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Virtual Care
“EMS telemedicine has the promise of opening the door to many opportunities that will broaden the assessment, diagnostic and management capabilities of prehospital providers. Recruiting a distant physician specialist to enhance the medic’s ability to employ increasingly advanced diagnostic analyses can only result in a higher level of professionalism and improved patient care. I am looking forward to seeing EMS cross this new frontier.” —Raymond Fowler, MD, FACEP
While EMS appears to be the ideal setting for the use of telemedicine, the technology has been slow in gaining acceptance for a wide variety of reasons. What is the future of EMS telemedicine and how does one navigate the technical and operational issues associated with it? This article is an introduction to a more comprehensive discussion on telemedicine that will be featured on EMSWorld.com over the next few months.
The generally accepted definition of telemedicine is: “The use of information exchanged from one place to another via electronic communications to improve a patient's health status." From the standpoint of EMS, from voice-based medical oversight, pre-arrival notifications and ECG telemetry to sending still or moving images, use of various forms of telemedicine has always been a routine occurrence. In fact, EMS may actually hold the title of first in telemedicine! According to a 1973 article in Chest that described an early deployment of ECG telemetry in Nassau County, New York, “ECG telemetry provides objective data.” The 21st century, image-centric version is just another step in this direction.
So why is telemedicine beginning to re-emerge in EMS? The reason is that the widespread deployment of highly advanced wireless communications and inexpensive computer technologies are beginning to allow virtually everyone to see and interact with distant others. For EMS, the implications are obvious. Broadband wireless, in the form of privately owned 3G and 4G cellular, and government-owned systems like LTE, provide the large, high-bandwidth “pipes” needed to send large amounts of data and images. If you are skeptical, check out the statewide public safety LTE system now being installed in Mississippi.
But do you really need those big pipes for EMS? It depends on what you need them for. For small amounts of data, such as 12-lead reports or still images, 3G cellular and some digital radio systems may be all you need. For streaming data and moving images, larger pipes are needed.
It’s a similar issue with equipment. For burn assessments, not much more than an inexpensive digital camera with a radio/cell phone connection is needed to send still images. For other applications, such as advanced forms of stroke assessment that employ virtual presence, a system like one used in Tucson’s ER-Link or Baton Rouge’s BR Med-Connect may be needed. Again, it all depends on what you want to do.
Doing something simply because you can is not a good reason to think about using telemedicine. Improving EMS’s ability to care for patients, and this includes lowering costs, is what it’s all about. As discussed in the full article, many recognized leaders in EMS like Ray Fowler, Randy Kearns and others are taking a serious view of the merits and implications of this new modality. For example, they are considering applications like recorded refusals, stroke and burn care and disaster response. While there is no firm evidence of efficacy, costs or outcomes, the new logic is beginning to provoke some interest in the subject.
The key factor in any consideration of implementing an EMS telemedicine system is good planning. Unlike an interfacility telemedicine system, the number of participants and “moving parts” in an EMS telemedicine system are larger than may initially meet the eye. To maximize the effectiveness of any proposed system, ensure a successful deployment and avoid the many potential pitfalls, consider the following more significant planning issues:
Buy-Ins and Stakeholders
An EMS telemedicine system is inherently complex and involves many participants. Identifying each of their needs and making them stakeholders is the best way of getting buy-ins. Stakeholders include physicians, EMS and the organizations involved (hospitals, fire departments or private EMS agencies), and having support from all three is a requirement for success. For example, the legitimacy of medical need hinges on docs actually using the system. Without EMS’s support and resolving concerns about “big brother” and professionalism, any system, no matter how good, is doomed from the start. The organization that will have to pay for and manage an EMS telemedicine system has to see a real advantage to it, which can take on many forms ranging from financial and improvement in ED activities to enhanced competitiveness.
Defining Specifications, Goals, Objectives
The specifications, goals, objectives and metrics of an EMS telemedicine system should be clearly defined at the beginning to ensure that all participants will get what they expect and the results will be measurable. What the system is and what it will be expected to do should be determined by the medical, organizational needs and available technical capabilities. For example, from a medical standpoint, addressing stroke assessment may be vastly different from the needs of cardiology or trauma. If the organizational needs are strictly financial, that aspect needs to be factored in. If the region or state has (or is planning to have) an advanced broadband wireless public safety communication system, communications may be a non-issue. Conversely, if an advanced system is simply unavailable (terrain, costs, population densities, etc.), then more advanced forms of EMS telemedicine are a rule-out.
Funding and Finances
As we all know, today’s economic climate is not good, with cutbacks and budgetary restrictions the order of the day. Securing sound funding sources for initial and ongoing costs should be addressed in early planning, as should the opportunities for cost savings. Remember that ambulance and hospital equipment costs for an EMS telemedicine system are directly related to needs and applications, and even the most comprehensive systems, when compared to the cost of common equipment like a monitor-defibrillator, are comparatively modest. Deployment of advanced publicly and privately owned broadband wireless systems now makes EMS telemedicine more affordable than is commonly thought.
Installation and Training
Installation and training are important and complex issues in any EMS telemedicine system, particularly those involving multiple (and oftentimes, competing) agencies. Just consider all the participants involved in an installation: the equipment provider; hospital’s communications provider; administration; IT; nurses' training; ED coordinator; buildings and grounds; and EMS. Consider managing the training of all the nurses, docs and medics with their varying shifts and staffing changes, then multiply that by each of the different agencies and organizations.
Ongoing System Testing and Maintenance
The surest way to kill anything in EMS is if it is considered unreliable. Regardless of how reliable equipment may be, plans must include regular system testing (daily or at shift changes) and quick and effective problem reporting and correction action. As with all wireless systems, “dead spots” need to be identified and made known to users. The expected level of performance must not exceed the reality.
IT and HIPAA
IT and HIPAA issues ranging from hospital information system security to protecting patient data and images are very real and must be addressed. For an IT administrator, an EMS telemedicine system presents special problems which will vary from organization to organization. It is important to incorporate IT in early planning and understand and address their concerns right from start. HIPAA is an issue whose complexity far exceeds the limits of this article and is addressed in greater depth in the online version.
Medical-Legal Issues
The legal implications of EMS telemedicine are completely new, and it is fair to say they represent uncharted waters. To get an idea of what this means, consider two divergent views of EMS telemedicine images: One view is that these images are just like any other medical information acquired by healthcare professionals; the other is that informed consent is needed to protect the organization from possible legal actions. Which is right? Planning should include legal consideration for local, state and healthcare organizations so that guidelines will be set and users operating within those guidelines will be protected.
Regulatory Considerations
Anyone planning for an EMS telemedicine system should be aware that under the new FDA rules, systems that do more than video (e.g.,: ECG, PACS images, vital signs, diagnostic information or remote control of medical devices) are considered medical devices and must be in compliance with FDA approval processes and GMP rules and regulations. For those considering building vs. buying and university collaborations, FDA rules apply to any provider of equipment, including universities and hospitals.
Internal Policies and Procedures
Just as with any patient care activity, hospitals and EMS agencies must have clear policies regarding when these systems are to be used, who is given access to the information, how information is stored and who has overall responsibility, in addition to training and maintenance issues. While this is sure to be an evolutionary process, including it in the initial planning stages may avoid problems later on.
System Phase-In
When planning the actual deployment of an EMS telemedicine system, it may be advisable to introduce it gradually (in phases) in the order of lowest risk and highest reward, particularly in terms of buy-ins. This approach has been successfully used in Baton Rouge.
Conclusion
So what does all of this mean to EMS? The use of telemedicine in EMS will ultimately be determined by four factors:
- 1) Can it be done?
- 2) Is it needed?
- 3) What will it cost and who will pay for it?
- 4) What will it mean to the practice of EMS?
Taking the long view, the technology and its effect on professionalism are largely non-issues. Needs (applications), while yet to be proven, appear to be real. The most serious challenge to EMS telemedicine is financial, having to do more with the current economic and political climate than anything else. Despite strong arguments in favor of the economics of telemedicine, will municipalities be able to afford more than the level of service they are currently providing, and will reimbursement become available?
What is needed now are: 1) those with the energy, vision and ingenuity to take on this challenge, and 2) objective studies that demonstrate what works and what doesn’t. We encourage those in EMS to take a close look at telemedicine and discuss its merits and weaknesses objectively. Those who preceded us brought us to where we are. What will we leave for those who follow us?
To read more on this topic, see Telemedicine Today: Part 1 online at EMSWorld.com.
The author wishes to extend a special note of appreciation to those who contributed to the preparation and review of this article:
Dr. Roy Alson, head of the Section on Prehospital & Disaster Medicine, Associate Professor, Wake Forest University School of Medicine;
Dr. Ethan Brandler, EMS Medical Director, SUNY Downstate Medical Center, New York;
Dr. Raymond Fowler, Professor of Emergency Medicine, University of Texas Southwestern at Dallas;
Chad Guillot, EMS Director, East Baton Rouge Parish, LA;
Dr. Cullen Hebert, Critical Care Medicine Services, Our Lady of the Lake Regional Medical Center, Baton Rouge, LA;
Randy Kearns, MSA DHA(c), School of Medicine at the University of North Carolina;
Dr. Steven Levine, SUNY Downstate Medical Center; New York
David Ridings, EMS Assistant Chief, Tucson Fire Department, Tucson, AZ;
Michael Smith, BSEE, MSBME, CEO, General Devices
Curt Bashford is the president of General Devices and has held many other positions within the company. He holds a BS in Electrical Engineering and a master’s in Biomedical Engineering. His experience over a 25-year period includes designing many devices used in EMS for sending, receiving and managing information, FDA compliance officer, and managing the design and installation of numerous pieces of equipment, including FDNY, Nassau County EMS, Tucson’s ER-Link and Baton Rouge’s BR Med-Connect.
