City of McCook responds to SWNPHD policy on release of information

McCOOK, Neb. -- McCook City officials have been frustrated about the Southwest Nebraska Public Health Department's policy to not release information on local residents who have COVID-19 to local first responders who may be called to their homes.

The original SWNPHD release from June 22, 2020, can be read here.

The complete text of a city response released today follows:

This is a response from the City of McCook in reference to a Press Release issued by the Director of Southwest Nebraska Public Health, Myra Stoney that appeared in the McCook Daily Gazette on Monday, June 22, 2020. The City of McCook intended to refrain from responding in order to promote communication between the City of McCook and SWNPHD. Unfortunately, for reasons described below, the communication has become strained. As a result, the City of McCook feels that a response to the June 22, 2020 Press Release issued by the Director of SWNPHD is necessary to provide a counterpoint to some of her assertions.

The Press Release from Southwest Nebraska Public Health Department (SWNPHD) centers around limiting the release of information on COVID-19 patients. Several points were brought up in the release as to why the information would not be shared with local first responders, law enforcement and emergency managers.

At the June 11th SWNPHD meeting, a request from the City of McCook to share COVID-19 information with area first responders pursuant to Governor Ricketts Executive Order 20-15 was discussed. SWNPHD’s article stated the Board of Health, after “quite a robust discussion about the legal and policy issues,” had voted to “limit disclosures to those necessary to aid in enforcement of the directed health measures.” Fire Chief Harpham, Police Chief Brown and City Manager Schneider attended the meeting and at the conclusion of the discussion SWNPHD agreed to form a committee that consisted of three Board members and representatives from the City and other area first responders to further discuss the information sharing issue. It was our understanding that the committee was being formed to act as a liaison between first responders and SWNPHD to improve communications between entities. Following the June 11th Board meeting, the SWNPHD failed to make contact with the City of McCook regarding the status of the joint committee, despite the efforts by City of McCook to spur the formation of the committee. On Friday, August 21, 2020, Myra Stoney, Director of SWNPHD sent an email to City Manager Nate Schneider advising that the SWNPHD Board of Directors had decided to dissolve the committee, before the committee even met. It is interesting to note that SWNPHD failed to inform the City that the dissolution of the committee was an action item to be discussed at the August 13th Board meeting, despite the Health Department’s pledge to work with the area first responders via the committee at the June 11th meeting. To that end, this article does not address the lack of communication and openness on the part of SWNPHD with respect to the City’s Executive Order 20-15 request. It strictly serves to provide a counterpoint to Myra Stoney’s June 22nd article. The City of McCook’s article was delayed in an attempt to promote the formation of the committee. Now that SWNPHD disbanded the joint committee, the City of McCook has no recourse but to provide a needed contrasting opinion to SWNPHD’s June 22nd piece. The City of McCook will address its additional concerns regarding the lack of communication and openness on the part of SWNPHD at a later date and time.

Myra Stoney’s June 22nd Press Release states that, “After receiving requests for addresses and/or names of patients who have tested positive for COVID-19 or are presumed to be positive for COVID-19, Stoney said she gave the requests a great deal of consideration, discussed them with the Nebraska Department of Health and Human Services and other local public health departments around the state, the executive committee of the Board of Health and legal counsel.” Governor Pete Ricketts signed and Executive Order #20-15 on April 7, 2020 (https://govdocs.nebraska.gov/docs/pilot/pubs/eofiles/20-15.pdf). The Executive Order only allows disclosures to first responders on COVID-19 related health information and is intended to permit disclosures like those permitted under the federal Health Insurance Portability and Accountability Act (HIPAA) to first responders and other sharing patient information, including disclosures when:

-- When first responders may be at risk of infection;

-- When disclosure to first responders is necessary to prevent and lessen a serious and imminent threat to the health and safety of a person or the public;

-- When notifying a public health authority in order to prevent or control spread of a disease; and

-- Other similar circumstances to prevent and lessen a serious or imminent threat.

There are several points made in Ms. Stoney’s Press Release that city representatives agree with. However, we feel the need to address other important points made that we hoped the joint committee between SWNPHD and area first responders could collaboratively work on and come up with solutions that will have a positive impact on the identification and communication of information concerning COVID-19 patients in our area.

Ms Stoney’s release continues:

* There is no timeframe for recovered COVID-19 cases to ‘fall off’ of the list, and these individuals would therefore remain on the list indefinitely.

The City of McCook has a sophisticated Enhanced 911 (E911) system that would allow a single appointed person to enter the COVID information into the database. This information would not be available to anyone else. When the information is entered into the database it is “flagged” meaning that if a call is received from this name, number or address a flag would appear on the screen when the call comes in. This would alert the dispatcher that this is a COVID patient. The dispatcher would relay that to the first responders who are responding to provide care. The “flag” would be entered so that after two weeks it would reset to normal and no longer show the flag in the system.

* Testing in the health district is currently not at a high enough level.

While we understand there are people that have contracted COVID-19 that were never tested, we disagree that Ms. Stoney’s point invalidates our request. Any modicum of known information possessed by area first responders will assist our first responders in their preparation, screening and response to potential COVID-19 positive patients. Additionally, the number of tests that have been conducted has increased since June 22nd and will continue to increase as resources become available. It is Governor Rickett’s intent to continue increasing the number of tests administered. We must be proactive in planning for the future, especially when our leaders express optimism in our future testing capacity.

* The possibility of these names or addresses being leaked out to members of the public.

The City of McCook follows and is bound by the same privacy laws and regulations as any other healthcare agency. Additionally, City Manager Schneider offered the possibility of creating an indemnification agreement to assure SWNPHD would not be held liable should any information be leaked. We are confident that the City of McCook first responder personnel will not release private information and we are willing to back that up. We are confident in our processes and our ability to operate professionally.

The privacy concern expressed by SWNPHD with respect to area first responders becomes moot when comparing it to their contract tracing process. When SWNPHD contacts a potentially exposed person for contact tracing purposes; they release identifying information to the potentially exposed person. In most cases those people are unfamiliar with HIPAA rules and regulations. There are no safeguards to assure the contacted people won’t share the identifying information with other people. The City of McCook is aware of cases where people who have been given identifying information have shared the identifying information with others in the public, contrary to HIPPA doctrine. All of this said, we agree with the contact tracing process, however, we question SWNPHD’s logic that allows for identifying information be shared with potentially exposed people who then share that information with other individuals, and not with first responders who are trained extensively in HIPAA.

Furthermore, the current system utilizes the CDC guidelines for emergency calls and transmissions. Pursuant to the CDC guidelines, if the caller/patient meets any of the criteria for being a potential COVID-19 patient, the call is dispatched as a “COVID-19 POSITIVE” call. Those who monitor radio traffic via scanners are hearing the response page being issued to a specific address as COVID positive. If these names were entered into our 911 system, we would be able to eliminate the need to transmit a COVID positive message as we would know this prior to the response.

* Currently in some areas of the United States the sharing of personal information has resulted in stigmatization and discrimination by members of the community against those who have tested positive for COVID-19, as has occurred historically with HIV/AIDS.

HIV/AIDS is not a pandemic as defined by Governor Rickett’s Executive Order 20-15 and sharing of any information related to HIV or AIDS is not allowed under Executive Order 20-15 or HIPAA. Executive Order 20-15 is specific to the COVID-19 pandemic and is necessary due to the high rate of transmission. Ms. Stoney is perpetuating a straw man argument.

* Dr. Anthone’s and DHHS’s guidance is that disclosure of protected identifiable health information be shared only when there is “a good faith belief that such use or disclosure would prevent and lessen a serious and imminent threat” to health and safety. Although COVID-19 is certainly a serious threat, it is not necessarily imminent where PPE is available and appropriately utilized by first responders.

The problem with Ms Stoney’s assertion is that first responders don’t know when a COVID-19 threat is imminent and we don’t have the PPE to make the assumption that every call is a COVID-19 call.

The PPE available to first responders is in short supply. If EMS staff utilizes the recommended PPE on every call, we would deplete our supply in less than two weeks. Therefore, we have to be selective when utilizing PPE. This includes dispatch screening the calls and asking specific questions regarding potential COVID illness, EMS performing a doorway triage upon arrival at the location and, if needed, donning additional PPE. At the current time, EMS personnel utilize surgical masks, eye protection and gloves on every EMS call. However, if the call is a potential or confirmed COVID call, the CDC recommends a higher level N95 mask, goggles, gloves and gown. Our current stock of PPE, specifically gowns, is less than ideal. The gowns that we have been supplied by SWNPHD do not provide the minimum protection that we need to protect ourselves against COVID. Our current stock of sufficient gowns is extremely limited. Therefore, knowing in advance when we are responding to a COVID call would allow us to save on the use of PPE.

* There is concern that sharing such information may result in reduced quality of care from insufficient staffing on first responder units if the status of patients as positive for COVID-19 were known.

This statement is complete hogwash and it is insulting to the City of McCook’s first responders. The City of McCook’s first responders have a legal obligation to treat every contact with the highest level of care, regardless of individual’s physical status. Ms. Stoney’s assertion is her own unsubstantiated opinion and it only serves to harm to the credibility of our first responders.

* The DHHS guidance is that first responders treat every address as a potential COVID-19 positive site.

With limited PPE, it is impossible to treat every call as a COVID call. Ms. Stoney reached out to the Western Region EMS Specialist and asked if he could point her in the direction of appropriate PPE to wear for EMS when going out on a call. He advised me in a separate email that she reached out to him and he assumed she was referring to COVID-19 calls, even though she didn’t state that in her question. In his response to me he stated that he was, in no way, sharing COVID-19 PPE information to be misconstrued for us to be wearing full PPE on all calls. He also stated, “I know it isn’t a good use of an already small supply of PPE resources to use it up on calls that don’t need it.”

"It is important to us to all work together to find a balance that allows us to protect the safety and health of the public as well as the individual. We understand the needs of first responders. Therefore, we make the following recommendations for universal PPE to our first responders.:

* Maintain a minimum distance of 6 feet from members of the public whenever possible.

When we respond and treat any patient with illness of injury, it is impossible to maintain a 6’ distance from them. In order to provide the best treatment, we are required to have physical contact with every patient. Maintaining 6’ would be impossible.

* Appropriate PPE for first responders includes mask, disposable gloves, and eye protection. In certain circumstances gowns may also be appropriate, but these are not required or recommended on every call, especially when contact can be limited to 15 minutes or less and where physical distance can be maintained.

We don’t believe SWNPHD truly understands the needs of our first responders. According to the current CDC guidelines, gowns are recommended for treatment of any suspected COVID patient. Again, we cannot assume every patient is COVID positive and doing so would, again, put a strain on our already limited supply of efficient gowns. It is nearly impossible for us to limit contact to 15 minutes or less and social distancing is also impossible.

From the CDC website, July 15, 2020, the CDC states that eye protection, gown, and gloves continue to be recommended; contrary to what Ms. Stoney states in her comment that, in certain circumstances gowns may be appropriate, but these are not required or recommended on every call.

The City of McCook has an obligation to protect the citizens that we serve and also to protect those who provide that service. Our concern is if we start to lose Fire, EMS and/or Law Enforcement personnel due to a COVID-19 exposure, we could be in a position where our ability to provide this protection could be in jeopardy. We have a finite number of first responders. Furthermore, if we expose our first responders to a COVID patient and we’re not aware of the exposure, we could end up exposing those patients who call 911 and are already in a high-risk category. Anything we can do to protect our emergency responders to allow them to continue providing the care and protection or our citizens is of the utmost importance. We’re all in this together. These are unprecedented times and all of us in the healthcare and emergency response services need to recognize this.

In closing, we want to assure the public that the relationship between Southwest Nebraska Public Health and the City of McCook is intact, albeit strained. In order to combat this pandemic, or any other public health crisis, both entities have a responsibility to protect the public and that is the goal we all need to strive to achieve. The most effective way we can achieve this is by working together and communicating with each other by providing input and ideas that we can share and find common ground with.