Telemedicine Today: Part 2—Applications and Essential Steps

What is telemedicine, and what might it mean to the future of EMS? This three-part series will discuss potential benefits and offer thoughts on approaching this emerging technology.Part 1 outlined its basics and history.Part 3 discusses system examples and lessons learned. 

While there is not yet solid evidence supporting the efficacy, utility or cost-effectiveness of any EMS telemedicine application, there are several uses we might find appropriate and worthwhile.

Recorded refusal--Prominent emergency physician Raymond Fowler, MD, chief of EMS operations for the Dallas-area BioTel system and an advocate of EMS’ use of advanced data collection tools to support evidenced-based improvements to care, summarizes the value of recorded refusals using EMS telemedicine this way:

“Technology, hardware and data bandwidth is now available to directly connect the field encounter to a medical oversight platform with the resources necessary to assist in difficult patient situations. The case where the patient demonstrates adequate capacity for understanding the medical condition and refuses the care advised by the medic allows a telemedicine platform…to lend support to the medic by providing medical control the ability to clearly evaluate the patient from a video, audio and physiologic data perspective. The entire episode…including the patient being told that declining care would remain as a part of the permanent record of the event can then be recorded and archived, clearly documenting the evaluation of the patient, what the patient was told regarding risks and benefits and the patient’s declining of care.”

Stroke assessment--The single most important factor in determining good outcomes for patients with acute ischemic stroke is time to treatment, notes Steven Levine, MD, a stroke neurologist at the State University of New York Downstate Medical Center and expert in the assessment and treatment of stroke using telemedicine techniques.1 Linking prehospital acute stroke care to ED physicians and stroke experts, Levine says, would allow earlier recognition, support and triage of patients before hospital arrival. Current communications and imaging technologies make this possible. Using these technologies could also help speed use of tPA therapy, as well as making greater use of prehospital data. This should result in improved outcomes and reduced costs.

Treat and release--Cullen Hebert, MD, a pulmonologist at Our Lady of the Lake Regional Medical Center in Baton Rouge, LA, and one of the “fathers” of the local BR Med-Connect system, believes EMS telemedicine can help bring more advanced forms of healthcare to the poorer outlying areas of East Baton Rouge Parish. He feels medics are often trapped by the current medical/legal paradigm into transporting patients who could be cared for at home to hospitals. He describes how an EMS telemedicine system could provide a better way to treat a child with an asthma attack:

“The mom calls EMS, which arrives promptly. The patient is evaluated by the medic, who feels the need to transport is questionable. A remote ED physician is brought to the scene by telemedicine. He assesses the vital signs and observes the patient during and after appropriate therapy. The physician and mom then speak. He determines she is competent to provide the needed therapy, and they agree to follow the patient’s response by phone. The medic reviews the treatment plan with the mom, and the decision is made not to transport. Audio, video and data are captured for medical/legal purposes.”

Hebert considers such a scenario a win-win, with lower costs, less disruption to the family, reduced ED overcrowding, and a far less traumatic event for the child. “This is what I want BR Med-Connect to be able to bring to my parish,” he says.

Burn assessment--Randy Kearns, MSA, DHA(c), CEM, is a former paramedic who currently serves as North Carolina’s state burn disaster program coordinator. “It is well recognized that patients with moderate and severe burn injuries have the best outcomes when managed at a burn center with specialized expertise in all aspects of burn care,” he says. “Because of the limited experience most clinicians have with burn injuries, the extent and quality of burns can be deceiving for most prehospital and hospital emergency care providers. An EMS telemedicine system could address this problem by having a burn specialist view and discuss the patient’s injuries and offer assistance at many levels of the decision-making process. Telemedicine is one way to help ensure those who need specialized burn care are routed directly to the burn center.

“Telemedicine can also aid with triage,” he adds. “Burn injuries can be particularly gruesome and distracting. Nonetheless, minor burns can be managed at the local hospital. Furthermore, some patients with combined burns/trauma should first be cleared of potential traumatic injuries that may be a more likely cause of early death. Seeing is believing, and telemedicine, even in the form of a still image, is a natural progression that has evolved from our phone calls and radio networks that will help us work smarter and contribute to improved outcomes.”

Disaster response--Roy Alson, MD, PhD, head of the Section on Prehospital and Disaster Medicine and associate professor at the Wake Forest University School of Medicine, believes EMS telemedicine has an important role in the challenging and austere environments found in disaster settings.

“It can do this,” he says, “because of its ability to improve both triage and the quality of care by 1) making the knowledge of the specialist available to the provider in the field, and 2) as a ‘force multiplier’ for maximizing limited treatment and transport resources. It can also provide distant observers with a coherent set of objective information. Considering that much of the care delivered during disasters, especially after the initial rescue phase, is to replace or augment damaged or overloaded medical infrastructures, there is a need to be able to provide disaster managers with information needed to rapidly assess and anticipate the needs of this second phase. The assessments and decisions needed to make these determinations are not normally within the area of expertise of most medical responders deployed to an event, making a coherent set of images of disaster victims, provided easily and quickly to a distant disaster manager, something of potential value. If the gathering of that information does not interfere with immediate care--which in a well designed system it should not--supplementing existing forms of text and verbal information may provide a valuable key to better understanding what will be needed later.”

Seven Essential Steps

Starting an advanced EMS telemedicine system is complicated and should not be undertaken by anyone not fully prepared for it. Some of the issues that must be addressed are:

1. Buy-in by 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-in.

Physician buy-in--Physician support is critical, as they represent the end user of the system as well as a strong political force necessary to pull all the various and often competing factors together. Physicians who stand to gain from advanced prehospital care, such as neurologists, pulmonologists and cardiologists, should be recruited as stakeholders and advocates of an EMS telemedicine system.

EMS buy-in--Much as with the physician group, buy-in from the medics is also essential. They are ones who will use the system, and they ultimately decide whether it will work. Addressing medics’ chief concerns is one way to help make them stakeholders. These often include:

• “Big brother”: No one wants to have a camera looking over their shoulder--unless that camera is there to help them. Cameras will help protect medics from accusations of theft and improper care, and with difficult patients. Perhaps as important, it will let physicians and nurses better understand the work medics do and the conditions under which they do it.  
• “I don’t need this to care for my patients”: An EMS telemedicine system is not there for every call, and policies and procedures should reflect that. Because most physicians and nurses know most medics know how to deal with most situations, medics have little to fear about jeopardizing their professionalism. An EMS telemedicine system should be there to help medics when they feel they need help--just as any responsible physician or nurse would call for help when they felt they needed it--or to address a set of well-defined special cases.  
• “It doesn’t work the way I was told it would work”: Just as there are times and places where radios and computers don’t work, this is also the case with an EMS telemedicine system. First, the system will only be as good as its connectivity, and locations with connectivity problems need to be identified, fixed or declared “no-fly” zones. Second, the image quality of the system will not be HDTV quality. Think back to the “pipes” mentioned in the last article. These and other limitations must be made clear to medics, nurses and physicians at the beginning. Overselling the system is a sure path to failure.

Hospital buy-in--Just as EMS, ED physicians and nurses need to understand what a system is expected to do, the roles they play and the benefits they will derive. ED staff is busy, and you don’t want them viewing an EMS telemedicine system as “one more job” to do with no clear benefit. For them to be true stakeholders, direct benefits such as improved prearrival information, more accurate pretreatment patient information, fewer unnecessary admissions, improved trauma team responses, etc. must be clearly explained.

Organizational buy-in--Organizational buy-in may be complicated by many factors, including the perception that an EMS telemedicine system provides little or no benefit to the organization paying for it. But as with all new technologies, there may be benefits not immediately recognized. For example, a potential benefit explored by Dave Ridings, head of EMS for the Tucson Fire Department, was a treat-and-release (Alpha Truck) program intended to save the FD money by replacing some of its expensive and costly-to-operate heavy ambulances with light-duty trucks staffed by basic EMTs. This topic was discussed in a 2008 EMS World article entitled “EMS Technology--On the Edge of Tomorrow.”2 If two-way telemedicine (telepresence) is used in conjunction with an Alpha Truck-style program to address liability issues and afford a higher level of care, not only will the FD and EMS benefit, but so will the ED, with fewer unnecessary admissions and lower costs. According to Ridings, “Savings can accrue to a fire department by 1) reduced personnel costs with smaller crew size, 2) increased service life for larger apparatus that no longer respond to low-priority calls, and 3) increased availability of four-person fire apparatus for firefighting and ALS activities. This is a different approach than just adding more trucks and people to address increased call volume.”

Reimbursement is the wild card in the cost-related buy-in equation. Consider what would happen tomorrow if treat-and-release were reimbursed as an ED admission! Mainstream interfacility telemedicine has begun to be reimbursed; why not EMS? We believe EMS telemedicine has the potential to save the healthcare system significant money by preventing unnecessary ED admissions through physician-guided and fully recorded refusals. The economics of EMS telemedicine have yet to be discovered and should be considered carefully.

2. Defining specifications, goals, objectives and metrics

These should be clearly defined at the beginning to ensure all the participants get what they expect and the results will be measurable. Examples are as follows:

Medical--Explicitly defined goals and objectives will determine what medical issues the system will address, help define the actual system and help determine what study methods will be used. For instance, a system focusing on stroke assessment may require video and telepresence techniques, like those now being explored by neurologists at SUNY Downstate, with defined goals and methodologies. If successful, not only would this result in improved patient care, but savings to both the healthcare system and society would be considerable.

Organizational--The organization’s goals and objectives will define what benefits it expects from a telemedicine system. This will help set a budget for initial and ongoing costs and also define evaluation metrics. For example, a system intended to address ED overcrowding with a telemedicine-based treat-and-release program has a given set of objectives, equipment and medical requirements, and study methods and metrics.

Technical--Explicit technical goals and objectives, following the medical and organizational goals and objectives, will define the system in terms of performance (image and sound quality), reliability, areas of coverage, security, maintenance and periodic testing, costs, etc.

3. 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 the ambulance and hospital equipment costs for an EMS telemedicine system are directly related to needs and applications, and that even the most comprehensive systems, when compared to the cost of common equipment such as a monitor-defibrillator, are comparatively modest. The deployment of advanced broadband wireless systems now makes EMS telemedicine more affordable than is commonly thought.

4. Installation and training

Unlike an interfacility telemedicine system, an EMS telemedicine system has many more “moving parts,” such as ED staff, EMS and other ambulances agencies, medics, EMS and ED administrators, IT folks and specialty physicians.

For an example of the complexity of a multiagency EMS telemedicine installation, consider BR Med-Connect’s simultaneous installation of telemedicine workstations at five hospitals and its local Office of Emergency Preparedness. Each installation site required one or more representatives from the equipment provider, the hospital’s communications provider, IT, nurse training, ED coordinator, buildings and grounds, EMS, and the BR Med-Connect representative. All these people had to attend planning meetings, accomplish their parts on time and be available on the day of installation. Now multiply that by six! The planning that allowed this installation to be accomplished in less than two weeks, on time and without incident, was considerable and time-consuming.

Initial and ongoing training of ED nurses and physicians is a critically important but difficult task, considering their busy schedules and variable shifts. While the equipment itself should be easy to use, complications include fear of new technology, dealing with inherent technical limitations, situational stress and, of course, scheduling. Training is simplified in a fully integrated system that merges telemedicine with day-to-day EMS because the system is always in use.

5. Ongoing system testing and maintenance

Much like a hospital’s emergency generators, an EMS telemedicine system may not be used for days at a time, but still must work when needed. Regular testing and prompt repairs are essential, as nothing will kill an EMS telemedicine system faster than unreliable performance. One way to do this is to perform a simple test of connectivity and operation at the beginning of each shift, with any deficiency reported to the shift manager. Given the distributed nature of the system, managing all this is not a simple task and should be worked out in advance.

6. Internal policies and procedures

Just as with any patient care activity, hospital 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 this in the initial planning may avoid problems later.

7. System phase-in

When planning the actual deployment of an EMS telemedicine system, it may be advisable, particularly in terms of buy-ins, to introduce it gradually (in phases), beginning with the applications of lowest risk and highest reward. This approach has been successfully used in Baton Rouge.

What to Avoid

Some of the pitfalls to avoid when starting an EMS telemedicine system are:

No clear objective--“The competition has one, so we should too” isn’t a reason to pursue EMS telemedicine. If the system’s goal is just PR, as opposed to meeting real medical or organization needs, it’s better to spend the money on a good ad campaign. A successful program needs to address real medical or financial needs, as well as the needs of the other stakeholders.

No initial stakeholders--“Build it and they will come” is a shaky proposition and risks creating a system that may not satisfy needs subsequently identified. Need, organization and funding come first--the system comes later.

Ignoring the opposition--“Everyone except [fill in the blank] wants the system. Let’s do it.” All the players--EMS, ED nurses and docs, IT, administration and everyone else--must be in agreement and see a benefit, or the risk of failure is heightened. Sound planning and buy-in from meaningful stakeholders are essentials.

“Let’s build it ourselves!”--Unless you are interested in just the basics (which in fact may be a good way to get started), a full-function EMS telemedicine system is very complex and technically sophisticated. It is not just some IP cameras connected to a networked laptop. Camera controls, dealing with latencies and drop-outs, variations in bandwidth, security, ease of use, lighting, audio and documentation…the list goes on and on. And then, any system that provides more than images falls under FDA guidelines, and the FDA will consider you as a medical device manufacturer, with all that that implies (see Regulatory Considerations, below). Remember, there is no free lunch, and you get what you pay for--always.

If you are considering implementing an EMS telemedicine system but don’t have solid reasons (medical, organizational, financial) to do it, sound planning and organization and buy-in from all concerned, my advice is, do not do it!

Regulatory Considerations

What does an EMS telemedicine system require in oversight and mean for liability? Because the technology is new, there is little hard evidence proving (or disproving) it will be a useful tool to address claims of theft, patient mistreatment, improper care, or even that images of patients can be taken without their consent. For insight, look at next closest thing: the use of cameras by police3 and traffic authorities. While the police were initially opposed to cameras for many of the same reasons medics now express, once they recognized their advantages, the picture quickly changed. At present, around 72% of all state and highway patrol vehicles are equipped with cameras, and the images are regularly used in court and for training. We suspect EMS telemedicine will follow this same path.

In addition to HIPAA and FCC issues, the FDA also has regulatory authority over specific aspects of telemedicine systems. Those considering EMS telemedicine should be aware that although the imaging aspects of a telemedicine system are presently exempt from FDA jurisdiction, anything related to physiologic data or information is not. Transmission of medical data such as ECGs, PACS (picture archiving and communication system) images, vital signs, diagnostic information or remote control of medical devices, under the new FDA rules governing medical device data systems,4 falls under the FDA’s device approval process and “good manufacturing practices” (GMP) rules and regulations.

Note that the FDA has determined that any entity that assembles such systems, even using a combination of off-the-shelf components, becomes the “manufacturer” and must register with the FDA and comply with GMP and other rules. This includes hospitals and EMS agencies. Additionally, the FDA has released guidance documents that address healthcare applications for mobile devices (iPads, smartphones, etc.) and will be looking more deeply into this new mobile technology. Expect that the FDA’s position will restrict do-it-yourselfers, university research projects and nonmedical commercial vendors from offering full-function EMS telemedicine systems. While FDA compliance is a painful and costly process, it ultimately translates into better solutions, enhanced reliability and more responsible vendors--as well as, unfortunately, higher costs.

References

1. Henry O. Clark, Jr. Foundation. Telestroke--A New Tool in Stroke Treatment.

2. Smith M, Ridings D. EMS Technology--On the Edge of Tomorrow. EMS World.

3. Univ of Central Florida, Public Administration Department. Police Technology: An analysis of in-car and body worn cameras. April 2011.

4. New FDA Rules re. Telemedicine. 

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.