ABSTRACT
During a disaster, unsolicited health care volunteers pose significant legal, medical, logistical and safety concerns. Coordination and deployment of qualified health care volunteers also has been a major challenge to emergency managers. In response to these concerns the Health Resources and Services Administration (HRSA) encouraged each state to develop an Emergency System for the Advanced Registration of Volunteer Health Professionals (ESAR-VHP). The successful development of California's ESAR-VHP programs required significant planning to address challenges such as license verification, credentialing, privileging, volunteer typing, security and privacy of data, civil liability and workers compensation protection. This article is the first in a three-part series outlining the experience of the California Emergency Medical Services Authority (EMSA) in the development and deployment of the state's ESAR-VHP system.
This paper is the first in a three-part series discussing California's Emergency Medical Services Authority's (EMSA) experiences in developing, testing and implementing an Emergency System of the Advance Registration of Volunteer Health Professionals (ESAR-VHP [ee-sar-vip]) program in California. Since the tragic attacks of Sept. 11, 2001, there has been a surge of interest in developing a system by which to manage volunteer health workers in the setting of a disaster and, more importantly, to ensure these volunteers are qualified to provide medical aid during such events. In response to this need the HRSA encouraged and funded states to develop ESAR-VHP programs that would allow for the advanced registration and credentialing of volunteer health care providers for use during a disaster.
In this first paper, we will discuss the need for an ESAR-VHP system, as well as EMSA's experience during the development and implementation of this system in California. We will discuss the challenges surrounding licensing, credentialing, privileging, volunteer typing, security and privacy of data, civil liability issues, legal issues, workers compensation protection, emergency verification and criminal liability issues.
A subsequent paper, Part 2, will be published after EMSA has completed a full-scale disaster drill with implementation of the ESAR-VHP system. In Part 2 we will discuss EMSA's experience during this drill. The final paper in this series will be published after the ESAR-VHP system is used in a real disaster and will discuss its effectiveness during that disaster. We hope to never have to write this third paper, but, as disasters are inevitable, we can only hope that the outcome is the best possible for all involved.
WHAT IS ESAR-VHP?
After recognizing the concerns posed by the flood of unsolicited health care volunteers in the setting of disasters, the HRSA encouraged each state to develop an Emergency System for the Advanced Registration of Volunteer Health Professionals (ESAR-VHP) through the National Bioterrorism Hospital Preparedness Program (NBHPP).1 The ESAR-VHP program is intended to meet Critical Benchmark #2–4: Surge Capacity: Advance Registration System2 as outlined in the NBHPP, which reads:
Develop a system that allows for the advance registration and credentialing of clinicians needed to augment a hospital or other medical facility to meet increased patient/victim care and increased surge capacity needs.
The primary goal of ESAR-VHP is to eliminate a number of the significant problems encountered when attempting to utilize medical volunteers in complex emergency response situations and disasters, and to optimize the use of these volunteers.
The ESAR-VHP program is guided by four fundamental objectives, which ensure the proper development and operation of each state's ESAR-VHP System. These objectives are:
Ensuring an adequate and competent health volunteer force surge capacity
Enabling efficient and effective emergency operations
Allowing sharing of health volunteers across state lines
Establishing clear protections for health volunteers, hospitals and others
The goal was for all states to have functional ESAR-VHP systems in place by August 2007. As ESAR-VHP systems are developed in coordination with HRSA, it allows not only for in-state management and development of health care volunteers but also allows for a state based national system of mutual assistance in the setting of a regional or national disaster.
WHY DO WE NEED AN ESAR-VHP SYSTEM?
Unfortunately, disasters occur. California experiences more natural and man-made disasters than any other state, except for Texas. Since 1950, California has declared more than 1200 States of Emergency in response to earthquakes, floods, fires, freezes, outbreaks of infectious disease, droughts, pestilence, civil unrest, mudslides and chemical spills3, and 73 of these events were considered major disasters by federal authorities.4,6 Since 1989, every one of the 58 counties in California has filed at least one declared disaster.
Following every major disaster, American medical providers have been eager and ready to volunteer their professional health services to meet the perceived large scale need. Local and state governments, along with private health care providers have depended upon the services of these health volunteers to meet the medical demands of the disaster.5 Unfortunately, coordination and deployment of health care volunteers during a disaster has been a major challenge for hospitals and emergency authorities, and frequently volunteers are underused or in-effectively used during these times of need. As has been evidenced by several recent incidents, after a large disaster occurs, thousands of people often spontaneously arrive at the scene of the event to volunteer their assistance. Many of these volunteers can provide qualified medical assistance to the victims, while others are well intentioned yet not qualified.6 In the past, authorities have been unable to distinguish those that are qualified from those that are not, potentially leading to inappropriate use of unqualified individuals or underutilization of qualified volunteers. Because this response is unsolicited, there is often no mechanism for coordination and implementation of these volunteers. Thus, the overall effectiveness of these volunteers is significantly reduced, and the added burden of trying to manage these volunteer falls onto the disaster commanders. In some instances well-intentioned volunteers become victims themselves requiring rescue by the already overwhelmed emergency professionals.
CALIFORNIA'S ESAR-VHP FEATURES
In an attempt to develop an ESAR-VHP system, states have encountered a variety of legal and administrative obstacles. California has answered this challenge by developing a tiered system that attempts to register volunteer health professionals before and during a disaster. This system, by pre-registering volunteers and verifying their credentials prior to a disaster, allows the state to have an extensive working network of appropriately licensed, trained and credentialed volunteers who can readily be deployed once a disaster occurs. For marketing and deployment purposes, the California ESAR-VHP system has been named California Medical Volunteers (Cal-MV).
California's ESAR-VHP system is designed to:
Promote volunteerism among emergency medical professionals
Help medical professionals volunteer before a disaster strikes
Perform license verification and credentialing before a disaster strikes
Handle all of the notification and deployment once a disaster occurs safely and smoothly
Provide information to the volunteers to help them to determine whether or not to accept a particular mission along with the appropriate mission briefings
Determine what liability coverage and workers compensation protection are available to protect volunteers deployed under this program
During the initial development of Cal-MV, EMSA followed the HRSA recommendations, which describe in detail the federal ESAR-VHP model.7 Although this model is very comprehensive EMSA quickly realized that implementation of this model in California would have its own discrete challenges.
Prior to California's implementation Cal-MV the largest states to have successfully implemented ESAR-VHP were far smaller in both size and population. California is a very large state with more than 450 acute care hospitals and 10–15 percent of the licensed health professionals in the nation. EMSA immediately identified the amount of funding allocated, and the amount of resources recommended in the federal model was going to be far too small for their large state. To rectify the funding insufficiency EMSA applied for an additional HRSA grant, which allowed them to fully implement their ESAR-VHP system, which is based upon the federal guidelines, but is of adequate scale for California. To date, the cost of development of Cal-MV has been $2.5 million, not including ongoing costs.
After establishing a program advisory committee, composed of the significant stakeholders pertinent to volunteer health professionals in California, EMSA embarked upon a limited proof-of-concept pilot. The pilot sought to demonstrate the ability to use contemporary, commercial off-the-shelf software to meet the federal ESAR-VHP mandate. The pilot was limited in the number of volunteers that could register, and the types of professions enrolled, but proved conclusively that currently available, off-the-shelf software could meet the state's needs. This software was purchased through the state's standard procurement process and has been fully implemented.
Once the design and implementation of the pilot software program was completed, EMSA began to enroll interested volunteers. Initially they only recruited by word of mouth so as to provide initial feedback and to beta-test the system.
Upon installation of the final software package, EMSA began to globally recruit volunteers in all areas of medicine. EMSA has already received support from most state health care licensing boards, which plan to send out recruitment information to their members. In addition, EMSA plans to advertise by distributing brochures to local hospitals and other health care providers, and will continue to advertise on their website. Additional marketing efforts will include partnerships with health systems, outreach to counties and professional societies.
Interested volunteers self-register for Cal-MV, using the website, www.medicalvolunteer.ca.gov. This site asks, volunteers to provide information regarding their licensure, specialty, health and vaccination status, other skills and contact information. Volunteers are also asked to indicate their deployment preferences (local, national or international) and typical availability (immediate, within and few days, or within a few weeks). Registration on the site takes approximately 10 to 15 minutes.
Once a volunteer has registered on the website, their license is automatically verified against state and national databases to ensure that each volunteer has a full and unrestricted license. While license checking, is relatively straight forward for most professionals, some license types pose unique problems. One group of note are California EMTs, as they are all licensed by individual counties and not at the state level, and for whom background checks are not required. Because public protection is of paramount importance for EMSA, volunteers licensed without a background check will not be allowed to register.
The Federal ESAR-VHP guidelines allow for credentialing in four general categories based on available licensing and practice verification [Table 1].8 Physicians placed in group 1, for example, have demonstrated an unencumbered license, medical degree, American Board of Medical Specialties specialty board certification, and a Drug Enforcement Administration (DEA) license.8 Additionally, they have verified hospital practice privileges, and have the ability to bill Medicare or Medicaid.8
Credential Element Verifications for Resource Typing of Physicians8
Upon initial registration, all volunteers are placed into group 4, and as their license and credentials are verified, they are advanced to the next group. Once a volunteer has had all the license and practice requirements verified they are eligible to be in group 1. Some volunteers will never be able to be placed in group 1 as they lack the credentials needed. These individuals will remain in the highest level group to which they could be verified.
When a disaster strikes, emergency managers at EMSA arrange specific aid missions and determine what levels and types of volunteers are needed for these missions. EMSA managers then use the Cal-MV database to search for volunteers that meet the specific requirements for the particular mission.
Once volunteers are identified, they are contacted and given a quick synopsis of the mission, as well as instructions as to how to accept or decline the mission. Once the mission assignment is accepted the volunteer is provided with any necessary additional information regarding the mission including location and time of deployment, what is expected and what is needed. The assigned volunteers are given documents generated by Cal-MV that shows their level of verification and credentials. These documents can then be shared with the hospital or medical team to which they are assigned.
Once Cal-MV is activated the logistical support team is immediately put into place and is responsible for ensuring the overall well being of our volunteers. This team arranges housing, meals, counseling and security for the volunteers and helps with any other logistical problems that may arise while the volunteers are at the site of the disaster.
In addition to developing Cal-MV, California has also chosen to develop additional resources for health care volunteer recruitment, training and credentialing. These resources include:
Developing Mission Support Teams to provide logistics and field support to deployed volunteer health professionals.
Coordinating, improving and supporting the work of local Medical Reserve Corps (MRC) teams. There are currently 28 MRC teams in California with various levels of preparedness and deployment capacity.
Developing three state-sponsored California Medical Assistance Teams (Cal-MAT) following the model of the federal Disaster Medical Assistance Teams (DMAT).
Continuing coordination of efforts with the federal DMAT in California (six medical and one mental health).
Utilizing Cal-MV for just in time registering, training and deployment of health volunteers not registered in advance of a disaster.
Mobilizing up to three, 200-bed mobile acute care hospitals.
This portfolio of programs, in addition to Cal-MV, is intended to provide opportunities for any licensed health care worker to assist before and during a large-scale disaster.
PROTECTING OUR VOLUNTEERS
One important factor that EMSA addressed at the initiation of Cal-MV was how their volunteers would be legally protected while providing volunteer services. All volunteers are covered under the California Emergency Services Act (CA Gov Code §8657), which provides them with workers compensation coverage, as well as limited liability coverage.
In addition, personal information provided by volunteers during the registration process is only authorized to be used by specific Cal-MV administrators in accordance with the terms of service. The terms of service are available on the Cal-MV and EMSA websites.
LEGAL STATUTES AFFECTING ESAR-VHP
A variety of federal and state statutes provide guidance to hospitals and emergency officials when dealing with health professionals. Unless specifically superseded by an emergency disaster declaration, all such statutes must be considered when deploying volunteer health professionals in the setting of a disaster. Federal Statutes and Regulations to consider are included in Appendix A, and State of California Statutes and Regulations are included in Appendix B.
WHERE ARE WE NOW?
EMSA's full-scale Cal-MV system went live Dec. 28, 2007, and they are currently recruiting volunteers. More than 1,000 volunteers have signed up on the Cal-MV website and are undergoing credentialing. Several hundred are already adequately credentialed to be available for deployment to any disasters that may occur. EMSA plans to run a full scale assessment of Cal-MV during this year's state medical and health disaster drill (Rough and Ready 2008) and we will discuss their experiences during this assessment in our next paper.
HOW CAN I REGISTER FOR ESAR-VHP?
Interested volunteers can register for Cal-MV at www.medicalvolunteer.ca.gov.
APPENDIX A: FEDERAL STATUES AND REGULATIONS
42 U.S.C. §14501-§14505: The Volunteer Protection Act (VPA) of 1997 is similar to state Good Samaritan Laws. It provides liability and civil protection for health volunteers assisting victims of a disaster.
42 CFR 482.22 Condition of Participation, Medical Services: The Medicare conditions of participation indicate that hospitals must have an organized medical staff that is responsible for the medical care provided to patients by such hospital, including hospital privileges granted to individual practitioners, and the procedure for granting such privileges.
42 CFR 482.24 Condition of Participation, Nursing Services: This regulation requires hospitals to have a nursing service with adequate numbers of licensed registered nurses, licensed practical (vocational) nurses and other personnel to provide nursing care to all patients as needed. Non-employee licensed nurses who are working in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of the clinical activities of non-employee nursing personnel, which occur within the responsibility of the nursing service. (These regulations are mirrored in California Regulations, Title 22, Division 5, Chapter 1, General Acute Care Hospitals).
APPENDIX B: STATE OF CALIFORNIA STATUES AND REGULATIONS
CA Gov Code §8657, Emergency Services Act: The Disaster Service Worker Volunteer Program (DSWVP) provides workers compensation and a limited immunity from liability for volunteers who are registered as Disaster Service Workers while providing care during a disaster. There is no similar provision for individual volunteers who present to a hospital and are accepted as part of the medical or nursing staff. The hospital bears all responsibility for workers compensation and liability from the volunteer's actions, even if the volunteer receives no compensation for his or her work as a volunteer. Additionally, the hospital has potential liability of negligence or even gross negligence in accepting a volunteer worker without due diligence for credentialing, training or supervision.
CA Gov Code §8659: Any physician or surgeon (whether licensed in this state or any other state), hospital, pharmacist, nurse, or dentist who renders services during any state of war, emergency, a state of emergency, or a local emergency at the express or implied request of any responsible state or local official or agency shall have no liability for any injury sustained by any person by reason of such services, regardless of how or under what circumstances or by what cause such injuries are sustained; provided, however, that the immunity herein granted shall not apply in the event of a willful act or omission.
CA Labor Code §3211.92(b) and CCR Title 19 §2572.2(3)(b)(1) as well as the above DSWVP, provides protection even during training for disasters.
CA Gov Code §8623: Persons from other states holding licenses or certificates or other permits for professional skills may render aide in an emergency as if the license was conferred in California.
CA Bus & Prof Code §3502.5: A physician's assistant may perform medical services he or she is permitted to perform during emergency at the request of a responsible federal, state or local official or agency or pursuant to the terms of a mutual aid operation plan established and approved pursuant to the California Emergency Services Act, regardless of whether the supervising physician is available to supervise, as long as any licensed physician is available to provide supervision.
The key word here is “licensed”. No unlicensed persons, including health care professionals with inactive licenses, are allowed to provide services that normally require a license. Effective July 1, 2004, Section 2439 was added to the CA Business & Professions Code, which previously prohibited the practice of medicine or practice of podiatric medicine by the holder of a “Retired License.” Section 2442 of the CA Business & Professions Code was amended to allow waiving the renewal fee for a physician who certifies the license renewal is for the sole purpose of providing voluntary, unpaid service, in effect creating a “Voluntary Status Licensure”.
CA Bus & Prof Code §900 and §921:
Nothing in this division applies to a health care practitioner licensed in another state or territory of the United States who offers or provides health care for which he or she is licensed, if the health care is provided only during a state of emergency as defined in subdivision (b) of Section 8558 of the Government Code, which emergency overwhelms the response capabilities of California health care practitioners and only upon the request of the Director of the Emergency Medical Services Authority.
The director shall be the medical control and shall designate the licensure and specialty health care practitioners required for the specific emergency and shall designate the areas to which they may be deployed.
Health care practitioners shall provide, upon request, a valid copy of a professional license and a photograph identification issued by the state in which the practitioner holds licensure before being deployed by the director.
Health care practitioners deployed pursuant to this chapter shall provide the appropriate California licensing authority with verification of licensure upon request.
Health care practitioners providing health care pursuant to this chapter shall have immunity from liability for services rendered as specified in Section 8659 of the Government Code.
For the purposes of this chapter, “health care practitioner” means any person who engages in acts which are the subject of licensure or regulation under this division or under any initiative act referred to in this division.
For purposes of this chapter, “director” means the Director of the Emergency Medical Services Authority who shall have the powers specified in Division 2.5 (commencing with Section 1797) of the Health and Safety Code.
CA Government Code §179-179.9: (b) The Emergency Management Assistance Compact provides for assistance between the State of California and other states that are parties to the compact.
“When any person holds a license, certificate, or other permit issued by any state party to the compact evidencing the meeting of qualifications for professional, mechanical or other skills, and when such assistance is requested by the receiving party state, such person shall be deemed licensed, certified, or permitted by the state requesting assistance to render aid involving such skill to meet a declared emergency or disaster, subject to such limitations and conditions as the governor of the requesting state may prescribe by executive order or otherwise.”
- Copyright 2008 Federation of State Medical Boards. All Rights Reserved.
REFERENCES
- 1.↵“Credentialing volunteers during disasters”, Hospital Peer Review, Aug2003, 28( 8), pages108– 110.
- 2.↵General New York Hospital Association, “Emergency System of Advance Registration of Volunteer Health Professionals (EASR-VHP) Plan”. Accessed at http://www.gnyha.gov.
- 3.↵American Hospital Association, “Emergency Preparedness”, April 30, 2006. http://www.aha.org/aha/key_issues/disaster_readiness/content/ESARVHPGuidelines20050614.pdf.
- 4.↵EMTALA, “Application of EMTALA in a State of Emergency”. Accessed at http://www.emtala.com.
- 5.↵State of California, Executive Order S-04-06, http://gov.ca.gov/index.php?/executive-order/558/ Accessed on April 30, 2006.
- 6.↵Federal Emergency Management Agency. http://www.fema.gov. Accessed on April 30, 2006.
- 7.↵“Emergency System of Advance Registration of Volunteer Health Professionals”. Health Resources and Services Administration http://www.hrsa.gov/bioterrorism/default.htm Accessed on April 30, 2006.
- 8.↵General New York Hospital Association, “Will the states' Emergency System for Advanced Registration of Volunteer Health Professionals Build Adequate Hospital Personnel Surge Capacity?” http://www.gnyha.gov
- 9.Health and Human Services, Office of the Inspector General, http://www.oig.hhs.gov/fraud/exclusions.html
