would be three busses 16 which would be used to service non-emergency, medical 17 patients, and also funds are requested for family health care 18 stations, circuit riders. 19 In reviewing this, although it is submitted as part 20 of an emergency medical system, it really discusses total care, and discusses it in a completely different way, than one 21 22 I think would interpret the guidelines. It is a three-year 23 grant application from a nonprofit community hospital, with 24 requests including, as I have indicated, not alone, emergency Ace-Federal Reporters, Inc. vehicles, but funds for family health care stations, busses 25 19 9 1 to transport patients from the rural area to the hospital, 2 itself. 40 3 There are points of value in this, in that there is 4 active involvement of the community. The area served is rural, 5 involving some 700,000 people, but my concern is that it 6 tackles a much larger area than just emergency medical ysstems, 7 and even when it approaches emergency medical systems, there 8 are large areas not discussed, such as the training program, 9 physician coverage, equipment which would be on some of the 10 emergency equipment discussed. 11 Before recommending any funding on that, I would 12 like to have the secondary reviewer make anv comments which he 0 1 3would feel appropriate. That is Mr. Toomey. 14 MR. TOOMEY: I would -- I felt the same way you 15 did about the Kansas City General Hospital, they were asking 16 funds to improve the services within the hospital but without 17 mucy concern for an emergency medical services system, as 18 far as the area was concerned 19 I think I felt -- I do not know how you feel, but 20 I felt that this proposal from the Lester Cox Medical Center 21 in Springfield; (a) was very interesting, but it really had only one part of it devoted to providing an emergency medical 22 23 service for the area. 24 I felt the family health care station proposal, Ace-Federal Reporters, Inc. while interesting, was not really pertinent. I felt the circuit 25 200 ter-5 I rider was not exactly pertinent. One thing -- I do not know, 2 did you mention the fact that this is the second time this 3 proposal has been submitted, and the letters of -- 4 DR. SCHERLIS: For '68 and '69. 5 MR. TOOMEY: The letters written in support of it 6 were dated in 168 and '69 with the statement that the people 7 who supported the thing were supporting it now. 8 DR. SCHERLIS: Thev still like it. 9 MR. TOOMEY: Yes. 10 DR. SCHERLIS: They have -- the intent is to make 11 health care service available among those people who live in 12 the hinterland sectors. And while I would concur that these 13 are very valuable goals, this is not what we are addressing our- 14 selves to under the ED4S guidelines. 15 MR. TOOMEY: In summary, what I said, the portion 16 of this proposal which deals with the development of a centrally 17 controlled and coordinated system of ambulance services for 18 33 counties, is a desirable project perhaps, but the hea t 19 care stations and the physician circuit rider are interesting, 20 would be of some value, but they are not appropriate and r6la- 21 ted to the project. 22 DR. SCHERLIS: Did you recommend the sum? What was 23 the sum? 24 MR. TOOMEY: They are requesting one million, forty- Ace -Federal Reporters, Inc. 25 five. I 201 ter-6 1 DR. SCHERLIS: A million, forty-five? 2 MR. TOOMEY: No, I did not recommend the sum. 3 DR. SCIIERLIS: I gave this a rating of two and 4suggested somewhere between -- I had fully suggested 75,000 5to help get the planning going, because I think there are some 6parts in here that can be put together. But I would not 7suggest it go to the Lester E. Cox Medical Center, but rather 8the regional medical program office, for planning. 9 MR. TOOMEY: I would support that. 10 DR. SCHERLIS: The motion then is $77 thousand for 11 No. 2, at a rating of two. That is actually application 87, 12 to keep it accurate. 13 The sum of $77 thousand for a priority of two, and 14 the other Project 85, no support. 15 Second rbviewers? 16 MR. TOOMEY: Yes, okay. 17 DR. SCHERLIS: Any comments? 18 DR. BESSON: I did not. 19 DR. SCHERLIS: Yes, sir? Dr. Keller? 20 DR. KELLER: I just want to ask with respect to 21 guidelines, we have had just one or two other projects today 22 that seem to emphasize the interface between emergency medical 23 centers and the rest of the health care system. If I under- 24 stand our guidelines correctly, that is something we are aiming Ace-Federal Reporters, Inc. 25 at, rather than backing away from? ter-7 202 1 DR. SCliERLIS: Yes. 2 DR. KELLER: I just had a moment to look this through 3 and it is a very complicated application, and I am sure that 4 there are many difficulties. But, is there something in 5 here that can be funded.. That help is to emphasize the desira- 6 bility and the importance of this kind of linkage? tlhat I 7 am afraid of is that in manv of the programs that have been 8 presented, the people who are specifically enthusiastic for 9 emergency medical services will gain such ascendancy in these 10 things, that eventually the linkage between that and the 11 rest of the health care delivery system will begin to be 12 deemphasized. 13 DR. SCHERLIS: Yes. I view the system as being not 14 just in the emergency aspect and ending in the emergency -- 15 when the emergency is taken care of. But it should certainly 16 go the entire loop. 17 I think some of the guidelines emphasize this as well. 18 I think in this particular instance, the first one only looks 19 at a verv small -- not just aspect, but a physical area as 20 part of the system. 21 As such, I think it falls outsidel'of the guidelines. 22 The second one has the problem of being a 168 - '69 application, 23 which they say everybody still agrees with. Secondly, it there- 24 fore does not have the opportunity to review itself in terms Ace-Federal Reporters, Inc. of the guideline, but yet so much has gone into that, that 25 ter-8 203 planning and training aspects look like they should be salvaged. I felt as a secondary reviewer these could best be moved from 2 3 the responsibility of the Cox Hospital to the regional program 4 office, itself, so we get -- we would hope we would get a 5 better correlation with the other services in the state. 6 It has aspects that are interesting that might be favorably look upon under general regional medical program 7 8 supports , like area health centers. but this is not part of 9 what we can support under our present mechnism, at least within our responsibility todav. 10 I 11 MR. TOOMEY: Can I comment just a moment? 12 DR. SCHERLIS: Sure. Yes. Please do, Mr. Toomey. 1 3 TAR. TOOT@-EY: The first program was just internal 14 operations of the emergency room, and I do not consider that 15 to be part of our responsibility. The other one is more of 16 a conceptual thought. I am rather amazed at one institution 17 in Springfield wanting to accept a responsibility for coordin- 18 ating ambulance services and other services to people in a 19 33 county area, and to the degree that it is my opinion, that 20 the hospitals will be moving in the direction of sharing serv- 21 ices and in the direction of finding a major institution who 22 accepts a major role in integrating various kinds of services, 23 ambulance and other institutions, - 24 we may be looking at tradition when we say, "Move Ace -Federal Reporters, Inc. it away from the hospital and put it back in RMP," rather 25 204 ter-9 I than looking at what seems to be coming in the future, which 2 is the enlarged role of institutions covering and with a 3 responsibility for a larger area than they have had in the 4 past. 5 I do not know what the answer is to it, but I end #17 6 think it is one of those things that is happening. 7 8 9 1 0 1 1 12 13 1 4 15 1 6 17 18 1 9 20 21 0 22 23 24 Ace -Federal Reporters, Inc. 25 205 xxxxxx CR 6307 DR. SCHERLIS: We now move to New Mexico, Mr. Toomey #18 dh-1 2 @and Dr. McPhedran and the secondary reviewer. 3 MR. TOOMEY: The application is New Mexico -- 4 DR. HINMAN: Let the record show that Dr. Hendry-son, 5 left the room during the review. 6 DR. SCHERLIS: Don't go far. 7 MR. TOOMEY: Funding is requested for $425,000.the 8 first year, and $139,000 the second year, $147,000 the third 9 year. 10 This grant request was from a previous grant funded 11 in 1968 to study the health delivery system of the state of 12 New Mexico. Due to the 1968 grant, quality of existing EMS 13 services have improoved but there are still 11 counties where 14 no EMS systems are available. 15 Therefore, this request is requesting primarily for 16 the establishment of an EMS by using a model developed in a 17 similar community of New Mexico providing primary medical care, z 18 communications, transportation, and hospital@emergency linkages 19 for those rural counties without these services. 20 New Mexico has a 121,000 square miles and is the fift largest state in the nation. The economy peramaters include 21 22 ranching, farming, mining, oil production, light industry. It 23 has a population of a million, amillion, 20 thousand. It is 24 by sected by the Rocky Mountains of which roughly a third of Ace -Federal Reporters, Inc. the central portion of the state is occupied by mountain terrair 25 206 dh-2 I with the remainder configuration of the state being flat plain. 2 The 3 major:ethnic groups comprise the population including 3 white, white Spanish, and Indians. 4 The primary objective of this grant application is 5 to establish an EMS system in 7 rural communities employing the 6 model tested in San Rafael County, and to improve the quality 7 of existing EMS systems in the state of New Mexico, with iden- 8 tification of present weaknesses and other components of the 9 total health care delivery system. 10 Second area objectives include the development of 11 data relating to emergency ambulance care crisis and to create 12 2 working pilot projects to attack the problem, to evaluate the 13 dfficiences of the Plan's training program that concerns time 14 and resources in its delivery; enhance the availability and 15 accessability to the educational experience, to establish a 16 regional coordinating center to standardize and develop training 17 and treatment methods; to influence improvement of the total 18 health care system. 19 The plan primarily emphasis is the development of 20 more administrative control and internal organization for ad- 21 ministering a total EMS. Of the $483,000 requested for the 22 first year, only approximately $80,000 is for equipment. The 23 remainder is $4OOiQOO for personnel training, instruction, and 24 fringe benefits. Ace -Federal Reporters, Inc. The narrative describes a geographical area to be 25 207 dh-3 I served, however, the only portion I delineate is a clear under- 2 standing as to how the various elements will be integrated or 3 the identified deficiencies within the present system overcome. 4 The application is. a community based program, has 5 broad representation and involvement from providers, public 6 agencies, and community interests. 7 Existing medical service resources and needs have been 8 identified and documented. The plan defined how the various 9 operating cooperatives will be coordinated and tied together 10 with already operational cooperatives. Linkages with local 11 health care systems to assure adequate referran and follow up 12 of treatment. 13 Emergency treatment is only partially described and 14 briefly referred to in regard to master plans. 15 The narrative includes techniques to utilite existing 16 financial resources and a means of obtaining additional financial support. 17 18 All local state and national operating standards are 19 complied with, evaluation procedures and techniques for determin- 20 ing the effect of this system are perhaps the weakest section 2 1of the proposal. 0 22 This grant request narrative includes many details 23 about-@the various counties which require careful sorting and 24 review to gain any understanding of the application, or a thorough Ace -Federal Reporters, Inc. Understanding of the application,, even though the application 25 208 dh-4 I appears wordy and pale, it appears to meet the criteria of an@ 2 EMS system which is designed to meet the needs of the population 3 and topography in the state of New Mexico, and it is my recom- 4 mendation that it be given -- I'll wait until we have the sec- 5 ondary reviewer. 6 DR. MC PHEDRAN: I rated it a 4. I won't repeat what 7 Mr. Toomey has said. I want to underscore, though, the commun- 8 ity involvement. There is evidence in this application of com- 9 munity input that I found in no other applications that I re- 10 ceived. 11 DR. SCHERLIS: It isn't just the lateness of the hour? 12 DR. MC PHEDRAN: No. I think it is very good. This 13 is one of the 2 or 3 best, and I was particularly impressed with 14 that. 15 DR. SCHERLIS: What level of funding do you suggest, 16 Mr. Toomey? Do you have a suggestion on that? 17 MR. TOOMEY: I do have a suggestion that. I suggest 18 that it be funded as requested. 19 DR. SCHERLIS: You both recommend full funding and a 20 rating of 4? That is one of the best reviews we have had in 21 terms of the recommendation. 22 All those in favor say aye. 23 (Chorus of ayes.) 24 Opposed? Ace - Federal Reporters, Inc. All right. Next state is Oklahoma. 25 209 dh-5 1 Mr. Toomey. In fact, you have the next one as well. 2 You also have South Dakota. 3 Mr. Toomey? 4 MR. TOO@IEY: The funding is requested for A $104,000 5 for the first yeari $124,000 for the second year, and $64,000 6 for the third year. 7 It should be noted this proposal was originally sub- 8 mitted in advance of 172, prior to the development of guidelines 9 for submission of proposals. The proposal was also submitte as 10 part of a regular funding request application to RMP as of 11 February 1, 172. 12 This project proposal is part of the total anniver- 13 sary application for the fourth operational year to be acted 14 upon by the 1912 National Advisory Council. 15 okay, considered to be a rural state, has half of its 16 total inhabitants in 3 standard metropolitan statistical areas, 17 including Oklahoma City, Tulsa, and Lawton. Of the state pop- 18 ulation of 2 and a half million, approximately 65 percent live 1 9in cities of 10,000 or more. 20 Topography influence As the location of the inhabit- 21 ants with the bulk of the population on the axis from the north- 22 east to the southwest corners. The Northwest Quadrant is large 23 wheat fams and cattle ranches and the southeastern, extensive 0 24 and rugged hill ranges. Ace-Federal Reporters, Inc. The state's medical and health community parallel the 25 210 dh-6 1 general population where half of the city,centers in the state 2 live in 30 minutes drive of a large medical center. Approximate- 3 ly 20 percent of the inhabitants of the state are located'in 4 one third of the geographical area do not have immediate access 5 to specialized services and facilities or live beyond a 30 mile 6 range, 7 The primary objective of this request is to raise the 8 standards of emergency medical care transportation to each city 9 in the state, to have access to medical services through provid- 10 ing advanced emergency training by physicians for ambulance 11 Attendants. 12 Specific objectives,indlude development of a program 13 providing comprehensive training to evaluate the skills of all 14 ambulance service personnel in Oklahoma. The plan, the mecha- 15 nish, is the development of a 72 hour EMS training program sus- 16 tained as a community-based, physician-oriented course to raise 17 skills of personnel conunesurate with the emergency medical re- 18 sponsibiliies of individuals already engaged in providing care 19 and transportation services. 20 This course of instruction includes academic instruc- 21 tion as well as practical exercises in accordance with the cur- 0 22 riculum developed by the American College of Surgeons Committee 23 on Trauma. 24 The evaluations, the application has not demonstrated Ace-Fedefal Reporters, Inc. a thorough@,knowledge and understanding of an emergency medical 25 211 dh-7 1 service system or discussed the various components and elements 2 of this system. Does not describe how the various phases will 3 be integrated into the current system, nor has he identified 4 present definitions in the present system. 5 The specific geographic area to be served has been I identified as a state-wide proposal, however, there is inade- 0 7 quate information to determine community organization and lead- 8 ership to include a broad repetition of procedures, public 9 agencies, and community interests. 10 The application has identified facilities and equip- 11 ment currently rendering emergency service and has briefly ident- 12 ified other resources, and existing medical services. But the 13 current deficiencies have not been addressed. The plan does 14 not clearly delineate how the various components will be coor- 15 dinated with components already operational or how new additions 16 will affect the total system. 17 Linkages with local health care systems to assure 18 adequate provisions for referring and follow up of emergency 19 patient needs and in cooperation with disaster planning and 20 long range growth have not been referred to or described. 21 The application briefly speaks to obtaining addition- 22 al financial support with the initial grant request and for 23 future support after the grant expires. 24 There is not adequate information to determine the Ace -Federal Reporters, Inc. quality of care to be provided or to determine an effective plaii 25 212 dh-8 1 for evaluating the various elements. 2 I have a note to refer to Dr. Kaplan's comments. 3 "Unfortunately this complete project is nothing more 4 than just a projection. While it is well developed, well organ- 5 ized, competently organized, and stated to be top priority, it 6 does not meet our priority for the EMS application. The Appli-- 7 cant,has submitted a state-wide plan. However, this plan, based 8 on criteria that an ideal plan should identify problems, estab- 9 lish objectives, and give details on the ways to meet the objec- 10 tives, is not in fact a plan. 11 The applicant.does not directly.relate his projection 12 to this plan. Furthermore, the project which is designed to 13 train ambulance attendants doesn't give any indication of a 14 communications system which would stimulate these ambulance 15 attendants to act. It does not give any indication as to what 16 type of communications would exist between the ambulance and the 17 hospital or the ambulances home base. 18 It does not give any indication as to the quality of 19 emergency rooms to with the attendants trained in this project 20 would bring their patients. 21 Finally, the applicant does not give any indication 22 of how these trained personnel will be deployed in relationship 23 to the needs of the involved communities. 24 DR. SCHERLIS: Your recommendation then is? Ace - Fedeial Reportefs, Inc. Or Dr. McPhedran? 25 213 dh-9 1 DR. MC PHEDRAN: I agree. You recommend no funding, 2 is that correct? 0 CR 6307 3 MR. TOOMEY: Yes. end #18 4 DR. MC PHEDRAN: I agree. 5 6 7 8 9 1 0 1 1 12 13 1 4 15 1 6 17 18 1 9 20 21 22 23 24 Ace-Federal Reporters, Inc. 25 214 mea-1 CR 6307 #19 DR. SCHERLIS.', All right. Any dissenting voice? 2 Well, then, go ahead to South Dakota. 3 Mr. Toomey, again. 4 Following South Dakota, I assume Alabama. Is that 5 the correct order? 0 DR. HINMAN: Yes, sir. 7 DR. S.CHERLIS: Alabama will be next, so contain 8 youts@el f . 9 MR. TOOMEY: The University of South Dakota is the 10 applicant. The funding is requested for the first year, 470,000 11 and I have none in the second and third year. 12 Is that right? 13 DR. MC PHEDRAN: That's right. 14 MR. TOOMEY: South Dakota does not have an effective 15 emergency health service; hence this grant will cover the entire 16 state. 17 The basic problems are those of small rural popula- 18 tions with large geographic directions. There are very few 19 trained ambulance drivers or emergency technician personnel 20 manning the ambulances of the existing emergency transportation 21 system. 0 22 There is little public knowledge as to lifesaving. 23 techniques in the utilization of ambulance and training 24 techniques. Ace -Federal Reporters, Inc. 25 Generally South Dakota has few hospitals and they I mea-2 215 I have varying capabilities. It has a high tourist population in 2 the summer months with a high incidence of traffic accidents. 3 The state geographically encompasses an area the size 4of Delaware, Maryland, Virginia, and West Virginia, but has only 51/17th the population. 6 The specific objectives of this project include the 7establishment of medical technician and training programs, the 8establishment of hospital technician training programs, 9categorization of present hospital emergency services, establish- 10 ment of health consumer education programs, and the purchase of 11 medical equipment for ambulances. 12 The planning process includes three phases of 13 implementation: Phase one includes planning, demonstration and 14 procurement; phase two, the implementation and utilization of 15 the planning demonstration projects and procured resources;and 16 phase three, the operational phase. 17 All three phases encompass the total components of ar 18 EMS system including consumer education, ambulance purchase and equipment procurement, classification, categorization of 19 20 emergency health services, emergency medical training, 21 standardization of emergency services, communications develop- 22 ment, physicians, assistants program, integration of emergency health services components into the current system. 23 24 The narrative does not indicate how the various Ace -Federal Reporters, Inc. phases will be integrated into the existing system. 25 mea-3 216 1 The geographic area has been described. However, 2 there is only partial reference to involvement by providers, 3 public agencies, planning agencies, and communities. 4 The narrative does not define existing medical 5 service areas in the region. However, it does partially 6 speak to potential resources, and the assessment of needs and 7 resources in the area. 8 There are not adequate facts to document statements 9 referred to in the narrative. There's inadequate information 10 to determine how the operating components will be coordinated with already existing elements of an EMS system. 12 The narrative does not describe the linkages with local health care systems nor is there adequate information to 1 3 14 determine whether there's cooperation in community disaster 15 planning or preventive medical systems. 16 The application speaks briefly to the pointiof 17 utilizing additional financial resources and for obtaining 18 additional financial support after the expiration of this 19 grant. 20 There is no general, overall innovative approac to 21 the development of an EMS system in this area or any assurance 22 as to the quality of care to be rendered. 23 Once again, to turn to the staff evaluation -- while 24 this application has many good ideas, as an application, as a@% Ace-Federal Reporters, Inc. plan and as a tool to achieve a total EMS system, it in my 25 mea-4 217 1 opinion fails. 2 There does not appear to be sufficient depth in the 3 description of the problem of EMS in South Dakota. Statements 4 are made but they aren't backed with facts. 5 For example, they state many lives are lost, but 6 don't state how many, where, why, when, and so on. 7 The applicant talks about utilizing PERT, PPBS, 8 management by objectives. They have demonstrated its use. 9 The application needs better organization, a clearer 10 definition of problems, needs and objectives and a clearer 11 picture of a total EMS plan and a better interpretation of the 12 EMS elements. 1 3 DR. Dr. McPhedran? 14 DR. MC PHEDRAN: I agree essentially with the 15 evaluation, that it is a portion of what we would want to have 16 in an EMS but not the whole thing. 17 Notice that the projected budget for year one is 18 greater than the total annual budget for the South Dakota 19 regional medical plan. 20 Is that right? 21 DR. HINMAN: Yes, sir, but I think there should be 22 a comment made. 23 South Dakota is in a planning phase, not an 24 operational phase. They have just split from Nebraska last year. Ace -Federal Reporters, Inc. 25 DR. MC PHEDRAN: I was going to bring this out, that I mea- 5 218 1 this is really essentially a brand new region. I would not like 2 to recommend that they get no funds; I just think that this is 0 3 an enormous amount to expect them to spend sensibly at this 4 time. CH 5 DR. S. ERLIS: What would be the rating of this? 6 MR. TOOMEY: I would say it would get 2 to 2.5. 7 DR. MC PHEORAN. I gave it a 2. 8 DR. SCHEPJIS@*. Would you agree on 2? 9 Two is the rating. 10 MR. TOOMEY: I think they should be given a planning 11 grant. 0 12 DR. SCHERLIS-.-, What sum would you think would be -- 13 MR. TOOMEY: My estimate would be $50,000. 14 DR. S@CHERL IS Dr. McPhedran, what would your 15 feeling be on that? 16 DR. MC PHEDRAN: Yes. 17 DR. $CH@'PLIS -. These are numbers from the air but 18 at least the).r are based somewhat on the project itself. 19 DR. MC PHEDRAN: On looking at the figures, that is 20 sort of about half of what they had requested for personnel for 21 the first year. 0 22 I think that is a reasonable figure. 23 DR. '.5CHERL.IS,@-,@ Do we have comments from the group 24 on this? Ace -Federal Reporters, Inc. 25 DR. HINMAN: Did you say 150? mea--6 219 DR. MC PHEDRAN: Fifty. 2 DR. SCHERLIS: Fifty? 3 DR. MC PHEDRAN: Fifty is what I said. DR. SCHERLIS: All right. 4 Dr. Besson? I have saved Alabama for you. Is that 5 the next state? > 6 DR. HINIAAN: Does everybody accept that? 7 DR. SCHE-RLIS: Everybody accepted this. 8 9 DR. BESSON: Alabama, has two projects, oroject number 10 42 and 43. 11 I suppose they are overlapping but they have an 12 entirely different vantage point. Project 43 is statewide and project 42 begins with 13 14 Birmingham and then contiguous cities, And then other counties 15 in the area, then Alabama, and then tomorrow the world, I guess. 16 The application is prepared both for submission to 17 HSMHA as well as RMPS. It is for health planning region 3. It is phased in as I have described. 18 19 The summary of the application is to develop a fully functioning EMS system in that spreading geographic manner; 20 21 to develop an evaluation methodology; to coordinate all present 22 EMS groups, and then do that in a spreading fashion. 23 There are several components to the system: Consume3 education, manpower, training programs, communication systems, 24 Ace-Federal Reporters, Inc. transportation, and guidelines for emergency room 25 mea-7 220 1 classification and expansion or modification of facilities in an 2 integrated fashion; components for organization and management 3 of the system, for evaluation of the system, and then for 4 expansion. 5 It is really a very complete package that this 6 first project 42 presents. 7 Some comments about the individual components of the 8 package: First, the organization, Dr. Dimick, a consultant for 9 this review group, is project director. It is obvious that he 10 has provided the very great impetus for the development of the 11 entire program in Alabama. 12 Planning for the entire program is in three phases. 13 First, there is a demonstration area in the Birmingham area, 14 and then coordination of five contiguous cities,, and then the 15 rest of Jefferson County, and then finally the CHP B agency 16 area. That encompasses this county area and further. 17 The component of consumer education has the usual 18 methods of consumer education and public information plus the 19 innovation of being the first state I think to incorporate into 20 their school system courses on first aid as part of their 21 secondary school education, I think. 22 They hope to hire a full-time public information 23 specialist. They have a large increase in personnel for the 24 Alabama regional medical program, and we will go into that Ace-Federal Reporters, Inc. when I discuss budget in just a minute. 25 mea- 8 221 1 Training, they hope to have seven rescue units in 2 this first small area, training enough elements to staff them, 3 and have a coordinative training program in the area. 4 They have become very much interested in mobile primary care units, and give some interesting but usual 5 6 statistics on the number of deaths from coronary disease prior 7 to getting to the hospital, the length of time it takes to get 8 to the hospital, the fact that emergency equipment like the 9 local fire department 90 percent of those emergency vehicles 10 reach the victim -- they use the term "victim" in this 11 circumstance, rather than "patient" -- in less than three 1 2 minutes. So, they want to move their entire mobile coronary 1 3 14 care units in the direction of having them instantly available, 15 staffed with good communications with physician monitors. 1 6 They hope to provide eight mobile units with EMTs@@, 17 and equipment for them, as well as monitoring stations that 18 are portable, with physicians monitoring:them@,.@-. 1 9 DR. SCHERLIS'-. Is this telemetered monitoring? 20 DR. BESSON: What do you mean by this? Two-way communication? 21 22 DR. SCHERLIS.@ The physician will not be on the vehicle? 23 DR. BESSON: What are the dedicated vehicles? 24 Ace-Fedefal Reportefs, Inc. DR. S CHERLI'S Purely for coronary care. 25 mea-9 222 1 DR. BESSON: Yes. 2 DR. SCHERLIS:@ Purely for coronary care? DR. BESSON: No, they are emergency rescue vehicles, 3 but they are called coronary care unit vehicles and I suppose 4 5 they are equipped for more than coronary care but I can't 6 really answer your question. DR. S,CHERLIS.-: This is a critical question, at least 7 8 in my mind. 9 DR. BESSON: They are equipped for it. I don't know. 10 DR. SCHFRLIS:.@- Maybe I can dig that up. 11 DR. BESSON: I get the impression that -- they are called coronary care unit vehicles but I think they are equipped 12 13 for that plus other emergencies. 14 They go into great detail giving plans for 15 hospital coordination, for management, for interco@mmunity 16 relations, for legislation, for description of existing 17 systems, the accomplishments in the past, and go on for 247 18 pages of what is really a very well thought out program and for 19 which Dr. Dimick certainly deserves high grades. 20 Let's talk about budget information a moment. The components of the budget which come to a total -- project 46, 21 22 this first project -- 1.2 million for the first, 1.0 for the 23 second year,139 for the third year, and a total of 2.2 million 24 for the three years ate made up of central operations,. Ace-Federal Reporters, Inc. I won't go into too much detail, but central 25 mea-10 223 1 operations requests 394,000, of which the bulk, 128,000, is 2 made up of salaries for project director, executive officers, 3 administrative officers, and so forth. 4 And operations center equipment, equipment for 5 coronary care, 54,000. Consultant fees, 87,000. The Component of public information is going to be 6 7 subcontracted. It just said subcontracted to a consultant firm 8 experienced in the field. They don't go any further than that except to say that that amounts to $107,000. 10 Emergency medical training will be the Dunlop 18-hour 11 course with three programs, 20 students each. 12 Mobile CCU will have monitors and two medical residents, if you please, as riders on the mobile CCU vans, 1 3 14 hoping to give EMTs training right on the spot, as well as 15 providing medical care. 16 The $30,000 that they have programmed for two 17 second-year residents as monitors, two second-year residents as 18 riders on these things, I have some question about that. I am 19 not sure that this is the question raised here on our funding 20 sheet, tuition charges should be disallowed for project 46. So, whether that refers to another one, I don't know. 21 22 They speak of career ladders moving there. People up in the junior college system from EMTs to higher things, and 23 24 thereby they hope to pay some junior college salaries, w ic Ace-Federal Reporters, Inc. have some questions about, But if it is okay with staff, I 25 mea-11 224 1 guess it is okay with me. 2 They have a program for rescue training which I think 3 is all right, communications. They have some 80,000 -- purchase 4 and maintain system over a three-year period, that is going to 5 come to approximately 80,000. 6 Transportation, they want to buy eight ambulances for 7 112,000, and pay 48 EMTS, 75 percent of their salary while they 8 were on a training basis and the ambulance people, will pay 20 9 percent of their salary, and that comes to a total of $82,000. 10 So that while this is an extremely ambitious program, 11 it is very comprehensive, and it is very ambitious fiscally. 12 I would grade the program as a 4.5 or a 5. I think 13 it is a very comprehensive program. I will defer making a 14 decision on numbers unless you force me to. 15 DR. , SCHERLIS,.: I won't force you to do anything. 16 We will need numbers -- 17 DR. BESSON: Do I need a secondary reviewer on that? 18 DR. SCEIERLIS:, Let's have a secondary reviewer of 19 that project, if we might, Dr. Roth. Do you have any comments? 20 DR. ROTH: No, I have nothing to add. I, have to 21 admit that I did not have these with me. I had 80 pounds of 22 these things the day before I left to go to the west coast and 23 back to Georgia, and then to Texas, and then here and I just 24 couldn't carry them. Ace-Fedetat Reporters, Inc. E 25 DR. SCH..,@IS:- There are certain questions maybe I mea-12 225 you can clarify. We'll get to that, I guess. CR 6307 End #19 2 DR. BESSON: We can take them up separately. 3 4 5 6 7 8 9 1 0 12 13 1 4 15 1 6 1 7 18 1 9 20 21 22 23 24 Ace -Federal Reporters, Inc. 25 CR 6307 226 20 eak 1 1 DR. SCHERLIS: What is your funding recommendation 2 on this, then? 3 DR. BESSON: You want a funding recommendation? 1 4 will bring that up in context of the project 43. 5 DR. SCHERLIS: Fine, however, you prefer doing that. 6 DR. BESSON: Project 43 is an entirely different 7 kettle of fish and it is a very elusive proposal. I spent 8 several hours before I got the drift of it and I may not have 9 it right yet. It apparently begins historically with a 1964 10 State Department of Health medical self-help training course 11 which tried to improve training of individuals and also set 12 up an ambulance training program. And then 1967, Biminghwn developed an EMS committee which was chaired by Dimick. 1 3 14 1968, the State Health Department did a survey of EMS and 15 recommended some legislation regarding ambulances. In 1970, 16 apparently the Regional Medical Program discovered Dimick, 17 following a study of cardiac resuscitation efforts by the 18 University hospital that Allen became involved in. T ey 19 became involved then, ARMP, in a study of cardiac deaths, and 20 that lead to very deep involvement in EMS. They set up 21 councils in other areas and began to coordinate various EMS 22 activities. 23 Along came the Health Department in 1971 again that 24 influenced the passage of an act which created the authority Ace - Federal Reporters, Inc. for the Department of Public Health to develop standards for 25 eak 2 227 1 ambulances. They said, well, if we have to develop standards 2 for ambulances we'd better get some advisory committees so 3 they appointed a statewide advisory committee which was also 4 chaired by Dimick, and his impetus then led them to move 5 from the development of ambulance regulations and standards 6 as authority for this act to the establishment of an interest 7 on a statewide basis in training programs, communications, tran;- 8 portation, and equipment. 9 Now, this program, then, is to enable the State 10 Department of Public Health, via this extended authority, which 11 they really don't have, but nonetheless it is good that they 12 are involved, to contract out these various aspects of their 13 interest, a training program at 104,000, the development of 14 a demonstration area at 125,,000, to provide what they call a 15 contingency fund for the development of local EMS councils, 16 to provide training of emergency vehciles, to provide communi- 17 cations and evaluation systems. 18 Now, that is the meat of the program but there are 19 a lot of fuzzy edges to it and if I were to read from the 20 proposal summary, the proposal summary in our project says, "To create through planning, training and development the 21 0 22 regulations and standards a solid foundation upon which to 23 build an effective, statewide EMS. To continue planning and 24 training activities, supplemented by acquisition or necessary Ace-Federal Reporters, Inc. equipment and material needed for effective operation of the 25 eak 3 228 I EMS. 2 And they say that will be accomplished by staffing 3 the Department of Public Health, beefing it up for creating 4 their division of EMS. They are developing some kind of 5 statewide plan which they are not very explicit about to draft 6 regulations which will implement this statewide act for ambu- 7 lance standards, to train the general public in medical self- 8 help, and American Red Cross, to extend the EMT training of the 9 81 Dunlop programs througliGut the state, hopefully, and to 10 contract with hospitals to develop courses for their emergency 11 room personnel, to inforta the public by creating what they 1 2 call road shows, to coordinate various agencies involved in 13 EMS, and to develop a demonstration area which will produce 14 full scale EMS. 15 Now, this effort is, in their words, to complement 16 the previous project, 42. I think their budgeting program is 17 very loose and totally unseparable, as far as I am concerned. 18 1 am particularly concerned about their $250,000 slush fund 19 which they say they will use for very worthy purposes. They 20 have very loose contract statements for the subcontracting 21 they are going to do for all of these component parts. I am 22 not sure,, although I asked Dr. Margulies the question about 23 our authority to fund public agencies, and he said it was 24 perfectly all right if it was an essential partof the system. Ace-Federal Reporters, Inc. I am not so sure this isn't a bottomless pit to begin funding 25 eak 4 229 1 state health departments for things that are rightly theirs. 2 So while we have two programs that are said to be 3 complementary, that I would be much more inclined to look to 4 program No. 42 as being the nucleus for a statewide program, 5 fund generously, and then let it spread. 6 However, the area, statewide area, has had such a 7 momentum that I would at the same time hate to discourage it 8 by not providing some funds for 43. So I would compromise 9 by providing some funds for Project 43, the statewide program, 10 as follows. 11 DR. SCHERLIS: Is 43 the same at 46? 12 DR. BESSON: 47. 1 3 DR. HINMAN: That is the same as 47. 14 DR. SCHERLIS: 46 is the same as 42. 15 DR. HI14MAN: Right. 16 DR. BESSON: Right. 17 DR. SCHERLIS: 46 is 42 and 47 is 43. 18 DR. BESSON: Right. They request 640,1000 for the 19 year 1. I would eliminate most of the salaries, eliminate 20 the money for the demonstration project which I think is going 21 to take place in Birmingham anyhow, eliminate that 250,000 for 22 contingency. I would recommend funding them at a level of 23 150,000, providing they give us sharper budgetary figures for 24 the EMT costs and sharper figures for how they mean to develop Ace-Federal Reporters, Inc. local councils, sharper figures for the public education 25 eak 5 230 1 program and an indication of how the EMT program is going to 2 be cost-sliared with the institutions and the ambulance services 3 that are going to use these people. 4 DR. SCHERLIS: Before you go into the figures, 5 could I ask Dr. Pnqe, have you had some contact with the 6 Alabama group.> 7 DR. ROSE: Yes. 8 DR. SCHERLIS: Could you answer a question I had 9 before, is this dedicated for pure coronary care? 10 DR. ROSE: They do carry other equipment on the 11 vehicle but it is specifically set up for such things as -- 12 DR. SCHERLIS: If somebody calls and they have chest 13 pains, that ambulance goes out. 14 DR. BESSON: Yes. DR. SCIIERLIS: Sup 15 pose somebody else has call,, 16 the vehicle does hot go out for that? 17 DR. BESSON: It does go out. 18 DR. SCHERLIS: If is is coronary care -- 19 DR. GIMBLE: It is also carrying a medical resident, 20 so it sounds like it is dedicated. 21 DR. ROSE: It can go out in times of disaster, 22 a large number of emergencies, but generally it would not be 23 used for purposes other than suspected coronary patients. 24 DR. SCHERLIS: How many are they planning, how many Ace - Federal Reporters, Inc. vehicles? 25 eak 6 DR. BESSON: Eight. 2 DR. SCHERLIS: Is there any justification for that 3 number of vehicles and the staff necessary for all those 4 vehicles, any justification that they need and will have 5 enough calls to make that item that can be justified in terms 6 of dosts? Most communities have moved away from this, the 7 concept of a dedicated vehicle. That was anexcellent concept 8 at the time when there were materials being collated on a 9 research basis but at this time most thinking is in terms of 10 upgrading training to other people, not to have the physicians 11 on board. It was very expensive to have this expensive a 12 vehicle devoted purely to coronary care. I would be very much 13 in favor of eliminating what fraction of this appears to be 14 related to that. I think they have eight Holter Avionics 15 tape recorders present at the cost of $10,000. I think that 16 is guilding it a bit. 17 There is enough information now from the supporting 18 units to give us the information necessary, Dr. Nagle's group, 19 Dr. Warren's group, the Vincent group. You can go on and on. 20 There is plenty of information. 21 DR. BESSON: They are using this in an operational 22 fashion, rather than a research fashion. I agree, having 23 monitors on these vehicles -- eight ambulances for 112,0 0, I 24 don't know. I would be willing to cut that down. I don't Ace -Federal Reporters, Inc. 25 know how big Birmingham is and I don't remember the eak 7 232 1 justification for that number, how they picked out that 2 number. I think we can make an arbitrary cut of this whole 3 program, I think, at 3.2 million, although it is an excellent 4 program, that is far too much. 5 DR. SCHERLIS: The nearest of eight mobile and 6 coronary care 7 DR. BESSON: The sequence of events that leads to thB 8 justification of this is that three minute time they go to 9 great length to point out is the time that fire departments lo@ can get to a person, and they figure the number of lives that 11 they can save if they can match that kind of distance. Whether 12 it is cost effective or not, I have my doubt. 13 DR. GIMBLE: That points out the basic flaw. 14 Let's use the ambulance system performing well already. Why 15 build eight special ambulances? Why mimic it when you can 16 use what you have? I think that is the basic flaw of the pro- 17 posal. 18 DR. SCHERLIS: Let the record show that I agree with 19 Dr. Gimble. 20 DR. BESSON: I would make a condition for the 21 award, then'. to delete the mobile CCUS, therefore, perhaps, 22 deleting a significant portion of the costs of the monitors 23 and riders and a portion of the EL@IT practical training. 24 DR. SCHERLIS: My concern is that this really Ace-Federal Repotters, Inc. casts some doubt on the entire system they have drawn up when 25 eak 8 233 1 they have gone that route. 2 DR. BESSON: I understand what you are saying. 3 DR. SCHERLIS: Because I think a few years ago this 4 would have been something that would have been looked at with 5 a great deal of interest but certainly for the last few years the emphasis has not been on the dedicated vehicle but an 0 7 upgrading of existing emergency systems. And this is why 8 that rosy glow that you imply pervades Alabama might be fading 9 a bit. 10 Dr. Joslyn? 11 DR. JOSLYN: I was reviewing these two applications 12 and I think I feel as Dr. Besson does, that they are two quite different applications, although they are Complementary. I 1 3 14 share his concern about the fuzziness of the statewide, No. 43, 15 and the beauty and completeness of the Birmingham, No. 42. 16 I guess I feel No. 42 was designed for complete funding at the 17 $3.5 million level and I thinkit was designed to be submitted 18 upstairs. I cannot judge whether they really expected us, 19 in RMPS, to fund that, or whether they sent it to us to 20 show you this dovetails with the other one they have or what. 21 But it seems to me we could cut away at different parts Of 22 this beautiful large system, but I feel the system is designed 23 to demonstrate almost everything you can do, short of 24 complete helicopter services, in one area, and it is not really Ace -Federal Reporters, Inc. designed to spread out and affect the state, altho h t ey 25 234 eak 9 1 talk about this. It is designed for a complete system in 2 Birmingham and a few areas right next door. I think that is 3 the reason there are two applications, because the second 4 application, as Dr. Besson pointed out, comes from a completely 5 different point of view. It is more of a grass roots, 6 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 RMPs 9 is in any position to fund the Birmingham one, since the 10 Birmingham application says right off, they have a superb 11 EMS system right now, far better than most places in the 12 country. They just want to make it perfect and they 13 want to answer some of the questions that people are asking 14 about, you know, what is the direction we are going. 15 DR. SCHERLIS: I think -- 16 DR. JOSLYN: I don't know. I am throwing this out 1 7 in terms of the relationship of these two programs and 18 wondering how the committee can react to both of them and look 19 at them also in relationship to what was said earlier about 20 using the RMP's money to nurture the seedlings everywhere 21 rather than give to the rich. 22 Now, I am hot saying that Birmingham can't make good 23 use and probably better use of a block of money if we were 24 sending it to Alabama. I don't know what the resolution Ace-Federal Reporters, Inc. end 20 25 to this problem is. I 235 CR 6307 Take 21 1 DR. SCHERLIS: What steps of the total program dw 1 2 do they.actually cover? 3 We have heard a great deal about the transporta- 4 tion system. 5 You said it is a total emergency system? 6 DR. JOSLYN: In Birmingham? 7 DR. SCHERLIS: What else is incorporated? 8 DR. BESSON.- Employee training, public information 9 and consumer education. 10 DR. JOSLYN: Transportation. 11 DR. BESSON: Transportation and communication. 12 DR. JOSLYN: Rescue operations. They are talking 13 about developing a career ladder. 14 DR. SCHERLIS: When the ambulance is called, it is 15 from the nearest hospital, is that correct? 16 DR. BESSON: Not necessarily. 17 DR. JOSLYN: They are going to look at all of 18 Birmingham and decide where exactly ambulances need to be 19 placed to give the best, shortest in time coverage, if I 20 remember correctly. 21 DR. SCHERLIS: Are emergency rooms part of the 22 total system? 23 DR. JOSLYN: There wasn't that much emphasis on 24 emergency rooms in this part. Ace -Federal Reporters, Inc. DR. ROSE: I had the impression, and maybe somebody 25 236 dw 2 1 could help me with this.. 2 I had the impression most of these ambulances 3 related to one emergency room. DR. SCHERLIS: This is what I was driving at. 4 5 DR. ROTH: Since I did not have a chance to go 6 into this in depth, I don't want to prolong this 7 discussion, but this relates in a fascinating fashion to me 8 to the opportunity that some of us had to go into depth in 9 the Russian plan, with its dedicated vehicles of eight 10 varieties. 11 I might say that I believe this is more coronary 12 emergency units than supply the whole City of Moscow. But 13 the figures that come out from the Russian system in terms 14 of theri salvage rate, and so on, are fantastically good, if 15 we can believe them, you know. 16 We are involved in trying to get some knowledgeable 17 people from this country who know our results, in taking the 18 ambulance out and bringing the patient back to the source 19 of expertise, as contrasted to the Russian system which is 20 taking the expertise out with them. 21 They have the physicians and the trained 22 specialists on each one of these emergency types of ambulances 23 And to me, this is an innovative feature of this thing, as 24 a demonstration project, that I wouldn't want to slough off Ace -Federal Reporters, Inc. lightly. 25 237 dw 3 1 I think it would be awfully interesting to see 2 this sort of thing done. 3 DR. GIMBLE: It has been done 20 or 30 times in 4 the last five years, there are similar projects of this 5 nature, currently funded in this country. 6 DR. SCHERLIS: This is the thing that troubles me. 7 And that is, with the health dollar for emergency services 8 available, the supply we have, I would rather they spoke to 9 a transportation system where they upgrade the existing 10 emergency staff to handle cardiovascular emergencies as well 11 as otehrs rather than going into the dedicated group, because 12 there are a lot of second thoughts, I think. 13 The lives are saved, I grant that, but I don't thin]: 14 they have to be saved by a dedicated vehicle. I think this 15 is overkill, or oversave, I guess is a better word. 16 DR. BESSON: May I make a motion? 17 DR. SCHERLIS: My other concern is -- May I bring 18 this up? 19 DR. BESSON: Yes. 20 DR. SCHERLIS: I am scanning this, you have gone 21 through it. I don't see where they relate to the problem of 22 bringing this individual who is getting cardiopulmonary , 23 resuscitation into the emergency room. What happens in the 24 emergency room? Ace -Federal Reporters, Inc. 25 DR. BESSON: TheYdrop it from there. I 238 dw 4 1 DR. SCHERLIS: If the staff can't carry on the 2 emergency service, if they aren't geared to handle it, this 3 is why we are talking about a system of care under a 4 regional medical program. 5 We are looking at a system, not at this phase 6 of transportation. You will frustrate every emergency 7 technician unless you have a system built into it of a 8 continuum of care. 9 DR. BESSON: I don't pick up where they take over 10 as soon as TER is mentioned. 11 DR. ROSE: I think this might be part of the 12 constraings of the contract program again. 13 DR. SCHERLIS: Let them have their constraings. I 14 don't think we have ours. 15 Dr. Matory? 16 DR. MATORY: So far as the emergency service is 17 concerned, one of the problems they have is that a significant 18 number of the 13 hospitals in Birmingham do not have emergency 19 rooms. And I am not sure but what that may fortify that 20 need for having better ambulance capabilities. 21 DR. SCHERLIS: The point I would make that if they 0 22 spoke of a system of having transportation -- decided they 23 would have three or four emergency rooms in that system and 24 geared to handle the catastrophe when it was brought there, Ace - Federal Reporters, Inc' I would subscribe to this as being a way of upgrading it. 25 239 dw 5 1 But if they are just isolating this and having an 2 academic approach in one area and zero elsewhere, it isn't a 3 system. DR. MATORY: I think they lean towards that 4 5 because they speak of strengthening the categorization 6 principle. 7 One other thing, I was just wondering if perhaps, 8 could I offer the alternative of instead of wiping out all 9 of the coronary care units, perhaps there may be some 10 proportion, one, two, that remain as part of that 11 demonstration. 12 DR. SCHERLIS: Dr. Besson? 13 DR. BESSON: I think that is a reasonable 14 approach. I share your concern about this degree of money 15 on a program which doesn't need demonstration. 16 But there is more than just the Birmingham area 17 we are talking about, we are talking about a five-city 18 area, and eventually a larger conglomeration of maybe three 19 counties, is that correct, or five counties. DR. JOSLYN: Aren't these five cities suburbs? 20 21 DR. SCHERLIS: It is Greater Birmingham we are 22 talking about. 23 DR. JOSLYN: The counties, as I got it to mean, 24 are the counties in Birmingham proper, tapering off, the Ace -Federal Reporters, Inc. locale directly around it. 25 240 dw 6 DR. BESSON: I don't know what the geographic area is that these mobile CCUs are going to address, but 2 3 I would be personally happy to cut down both on the number, 4 and maybe if we think in terms of two rather than eight, at 5 least it is the equivalent of what Moscow has. That might 6 be an approach. I don't know what else, 7 DR. SCHERLIS: The Chair would vigorously oppose 8 any support of a dedicated vehicle, even one, and I am a 9 cardiologist, I would like the record to show that. 10 But having just spoken of that, there was a 11 film that came out which was supposedly for systems of 12 care, to save a life, and having had the support of American 13 Heart, re-shot in great measure so it.addresses a total 14 system of care rather than a dedicated vehicle. 15 I think to support a dedicated vehicle concept 16 at this time is against the whole concept of making your 17 emergency medical technicians be able to handle that type' of 18 situation as well as others. 19 This is the sort of training we are talking about. 20 This is the course of training that is certainly 21 recommended, the only one I think we should support. 22 Furthermore, if we are going to talk here about 23 transportation in bringing them to emergency rooms, which aren't able to handle the level of care necessary you are 24 Ace-Federal Reportefs, Inc. going to have them just dying in the emergency room instead 25 dw 7 241 1 of in the street and I don't think that is commendable as 2 an approach either. 3 DR. BESSON: Okay. I will accede to the representative from the cardiology section, with greater 4 5 wisdom. 6 MR. MATORY: I was aware that we were fighting 7 that battle all along. 8 DR. HINMAN: Approximately 300, a little over 9 300 thousand tied up, as best I can estimate, in the dedicated 10 ambulances. 11 If you use a figure of 112 thousand for ambulances, 12 43 thousand for equipment, 95 thousand direct costs for 13 mobile coronary care training, half of the other -- 14 DR. BESSON: I will let you do the figuring but 15 if that is one of the conditions for the award, I would 16 certainly go along with that. 17 DR. SCHERLIS: Another strong condition, they have 18 to survey their emergency room,s and I think we can lay that 19 down, can't we -- survey their emergency rooms and integrate 20 that with their system of care, if any support is given. 21 I couldn't support just transportation. 22 DR. ROSE: That is a rather massive effort in 23 itse . 24 DR. SCHERLIS: My own feeling is that this was Ace-Fedefat Repofters, Inc. put together for a contract and it doesn't fit our guidelines. 25 242 dw 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 presented to us. 4 5 DR. SCHERLIS: Surely. 6 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, bLt 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 dome out, this was originally developed 12 for the contract group, and there was some discussion between 13 the Birmingham proposal, the one down state, and during the 14 process of all this discussion, they agreed to submit them 15 both places but @ originally was developed for the 16 contract. 17 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 21 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 24 approach to the ER, and at least an inventory of ER facilities Ace-Federal Reporters, Inc. then I would accept that as -- 25 24 3 dw 9 1 DR. HINMAN: That would be approximately $900,000 2 for the first year. 3 DR. SCHERLIS: Dr. Joslyn? 4 DR. JOSLYN: Another question is, it seems this 5 -- although this is submitted by the state-wide RMP -- 6 addresses only Birmingham, even in Phase II and III. 7 I wonder about -- in other words, it seems to me 8 it was submitted as a contract proposal for Birmingham and 9 doesn't address the state. 10 I don't suppose it is my rule to put a condition 11 on but I wonder if one of the things, that they be,.more 12 serious about the spread of this proposal to the whole 13 state. 14 I share Dr. Besson's concern that this one is 15 more likely maybe to succeed and spread out across the 16 whole state maybe than the other one because the other one is 17 much younger and much less well formed, but I don't think in 18 the form it is presented, it addresses a state-wide EMS 19 system in the least, it@addresses a city-wide system at a 20 sophisticated level. 21 DR. SCHERLIS: At this point you have suggested 22 for Projedt 43 $150,000, isn't that right? 23 DR. BESSON: Right. 24 DR. HINMAN: One year funding only. Ace-Federal Reporters, Inc. 25 DR. SCHERLIS: I have a feeling what you are trying 244 dw 10 1 to do is come up with some sum of money for this other project 2 and yet we find it hard to justify on any of the guidelines 3 that we have followed to date. I would submit that if we support this, we are 4 5 being rather inconsistent. 6 DR. BESSON: You wanted a number. 7 DR. SCHERLIS: Some of the numbers that I have at 8 hand are very low. 9 DR. SCHERLIS: You make your recommendation. I 10 am only functioning as a moderator, with a vote. 11 DR. BESSON: I think we have a meeting of the 12 minds, and I think it is a double bind that we are in, and 13 we are also constrained by time. 14 So I think as a proposal, if it comes to nine 15 hundred thousand, that seems like a lot of money for the first 16 year for the City of Birmingham and we can just arbitrarily 17 cut it from there. 18 They are going to need less central operations, 19 I suppose, if they are not going to have the CCUs to play 20 with, less of the transportation. 21 DR. SCHERLI8: My own feeling is let this go in 22 as a contract proposal which is what they drafted it for because it doesn't fit our outlines. 23 DR. BESSON: Can 't we defer action on this and 24 Ace - Federa I Repof tefs, Inc. not give a figure? 25 24 5 dw 11 I DR. SCHERLIS: Let's not support it. 2 DR. HINMAN: What do you mean by defer action? Re- 3 fer it to the Council without recommendation? 4 DR. BESSON: Without recommendation, to integrate 5 it -- I think council can make a decision based on the 6 conditions that we apply on the award, the conditions on the 7 funding level for 43, and as far as 42 is concerned, if HSMHA 8 is not going to fund it, then I think the Council can operate 9 on the basis of the conditions that we have offered. 10 DR. SCHERLIS: I don't think they are going to be 11 able to. 12 DR. ROSE: They won't know at the time that the 13 council meets whether HSMHA is going to fund it or not. 14 DR. SCHERLIS: Is any of that $150,000 available 15 for general planning of an emergency medical system which 16 is where I think they are at, as I read that. 17 DR. BESSON: The 47? 18 DR. SCHERLIS: Yes. 19 DR. BESSON: They talk about a demonstration area. 20 I assume this can be the demonstration area, par 21 excellence, and I have deleted that from the proposal. 22 DR. HINMAN: The notes I have about 47 are one 23 year at $150,000 with the advise to sharpen the EMT cost, 24 local councils, public education, with no salaries and no Ace -Fedefat Repofters, Inc. demonstration project. 25 24b I DR. BESSON: Right. dw 12 2 Okay, that we can set aside. 3 Talking about 42, If the best we can do by eliminating the mobile CCUs is to cut it from 1.2 to $900,000, 4 5 that still is -- 6 DR. SCHERLIS: I don't see what we get with that. 7 DR. BESSON: Let me just then arbitrarily give a 8 figure of $300,000, which is 25 percent of their request. 9 That is hardly consistent with the sharpness of 10 the whole proposal, but maybe I have been led astray by 11 the rhetoric. 12 DR. SCHERLIS: Dr. McPhedran, can I get An opinion 13 from you on this? 14 DR. McPHEDRAN: I don't know how you would 15 decide -- I don't know how one decides things like that. 16 I don't see how we are going to decide it any better in 17 council than we can decide it here. 18 I think if we make an arbitrary award here, that 19 council will probably be relieved that we made this arbitrary 20 award and it will go in. 21 DR. SCHERLIS: Dr. Joslyn? 22 DR. JOSLYN: Checking back on the demonstration 23 area for Project 47 or the state-wide one, that is to be a rural 24 demonstration, which seems to me quite different from Ace-Federal Reporters, Inc. Birmingham. 25 247 dw 13 I am just raising that point in which we are saying Birmingham can be the demonstration area for the 2 3 state-wide one. I think they need coordination but I am not sure 4 5 that was the point they had then they designed it. 6 DR. SCHERLIS: My own suggestion is the hard 7 one, and that is, it is a good grant request, but I don't know 8 if they are requesting it from the right people in terms of 9 what they are asking for. 10 This is my view. 11 DR. BESSON: I would like to defer action but 12 apparently we are not going to do that. 13 We are going to have action. 14 DR. SCHERLIS: If we say no, that doesn't prevent 15 them from coming in later? 16 DR. BESSON: Later when, next cycle? Three months 17 from now? 18 DR. HINMAN: Four months, we are on a tri- 19 annual basis now instead of quarterly. 20 DR. BESSON: Defer it to HSMHA funding and if HSMHA 21 doesn't fund it and review it, next cycle. 22 DR. SCHERLIS: With the 1 mitationsthat we have 23 placed on it. It must come in as a system. 24 DR. BESSON: Number 47 with the recommendation Ace-Federal Reporters, Inc. that we made. 25 248 dw 14 1 DR. SCHERLIS: Dr. Rose? 2 MR. TOOMEY: I will second the motion. 3 DR. SCHERLIS: Yes. 4 DR. MATORY: Point of information. 5 Your statement that it was not applicable to the 6 guidelines was based upon what, area involved, or what? 7 DR. SCHERLIS: I think if we are going to talk 8 about an EMS, emergency medical system, that even though you 9 can support one phase of it, it has to be tied in, as I view 10 it, into the entire system. 11 And this B specifies it is to the problem of 12 one categorical area, essentially, coronary disease, without 13 the total phases of emergency room on one end, coronary care 14 unit on the other, a stratification of care in these areas, 15 following recommended ICHD contracts, and so on. 16 To me, it establishes a high priority on one 17 limited aspect of the total emergency system, and the 18 emphasis we have had right along is that it should not be 19 categorization. 20 This is one of the objections we have had to trauma as an isolated approach, and this, again, doesn't 21 0 22 go to coronary care and dedicated vehicles. 23 DR. MATORY: I am sure those of you who read 24 that -- I didn't read it, but I say coronary care was one o Ace - Fedefal Repofters, Inc. them, and I felt it was dealt to coronary care. 25 249 dw 15 1 DR. SCHERLIS: I thin]-, this was its major focus. 2 DR. BESSON: It is not its major focus. 3 DR. SCHERLIS: According to what you have mentioned, 4 it is. 5 MR. TOOMEY: He is talking about the equipment. 6 DR. BESSON: There are six or seven components, 7 as far as equipment is concerned, yes. 8 DR. HINMAN: I am uncomfortable. 9 DR. SCHERLIS: We haven't made any motion yet. 10 Would I accept separation -- 11 DR. BESSON: I am going to move adjournment. 12 DR. SCHERLIS: You recommended $300,000. 13 DR. BESSON: I recommended deferring it to the 14 next cycle if HSMHA doesn't fund. If HSMHA funds, we are 15 off the hook, f. or Project 46. 16 For 47, $150,000. 3.5 for 47. 4.0. 17 DR. ROSE: We are likely not to have that. 18 DR. HINMAN: It is possible. 19 DR. BESSON: Okay. 20 If I have to-give a n@r, then, with all of 21 that we have had, and the blush taken off this rose, from 22 1.2, 25 percent is the figure that I suggested. 23 DR. SCHERLIS: $300,000. 24 DR. BESSON: Right. Ace-Federal Reporters, Inc. 25 DR. SCHERLIS: Is there a second to that? 250 dw 16 1 DR. MC PHEDRAN: Second best one year funding. 2 DR. SCHERLIS: Who would be in favor for Project 3 42, $300,00 with a rating of 4? 4 (Chorus of ayes.) 5 DR. SCHERLIS: All right, that passes. 6 And a hundred and fifty thousand dollars for 7 Project 43. 8 DR. BESSON: Yes. 9 DR. SCHERLIS: Was that for one year? 10 DR. BESSON: Project 47, yes. 11 DR. SCHERLIS: 42 was for what? 12 DR. BESSON: One year. 13 DR. SCHERLIS: All right. 14 We now have the peculiar dilemma of having 15 several more projects to review and time having run out. 16 I wonder what -- I know we can finish in 45 minutes, 17 but that cuts out the plane travel. 18 DR. HINMAN: The problem that we have is that we ha7e 19 to go to council two weeks from today, three weeks from 20 today, whever it is, and we have to give them some sort of 21 answers about these applications. 22 DR. SCHERLIS: Yes. I have no problem, 23 24 DR. MC PHEDRAN: I can stay. Ace -Federal Reporters, Inc. DR. SCHERLIS: Who else has to leave? 25 251 dw 17 1 DR. ROTH: Only plane I have is 5:45. 2 DR. SCHERLIS: All right. 3 And you go where? DR. ROTH: Erie, Pennsylvania. The last plane 4 5 I can get out is at 6:00. 6 DR. HINMAN: With three, that still is some 7 representation. 8 DR. BESSON: How about you, Bob? 9 MR. TOOMEY: My plane leaves at 9:00, so I am 10 all right. 11 DR. SCHERLIS: Well, Dr. Roth, you are primary reviewer for some of the remaining ones. 12 13 DR. ROTH: Some of mine are real short. end 21 14 15 16 17 18 19 20 21 22 23 24 Ace - Federal Reporters, Inc. 25 CR6307 252 Lee#22 jrbl I DR. SCHERLIS: Dr. Roth? Which one would you like 2 to begin? xxxxx 3 DR. ROTH: Florida. I hope I can dispose of this 4 very quickly, because on the basic assumption that funds are 5 not available for the satisfaction of all grant requests, I would 6 take the position that Florida is not being discriminated against 7 if the request is denied, because Florida is a resubmission 8 of a grant which has gone throubh council, which has been 9 approved by council as a regular RMP operation. 10 The Florida position is 'that they should not be I I 11 discriminated against because if they could get the funds from 12 this, it would liberate the other funds for them to carry on tv 13 some other, unrelated projects. 14 I think this would be nice if you had unlimited fun@ 15 ing but my sentiment is to say that that is too bad, not to 16 fund it. It is an excellent application. 17 DR. SCHERLIS: I thought it was a rather plaintive 18 statement to say that got the money before they knew they 19 could get it from another @source. But I concur with you 20 completely, that they are already in this and what they want iE 21 double funding in a way so they can spin the money for 22 something else. 23 Staff have any comment? 24 VOICT: Dr. Sloan concurred in that feel. Ace-Federal Reportersi Inc. 25 MR. TOOMEY: She did? JRB@ 2 253 1 DR. SCHERLIS: Fine. 2 Florida is taken care of. 3 VOICE: What kind of rating? 4 DR. SCHERLIS: No money, no rating. 5 Northlands? 6 DR. ROTH: Northlands is a very superior application. 7 They are building on a solid basis. Excellent resources. 8 MAjor accomplishments to date. And in terms of a program to 9 which RMP is likely to be able to point with pride, I would feel 10 that it is most promising. 11 The'requested amount is relatively small in relatiol 12 to the population to be served. However, it carries follow-up 13 requests totalling $1,250,000. 14 But the current request of $63,800 seems to me 15 to be exellent. I would rate it 4 and recommend full funding. 16 DR. SCHERLIS: For one year 17 The second year request was $246,000. 18 DR. ROTH: Add them all up you come up with ti 19 $1,2000000 figure. 20 DR. SCHERLIS: You are recommending approval of the 21 first year? 22 DR. ROTH: First year. 23 DR. SCHERLIS: I also reviewed that and felt that 24 this would be dollars very well spent because they are trainin Nce -Federal Reporters, Inc. 25 emergency physicians, hospital personnel. I think they are I 254 1 beginning with a solid basis of training personnel first. 2 MR. TOOMEY: Is this Georgia? 3 DR. SCHERLIS: This is Minnesota,, first. 4 DR. HINMAN: You are recommending the first year 5 only? 6 DR. SCHERLIS: 63. 7 DR. HINMAN: with rating of 4? 8 DR. ROTH: Yes. 9 DR. HIMAN: Okay. 10 DR. SCHERLIS: I agree with that. That @was one of I 1 the nicer ones to read, I.i' thiia-k, in terms of content. 12 Any dissenting opinion on that? 13 All right. 14 That is Northiands. 15 The next one, alphabetically, for you, at least, 16 is Ohio Valley. 17 DR. ROTH: Ohib Valley is another one of these 18 things. This is a limited area in Northern Kentucky. 19 Its-,resources are close to zero, the grant application is very 20 poorly constructed, there is no documentation that they 21 can produce or that they can care for the emergencies they 22 bring in. s one of those situations 23 I feel probably it i 24 where it would be morally wrong to blank them out completely. Ace-Federal Reporters, Inc. 25 I would give them some money with which to continue to do jrb4 255 1 planning. And I think you have to rate the program sort of 2 minimally, perhaps a 1. I would like to give them some arbi- 3 trary figure -- 4 DR. SCHERLIS: They requested $62,000? 5 DR. ROTH: $63,800, is what they have requested. 6 I know the RPM. I have site reviewed it; I know they have 7 a good core group, and one of their needs is to diversify 8 and regionalize a little further than they have been able to 9 do. 10 I'll come out with a figure of $20,000, over the 11 top of my head. 12 DR. SCHERLIS: That is what I wrote down,, off the 13 top of my head. I thought they might rate a 2 on the basis of 14 hope. 15 DR. ROTH: Yes. 16 DR. HINMAN: "2" is the figure? 17 DR. ROTH: That is perfectly all right with me. 18 DR. ROSE: May I remind you the implication of 19 that is that the $20,000 is now low in priority? It is not lilel 20 that the money would be funded because of the priority? 21 Do you see what I am saying? 22 DR. SCHERLIS: The statement has been made that 23 with that low priority, $2,000 would probably be the funding; 24 is that the point? Ace-Federal Reporters, Inc. 25 DR. HimAN: "2", and $20,000, then? I jrb5 256 I DR. ROTH: Yes. 2 DR. SCHERLIS: Any comments? 3 The recommendation has been made, Ohio Valley, 4 $20,000, with a rating of 2. That is one year. 5 All right. xxxxx 6 The next is Memphis. Is that right? 7 DR. ROTH: 1 have Memphis. 8 Memphis, again, I don't know whether I got all of 9 the bottom of the hope onesi But here is another one n wi c 10 I would concur with Dr. Sloan's review comments when he 11 said that if need is to be taken into account that since this 12 one is starting from Ground Zero, it might deserve support. 13 But the requested amount is large, and the need is 14 great. It is a fragmentary program in terms of addressing 15 its total development of a full emergency medical service 16 system, and it has a dilemma in it in that it extends over 17 to Mississippi, and into some other areas, and 1 don't know 18 how we deal with this. 19 To break it down into components, I tried to do 20 with the elimination of some components. I couldn't come up with 21 anything very satisfactory. 22 I don't know what to do with this one. 23 DR. SCHERLIS: Do you think it justified support? 24 DR. ROTH: I really didn't think it was well enough Ace-Federal Reporters, Inc. 25 thought out and presented, -nd I gather the Staff reviewers I jrb6 257 1 didn't think so, either. 2 DR. SCHERLIS: I had reviewed this and this is one 0 3 that I rated as essentially the bottom of the heap -- it was ole 4 on the bottom. 5 This was grouped together with those which I 6 think were least worthy of support. 7 Did you think there was any element of this which 8 could be salvaged in terms of helping them to arrive at a 9 plan which would be worthwhile? 10 DR. ROTH: If they could be encouraged to 11 continue their planning, I think it is manifest that they need 0 12 it. But again, I think we're going to have this dilemma 13 of giving them a low figure. 14 I don't see how you could come up with anything 15 better than a 2 in this and if you cut the grant request, 16 it would have to be very sharply, I believe. 17 DR. SCHERLIS: This is an area with real need, 18 I'm s ure. 19 Is Mr. Van Wingle here? Do you want to 20 comment on Memphis? 21 VOICE: Mrs. Kindall is the operations officer. 0 22 VOICE: I don't know a great deal about it, other 23 than one thing that may.@be significant here. 24 If it seems to be just a portion of a program, it Ace -Federal Reporters, Inc. 25 is that the state has carved out roles for certain provider I j rb7 258 1 groups, and the role of the emergency room is the one identi- 2 fied for Memphis, and the activities, and it is quite logical, 3 Dr. Roth, that they would extend into Mississippi, because mos.. 4 of what Memphis does, does extend into Mississippi. 5 DR. ROTH: It is very logical, geographically, 6 a medical supply area. 7 DR. KELLER: It would be strange if it didn't. 8 DR. ROTH: Into Arkansas, too. 9 VOICE: But it is rather confined, when you think 10 of it in a total programmatic sense, but that is the confine- 11 ment of the master plan. 12 The Department of Transportation has a role, and 13 different groups have different roles, and the emergency room 14 has been identified at the RMP's role. 15 DR. SCHERLIS: Some of the comments, I think, of 16 Staff are important in this regard as far,as the narrative is 17 concerned; incompatible equipment, this not being a justifiable 18 system. 19 my own feeling is that I would like to see somethitc 20 salvaged from it -- 21 DA. ROTH: If it would be possible to give them on 22 Items 1 and 2, the request for planning and administration and 23 survey needs -- that comes out to $67,038; I would support 24 this. Ace-Federal Reporters, Inc. 25 DR. SCHERLIS: What priority would you give that? I 259 1 DR. ROTH: For that phase of it, in order to give 2 them half a chance, could we go 3? 3 DR. SCHERLIS: Yes. 4 Any comments on this Solomon-like decision? 5 Solomon wasn't always right. 6 DR. ROSE: one year? 7 DR. SCHERLIS: Yes. I concur. I think in going 8 over this, there are aspects of this in terms of need and 9 planning that I think do justify support. 10 I would concur with that recommendation. Lee#22 11 DR. ROTH: Okay. CR6307 12 13 14 15 16 1 7 18 19 20 21 22 23 24 Ace -Federal Reporters, Inc. 25 260 LEE #23 ty 1 DR. SCHERLIS: Any other comments, pro or con? 2 Next is Northeast Ohio. 3 DR. ROTH: Northeast Ohio, this was totally different 4 from any of the other applications I had. It concerned every- 5 thing except automobile casualties and so on. It was all 6 planning the plan and I would feel that Dr. Sloan probably cn 7 hit the problem on the head here with a new coordinator, and 8 she ends up her narrative evaluation of the proposal by 9 saying in this respect that she believes he should be asked 10 to try again. And if it is a proper thing I think we should 11 encourage Northeast Ohio to resubmit for a subsequent cycle. 12 DR. SCHERLIS: All right. 13 Yes? 14 VOICE: Dr. Glover did prepare this and submits 15 it back in January, long before our guidelines were out. 16 So if it is not relevant, that is why. 17 DR. SCHERLIS: I think that explains some of the 18 problems I had in reviewing it, too. I had not recommended 19 it for support, either. 20 Any other comments? 21 Now, let me see. 22 Do you have any other comments on these others? 23 DR. ROTH: No, I didn't. I apologize. 24 DR. SCHERLIS: Perhaps we can move to California. Ace -Federal Reporters, Inc. 25 We still have a quorum and I gather the three of us will 26 1 ty 2 1 remain until the bitter end. 2 DR. HINMAN: We haven't finished up the South 3 Central Branch. Illinois, Georgia. 4 MR. TOOMEY: Wisconsin. How did Wisconsin get in 5 the South Central Branch? 6 DR. HINMAN: Central emphasis. Georgia should be 7 next, I believe. 8 DR. SCHERLIS: The Chair would be in favor of 9 entertaining A suggestion we have a five-minute break. 10 MR. TOOMEY: I so move. 11 DR. SCHERLIS: So ordered. 12 (Recess.) Pd 13 DR. SCHERLIS: We will do Georgia, now. 14 I am the primary reviewer for Georgia. 15 Georgia posed a dilemma for me. They state that 16 in Georgia, large areas of the state do not have adequate 17 emergency medical services available and those services which 18 do exist ate indeed substandard. 19 So in conjunction with the Office of CHP, Emergency 20 Service Division of the Georgia State Public Health Department, 21 State Highway Safety Coordinator, they developed a plan 22 for a comprehensive EMS system for the region. 23 They are aiming at supporting emergency room 24 service, backup-facilities and specialists to apply definitive Ace-Federal Reporters, Inc. 25 care, transportation, communication systems, training of I 26 2 ty 3 1 personnel, development of physical mechanisms, so on, and the 2 Georgia regional medical program will provide initial salary 3 support and training for emergency medical technicians to 4 supplement ambulance and communications equipment provided 5 by the Highway Safety Bureau to provide intensive care 6 capability, life support systems, monitoring to enhance the 7 ambulance capabilities. They would charge fees for the 8 ambulance services in the subsystems. 9 The project in a bit more detail asks for -- as 10 far as funding is concerned -- a level of $242,000 for the 11 first year, 343 for the second, and $356,000 for the third. 12 Most of the support is actually for ambulance personnel. 13 1 had some serious questions about this, because first of all 14 there is the problem of what happens when this grant subsides. 15 I see no more reason for there being any likelihood of 16 support 2-1/2 years from now as compared to the present time. 17 They ask for equipment in terms of dispatch equipment which 18 comes to approximately $30,000. 19 There is excellent documentation in the request 20 as far as the needs for the funding. My concern is that this 21 essentially relates to ambulance support, rather than being 22 a total system. When one looks at the budget, the requests 23 that were originally put in appear to be aimed at another sourc 24 for funding, rather than to the type of emergency medical system Ace -Federal Reporters, Inc. 25 which is being looked at the present time. I 26 3 ty 4 1 They have already purchased some 40 ambulances. 2 As I have said their aim is to develop and demonstrate the 3 effectiveness of a multi-county emergency medical service 4 system. The yellow sheets were reviewed by Dr. Sloan,, 5 and part of her comments state, again, what I have reiterated. 6 She states that they havetouched all the basis of government 7 and local support, reiterates the sums that have been involved 8 as far as requests are concerned. 9 My biggest problem relates to the fact that so 10 much of the funds requested really look at the support of 11 ambulance personnel as the main item, rather than anything 12 else. I want to get the detailed budget so that I can document 13 that for you. If you find it before I do, that will be just 14 fine. 15 Part of the difficulty I am having relates to 16 the fact that the grant is not put together very well. 17 Here it is, budget justification. 18 Their ambulance personnel will be in terms of 19 total coverage of the ambulances for a complete, round-the- 20 clock coverage. This comes to a base salary of some $245,000. 21 This concerns me, that in essence, we areproviding the staff 22 support for their ambulance system. 23 I think this goes well beyond what the RMP should 24 basically be requested to do. It does not address itself Ace-Federal Reporters, Inc. 25 as it should to the total system of care but more specifically, I 264 ty 5 1 as I have indicated, just to mananing the ambulances, and this 2 is where most of the funding is. 3 Also for equipping the ambulance service. 4 My own feeling, as far as this grant request was 5 concerned, was that it did not merit support as a total 6 system, that I would be much more in favor of their looking 7 towards a plan. It gets down to what we have discussed 8 previously. I don't think the RMPs can be in the business of 9 staffing the ambulances around the country, as this request, 10 I think, would put us in the position of doing. 11 My initial feeling had been to fund this at a 12 very low level, and after having heard the various reviews 13 today, I still feel that way. 14 Do you have any comment? You haven't had a chance 15 to review this, have you? 16 MR. TOOMEY: No. I have just read this. 17@ DR. SCHERLIS: Who in staff has had contact with thE 18 Georgia system? 19 VOICE: I had a little contact, Doctor. 20 DR. SCHERLIS: Do you have any background on this 21 grant itself? 22 VOICE: No, sir, I don't. 23 MR. TOOMEY: I think from a philosophic standpoint, 24 I agree with you. Ace -Federal Reporters, Inc. 25 DR. HINMAN: I am trying to find the backup, and 265 ty 6 1 I can't find this letter. 2 DR. SCHERLIS: You see, my concern is that the 3 County Board of Commissioners says after 2-1/2 years, we will 4 pick up the support of that staff. And my concern is, you know 5 why not now? Why should we pick up the 24-hour -- at least 6 the main coverage as far as these individuals go? My feeling 7 is they do merit some support more in a planning phase than 8 actually sut)porting these individuals. And there is 9 enough element here, as you look through it, of bits and pieces 10 of a total system, that I recommend more limited support, 11 possibly to the sum of $50,000, so they can move this along 12 for the first year. 13 Do you have any comment on that? 14 MR. TOOMEY: Just a comment of agreement. 15 DR. SCHERLIS: All right. 16 If that is satisfactory, then we will move on. 17 DR. HINMAN: You are recommending 50,000 for the 18 first year and what rating? 19 DR. SCHERLIS: But not the support. I suggested 20 three. But not for support of the actual ambulance drivers. 21 I think that has to come from other sources. Most of the fundirg 22 would be for that and I think they should emphasize the 23 training aspects. It will go much further than paying the 24 salaries of individuals. Ace-Federal Reporters, Inc. 25 All right? I 26 6 ty 7 1 MR. TOOMEY: Was there any amount provided for 2 training purposes? Because along with the planning for the -- 3 DR. SCHERLIS: They have a very highly detailed 4 schedule here as far as lectures and background and training, 5 and this would be of some help. They do discuss specific 6 material that would be part of their program. The problem is 7 that they have put most of their money into salary support 8 for the ambulance crew, rather than in the training. I think 9 we should suggest this is the area they should emphasize. 10 MR. TOOMEY: The planning would provide for the 11 development of budgets for training programs. 12 DR. SCHERLIS: Right, the training. 13 MR. TOOMEY: As well as other facets. 14 DR. HINMAN: Just to understand, this is basically 15 planning and some training. 16 DR. SCHERLIS: Yes. 17 DR. HINMAN: 50,000 for one year only with a 18 rating of 3.0? 19 DR. SCHERLIS: Right. 20 DR. HINMAN: Okay. 21 The next one will be on 22 DR. SCHERLIS: He can come back in, then. Dr. 23 McPhedran can return. 24 DR. HINMAN: The record should show that Dr. Ace -Federal Reporters, Inc. 25 McPhedran was out of the room during that review. 26 7 I DR. MC PHEDRAN: Illinois is next? 2 Are we to Illinois, now? 3 Illinois is a proposal -- this is a proposal from 4 the Illinois Regional Medical Program to extend over three 5 years for a total of $1-1/2 million over the three years, 6 about evenly divided. it is for an extension of a current 7 trauma registry, and the beginning of an emergency system for 8 trauma. 9 The proposal is to build on this system now a system 10 which works through the state health department, department 11 of public health, and according to the application, this is a 12 satisfactory arrangement which they wish to extend for other 13 medical emergencies. They want to categorize hospitals in 14 the first year, they want to decide which ones would be suitabl(! 15 for various kinds of emergencies. They want to improve their 16 transportation personnel, and to establish a coordinated 17 communication network, the exact specifications for that are 18 not given, but they are talking about a common radio frequencyll 19 and the use of radios, in emergency rooms and ambulances. 20 There is an element of training, both for the 21 emergency personnel and also a public education effort. The 22 public education is also to be conducted through the department 23 of public health, and a trauma registry, which they now have, 24 apparently was set up in such a way that the means of putting Ace-Federal Reporters, Inc. 25 data into it can be adapted -asily to a registry for other 2 6 8 ty 9 1 kinds of acute illness. They point out that the evaluation of 2 the system can be effectively done through this registry, 3 that is, if standards are set for treatment of a certain 4 kind of medical emergency, when the help should be there, what 5 kind of help should be there, and so forth, they can decide 6 later on whether they got what they thought they should have. 7 So that this is perhaps one of the attractive 8 features of it, that is, that there is some -- there is a data 9 collecting system which is now working, which can be built 10 upon which would give them this kind of information. 11 I am a little disturbed because the coordinator, 12 Dr. Creditor, said that the technical review panel in his 13 area, in his region, or the review committee in this region, 14 on the basis of technical merit, gave it a rating of 3.25, 15 which is the reverse scale that we are using here. 16 In other words, 3.25 is low. Four is the lowest. 17 They submitted it anyway, they thought that there 18 were defects in details in the application, and there are, 19 indeed, some defects. The ones that I was concerned about wherE 20 the information on linkages, adequate referral of non- 21 emergency patient -- cooperating in community disaster, and 22 linkage with other non-EMS systems -- that was lacking, 23 pretty much. 24 But on the whole, I guess I thought that maybe the Ace -Federal Reporters, Inc. 25 review committee was harder on it than I would be. I thought I 2 6 9 ty 10 I that it was better than that rather poor rating, although they 2 give me pause when they give it such a poor rating. 3 I have a specific exception to make in the proposed 4 expenditure, and that is that some advance are proposed. 5 They have a special name. OCCVS. There is an enormous 6 amount of money proposed to be spent on them. Nine of them in 7 the first year for $126,000. 8 Now these are not, I think, quite dedicated vehicleE 9 in that they can be used for any kind of emergency, or a 10 seriously ill person who would have to be transferred. On 11 the other hand, I am not sure that it is clear that that kind 12 of special equipment is really necessary, and I would 13 propose that with a rating of 3 to 3-1/2 -- I will say 3-1/2 -- 14 ar.d with the exception that we not fund these OCCVS. I don't 15 see they are absolutely essential to the program. Maybe the 16 staff can correct me if I am wrong. If that reduction is 17 made, I think they all come in the first year, isn't that right, 18 the OCCVS? 19 So that would make the first year reduced@to 20 just a little over $300,000. 21 VOICE: Yes. 22 DR. MC PHEDRAN: $307,000, something like that. 23 And the 02 and 03 years I guess would stand that way. Is that 24 right? Ace-Federal Reporters, Inc. 25 DR. GIMBLE: I think the expenditure for the OCC was 27 0 ty 11 I the first year. I am not absolutely sure. 2 DR. HINMAN: They have large amounts of equipment 3in the second and third year. 4 DR. MC PHEDRAN: I may have overlooked that. 5 DR. HINMAN: 207,000 in the second year and 162,000 6for equipment in the third year. I don't know what it is 7for. 8 DR. MC PHEDRAN: They certainly do. 9 VOICE: The equipment expenditure remains constant 10 in the second year and I think that purchase of the vans were 11 to be staggered, Dr. McPhedran. 12 DR. MC PHEDRAN: I see, okay. Well, it seems to 13 me that -- I really just don't see why in something which is 14 developing like this, that you need to start out with this 15 kind of very expensive equipment. I would still -- 1 would like 16 to see it deleted from the budget, to see if they can't get 17 along with the same kind of thing with more conventional 18 equipment. 19 It sounds to me like the.rest of the program that 20 they are describing -- it doesn't seem to me that any part 21 of the program would be vitiated by not having these vans, so 22 I would think that they could be left out. 23 DR. SCHERLIS: They also include patient monitoring 24 equipment for outlying coronary care units. Ace-Fedefat Reporters, Inc. DR. MC PHEDRAN: That is part of the equipment cost. 25 271 CR6307 423-ter-1 folc,, TY-11 I DR. SCHERLIS: Yes. The 220,000. The rest is 2 helpfully oriented as far as training, is it not? 3 DR. MC PIIEDRAN: Training and communications. I 4 must say, I was taken with this matter of the way they handled 5 collecting data, and talk about having standards set up for 6 what ought to be outcome of care, and comparing what does 7 happen with what ought to be, if they can really establish 8 satisfactory standards. 9 We have been trying to do this just for the care 10 of neurologic patients in our division and I must say, it is 11 very hard. We quarrel a lot about it. I hope they do not 12 fight as much as we have. 13 DR. SCHERLIS: One of the better publications I 14 have seen on local data is the one from Chicago, on the 15 emergency rooms, transportation vehicles. 16 DR. MC PHEDRAN: That is the one Gibson did? 17 DR. SCHERLIS: Right. 18 DR. 14C PIIEDRAN: Isn't that so? 19 DR. SCHERLIS: I think so. I had the opportunity 20 to share a sight visit to Illinois, and their coordinator 21 runs a very tight shop. With the help of his wife, who controls 22 the pursestrings, at home, as well as for the unit. 23 DR. HINMAN: Should we ask Dr. G'lmble what emphasis 24 they are placing upon the critical care van, as part of the Ace - Federal Reporters, Inc. 25 system.> 272 1 DR. GIRIBLE: They are not, they talked about the 2 total system. The overland critical care vehicles were not 3 even designed for primary ambulance duties, but for transpor- 4 tation of patients between hospitals. 5 They discussed the stratified hospital system with 6 primary, secondary, and tertiary levels of care, or words to 7 that effect, and the use of the vans was for transportation of 8 patients between initial-care hospitals, and secondary"care 9 hospitals, and definitive-care hospitals, as part of complete I 0 EMS system. 11 The objection I raised was whether or not a need 12 for such vehicles and the number had been demonstrated. It 13 had not. And they were quite expensive. 14 DR. SCHERLIS: This can await their demonstrating 15 the need. 16 DR. GIMBLE: Yes. 17 DR. SCHERLIS: What sum of support did you come up 18 with? 19 DR. MC PHEDRAN: Well' taking that 126,000 out -- 20 I do not know which year it comes on. Mrs. Gimble suggests it 21 comes out of each one of the three years. I assumed it came out 0 22 of the first year. I will see if I can come up with that. 23 VOICE: I think they hope, after the three years, e 24 each of the nine regions would have three vans. They would Ace-Federal Reporters, Inc. he first year with one van for each of the nine regions 25 start t I 27 3 ter-3 I and increase it by one for each of the years. 2 DR. MC PHEDRAN: So what that means is three times 0 3 $18 thousand per year. 4 DR. SCHERLIS: It is roughly about $70 thousand a 5 year that would go to equipment. 6 DR. MC PHEDRAN: Yes. 7 DR. SCIIERLIS: Is that not right? 8 VOICE: I wish it were, but I do not think it is. 9 I think they propose to buy nine vans at $18 thousand, each, 10 the first year; nine vans at $18 thousand -- and that is 11 $162 thousand. 12 DR. MC PHEDRAN: Nine each year? 13 VOICE: Yes. There are nine districts. 14 DR SCHERLIS: I was not thinking that big. 15 VOICE: They want to cover each district with one 16 van in the first year, one more in the second. 17 DR. HINMAI4,.-. And there is an additional cost of $20 18 thousand a year for the telephone lines to support it. So you 19 are talking about subtracting 182,000 out of each year, is what 20 I hear you suggesting. 21 DR. MC PHEDRAN: That is what I do suggest, then. 22 Are you sure the phone lines are just to cover that? 23 DR. HINt4AN: Telephone lines for OCCV Network, 24 $20,000. And, then down on the budget sheet, it says -- .I Ace-Federal Reporters, Inc. thought I saw an expanded part of the budget sheet -- under 25 2 7 4 ter-4 1 "other," it says IRMP telephone lines, 20,000, training, 2 communications equipment, lines, etc. 3 VOICE: I think the 45,000 is related to the two. 4 DR. HIN14AN: Outlying coronary care units. 5 VOICE: I think they are hooked to these vans. 6 DR. HIN14AN: Yes., they sure are. 7 VOICE: I hate to say this. 8 DR. SCHERLIS: Do something to help this. 9 DR. MC PHEDRAN: Do you think that is also, 10 forty-five? 11 VOICE: I think all of the equipment -- could we have 12 a motion that we could find these out, and if they are, they 1 3 could be deleted? 14 DR. MC PHEDRAN: Why do you not suggest that what 15 we would do is say, we would like to delete the equipment costs 16 entirely, until we can see which of these are unrelated to the 17 OCCVsi okay? If they can just do something unrelated to that? 18 DR. SCHERLIS: You are talking about 262 thousand. 19 DR. HIN@IAN: It is 242,, because we took the tele- 20 phone lines out, too. 21 DR. MC PHEDRAN: 242 for the first year? 22 DR. SCHERLIS: We would not even let them talk to 23 each other. 24 DR. MC PHEDRAN: I gave iterating of 3.5. I thought Ace -Federal Reporters, Inc. that except for this large expense in equipment, I thought it 25 lwas kind of a good system. ter-1 27 5 CR6307 @,24 1 DR. SCIIERLIS: And your recommendation is as was 2 just repeated? 3 DR. "IC PHEDRAN: 242 the first year -- is that right, 4 Ed? 5 DR. IIINMAN: 24 2 , 97 4 . 6 DR. SCHERLIS: 330, 573; 351, 780. And the rating? 7 DR. MC PIIEDRAI\T: Three point five. 8 DR. SCHERLIS: Is there a second? 9 " R. TOOMEY: I will second it. 10 DR. HINIIAN: Total of 889, 327. 11 DR. SCIIERLIS: Are you seconding it because you 12 agree? 13 MR. TOOMEY: I am seconding because I agree. 14 DR. SCHERLIS: Let the record show that was voted 15 unon and it passed. 1 6 P@IP,. TOOMEY: We are still in south central, Wisconsin? 17 DR. SCIIERLIS: Wisconsin, @Ir. Toomev. 18 TOOMEY: This pronosal is submitted by Wisconsin 19 Regional @.,Iedical Program, Inc. It has a funding requested of xxxxxxx 20 approximately $648 thousand the first year, $756 thousand the 21 second vear, and $765 thousand the third year. 22 I have rather an extensive review. Do you want me 23 to go into it?, Because actually, I will jump to the conclusion cn 0 that it is the best program that I have read. The application 0 24 Ace-Federal Reporters, Inc. is excellent, well prepared, describes all elements of an 25 276 ter--2 1 emergency medical services system. It is factual, has clearly 2 defined objectives and methods for evaluating the effective- 3 ness of a total, comprehensive operating system. 4 It includes in its formulation -- it includes efforts 5 by the people in the Highway Safety Program, Comprehensive 6 Ilealth Planning Agency, the Hospital Association, Medical 7 Society, Governores task force, a health program and policy 8 council, greater Milwaukee agencies and Milwaukee Countv '@liedical 9 Society. The applicant represents the -- the application 10 11 represents the efforts of key groups of health providers in 12 the development of this program over the past five vears. I 13 think it is the best one I have read. I give it a rating 14 of five and would recommend full funding. 15 DR. SCHERLIS: Dr. McPhedran? 1 6 DR. P@IC PIIEDRAN -I concur. It is one of the two 17 best that I read. 18 DR. SCHERLIS: '@lhat was the other one? 19 DR. f.,@IC PHEDRAN: I thought tri-state was very, very good. This is terribly good, too, and it has been long in 20 preparation. And it shows it. 2 1 22 I cannot remember what rating I gave tri-state. I 23 am afraid I would be inconsistent. I do not think I gave it a 24 five. I would give this at least a four. Maybe it is a little Ace -Federal Reporters, Inc. bit better than tri-state. I-do remember the body of the 25 277 ter-3 I application, where the argument is built up about how the thing 2 is to be time-phased, and what the methods are, what are 3 the assumptions on which each step is based, and how these 4 assumptions can be validated. 5 It is really very good. 6 MR. TOOMEY: It provides for an organizational 7 structure to carry it out from the start to the finish. 8 DR. SCHERLIS: What about the money recommendation? 9 !AR. TOOMEY: I concur with the funding. It seems 10 for the project, in relationship to some of the requests or 11 other funding, this is quite reasonable. 12 DR. SCHERLIS: All right. The record should show 13 that they will be funded as requested, for t ree years 14 MR. TOOMEY: Yes, sir. 1 5 DR. SCIIERLIS: All right. 1 6 DR. HIN14AN., What is the rating? 17 PAR. TOOMEY: Did we submit it? 18 DR. SCHERLIS: Between four and five. 19 DR. MC PHEDRAN: I would say 4.5, and you are going 20 to say five, right? 21 DR. SCHERLIS: let us make that five, then. 22 DR. HINMAN: Five? 23 DR. SCIIERLIS: The staff has suggest we use the 24 number five, since they provided us -- we have been given a Ace - Fedefal Repoftets, Inc. quota system. We have a certain number of fives. 25 ter-4 2, Have we used up all of our twos and threes? 2 DR. ROSE: Right, several times over. 3 DR. SCHERLIS: All right. 4 Arizona. We are now on the western branch regions. 5 The first one in that area is Arizona. Arizona 6 has requested the sum of $116 thousand for one year for the xxxxxxx 7 organization and development of an EMS to provide accessible, 8 adequate, and appropriate emergency care to all residents of 9 Pima County. 10 It proposes to adopt existing technology to produce 11 a comprehensive plan for development of an integrated emergency 12 medical service for Pima County, Arizona. 13 The primary goal will be the development of a cost- 14 acceptable organizations. structure for the provision of EMS 15 for the semi-rural communities, and adjacent, sparsely populated 16 rural areas outside of the Tucson metropolitan area. 17 The second goal will be developing methodology for 18 the organization of specific alternatives, for the implement- 19 ation in principal metropolitan areas. 20 The staff request is approximately $85 thousand, 21 for a breakdown of the budget. The direct costs are $160 22 thousand. The approach seems to be a reasonable one. It does 23 build on existing needs and tliev intend as they go along, to 24 even define these much more fully. Ace-Federal Reporters, Inc. 25 I think they have indicated what their planning ter-5 279 1 process will be. It is a well organized T)rogram which will 2 cover some 350,000 population area, of something like 90 to 3 100 square miles. The organization sponsoring it is the 4 University of Arizona College of Medicine. They have the 5 endorsement of the Comprehensive Planning B Agency an t e 6 Governor's Highway Safety Coordinator. 7 It is a rather clearlv stated Project. I mention 8 the figures that I did because I think, in terms of what they 9 are talking about, they are asking for a somewhat higher sum 10 of money than they might require in terms of what thev are I 1looking at. 12 I suggested that they be rated at a level of three, 13 that in terms of the funds which thev are requesting, as I 14 said, this is just for Pima County, and a population of some 15 350,000 -- I think they are asking for an excessive sum, but I 16 would suggest that they be funded to the level of $65 thousand. This is essentially the planning phase at this time, 17 ,8 one which I think will be a Profitable use of the funds. 19 Is there any member of staff, here, familiar -- 20 VOICE: I am here. 21 DR. SCHERLIS: The question I was going to ask you is a question in terms of the involvement of the people of 22 23 Pima County. 24 I went through this in some detail. My own feeling Ace-Federal Reporters, Inc. is that they look as if they can move it along but essentially 25 2 8 0 ter--6 I at a planning phase which is what they are looking at and I 2 think with the help of the people tlie\7 involve in the school 3 and the act of involvement of their B Agencv, they should be 4 able to get this off the ground. 5 Are there any comments as far as other members of 6 the review group are concerned. 7 Then the motion I would make has been made in terms 8 of funding at 65. 9 Is there a second? Edn #24 10 DR. @4CPHIDRAN: Second. I 1 12 13 14 1 5 16 17 18 19 20 21 22 23 24 Ace-Federal Repoiters, Inc. 25 281 swl I DR. SCHERLIS: Any further discussion? 2 All right. I guess that takes care of Arizona. 3 Next is Hawaii. 4 DR. HINMAN: California. 5 DR. SCHERLIS: I am sorry, California. 6 Mr. Toomey. Pd 7 MR. TOOMEY: California has two projects that they 8 are proposing. The first one I have here in front of me is the 9 South Central Multipurpose Health Services.Corporationi project 10 NO..92, with funding requested of $292,000 in the first year, 11 $309,000 in the second year, and $291,000 in the third year. 12 The grant covers 33 square miles in central Los 13 Angeles, a population of 330,000, 80 percent black, 10 percent 14 Mexican American, 10 Percent other groups. 15 Between 30 and 35 percent of the families receive 16 welfare assistance, 40 percent are in the income category of 17 $4,000 annually. 18 The median age is 24 years with unemployment of 40 19 percent for males, ages 16 through 19 years, while 15 to 20 20 percent for males over age 20. 21 The median educational level is eight years, eight 22 years of school. 23 Infant and neonatal death rate in the target areas 24 are the second and third highest in the country. Ace-Federal Reporters, Inc. 25 It is a povertyarea and medically under served with I 28 2 sw2 1 a considerable deficit in the emergency services. The bulk 2 of the emergency care is provided by USC, L.A. County General 3 Hospital, Harvard General Hospital, and the new Martin Luther 4 King Hospital with which support from the grant will provide 5 facilities and services. 6 The objectives of this application are the estab- 7 lishment of a neighborhood treatment and transportation service 8 through development of a four-pronged effort which will 9 include providing improved emergency services by coordinating 10 emergency services now existing, optimal use of existing 11 emergency personnel, consultation from highly skilled pro- 12 fessi6nals to improve communication between hospitals and 13 emergency vehicles. by training and upgrading capabilities of 14 emergency care personnel, develop a cadre of 24 physicians to 15 handle emmergency in medical care centers and hospitals and to 16 upgrade emergency car people b@, creating career ladders, 17 development of community educational programs, and a research, 18 development and evaluation system to assess, upgrade, design, 19 measure, and improve the emergency care existing in the 20 operational aspects of this project. 21 The plan will be implemented through a four phase 22 program over a period of three years with initial efforts in 23 research activities for detailed planning, purchasing equipment 24 training personnel, developing community educational programs, Ace -Federal Reporters, Inc. and organizing community committees. 25 2 8 3 sw3 I The second phase effort will include operational 2 aspects of the plan for operation of communication system, and 3 emergency vehicles. 4 The third phase involves training of personnel and 5 implementation of the long-range planning efforts. 6 In summary,@ this application@appears to be,developed 7 as a community outreach program, involving many community 8 agencies in predominantly a black and Mexican-American popu- 9 lation. 10 The project is not developed very well or factual in 11 content. 12 The applicant does not display a very effective or 13 working knowledge of the components of an emergency medical 14 services system. There is little identification as to the 15 existing resources and components now in operation or how 16 those components will be integrated into a totla emergency 17 medical system. 18 Specific resources are not identified and there is 19 no reference to communication resources or ambulance services 20 available within the area. 21 There is not integration as to the various linkages 22 in the approach to the delivery system. 23 This application represents a haphazard compilation 24 of unrelated data with no apparent overall plan for the devel- Ace - Federal Reporters, Inc. 25 opment and implementation of an emergency medical system in the I 2 8 4 sw4 I area. 2 The project should require additional clarification, 3 more indepth analysis, as to identification of needs and a 4 definite plan for the development of the emergency medical 5 services system. 6 I don't think there is any doubt from reading the 7 application that there is a need for services in the area. 8 My memory as I remember the budget is that a tre- 9 mendous amount of money was provided in terms of salaries to 10 people in each of these phases to work in the emergency rooms, 11 and if my memoryis correct, Dr. McPhedran, they were expecting 12 RMP to provide not just the training, but the employment of 13 people to work in the emergency departments. 14 I think as an application, it probably would got a 15 2, a 2.5 as a rating, and I would feel very strongly that 16 further planning in picking out the areas in which the appli- 17 cation is deficient and making an effort to develop a better 18 and more adequate plan would be a desirable action. 19 I would recommend that this be done. 20 I would recommend that $50,000 be allocated right 21 now, or at this time, for that kind of planning. 22 DR. SCHERLIS: Dr. McP#edran? 23 DR. MC PHEDRAN: I think that is reasonalbe. 24 I didn't think that the thing@as written was satis- Ace-Federal Reporters, Inc. 25 factory, but I would hate not to provide any funds to assist I 28 5 sw5 I with planning, because it is quite evident that a lot needs to 2 be done. 3 I think the need is tremendouw. It puts something 4 together, but it isn't really a system, and I think that it 5 would be suitable to -- of course, if we give a rating of 2 6 and recommend that money -- I guess it is unlikely that any 7 will come, right? 8 DR. HINMAN: Is that recommendation $50,000? 9 DR. MC PHEDRAN: We will give it a rating of 2. 10 DR. SCHERLIS: You concur with a rating of 2? 11 DR. MC PHEDRAN: Yes. Either 1 or 2. 12 The plan as proposed is I will say 2. 13 DR. SCHERLIS: Is that stated then? $50,000, one 14 year? 15 DR. MC PHEDRAN: Yes. 16 DR. SCHERLIS: And a rating of 2? 17 DR. MC PHEDRAN: Yes. 18 Is that all right? Is that okay? 19 MR. TOOMEY: Yes. 20 DR. SCHERLIS: Is that concurred with? 21 MR. TOOMEY: Yes. 22 DR. SCHERLIS: All right. So be:it. 23 MR. TOOMEY: I believe the comments from the staff 24 survey also would support this. Ace-Federal Reporters, Inc. 25 "The projdct needs" -- this is the concluding_ 2 8 6 sw6 I statement -- "The project needs, truly needs, further reworking 2 and some indepth analysis of their problem." 3 The second California project is from Loma Linda 4 University School of Medicine and the California RMP. 5 The funds requested are a total of a hundred and -- 6 DR. HINMAN: $170,350. 7 MR. TOOMEY: I have $162,000 for the first year and 8 nothing for the second and third year. I don't know what 9 happens on that. That is from the application itself. 10 Well, this grant covers region 6 of California, 11 which includes four counties of some 45,000 square miles of 12 mountains, desert, agricultural land, urbanized community, 13 26 percent of the state. 14 The resident population represents some 6 to 10 15 percent of the total California population. 16 During weekends, holidays, and vacation, the popu- 17 lations of the more populas remote areas may increase ten-fold. 18 Due to the isolation of much of the area, serious 19 obstacles are presented in providing adequate emergency health 20 care services. 21 Communication services provided to this four-county 22 are are linked by a common communication network for emergency 23 vehicles, which includes highway patrol, local police, fire and 24 ambulances. Ace -Federal Reporters, Inc. 25 The specific objectives which have been listed in 28 7 sw7 1 order to reduce the morbidity and mortality by increasing 2 availability and accessability of emergency medical care, to 0 3 improve communication through a central dispatch system. 4 The system is here. Two-way radios in all ambu- 5 lances, an emergency radio telephone system for remote areas. 6 To facilitate rapid and effective patient handling 7 and evacuation by use of helicopters, and fixed wing aircraft, 8 military air-lift capability. 9 To publish listings of all available emergency care 10 of services in the region for personnel involved and transpor- 11 tation of patients, to formalize agreements among hospitals 0 12 in handling of emergency patients and among ambulance drivers 13 for effective transportation. 14 To increase and upgrade manpower by refresher 15 courses for ambulance drivers by offering associate degrees in 16 coordination with other programs for traninj employees. 17 The project plan is -- "Project consists of mounting 18 a number of smaller projects," each of which appears to have 19 relevance to the entire four-county area, but many of which wil'. 20 be executed in only one county. 21 Theproject includes the establishment of a central 0 22 emergency communications center, a -WATS line, a year-long 23 test of the helicoter operation based in a remote desert area, 24 a 20-h6ur medical refresher course for ambulance drivers, and Ace-Federal Reporters, Inc. 25 two Associate in Arts degree courses at two local community I 2 8 8 sws I colleges. 2 The narrative participations discusses the various 3 components and elements of an EMS system,however, it does not 4 indicate how the various phases will be integrated, nor does 5 it identify the deficiencies in the@present system. 6 The specific geographic area has been:identified, 7 however, there is little discussion as to broad representation 8 of providers, public agencies, planning agencies, and community 9 interests. 10 The narrative only partially delineates the various 11 community needs and resources. 12 There is limited data as to the assessments of these 13 needs and resources. 14 Within the project description the applicant deline- 15 ates how operating components will be coordinated with existing 16 components already in operation. 17 Linkages with local health caxesystems have not been 18 described nor is there evidence of involvment with community 19 disaster plans. 20 The applicant partially describes techniques for 21 utilizing existing financial resources and methods for obtainin([ 0 22 additional financial support after the grant expires. 23 The narrative does not give evidence of assurance of 24 quality of car being provided or the delineation after plan to Ace-Federal Reporters, Inc. 25 evaluate the effects of this system. I 2 89 SW9 1 This project was developed to serve a four-county 2 covering 40,000 square miles, but eliminated the primary area 3 having the highest rate of traffic just as delineated in the 4 statistical section. 5 Emphasis appears to be on providing services to San 6 Benardino area.for the establishment of a central emergency 7 medial communications center. 8 There are many facets to this plan which contradict 9 other areas in the developing of the total EMS system. 10 Contradictory areas includ the methods of financial support, 11 the coordinated working relationship with community agencies 12 in subregional areas. 13 There is no evidence of any plan for the integration 14 or coordination with the areas documented as having the great- 15 est need for an emergency medical services system. 16 This plan should be reviewed in more depth and 17 further documented with clarification of the contradictory 18 points. 19 The summary by the staff, Dr. Kaplan, says, "This 20 project purports to be interested in a four-county area, but 21 in fact appears to be only interested in San Bernardino County 22 and those parts of Riverside County which can be conveniently 23 included. 24 "The evidence for this arises, from the fact they ar(@ Ace -Federal Reporters, Inc. 25 only setting up one central emergency medical communications I 29 0 SWI0 I system in San Bernardino County." 2 In additional. their statement on page-29 concerning 3 Mono County and the simple two-line endorsement from Mono 4 County further supports this. 5 Further, the letter from the 17th states that thier 6 review and comments are@based on a November 18 communication. 7 It would seem if Mono County were truly involved the letter 8 of endorsement would have been based on a much more recent 9 review of the plans. 10 This is also applicable to marin. 11 There..are'other..commentsl but he ends by sayind, 12 "Finally, thre is no indication in this plan of any integration 13 or coordination with other parts of the surrounding area or 14 potential state plans." 15 I felt that this also was -- should get a rating of 16 2.5, and I felt also that the funding should be for the 17 continuation of the planning with particular reference to 18 including those counties that were more remote from San 19 Bernardino. 20 DR. SCHERLIS: What was the sum? 21 MR. TOOMEY: $500,0007 22 DR. MC PHEDRAN: That is more than their 01 23 year request that I have. 24 DR. HINMAN: The 01 year request was $44,000. Ace - Federal Reportefs, Inc. 25 MR. TOOMEY: I have it@down as $162,725. 1 29 1 swll I DR. SILSBEE: I think that is probably in terms of 2 the project director looking at the first year, and his form 3 16 relates to the regions' year. 4 It is a six month figure4 5 DR. HINMAN: $44,000 is only a six-month figure? 6 So your recommendation is for $50,000 for the first 7 12 months of the project? 8 DR. SCHERLIS: Is that r3ght? 9 MR. TOOMEY: That is correct, sir. 10 Dr. McPhedran? 11 DR. SCHERLIS: Dr. McPhedran? 12 MR. MC PHEDRAN: Yes. 13 I haven't got anything to add to the discussion. 14 Where they have identified the greatest need because of remote- 15 ness and so forth, it hasn't been addressed in the application, 16 how this proposed system would connect up with any other parts 17 of medical care. 18 of course, I suppose there really isn't very much, 19 but it just isn't clear. 20 So,I have rated it low. I gave it a 2, and I am 21 going to plead ignorance about how big a sum $50,000 for the 22 first year would amount to. 23 Is that a reasonable figure? 24 DR. SCHERLIS: I think in terms of what we have been Ace - Federal Reporters, Inc. 25 discussing, it is very reasonable. I 29 2 swl2 I DR. MC PHEDRAN: okay. 2 DR. SCHERLIS: Is there concurrence from both 3 reviewers? 4 DR. HINMAN: Is there:.a disparity between their 5 ratings? 6 DR. SCHERLIS: What was your rating? 7 DR. MC PHEDRAN: 2 and 2.5. That is not a big 8 disparity. 9 DR. HINMAN: I just want one figure. 10 MR. TOOMEY: 2.25. I think both these pr6jedts are 11 really critical projects as I read them. I thi'nk'they need 12 further study. 13 DR. HINMAN: Do you think they ought to be 3, then, 14 for the planning phases? 15 Is that what I hear you say? 16 MR. TOOMEY: I said 2.5. 17 MR. HINMAN: You wnat 2.5 for both of them? 18 MA. TOOMEY: Yes. 19 DR. MC PHEDRAN: okay. 20 DR. HINMAN: I'had@it dbwn'for 2 for the 92. 1 will 21 change it. 25 22 I am getting a little'fatigued. 23 24 Ace-Federal Reporters, Inc. 25 29 3 i,ee#6307 I DR. SCilERLIS: Two point five rating for both, and jr i 2 @five thousand for each of the plans. Is that correct? 3 The next application is Hawaii. Before I start to 4 review this, I have gone through this at least five times, 5 page by page, to look for a breakdown of budget, here. 0 Who is i'-Iawaii? Anyone here spoken for l@iawaii? 7 Do you have any breakdown of budget aside from the 8 large folding sheet? Because they come to sums of money that 9 go (lown to the very last dollar, like $871, and I have no way 10 of knowing -- I can't project their costs, which is a perturbing 11 feature to me. 12 All right. The proposal, itself, is submitted in 13 relationship to the State of Hawaii, and it comes in from the 14 Hawaii Medical Association. 15 They have prorated a program over some f our years in 16 a very well organized manner, so that they have indicated their 17 goals for each of the specific years in some detail. 18 There has recently been a forum in Hawaii, a meeting ig which discusses the emergency medical services for that area, 20 and I reviewed the program in it, they put in a great deal of 21 the content. 22 It strikes me as having been a very well organized 23 program cooperated with by many different agencies, And this 24 was something that probably helped them a great deal. Ace-Federal Reporters, Inc. The planning committee and their sponsors were 25 29 4 jr 2 1 widely representative of the State of Hawaii. I'm sure this 2 helped move them along in their total planning phase. 3 Their detailed program I'll report on very briefly. 4 What they propose to do, for example, during the 5 first year is to train their ambulance service personnel in EMT 6 before the start of their program. 7 They discuss this in terms of emergency medical 8 facilities, in terms of their ambulances, in terms of training 9 them with EKG telemetry, dardiopulmondry@resuscitation. 10 They will set up,emergency communications during 11 this time, and develop an EMS advisory committee, and develop a 12 comprehensive program for collecting data. This is first year. 13 The second year they talk in terms of additional 14 training, additional involvement of the neighboring islands, as 15 well as Oahu. There are Ambulances being set up as far as 16,advance communications and treatment. 17 They then introduce the concept of a trauma center 18 and there is contained in their application a detailed discus- 19 sion of a shock and trauma center, which is at the Queen's 20 Medical Center, which is the large teaching hospital in Honolulu 21 It is one which apparently has been planned for sometimes 22 The sum of money for this I am not sure of. Somewher(t 23 there sticks a figure of approximately $400,000 in my mind but 24 as I have indicated -- here it is -- as I have indicated there Ace-Federal Reporters, Inc. 25 s no breakdown of total budget except this one item, that comes 29 5 jr 3 1 from the first year to $253,000 for the trauma unit. And then 2 Isubsequently, sums of $76,000 for the second year and $79,000 40 3 for the third, these are essentially in terms of personnel for 4 the latter ..,two years. 5 The first year, most of this is in terms of facilities 6 and equipment. For example, remodeling costs, $194,000. 7 Equipment, a total of something like $89,000. I think we'll 8 have to address ourselves to that item specifically. 9 The trauma center would be the second year, with 10 again the development of emergency medical communications. 11 The third year, additional training program. A 12 trauma center would then be operative. The fourth yearlthe 13 evaluation of the fiscal analysis would be the most important 14 part of their program. 15 They request over a period of 3 years sums which are 1 6 as follows: $777,000 for the first year; second, $982,000; the 17 third, $382,000. And as I read this, I had a gut reaction that 18 their overall planning and program looked very good with the 19 exception of the shock-trauma unit, which requires renovation 20 and construction. I don't know if this could be supported. 21 The other problem that I had, although I rated this 22 3.5, was in terms of the support, because I have no grasp of 23 their budget. That is why I asked. 24 Perhaps it was omitted from my book. But I leafed through Ace-Federal Reporters, Inc. 25 this hot only at home but here, page after page, and I've done 29 6 jr 4 1 this three and four times. I can find no indication of a de- 2 tailed budget except for the trauma center which is the one 3 unit that I don't think should be supported because of the 4 renovations to the building. 5 DR. HINMAN: Three fifty for the trauma. 6 DR. SCHERLIS: Yes. r4y own feeling about that is 7 that having visited Hawaii and having surveyed their cardio- 8 pulmonary resuscitation program, I had the opportunity of 9 going to their major islands, and I guess I hit at least three I 0 or f our hosp tals in each. 11 I am impressed with the fact that they have already 12 set up excellent links, that the hospitals work with each 13 other, that they are training their emergency systems to re- 14 late to the hospitals. 15 They do have good CPR programs which again has 16 helped set up a @l' network so when you go with someone from 17 Honolulu he has access to everybody in the islands and it lends 18 itself very nicely for an overall emergency medical system. 19 They do have the concept of the hub center, there 20 are physicians who go out from Honolulu to the islands in 21 specialities and obviously flying back to Honolulu. 22 I have an overall good reaction, but I had difficulty 23 in translating that to dollars because there is no budget. I 24 don't know what it takes to work out this program. If I've Ace-Federal Reporters, Inc. 25 been narrow in hot seeing it, apparently you've not found it 29 7 1 either. If they can show with their training program, they jr 2 have to set up essentially five or so areas, one on each island 3 to work it through -- I can see where they might very readily 4 come to a budget of $3- or $400,000. 5 But I have a problem saying this is what you should 6 spend when they don't tell me what they want to spend. There 7 was no budget in this that I could find. 8 VOICE; Dr. Scherlis, we just received in, and I 9 think it is upstairs, the form 16's. 10 DR. HINMAN: We have a form 16 but it doesn't tell 11 you anything. 12 VOICE: That doesn't break it down. 13 DR. SCHERLIS: I have this one-fold sheet, and that 14 do6sn't tell me, and then as I go through the back, here and 15 there they set up on the islands emergency vehicles, which they 16 are in need of, with telemetry, but these come to small sums, 17 $10- or $12,000 each. 18 There is the other item of some $400,000 for the 19 trauma unit, which I don't think should be supported. And t en 20 I have problems looking at where the other 300 go to. I give 21 them a high rating but my concern is I can't translate that in 22 terms of dollars because I don't know what they want the money 23 for. 24 DR. MARGULIES: Perhaps, what you can do is to Ace - Federal Reporters, Inc. 25 actually endorse it on that basis with the understanding that I 2 9 8 jr 6 we will seek a budget and see if it is a reasonable figure and 2 bring it into the council that way. It may be an omission. 3 DR. MC PHEDRA14: Excluding the trauma. 4 DR. MARGULIES: Yes. 5 DR. SCHERLIS: My own feeling about the level of 6 support would be in terms of $3- or $400,000 for each of three 7 years but I'm arbitrary in that when I don't know what they 8 really require. 9 Can that be approved on that basiso that we will 10 come up with a number that is meaningful? 11 Is there a second to that rough motion? 12 DR. 14C PHEDRAN: Yes. 13 DR. SCHERL : The rating I gave was 3.5 and I 14 suggested three-year support. 15 DR. HINMAN: All right, 3.5. 16 DR. SCHERLIS: Is there a second? End 26 17 DR. MC PHEDRAN: I second. 18 1 9 20 21 22 23 24 .4-ce - Federal Reporters, Inc. 25@ 29 9 im 1 1 DR. SCHERLIS: All right. 2 Next is Mountain States' three projects. We're on the 3 home stretch now, I hope. 4 All right, Mountain States' request is for three projects 5 which come to the following: $375,000 for project 26. 6 DR. HINMAN: That is all three combined. 7 DR. SCHERLIS: Oh, okay. All right. There are 8 three different components; one from Idaho, the other from 9 Montana, the third from California and Nevada. The general 10 objectives are to develop a comprehensive emergency medical 11 service planning program for Montana, increase the existing 12 emergency council advisory activity, initiate needed training, 13 inventory all emergency facilities, form an area-wide planning 14 committee,for projec@t-resourres.:@.Staff and@@.!volutitee,.r:would,be%. 15 from other.sourcet,.And they have other funding@for that. 16 And for Montana, the following comments were made. This is similar to the other states, as I will indicate. it is 17 18 essentially the same as Idaho. They give only the barest out- 19 line. There is a very poor breakdown as far as salaries Are 20 concerned. They requested a total of $142,000 for their 21 program. 22 They requested specifically to support a staff of five 23 members in the Department of Health and Environmental Sciences, 24 eight in the coordination of five emergency medical service @ce -Federal Reporters, Inc. 25 planning committees in the state supporting training of 3 0 0 JM 2 1 emergency facility personnel, inventory the state resources 2 provide ambulances and equipment, and then there is a $70,000 3 budget item to purchase ambulances. This actually is not in 4 the budget. It appears to come from federal sources. 5 I would concur in the fact that I would not fund the 6 budget request at this time because, essentially, they should 7 be much more in line with planning. If you go through the 8 yellow sheets, and these are interesting because most of the 9 responses in terms of understanding the EMS system are on the 10 negative side. In fact, most of the comments of staff were on 11 the negative side, as far as the entire project is concerned. 12 This was Montana. 13 In terms of Idaho, again, this is a very similar one to 14 Montana. They specifically ask for funds for an emergency 15 health services advisory board. They want to provide EMT 16 training, EMS physician and nurse training, coronary care 17 evaluation, emergency rooms, coronary care units and other 18 hospital facilities, classify and evaluate emergency rooms in 19 Idaho, collect and tabulate data. 20 I rated this more favorably than I did the one from 21 Montana. They had requested some $178,000, which I thought 22 was somewhat excessive. They have requested mobile coronary 23 care vehicles, and I felt this should be under a separate fund- 24 ing. This was on -- if you want to check, it is on page 45 of Ace-Federal Reporters, Inc. 25 their application. They do have good data on the ambulances, 3 01 JM 3 1 good data as far as a lot of their information is concerned. 2 The goals were very well-stated, as well. This looks a little 3 better as far as being more of an emergency medical system. 4 They do have better planning than the others. Although they 5 are emphasizing only part of the EMS system, they do define 6 some of the other needs. I thought all in all this was a 7 reasonable approach. 8 The third was Nevada and California. This request was 9 for $55,000 for year 1, $62,000 for the second year Here 10 they specifically asked for funds for a program coordinator, 11 EMT.training and EMS committees to coordinate their planning 12 of a total system. Actually, although there is a need defined 13 in their grant, the grant request, they don't address themselves 14 very well to a total system. 15 My feeling here was to give them a low rating, although 16 they need their funds. I felt this was overall a poor presen- 17 tation. 18 What I came up with then, as far as California and Nevada 19 was concerned is that that would not be funded, but in terms 20 of the Idaho component where they had requested $178,000, is 21 that this be rated as three with a request for $100,000. 22 The third, Montana, I had a dilemma on this one. My own 23 reaction was to rate this as two. I thought their request for 24 funds was excessive, and in comparing it to the ones that came ce - Federal Reporters, Inc. in from the same Area, it should be refused. I suggest a sum 25 3 0 2 JM 4 1 of $50,000. 2@ DR. HINMAN: Do I understand you correctly? You are 40 3 recommending one-year planning for two of the components? 4 DR. SCHERLIS: And zero for the third. The other 5 was 100, and the other 50. 6 Is there any member of the staff who could speak to Idaho 7 or Montana, as far as how they have moved along with their 8 emergency systems planning at this point, aside from what is 9 present in the grant application? 10 Do you have any feeling on that? 11 VOICE: I was out there to a RAG meeting just 12 recently when these projects were pushed through the RAG, and 13 at that time, the projects were wer-e. heavily loaded with 14 equipment requests. That was the essence of it, basically, 15 and they had not followed or not had any idea what the EMS 16 guidelines were at the time. Subsequent to staff input they 17 went back and reworked them a little bit, and I think they have 18 taken out most of the equipment and are trying to plan aspects. 19 DR. SCHERLIS: These look thick, but they are all 20 appendix material, and there is a lot of padding of related 21 and unrelated material. 22 VOICE: I think there surely is -- 23 DR. SCHERLIS: The requests are scant, and I think 24 more in terms of planning, and I think they can probably move @ce -Federal Reporters, Inc. 25 on that. 30 3 JM 5 1 VOICE: The Idaho one has been conceptually worked 2 out much longer than the other two. I think you hit them in 3 the descending order they ought to be. Idaho, Montana, and 4 Nevada. 5 DR. SCHERLIS: Right. Is there a second to that 6 motion? 7 DR. MC PHEDRAN: I second. 8 DR. SCHERLIS: I think we have struck the coronary 9 units, ambulances, from that program. 10 Any further discussion? 11 We have one last state, Oregon. I think we should have 12 our director do that to see if he would like to participate in 13 the frivolity. 14 DR. MARGULIES: I feel that is completely out of 15 order. 16 DR. SCHERLIS: All right. The Oregon request is 17 for $532,000. That is a request specifically to establish a 18 state-wide emergency medical communication network, a two-way 19 radio system linking emergency data from hospital to hospital. 20 They say, "In general, hospital emergency room personnel are 21 unable to provide instructions to emergency medical technicians 22 at the scene of adcidents." They go through the reasons for 23 justifying this. The project proposes to purchase and install C) 24 the basic equipment for establishment of a two-way radio system ce- Federal Reporters, Inc. 25 based on the recommendations, information, or plan for JM 6 304 1 emergency medical communications in Oregon. 2 The communications system will be organized to utilize 3 Oregon's Association of Hospital Councils. An agreement has 4 been drawn up as far as this participation is concerned. This, 5 then, is a straight forward request in that regard. It is 6 purely for the network and it is limited to that approach. It 7 only speaks purely of the equipment. There is no indication 8 actually of anything else in this, and for what it is, it is. 9 But it is extremely limited in its approach. 10 Repeatedly, as I went through this, my comments were that 11 this did not talk to a broad system at all. There wasn't any 12 evidence that they were going to relate to a broad system. I 13 do not have a favorable response to it. It did not follow the even 14 criteria or the guidelines in terms of saying how this 15 would fit into the over all program. It is a very limited 16 project in terms of background data. Most of the information 17 is in terms of supporting letters. Then it goes into what the 18 equipment would be. There is very little, if any, support 19 requested as far as staff is concerned because all of this 20 would be through contributed areas. 21 Basically, what they ask for are the vehicles and equip- 22 ment and that is about it. I can't find this to be anything 23 more than a circumscribed part of the system. 24 Now, if this spoke to the entire system and said that kce-Federal Reporters, Inc. 25 this was the area of the greatest priority at the present I JM 7 3 05 they Vere I time while this was going on@stepwise going to do other things, 2@ I might react differently. But this addresses itself purely to 3 the package request for some technical equipment, and even 4 though it is part of, they say, the comprehensive plan, I see 5 it in a very limited way. 6 I do not recommend support of this one. 7 VOICE: This application was forwarded shortly 8 after the first of the year, and they chose not to revise it. 9 DR. SCHERLIS: Before the guidelines? 10 VOICE: Yes. 11 DR. HINMAN: They did have an opportunity to relate 12 it. 13 DR. SCHERLIS: They did? 14 DR. HINMAN: Yes, sir. 15 DR. ROSE: A number of very specific statements 16 suggested some documentation. 17 VOICE: A number of telephone calls were made. 18 DR. TOOMEY: Once again, is this a hospital planning 19 group, basically It reads like that. 20 DR. SCHERLIS: It comes in from the Oregon State 21 Health Division. 22 DR. MARGULIES: It sounds like something the RMP 23 dutifully sent on. 24 DR. SCHERLIS: I have that feeling because the kce- Federal Reporters, Inc. 25 project coordinators from the Oregon Health Division, hospital 306 cont 27 1 coordinator, assistant coordinator, are all from that area with lli@,W lee #6307 2 all the salaries donated to the project because essentially 3 there is nothing that goes on with the project. 4 Essentially they buy equipment and install it. There 5 is no evidence on the training. 6 What are they going to talk about once they set up 7 the communication, because even that -- this isn't part of a 8 total training program, it doesn't relate to emergency 9 facilities. I recommended no support. 10 MR. TOOMEY: As a hospital person, I get concerned 11 by the limited vision of some of the hospital-based or 12 hospital-involved applications. 13 That is why I thought that the one you have on 14 Springfield, Missouri, was so different because it was looking 15 at something broader than the inside operation of a hospital. 16 DR. SILSBEE: Dr. Scherlis, there is an EMT training 17 Project in their regular application. 18 DR. SCHERLIS: Yes, I know. 19 DR. MC PHEDRAii: I was out to Oregon on a program 20 site visit a month or so ago and I am surprised that they 21 haven't worked this up differently. 22 DR. SCHERLIS: Do you have their application there? 23 DR. MC PHEDRAN: I am not disagreeing with what you said about it, I'm just surprised. 24 Ace-Federal Reporters, Inc. DR. SCHERLIS: It perturbs me, because this could be 25 307 jr 1 part of their total system and what they want is that part of 2 of it but they don't approach it in a well-coordinated way de- 3 spite the communication from @IPS. 4 DR. MARGULIES: It does suggest that basically they 5 aren't terribly interested in it. 6 DR. MC PHEDRAN: I think so. We all thought it was 7 a good program staff. 8 DR. SCHERLIS: Well, is there a secon ? 9 DR. MC PIIEDRAN: I'll second it. 10 DR. TOOMEY: I agree. End 11 DR. SCHERLIS: We ate the whole thing. -4: 27 12 (Whereupon at 6 p.m., the meeting was adjourned.) II 13 14 15 16 17 18 19 20 21 22 23 24 Ace-Federal Reporters, Inc. 25