Telemedicine Today: Part 3—System Examples and Lessons Learned

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 2 discussed potential applications and essential steps.

There have been two new EMS telemedicine effort launched in the past four years: Tucson’s ER-Link and Baton Rouge’s BR Med-Connect. 

ER-LINK

In 2006, the University Medical Center in Tucson, AZ, the Tucson Fire Department and the Tucson Department of Transportation (DOT) teamed up to initiate ER-Link, the nation’s first citywide EMS telemedicine system.1 This system, built around Tucson DOT’s new mesh broadband wireless network, promised two-way telemedicine from a moving ambulance. Funded through a federal DOT grant and using General Devices' e-Bridge EMS telemedicine technology, the system was to be deployed throughout the Tucson Fire Department.2 The initial goals of the system were to address:  1) a set of special trauma needs identified by Dr. Rifat Latifi, a recognized leader in telemedicine; and 2) all other (day-to-day) non-telemedicine needs of EMS. 

The hospital side of the system was located in both the ED and the telemedicine room on the trauma floor of the University Medical Center in Tucson. The ED workstation was fully integrated with day-to-day EMS activities to ensure ease of use when the telemedicine elements were used in trauma-related applications. The mobile side was installed in all 19 of the city’s ambulances, with interior and exterior remotely controlled cameras. A 19-inch touch-screen monitor located on the cabin’s rear wall provided user controls and allowed the patient to fully interact with the distant physician. The interior camera was located above and to the rear of the cot, allowing the physician to fully visualize the patient. An optional exterior camera provided 360-degree visualization of the scene, a feature valued by the fire department.

The mesh system employed by ER-Link was designed primarily for DOT use and, because of budgetary constraints, followed the city’s major transportation corridors. Because this provided only limited coverage for ER-Link, plans were made, pending additional funding, to implement a larger mesh network that would extend ER-Link’s range of coverage throughout the city.

By any measure this was a large project, as it involved the entire Tucson FD/EMS organization. As with any pioneering effort, there were many initial technical and operational problems; however, in October 2007, after passing acceptance testing, the system, with full two-way telemedicine capability, was placed into use. 

The limited coverage provided by the mesh system proved to be the system’s main  shortcoming. Where the mesh system had coverage, ER-Link worked, and where it didn’t, it didn’t work. From the medic’s point of view, the system was unreliable because it could not work where and when it was needed. In 2008, a comprehensive one-year study was conducted on all aspects of the project and the results proved that the system worked within its operation limits and most, though not all, of the medics thought the system was worthwhile. To date, this study has not been released for publication. The system is described in a 2011 paper discussing its value for providing assistance in intubation.3

Unfortunately, the economic downturn hit the city of Tucson and the second round of funding to complete the coverage of the wireless network did not materialize, severely limiting ER-Link’s usefulness. In February 2011, the telemedicine part of the system was formally discontinued. The workstation in the ED remains in use, supporting the day-to-day EMS activities of the Tucson Fire Department.

Some of the lessons to be learned from the ER-Link implementation are: 

• The need for medic training and buy-in.
• The principle mission for any system must be carefully assessed to ensure usage sufficient to justify the expense and maintain medic proficiency and buy-in.
• The long-range funding must be determined in advance and secured as best as possible.
• The area of coverage must be sufficient to satisfy the system’s goals and objectives.
• An ongoing assessment program must be implemented to assess and demonstrate efficacy and utility.
• The use of back-up and secondary communications means should be given serious consideration.
• An ongoing test and maintenance program must be established.

BR Med-Connect

In March 2009, another EMS telemedicine effort was initiated in East Baton Rouge Parish, LA. 2,4  The program was spearheaded by Dr. Cullen Hebert and Parish President and Mayor Marvin “Kip” Holden. The impetus was a combination of Dr. Hebert’s dream of providing better healthcare to the poorer outlying region of the parish and the vision of Mayor Holden to bring this level of care to his parish. The system used a General Devices e-Bridge EMS telemedicine system in a configuration similar to Tucson’s.5 Implementation was to be in three phases, with the end goal of creating a fully integrated EMS telemedicine system bringing advanced prehospital care throughout the 472-square-mile parish.

BR Med-Connect’s first phase called for a pilot project to determine operational feasibility. The pilot, funded by EMS, employed two East Baton Rouge EMS ambulances and a telemedicine workstation in Our Lady of the Lake Regional Medical Center’s ED. Connectivity was initially provided over a limited coverage area using the city’s existing mesh system. It was then extended to a larger area using a combination of mesh and 3G cellular. The system was determined to have met the goals and objectives at the conclusion of the one-year pilot.

The goal of phase two was to provide a means of sharing day-to-day information between all area emergency rooms and prehospital providers and allowing the later implementation of the EMS telemedicine system. This addressed a longstanding need to not only share information with rescue crews, but also between the EDs. Funding for the second phase was secured in mid-2010 with a homeland security grant. 

EMS telemedicine workstations were installed in the EDs of all five area hospitals (Our Lady of the Lake, Oschner Medical Center, the Bluebonnet and the Mid-City campuses of Baton Rouge General Hospital, Lane Memorial Hospital and Earl K. Long Medical Center) and the Mayor’s Office of Homeland Security and Emergency Preparedness). In addition to addressing day-to-day EMS and ED activities, the system also provided a public safety messaging system for daily and disaster use.  Because of this, the non-telemedicine, day-to-day EMS parts of the system were put to immediate use prior to the final phase of equipping all 21 of the parish’s ambulances with telemedicine capability. 

The coordination of these activities was complicated and time consuming, with each hospital having special operational and policy needs and issues. That the installations and training went as smoothly as they did was attributable to the cooperation and hard work of those at East Baton Rouge Parish EMS and at each hospital. The process was completed in March 2011. 

Phase 3, equipping the ambulances with telemedicine capabilities, is now in the funding stage.  The introduction of 4G cellular, which just became available throughout East Baton Rouge Parish, simplifies the connectivity and operating cost issues and will do much to assist full project implementation. A complicating factor is the cutbacks in public safety funding due to the current economic climate.      

Some of the lessons learned from BR Med-Connect are: 

• Planning, buy-in, installation, IT, training and maintenance issues increase dramatically in multi-agency systems.
• Having an assigned person from every agency involved, who reports back to the larger group and keeps each agency on track, is essential for planning, installation and training.
• Gradual phase-in of the features and functions of an EMS telemedicine system is of great value.
• The need for medic, nurse and physician buy-in and training cannot be overemphasized.
• Physician buy-in for each separate application at each participating agency is vital and may be complicated by conflicting interests, affiliations and priorities.
• IT and HIPAA issues are to be addressed as early as possible to avoid disruption to planned implementation activities.
• There is a need for an ongoing program to assess and determine efficacy and utility.
• Long-range funding must be determined in advance and secured as best as possible.
• An ongoing test and maintenance program must be established.

Conclusion

So what does all this mean to EMS? The use of telemedicine in EMS will ultimately be determined by four factors: 

• Can it be done?
• Is it needed?
• What will it cost and who will pay for it?
• What it will mean to the practice of EMS?

The technology and the effect-on-professionalism issues are largely non-issues. Needs, while yet to be proven, appear to be real. The most serious challenge to EMS telemedicine is the financial one, 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 we need now are people with the energy, vision and ingenuity to take on this challenge and  objective studies that demonstrate what works and what doesn’t. We encourage the EMS profession to take a close look at EMS 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?

References

1. Tucson Channel 12 News. ER-Link. 

2. NBC 33 News. Medical Breakthrough: Ambulance Cameras.  

3. Sakles JC, Mosier J, Hadeed G, Hudson M, Valenzuela T, Latifi R. Telemedicine and telepresence for prehospital and remote hospital tracheal intubation using a GlideScope™ Videolaryngoscope: A model for tele-intubation. Telemed J E Health17:3, 185–188, April 2011.

4. EMSWorld.com. Baton Rouge Launches EMS Telemedicine Program, March, 2009. 

5. General Devices e-Bridge.  

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.