Telemedicine Today: Part 1—Getting Started

"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—from complex electrocardiographic interpretation to parsing through difficult patient medical scenarios—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 emergency medical services appears to be the ideal setting for the use of telemedicine for a variety of reasons, some valid and some not, the technology has been slow in gaining acceptance. What does the future hold for telemedicine? What might it mean to the future of EMS? How does one navigate the technical and operational issues associated with wireless EMS telemedicine? This three-part series will bring the reader up to speed on the current state of development and offer some thoughts as to how to approach this technology. Part 1 will outline its basics and history. Part 2 discusses potential applications and essential steps. Part 3 discusses system examples and lessons learned. 

Why Is EMS Telemedicine Important?

As with any new technology or technique, particularly disruptive ones like telemedicine, there are reasons both for and against adopting it. The topic of EMS telemedicine is ripe with all of these, and each facet deserves discussion. What should not be lost in the discussion, however, are the potential opportunities telemedicine presents to EMS, such as:

• Improved patient care: "Just as telemedicine is a proven method of healthcare delivery that allows patients to benefit from remote physician evaluations and leveraging physician manpower, for EMS it provides similar benefits by instantly bringing the physician to the field. Providing the right treatment at the right time allows time-sensitive injuries and illnesses to be addressed sooner, lowering complication rates and hospital LOS. The use of EMS telemedicine may also allow EMTs to avert transporting patients who may not have to go to the ED, saving money and reducing ED overcrowding. All of these things represent big wins for all, including the patient.” Dr. Cullen Hebert, Critical Care Medicine Services, Our Lady of the Lake Regional Medical Center, Baton Rouge, LA
• Accuracy of information: “In many cases, and particularly for serious cardiac events, the most important information about the patient’s symptoms, presentation and state of mind is seen by paramedics in the field. This information is vital to the treatment and outcome of the patient in a hospital setting. EMS telemedicine will give a truer picture of a patient’s condition before any stabilization efforts are started, thus giving the physician the opportunity to better plan an effective treatment plan. It also extends the paramedic’s skill set to include getting the most vital information to a hospital to become an important part of the patient’s treatment.” Chad Guillot, EMS Director, East Baton Rouge Parish, LA
• Advances in professionalism: “A properly implemented EMS telemedicine system used for stroke assessment would help make relationships between EMS and the hospital grow tighter with more collaborative practice-based synergy; better opportunities for EMS to be more connected to the team approach to stroke care; provide more advanced care in the field to improved outcomes; increase opportunities for collaborative research; and keep EMS better informed on what’s new or coming down the pipeline.” Dr. Ethan Brandler, EMS Medical Director, SUNY Downstate Medical Center, NY
• Cost savings: "EMS telemedicine would provide an important adjunct to the assessment of non-emergent and low-acuity patients. Now comprising approximately 17% of Tucson's fire/EMS calls and growing, we are managing lower priority medical emergencies at significantly reduced cost using smaller trucks with reduced crew size, each year saving the city $500,000 per truck. The addition of EMS telemedicine in these field units would save even more by assisting us with directing patients to appropriate treatment facilities without further screening in hospital EDs, thus reducing costly ambulance transfers and unnecessary hospital bills." Dave Ridings, Assistant Chief, Tucson Fire Department EMS, Tucson, AZ.

Background and History

Telemedicine is defined as: “The use of information exchanged from one place to another via electronic communications to improve a patient's health status."1Consider exactly what that definition means to EMS. From voice-based medical oversight, pre-arrival notifications, ECG telemetry, up to sending still or moving images, EMS’ use of telemedicine in various forms has always been a routine and everyday occurrence.

The origins of modern EMS2 go back to the late 19th century and the Napoleonic model of battlefield medicine. After WWI, the use of radios for dispatch was introduced, followed by advances in battlefield medicine and communications introduced after WWII and Korea. EMS then took on its present form with the introduction of the National Highway Safety Act of 1970 (NHTSA), complete with standards for CPR, ECG telemetry and defibrillation. While radio-based medical oversight took on a wide variety of forms throughout the country, one can safely say that telemedicine has been a part of EMS for at least 40 years. Other than physicians speaking with patients by phone, EMS may actually hold the title of “first” in telemedicine.

EMS telemedicine, by the most restrictive definition, began with ECG telemetry in the early 1970s. A 1973 article in CHEST3 (the journal of the American College of Chest Physicians) described a large program in Nassau County, New York, that studied the effect of telemedicine. The article, “Emergency Medical Transport Systems: Use of ECG Telemetry,” studied a period of 142 days and 1,000 patients whose ECGs were “exchanged from one place to another via electronic communications to improve a patient's health status." What jumps off a page from that 1973 article is “ECG telemetry provides objective data,” which strikes to the heart of why telemedicine is important to EMS. Far from being a “big brother” and fully recognizing the training and professionalism of paramedics, the utilization of objective medical data is a well-established cornerstone of modern medicine. Until the past few years, most in EMS viewed telemedicine with distrust and oftentimes outright hostility. It should be noted that when police were first introduced to cameras, hostility soon gave way to appreciation for the benefits that it brought them. Eventually, as will be discussed later in this article, the attitude of EMS will and must change.

Want to know what is going on in the larger world of telemedicine? Just set a Google Alert to “telemedicine” and watch what happens. It’s a real eye-opener.

Overview of Wireless Communications

All forms of wireless communications employ some form of radio transmission. Public safety’s use of radio precedes the 1930s, with the use of VHF (Very High Frequency, 30-300 MHz) bands, and the UHF (Ultra High Frequency 300-3,000 MHz) bands in 1958. While good for analog voice traffic, the data-carrying capabilities of UHF and VHF are limited (see below) to sending anything but some basic text or analog ECGs.

The 1980s brought us cellular telephone,4 and with all of its advances, it has been a very significant force in private and public safety communications. While reasonably reliable, relatively inexpensive and ubiquitous, it should never be forgotten that cellular telephone systems are designed for commercial purposes and are notspecifically designed for the critical needs of public safety: reliability, performance, security and coverage.

Broadband wireless5 comes in many forms and includes privately owned commercial (i.e.: Verizon) and publicly owned (government) networks.  Cellular 3G and 4G broadband data have recently undergone significant improvements in performance, reliability and cost, and are gaining ground in public safety communications. 4G data, already available in many local areas, is coming fast and holds the promise of providing a high bandwidth “pipe” big enough for EMS telemedicine. While infrastructure costs for broadband wireless are a barrier for publicly (government) owned systems, when properly implemented, they provide the advantage of reliability, performance, security and coverage. This important difference between government and commercial networks should not be overlooked. A good example of a government-owned system is the Long Term Evolution (LTE) broadband network public safety system that will soon be installed in Mississippi. 

Some Techno-Talk  

It is important to have some basic understanding of the highly advanced communications and computer technologies used by telemedicine, and EMS telemedicine in particular.

Radio, Wi-Fi, Cellular, Analog & Digital

Because the worlds of analog and digital blur somewhat in radio, it is best to start at the beginning.

The Marconi transatlantic transmission in 1901 was in Morse code, where the transmission used “dots” and “dashes”—a forerunner of the “ones” and “zeros” we use today. The year 1906 brought amplitude modulated (AM) radio, followed in the 1930s by frequency modulated (FM) radio. Both AM and FM possessed the ability to send binary or digital forms of information, but it was not until the advent of the computer that digital communications became relevant to most people.

Fast forward to 1983 and 1G cellular radio systems6 where a computer switched a mobile radio (cell phone) from one 824-894 MHz medium power, fixed-radio station (cell site) to another. This switching minimizes the distance between the transmitter and receiver to reduce transmission power (watts). The higher frequency permits sending much more digital information, including voice, text and small images. 2G and 3G, GSM, CDMA, EVDO, etc, are all improvements leading up to the high data rates and almost universal coverage of 4G WiMax and LTE that will soon be commonplace. Although not a true public-safety communications system, 4G cellular will have profound effects on EMS and EMS’s relationship to telemedicine, possibly pressured by public expectations (if my kids can send me pictures, why can’t EMS?).

Broadband wireless5 is another means of wireless digital transmission with many variants, including cellular (which is BB wireless), Wi-Fi, Mesh7, Wi-Max, EVDO, EDGE and LTE. These systems operate in the low GHz frequency range, following the general rule that higher frequency allows more data. Mesh networks add the feature of dynamic routing at both fixed and mobile nodes, improving performance by making each vehicle a part of the network.

Big and Small Pipes—Bits, Bytes & Data Rates4,5,6,7

In the digital world, “pipes” refers to bandwidth or data-carrying capacity, expressed in bits per second (Bit/S). The data rates of wired systems (LANS and fiber) have grown from 3 MBit/s (1972) to 10 GBit/s (2003), which is a really big pipe. Conventional radios (UHF/VHF) are (at best) about 2KBit/s (kilo-bits per second)—a really small pipe. Broadband wireless has grown from 2MBit/s (1997) to 600 MBit/s (2007). Cellular has grown from 1G cellular’s 1,200 Bit/s (1981) to 4G cellular’s 50 MBit/s (upstream) and 360 MBit/s (downstream)—a medium-size pipe. Note that cellular data rates are not symmetrical.

What Size and Type Pipe Do You Need?

The size of the pipe you need depends on what you want to do, how much you want to spend and what is available to you. For example: Sending analog ECG requires a small pipe (1-2 KBit/s), while two-way telemedicine with voice, data and moving image (full telepresence) requires a high-quality (low latency, low dropout), medium to large pipe (min 300 KBit/S, bi-directionally), as well as a high degree of security.

Pipes available to EMS go from small (EMS UHF/VHF radio) to medium/large (3G and 4G cellular or other broadband wireless). While larger pipes usually cost more, this is not always true. If your public safety system is, or will be, using 4G cellular or a dedicated public safety broadband wireless system, you just may get a medium/large pipe at a relatively low cost. Of course, you may “get what you got” if that’s all there is.

Whatever the case, always remember that privately owned cellular systems are intended to meet commercial, not public safety needs. Barring availability, the answer to the question of what size and type of pipe is needed goes directly to what the intended purpose of the system is.  

Wired (Interfacility) vs. Wireless (Mobile/EMS) Telemedicine

In the wired world, whether internal (intranet, LAN) or external (Internet), a “network connection” usually gives you access to a large, reliable and nearly continuous (low latency) pipe that allows you to receive voice, text or images that usually, but not always, appear in perfect order. For example, in VOIP (Voice Over Internet Protocol), digitized voice information is broken into “packets” of data that may not arrive at their destination in the same order they were sent. VOIP software “re-orders” these arriving packets to correct this. Unfortunately, sometimes latencies or data losses are such that successful reconstruction is not possible, hence the VOIP voice breakups and the “speckled” images you sometimes see on TV.

The wireless world is quite different and, despite the remarkable improvements over the past 5 years, wireless communications do not always give you that large, reliable and consistent pipe. While today’s cellular systems work as well as they do, never forget that they operate on a slender thread that may be easily broken or damaged. Variable bandwidth, latency, momentary dropouts or complete loss of connectivity are issues affecting transmission performance such as we see with cellular, Skype or Vonage. What this means is that the software that manages data in wireless systems must be far more robust than that used in wired systems. Compounding this, in the wireless world, these delays are unpredictable and highly variable, making them difficult to correct. Aside from voice breakups, which may be unacceptable for critical, life-saving communications, these delays play havoc with remote controls (such as camera controls). For example, when remotely directing a camera to a particular destination, latency delays not only affect your ability to visualize the distant image in real time, but may also cause your camera to overshoot the target. And what happens during a long dropout or complete disconnect in the critical environment of an ambulance? The system must automatically detect the disconnect and quickly reestablish connectivity, which is not as easy to do as it may sound. There are also environmental factors (temperature, vibration and rough handling) that accompany ambulance-based equipment.

These are only some of the differences between the wired video conferencing systems commonly used for Interfacility telemedicine and a system intended for the mobile environment. The bottom line is this: It is important to understand that wired and wireless telemedicine systems are NOT the same!

IT and HIPAA—Significant Factors

IT (Information Technology) is an important player in any telemedicine system. Every hospital’s IT department is charged with protecting the security of both patient data (HIPAA compliance) and the HIS system. When you consider what IT sees when they look at a telemedicine system comprised of multiple EMS agencies sending different types of patient information into their HIS over a variety of communications means and systems, you can begin to understand their concerns. If you are working with a multi-hospital system, as is not unusual for EMS, the complications grow dramatically. As frustrating as IT may be to work with, it is important to understand their concerns. If you can get IT to understand the needs of a telemedicine system and address their questions and concerns in terms they can understand, you may not have that much trouble with them. You can expect major problems if IT does not understand or is uncomfortable with what you want to do. 

While the technology side of HIPAA compliance is relatively easy to address using advanced encryption means, the operational aspects are another matter.  

Consider this: A 12-lead report with patient identification (patient name) or a recognizable image of a patient arrives at the hospital via a secure transmission and winds up on an ED computer screen or printer tray visible to visitors or unauthorized staff. What happens if the report is sent to other areas of the hospital, a physician’s office or to a hand-held device that may not be secure? Lastly, can any images of patients be taken without their consent? Such concerns are real and may be unique to each application, hospital and EMS agency.

Equipment Used In The Ambulance, Hospital and Mobile Devices

Notwithstanding the security issues, there are many possible “end points” in an EMS telemedicine system, with pluses and minuses dependent on target applications, nature of the facility and the budget.

The most practical implementation of an EMS telemedicine system is inside an ambulance, which has lighting, power, shelter, equipment-mounting capabilities, connectivity and, in most cases, a computer. In the EMS telemedicine systems deployed in Baton Rouge and Tucson, interior, remotely controlled Pan-Tilt-Zoom (PTZ) cameras were ceiling-mounted, forward-facing and positioned to visualize the patient’s entire body lying on the cot. A large touch-screen monitor on the rear cabin wall provided system controls and let the patient see the distant physician. Voice communication was by conventional two-way radio because the mesh and 3G data communication systems used had unacceptable latencies and discontinuities. The electronics package was mounted to not take away any working room in the cabin. These configurations proved entirely workable, with the equipment adequately protected from physical damage.

It may be expected that telemedicine capabilities will be built into the cot or be belt-worn in the future. While there are many problems associated with this (power, weight, lighting, camera positioning, exposure to physical damage, connectivity, etc.), these systems would extend the capabilities outside the ambulance and into the scene location—something of great importance, particularly in cities.

In the hospital, the most obvious place for an EMS telemedicine system is a dedicated telemedicine room or EMS communications area. This will consolidate all telemedicine activities and help address HIPAA compliance issues. The downside of this location relates to the nature of emergency medicine, which, unlike most interfacility telemedicine applications, is far more immediate, chaotic and complex, and expecting a physician to leave the ED for a telemedicine call may not be practical or possible.

The ED has the advantage of being in an area dedicated for emergency care. The system can be a stand-alone, PC-based telemedicine workstation, or may be incorporated within a full function workstation used for day-to-day EMS activities. The advantage of the full integration approach is that day-to-day EMS activities (routine calls, STEMI, etc.) are combined with EMS telemedicine so the staff will know how to work the equipment when a telemedicine call comes in. This configuration is deployed in the six hospitals in Baton Rouge and in the ED of the University Medical Center in Tucson.

For applications such as stroke, burn assessment or disaster response activities, an end-point may be outside the hospital, such as in a regionalized stroke or burn center, physician’s office or a disaster management control room, such as the unit located in the OEP offices in Baton Rouge.

Where fully mobile endpoints are needed, iPads and smartphones may already possess the necessary functional capability. A disadvantage of such mobile devices is that they may restrict certain functions, such as controlling distant cameras or providing hard copies—disadvantages that may be outweighed by the mobile device’s “handiness,” such as being able to immediately recruit a neurologist or other distant expert.

What Comprises An EMS Telemedicine System?

There is no one answer to this question because an EMS telemedicine system should be designed to meet one or more specific applications or user needs, as well as being able to accommodate future needs. Remember, implementing an EMS telemedicine system can be a big deal, and you don’t want to do it twice! Plan carefully.

To illustrate this, let’s consider several typical telemedicine applications, keeping it simple by restricting the examples to just ambulances and hospitals:

1) Sending single or 12-lead ECGs

• Ambulance: conventional radio and ECG modulator or cell phone with data
• Hospital: ECG demodulator or PC with ECG-receiving software

2) Sending still images or video clips

• Ambulance: cell phone camera or inexpensive digital camera and a networked laptop or on-board computer
• Hospital: standard PC with email and standard software

3) Sending moving (video) images from handheld camera

• Ambulance: webcam or IP camera with 3G/4G broadband wireless connection (think Skype)
• Hospital: standard PC with off-the-shelf software and appropriate connectivity

4) Telepresence: sending and receiving live video with remote camera control

• Ambulance: ceiling-mounted PTZ camera, 3G/4G broadband wireless connection and customized software
• Hospital:  standard PC or EMS workstation with customized software.

As you can see, there is a significant difference between the first and last example, and that only touches the surface. Now add multiple imaging devices (inside and outside cameras, laryngoscope, etc.); high-quality video; image capture-and-storage; off-line store-and-forward capability, and integration with other medical devices and information-gathering systems (ePCRs). Once again, you get what you pay for. While meeting minimal needs does not require much, a more advanced system requires considerably more.

So why complicate matters? Let’s go with the simplest system we can find. Aside from the medical, professional and cost-related issues, it may not be long before the public expects EMS to have the same capabilities that their smartphones have. In their view, healthcare is already very expensive, so why shouldn’t EMS have what they have in their $200 smartphone?

Next Month: Part 2—Applications, Essential Steps & Considerations

Register now for our free webcast: What You Need to Know About EMS Telemedicine, scheduled for Thursday, November 17, 2011, at 2PM EDT/ 1PM CDT. This webinar will discuss one of the most controversial topics in EMS today—the use of telemedicine in ambulances. The webcast will cover the technology, how to approach the concept, reasons for and against it, what to consider in implementation and much more. Is EMS telemedicine right for your agency? Attend the webinar to find out.

References

Author’s Note: Wikipedia is cited in several references because it provides some reasonably accurate but highly understandable technical information.

1. Telemedicine Defined. American Telemedicine Association, July 27, 2011.

2. Emergency_Medical_Services. Wikipedia

3. Lambrew CT, Schuchman WL, Cannon TH. Emergency Medical Transport Systems: Use of ECG Telemetry. Chest 63:477-482, 1973.

4. Mobile Phone. Wikipedia.

5. Wireless Broadband. Wikipedia.

6. Cellular Network. Wikipedia.

7. Mesh Networking. Wikipedia.

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, NY; 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; Mr. Randy Kearns, MSA DHA(c), School of Medicine at the University of North Carolina; Dr. Steven Levine, The State University of New York Downstate Medical Center; Mr. David Ridings, EMS Assistant Chief, Tucson Fire Department, Tucson, Arizona; Mr. Michael Smith: BSEE, MSBME, C.E.O., 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, and is a former EMT. His experience at General Devices spans 25 years and includes design of many devices used in EMS for sending, receiving and managing information, FDA Regulatory, 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. Curt has spoken at conferences, has served on discussion panels and was a member of the DOC NTIA Joint Advisory Committee on Communications Capabilities of Emergency Medical and Public Health Care Facilities.