DRIGI i

                                            Transcript of Proceedings

                                        ENT OF HEALTH, EDUCA
                        @DEPA@RTM                                             TION, AND WELFARE
                                                   -OIFIT @,U (@"O  l@@'
                                                   ti

                                                                                     y,, 15          I- 72

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   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.

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                                         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

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      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
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                                                                                   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
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                                                                              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.
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                 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.
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       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,

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                25 such as the fact that we are not going to  give  a  very  high

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                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
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        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
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                 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

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     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


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     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
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     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

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               25   knowing which the applications to HSMHA are, can you give us

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     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


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     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

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    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?
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    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
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     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

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                 25 it will be acceptable, and will be effective -- I think once

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    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

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  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

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                                                                              31
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                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


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                 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


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                  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

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                  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

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                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

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               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

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                                                                              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.
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                                                                             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

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       #                                                                     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
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     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
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                                                                               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
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    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.
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    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.
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    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,

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                                                                                                                                              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

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                                                                              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;
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                                                                           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


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     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

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     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,

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        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.

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              25               I wish that the telephone services could be


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         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

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        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,
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              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?

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         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

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      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
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       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

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                                                                              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.
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    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

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    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.
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    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

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                                                                              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.
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         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
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                                                                                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

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     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
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      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

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             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
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              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

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                                                                              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.

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                                                                             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.

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                                                                                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
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    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.

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        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?
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                                                                            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

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                                                                             186
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                                             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.
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      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,
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            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
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                                                                           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
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               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

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                              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
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                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
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     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
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                                                                           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
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    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.

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    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.
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        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
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     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
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                                                                               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

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                                                                              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
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                                                                               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
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                                                                              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.
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                                                                              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
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                                                                               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
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                                                                               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?
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                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.

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     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
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    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.
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     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
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      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

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    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
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     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.
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     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.
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     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
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     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
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     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

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          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.

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                 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


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                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
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   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
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   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.
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                                                                                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

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                21

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     CR6307                                                                     252
     Lee#22
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                 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.

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                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.

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               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?

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               25              DR. HimAN:  "2", and $20,000, then?

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       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

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       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

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        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.

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               25              DR. SCHERLIS:  What priority would you give that?
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                                                                             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.
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                               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

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               25 care, transportation, communication systems, training of

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                                                                           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

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               25  which is being looked at the present time.

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           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

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               25  as it should to the total system of care but more specifically,
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                                                                          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.

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               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.

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                 25              All right?

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         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.

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               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

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               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

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                25  review committee was harder on it  than  I  would  be.  I  thought

                  I


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                 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
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    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

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                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(@

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               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

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                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

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                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

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                  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

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               25   project coordinators from the Oregon Health Division, hospital


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   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


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      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.)
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