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Hurricane Katrina and the subsequent flooding destroyed much of the healthcare infrastructure in New Orleans—not to mention large swaths of thecity itself. But the Ochsner Clinic Foundation never did close (DOCNews, November 2005).
During the August 2003 blackout that left about 50 million people in NorthAmerica in the dark, Trinity Health, a large, Michigan-based network ofCatholic health systems, kept its computers humming the whole time, withouteven having to switch to a secondary data center in Indiana.
How? A bit of serendipity, sure, but mostly through thoughtfulplanning.
Ochsner got lucky: Its main campus is 2.5 ft above sea level. "Wewere high and dry," says medical director Richard Guthrie, Jr., MD. Sowere the emergency generators, located on the second floor of Ochsner'sflagship hospital. There is a 15-foot "moat" around electricalswitches on the ground floor to prevent flooding, and Ochsner dug a well about15 years ago to ensure a water supply if city water service were lost.
Trinity Health spent $10 million on a massive, secure data center in Novi,Mich., with redundant backups, and the investment paid off during the poweroutage.
Likewise, electronic medical records (EMRs) at Ochsner were available evenas the paper records of hundreds of thousands of people washed away across theregion. Physicians at a major Ochsner facility in Baton Rouge, La., hadcomplete access to records of patients who evacuated New Orleans.
"[EMRs] kind of saved the day," Guthrie says. "I thinkthose who didn't believe in electronic medical records beforehand believe inthem now."
Ochsner management and staff heeded earlier warnings and had devisedemergency procedures before Katrina roared ashore.
Many smaller practices were not so lucky. Floyd Buras, MD, president of theLouisiana State Medical Society, essentially lost his two-physician pediatricpractice. Located in the hard-hit Gentilly neighborhood of New Orleans, thebuilding was under 12 feet of water for twoweeks.
The practice re-opened in temporary space at a Children's Hospital facilityin suburban Metairie, but the mass evacuation of the city robbed Buras of hispatient base. Prior to Katrina, the practice held 15,000 active charts. As ofmid-March, only 551 were active.
"Most of the patients I am seeing now are babies born since thestorm," Buras says.
INSURANCE OVERLOOKED
Disaster—natural or otherwise—can strike any practice at anytime. Fires, civil disturbances, terrorism, public health emergencies, andhazardous-material incidents can disrupt business operations. A partner in thepractice can die unexpectedly.
"The less prepared you are, the slower your response," saysJonathan Bernstein, a crisis-management consultant in Monrovia, Calif."The slower the response, the greater the damage to your business andyour reputation."
Bernstein says even a simple brainstorming session among partners and theoffice manager can head off a potential crisis situation. "You can'tafford not to do it," he says.
Patrick Padgett, staff counsel for the Kentucky Medical Association (KMA),developed a model disaster plan for physician practices in 2000 by turning toa committee of medical office managers and combing through basicdisaster-preparation materials from the federal government. Even in apost-9/11 world, the information remains relevant, and the guide continues tobe the most popular item on the KMA Web site.
The two biggest things Katrina and the 2001 terrorist attacks showeddoctors are that practices must protect their documents and make sure theyhave the right insurance, according to Padgett.
"The No. 1 most overlooked part is insurance," Padgett says."I don't think that people understand [the claims procedure] forinsurance until they have to go through it, whether it's for their business ortheir home."
Padgett recommends that physician practices buy insurance to cover employeesalaries and lost income if the office has to close and also considerreplacement-value policies for medical equipment rather than coverage only onthe original price.
Buras, the New Orleans pediatrician, had business interruption insurance,but because he lost his practice in a flood, that policy did not apply.Furthermore, he did not have insurance papers in a safe place, so he could notget to them right away.
Practices with multiple offices could plan for disaster response at onelocation by shifting some operations. "You might be able to use yoursurgery center as your basic clinic," Padgett suggests. Cooperativeagreements with "friendly competitors" to share space during acrisis can be another practical solution, according to Bernstein.
OFF-SITE SALVATION
"Paper records could be lost forever in a fire or flood, butelectronic documents are vulnerable, too," Padgett says. This includesmedical records, billing claims, and other business documents. "If youhave electronic documents, you need to back them up and take the tapesoff-site at least once a week."
"If [the tape] is on-site, that's not going to do a lot of good ifthe building burns down," Bernstein agrees. That is why redundantbackups such as Trinity Health maintains are so important.
A backup could be in a safe-deposit box at a bank across the street. Butwhat if the street is closed due to a hazmat incident or burst water main?Bernstein says practices might consider an online backup service. "Imight pay 50 bucks a month for it, but how much would it cost if you lost yourdata?" he asks.
Buras admits that he overlooked the need to remove computer files from hisoffice before Hurricane Katrina. "Next time I will pull the server andput it in my car," he says. "That way at least I could reconstructmedical records from billing records."
Bernstein says most physician practices know how to evacuate personnel butare unprepared to deal with disruptions when nobody is in the office.
PEOPLE FIRST
If the building burns or is flattened by a tornado, what does the practicedo about restoring computer backups? How will the practice receive its mail?Will there be phone service? How are patients notified about appointmentcancellations?
The first thing to do in any crisis is to protect people, then protectproperty, Bernstein says. "Then think about whom you serve and whatnotification needs to be made," he says. "Do you have a list ofall your clients and vendors that you can get to without going into theoffice?"
Keep this information on hand-held personal digital assistants or onprintouts kept off-site, he advises.
Another area that often gets overlooked is communication with employeesduring an emergency. "Would everybody know where to reporttomorrow?" Bernstein asks.
Ahead of Hurricane Katrina, Ochsner management determined staffing needs invarious departments and medical disciplines. Anyone on duty during the stormwould stay until relief could get in.
Ochsner set up a toll-free hot-line for other employees to call to learntheir work status, but sent the number in an e-mail one day after Katrina hit.Of course, not everyone had access to e-mail in the storm's wake; so many didnot get the message. Now, management communicates the hotline number before anexpected storm and plans a conference call the day after, Guthrie says.
After Katrina, 5 days elapsed before another shift could be bused in fromBaton Rouge. All clinic executives stayed on-site during the storm, sleepingon air mattresses, while clinicians had beds reserved at the hotel adjacent tothe main hospital.
That was the right way to play it, according to Padgett. In an emergency,doctors should take care of patients first and deal with administrative andlogistical issues later. In New Orleans, says Padgett, "they needed thephysicians to be physicians." 
Footnotes
This is part one of a two-part series on how primary care practitionerscan prepare to provide for their patients during a natural or manmadedisaster. June's story looks at protecting a practice in order to continuecaring for patients. In July, we will explore how providers can help patientsbetter plan to take care of themselves when disaster strikes, and how doctorscan be sure they have access to medications when their patients donot.
The American Medical Association offers courses through itsNational Disaster Life Support Program, developed in partnership withfour major medical centers and three national health organizations. Moreinformation is available atwww.ama-assn.org/ama/pub/category/12606.html.
AMA's center for Public Health Preparedness and Disaster Responseoffers extensive resources and policies for physicians and patients on medicalpreparedness for terrorist attacks and other disasters. Visitwww.ama-assn.org/ama/pub/category/6206.htmlto learn more.
The American Academy of Family Physicians recommends curriculumguidelines for family practice residents for disaster medicine. Moreinformation is available online atwww.aafp.org/x16647.xml.
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