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Telemedicine and Telehealth Role

in Public Health Emergencies

Adam W. Darkins

OVERVIEW

Telemedicine and Telehealth

Telemedicine involves the use of electronic information and telecommunications technologies to deliver medical care ser- vices in situations in which patients and providers are sep- arated by geographical distance.1 Telemedicine technologies enable consultations and/or care delivery to take place remotely. Telemedicine has a role in improving access to care, for exam- ple in rural and remote areas that are medically underserved. Worldwide, people are becoming increasingly connected by a variety of telecommunications technology platforms. Existing and emerging applications on these telecommunications plat- forms are rapidly transforming homes and workplaces as well as how services such as healthcare will be provided. Hospitals and clinics have been the main locations for healthcare provision but technology is now taking aspects of these services into the home and local communities.

Telemedicine is a subset of telehealth.1 Telehealth2 encom- passes a wider use of information and telecommunications tech- nologies to deliver other aspects of healthcare. In addition to clinical consultations and care, telehealth includes the remote monitoring of health status, providing multimedia-based edu- cation to staff and offering information to patients to foster informed medical decision making. The role for telehealth in pro- viding healthcare services in public health emergencies should be considered within the context of a changing social environment created by emerging technologies.

Role for Telemedicine and Telehealth in Public Health Emergencies

A public health emergency creates rapid response requirements. General and specialist healthcare provider expertise is needed for immediate triage and treatment of the acutely affected popula- tion. Once this initial acute phase of a public health emergency abates, the need for healthcare expertise evolves into provid- ing aftercare and monitoring the remaining at risk population. Healthcare providers must assess the significance of any changes in physical and mental health status of the affected population

and provide accurate prognostic information about health risks to individual patients, their family caregivers, and the population at large. There is a wide spectrum of healthcare needs in a public health emergency. Meeting these needs involves the assessment of risk to both individuals and population subsets. Some of this assessment can be accomplished virtually or remotely. Thus there is a self-evident rationale for the use of telehealth in public health emergencies.

A vision for the vital role telehealth can play in public health emergencies follows.

Telehealth should be a vital adjunct to the public health emer- gency response to assist in saving lives, reducing avoidable morbid- ity and managing the care of patients with medically unexplained systems.

Patients who are concerned about an exposure, but not truly medically ill, can pose as much of a challenge to emergency re- sponders as those with major injuries or illnesses resulting from a disaster. Among this group of patients are people whose health status may dramatically deteriorate some time later, for example, from an emergency that may or may not have been precipitated by the concurrent event. A good example of this would be a patient who has a myocardial infarction in the aftermath of a major disaster. Within this group are also those with psychological trauma related to concurrent events that may have long-lasting sequelae (see case study 23.1).

Telehealth can play an important technical role in assisting first responders as well as first receivers in remote hospitals, clin- ics, and shelters. One area in which telehealth can be particularly beneficial is in providing guidance to manage large numbers of patients who present with “medically unexplained symptoms.” Healthcare providers can access specialist advice to distinguish between patients who are concerned about exposure and those who may be truly ill and require observation, treatment, and potentially further epidemiological surveillance. There are three main modalities of telehealth that are in routine use that can be used in emergency and disaster management.

■ Home telehealth ■ Telehealth via real-time clinical videoconferencing ■ Store-and-forward telehealth

345 Koenig and Schultz's Disaster Medicine : Comprehensive Principles and Practices, edited by Kristi L. Koenig, and Carl H. Schultz, Cambridge University Press, 2009. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/apus/detail.action?docID=564432. Created from apus on 2018-03-08 07:35:45.

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346 ■ ADA M W. DA R K I N S

CASE STUDY 23.13,4

During the morning rush hour on March 20, 1995 a cult terrorist group known as the Aum Shinrikyo placed containers of the nerve agent sarin in five of the carriages on three of Tokyo’s underground railway lines. The release of this material resulted in alarms from 15 subway stations as people arrived with breathing difficulties, muscle weakness, and altered levels of consciousness.

Approximately 6,000 people were exposed to the chemical agent. Of these, 3,227 went to the hospital. There were 493 hospital admissions to 41 hospitals. Those seen in the hospital manifested classic cholinergic symptoms, with nicotinic effects predominating. Twelve people died in the near-term as a result of the incident and several developed permanent neurological sequelae. The majority of the victims, however, were acute psychological casualties – people who feared they might have been exposed to sarin vapor but had no real contamination. For at least 5 years after the attack many of those exposed continued to manifest symptoms of posttraumatic stress disorder, a condition that may have been mitigated if there had been earlier recognition and treatment.

Practical Technologies to Provide Telehealth-based Services

Clinical videoconferencing systems such as that illustrated in Figure 23.1, together with the requisite telecommunications con- nectivity, enable real-time videoconferencing that provides con- sultation and advice on clinical care. Although it is not currently possible to examine directly a patient when using these systems, there are emerging telehealth technologies, which will be dis- cussed later, that suggest this will happen in the future.

Real-time videoconferencing for clinical purposes, also known as synchronous telehealth,1 allows an expert clinician from any specialty to help manage patients who are in geo- graphically distant locations (as close as several miles to as far

Figure 23.1. Clinical Video Conferencing System. See color plate.

Figure 23.2. Home-Telehealth Device. See color plate. Used with per- mission from Kimberly Boltom.

as thousands of miles away). Clinicians providing synchronous telehealth can

1) Diagnose 2) Triage 3) Make treatment recommendations such as advise antibiotics

and analgesic medications 4) Supervise procedures such as wound debridement and frac-

ture reduction

Synchronous telehealth services can, therefore, supplement or provide otherwise unavailable on-site specialist expertise in the immediate aftermath of a public health emergency. Examples include

1) Management of burn patients requiring urgent access to plas- tic surgical specialty care

2) Provision of access to specialist assets such as infectious dis- ease consultants to identify and manage an infectious dis- ease outbreak and proactively assist in disease prevention throughout all phases of the emergency

3) Provision of counseling and therapy services to both the affected population and emergency responders with mental health needs secondary to the traumatic events they have witnessed

4) Protection of specialist emergency response healthcare per- sonnel assets in a bioterrorism event by enabling clinicians to render advice from a distant location that does not expose them to contagious agents

Home telehealth1 devices such as the one illustrated in Figure 23.2 are in routine clinical use. They enable the monitoring of patients with chronic diseases, such as diabetes and chronic heart failure, in their own homes and local communities. The telecommuni- cations modalities used to support these technologies include regular telephone lines, wireless phone technology, and broad- band Internet.

The routine recording of vital signs and use of interactive disease management protocols via home telehealth devices can rapidly alert a clinician who is remotely located to the deterio- ration in the patient’s condition so that an appropriate response can be instituted. The appropriate response may vary from supporting patient self-management to providing advice, pre- scribing new drugs or adjusting medications, or initiating emer- gency hospital admission. If the clinician monitoring the patients

Koenig and Schultz's Disaster Medicine : Comprehensive Principles and Practices, edited by Kristi L. Koenig, and Carl H. Schultz, Cambridge University Press, 2009. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/apus/detail.action?docID=564432. Created from apus on 2018-03-08 07:35:45.

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TE L E M E D I C I N E A N D TE L E H E A LT H RO L E I N PU B L I C HE A LT H EM E RG E N C I E S ■ 347

needs further expert assistance, other colleagues can rapidly and easily assist in patient management via electronic systems. Once it is in place, the infrastructure of a home telehealth network readily lends itself to use in a public health emergency. Examples include

1) Quarantine of an exposed population (and isolation of an infected population) in the event of pandemic influenza or a bioterrorism event with a contagious agent such as pneu- monic plague or smallpox

2) Monitoring the definitely exposed and those at risk from possible exposure to a pathogen after a bioterrorism incident

In events such as these, the challenge for emergency and disaster responders may be the sheer numbers of people, who by virtue of being at risk, threaten to overwhelm a limited healthcare response capacity. These victims require management in ways that limit the spread of a contagious pathogen. Home telehealth offers a surge capacity5 that may otherwise be much more costly or even impossible to provide.

The acquisition, storage, retrieval, and forwarding of digi- tal clinical and radiological images, known as store-and-forward or asynchronous telehealth1 provides simple mechanisms for obtaining remote advice from expert clinicians who can report on digital images, radiographs, echocardiographs, and ultrasound studies. This resource makes it possible to deploy general and lesser skilled personnel to the site of the public health emer- gency who can receive advice on the triage, immediate care, and ongoing management of those they assess and treat.

Despite compelling reasons for the use of telehealth in the management of public health emergencies that have been recog- nized for over a decade, it remains an underutilized resource. Its lack of adoption by mainstream emergency and disaster man- agement teams is likely attributable to the following challenges.

1) Lack of standardized clinical pathways 2) Noninteroperability of information technology and telecom-

munications networks 3) Immaturity of the vital business and management processes

that are required to support and sustain telehealth-based services

4) Conservatism of those currently providing emergency ser- vices in the absence of compelling evidence of the clinical effectiveness and efficacy of telehealth as compared to tradi- tional practice

These challenges can be summarized as follows:

Underutilization of telehealth in public health emergen- cies is the result of a lack of a compelling vision of tele- health as a means of saving lives and reducing avoidable morbidity associated with public health emergencies and translating this into clear strategies and operations guides for its use.

Operations guides for implementing telehealth into the emergency response need to cover clinical, technical, manage- ment, and business requirements. Although these operations guides can be created at the local level, ultimately professional organizations, technology panels, standard-setting bodies, legal/ regulatory entities, and most importantly government must be fully engaged to make these guides valid and useful. Until this

wider collaborative approach to standardizing the role of tele- health in the emergency response is embraced, telehealth net- works cannot reach the necessary critical mass to transform public health emergency management. The technologies used by telehealth are already being used in other aspects of the emer- gency response, such as the remote assessment of physical damage and ongoing risk after disasters.6

The four challenges described previously to delivering ser- vices via telehealth in public health emergencies are similar to those limiting its growth in routine healthcare delivery. Early adopters who advocate the use of the telehealth response in pub- lic health emergencies often suggest developing unique telehealth solutions7 that are used exclusively for this purpose and not used in routine healthcare operations. A pioneering application of telehealth to provide support in a public health emergency (the Spacebridge project) suggests an alternate strategy (see case his- tory 23.2), that of building on existing systems that are used in nonemergency situations.

One of the reasons for Spacebridge’s success was undoubt- edly the long-standing expertise of both the U.S. National Aero- nautics and Space Administration and the Soviet Space Agency in the remote monitoring and managing of people (astronauts and cosmonauts) as part of their respective space programs. A recurring theme that surfaces when using telehealth in any widespread fashion to manage a public health emergency is that its success is more likely when building on existing systems rather than creating separate, stand-alone networks. Intuitive sense and experience, such as the subsequent use of Spacebridge, illustrate the value of deploying an existing telehealth network that pro- vides routine care delivery during an emergency. In this manner, the technologies have been previously implemented and eval- uated by an existing pool of clinicians with documented skill sets. Routine operations guides ensure that these clinicians are comfortable with telehealth technologies and familiar with the practicalities of using them to deliver care. The following issues must be addressed to achieve success.

1) Use of standardized clinical processes 2) Use of reliable, user-friendly, robust technologies 3) Ensuring adequate telecommunications bandwidth 4) Management of legal and regulatory issues, for example,

patient privacy issues 5) Addressing business and management aspects 6) Consideration of psychosocial issues

Telehealth and Systems Reengineering

To address the issues that make telehealth deployments suc- cessful, there has to be an associated business case that justifies embarking on telehealth implementation. For telehealth to be a serious proposition as a standard part of the routine emergency response, there must be clear clinical and economic justifications for its widespread implementation. Supplementing existing rou- tine and emergency healthcare delivery systems with telehealth is a sophisticated process. Widespread deployment of telehealth requires major reengineering of current healthcare delivery sys- tems. Redesigning a system involves more than merely adding telehealth technologies and their supportive information tech- nology platforms to deliver essentially a duplicative version of current services. A “provide the technology and they will use it” approach to technology implementation without strategic direc- tion is likely to fail. Rather, fundamental changes in clinical and

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CASE STUDY 23.28,9

On December 7, 1988, an earthquake measuring 7.2 on the Richter scale struck Spitak, Armenia killing 50,000 people. The Soviet Union took an unprecedented step in allowing international relief workers to provide aid to the homeless and injured. With town and surrounding community hospitals destroyed, there was an urgent need for medical services. One element of this response was an offer from the U.S. National Aeronautics and Space Administration to the Soviet Government to provide telehealth support. This project was called “Spacebridge” because it was established under the auspices of an existing 1987 agreement between the United States and the Soviet Union that allowed for the joint exploration of space for peaceful purposes. The aims of Spacebridge were to provide consultations to a hospital in Yerevan in the Soviet Union from U.S. medical centers in Utah, Texas, Maryland, and the Uniformed Services University of the Health Sciences in the specialty areas of rehabilitation, plastic surgery, mental health, rehabilitation, public health, and epidemiology.

Technical issues that needed resolution before implementing the project were

1) Establishing terrestrial and satellite-based telecom- munications links

2) Harmonizing technology protocols and procedures to enable video, voice, and fax communications to support remote consultations

3) Agreeing on common telehealth and staff training procedures

4) Finding suitable translation services to accommo- date different languages

5) Ensuring patient privacy for telehealth consultations

The outcomes of the project were that 400 clinicians from the Soviet Union and United States provided expert consultations to 253 of the injured. The Spacebridge was deployed again on two further occasions with similar success. The first was following a train collision outside Ufa Russia when 300 people were killed and many burned following a gas explosion. The second was to help trauma victims following the political uprising in Moscow in October 2003.

business processes are necessary to reengineer healthcare services to develop and sustain telehealth networks.

Creating telehealth networks that can provide support in public health emergencies will radically transform emergency preparedness in both developed and developing parts of the world. This endeavor requires investment in technology, clini- cal change management, and associated organizational develop- ment. The widespread investment to implement these changes, i.e. those required to sustain the clinical, technology, and busi- ness processes for telehealth networks, has not yet been made. Decision makers should carefully consider this investment before

implementation. Once such changes are made to incorporate telehealth into standard practice, they will likely need to be sus- tained for daily operations. For example, hospitals that have adopted picture archiving and communication systems to replace the use of x-ray film in routine radiology services do not antici- pate reversing the process.10 Resources to reverse implementation of this system would include recreating x-ray film archives, reem- ploying staff, reinstituting radiology storage rooms, and then investing in additional equipment and staff training. This brief description of the business process reengineering that accompa- nies the implementation of picture archiving and communica- tion systems illustrates how telehealth implementation requires a systems approach, one that usually creates multiple interdepen- dencies. Risk management strategies associated with telehealth require the clinical, technology, and business components parts of the new system to be documented, managed, maintained, and updated. Creating an initial telehealth project or program is com- plex and the long-term support of a new program must include systems maintenance. The vital roles of training and mainte- nance/support are often neglected when considering implement- ing a telehealth system.

The benefit of connecting local hospital sites and their asso- ciated clinicians with the site of a public health emergency is well described.11 This chapter assumes general familiarity with such point-to-point approaches to telehealth in public health emergencies12 and will therefore concentrate on the systems approach to create interoperable telehealth networks. The mag- nitude of public health emergencies and the challenges they present require telehealth to provide a sizeable, consistent, and reliable resource that deals with the substantive and often acute problems that must be addressed efficiently, effectively, and con- sistently.

The will, financing, and focus involved in undertaking a widespread radical systems reorganization to implement a tele- health program requires that decision makers embrace change. Which of these drivers is the eventual vehicle varies according to circumstances. In the case of implementing technology-based telehealth solutions, the pace of change typically depends on the baseline level of sophistication of technology within the organi- zation.13 In regard to telehealth’s role in supporting emergency preparedness, there are currently some early innovators, but a preponderance of traditionalists remain who resist these pro- grams. Given a general resistance to organizational change and a comfort with the traditional emergency response, there is cur- rently no overarching driver at the operational, policy, or polit- ical levels that supports the changes involved in creating and then sustaining telehealth networks. Understanding how these systems will eventually evolve and creating the accompanying clinical, technological, and business systems is neither a concep- tual exercise nor a question of fashionable technology. It must be based on practical considerations of underlying patient care needs in population terms coupled with appropriate support sys- tems. This needs-driven approach to shape systems that support care requires a service-oriented architecture14 in an organization, something that will be discussed later.

Health Needs as Drivers of the Implementation of Telehealth into Emergency and Disaster Management

Whether voluntarily adopted in the short term or imposed out of necessity in the future, developing telehealth networks to

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support public health emergencies requires a clear understand- ing of population-level patient needs. Telehealth must function to

1) Manage these needs more effectively than can be done by the elements of the traditional emergency response

2) Manage these situations at lower cost 3) Protect healthcare workers

Meeting these stipulations raises the following questions: what are the challenges confronting traditional management of public health emergencies that telehealth can meet and can telehealth offer itself as a viable solution to these deficiencies? A case for creating telehealth networks to systematically support emergency services requires more than embracing new technology. The suc- cessful creation of telehealth networks to support public health emergencies depends on ensuring they support clinical processes that management personnel can readily apply at the scene in real-time situations. The system must provide a useful adjunct for management and treatment of the acutely ill and injured population. It is the ability of a technology to resolve a clinical need in this way that ultimately drives its adoption into main- stream healthcare usage. What are the needs of patients and staff associated with public health emergencies that telehealth can fill?

By their very nature, public health emergencies and disas- ters are unpredictable. They are unpredictable in terms of their causation, timing, occurrence, location, and the damage and disruption that they may cause. RAND defines public health emergency preparedness as15

The capability of the public health and health care sys- tems, communities and individuals to prevent, protect against, quickly respond to and recover from health emer- gencies, particularly those whose scale, timing or unpre- dictability threatens to overwhelm routine capabilities. Preparedness involves a coordinated and continuous pro- cess of planning and implementation that relies on mea- suring performance and taking corrective action.16

The chief mission for the field of public health emergency preparedness is, therefore, to provide an anticipatory response to unpredictable events. Ideally this response prevents, proac- tively manages, and adapts to the changing way in which most public health emergencies unfold. The traditional emergency preparedness approach has been based on trying to manage this unpredictability by creating systems that seek to impose elements of certainty. Such certainty includes

1) The range of possible eventualities that an emergency pre- paredness response team might have to face has been fully determined

2) Clear procedures and processes have been formulated to deal with these situations

3) The logistics in terms of people, equipment, supplies, com- munications, and transport that will be needed to manage likely eventualities have all been determined

4) The command and control structures are in place to manage the initial response and subsequent activities

This traditional approach to preparedness of defining certainty in relation to public health emergencies is essentially an exercise in Newtonian physics. Newtonian physics theory takes a linear

view of systems, one in which knowledge of the constituent parts of a system allows its behavior to be accurately predicted there- after. The reality of public health emergencies is that they are anything but certain. The only thing that is predictable is that the disaster response will not be implemented precisely according to the plan. Yet, if responders use a basic command and control infrastructure, the event can be managed well. The emergency response attempts to bring order, predictability, and ultimately levels of control to disaster management. Information technolo- gies have fostered new approaches to the logistics and manage- ment of situations from industrial production to military conflict by enabling just-in-time systems to operate. This creates a more flexible and adaptable response, one that replaces the Newto- nian view of events and their management with one in which situations are seen as part of a complex adaptive system. This changed approach is relevant to the role of telehealth networks in providing flexibility and adaptability of healthcare services in an unfolding public health emergency.

Telehealth offers a way in which population needs for health- care services can be addressed dynamically. The traditional New- tonian approach has its merits in that it is necessary to have an armamentarium of services. The complexity of a public health emergency does not result from unidentified healthcare needs. Usually, the resources to meet these needs are ones that have been considered and are potentially available. It is the logistics of making sure the right care is available at the right time in the right place that is the main challenge. Telehealth offers this “just-in-time” flexibility to supplement the traditional physical response to a public health emergency or to provide urgent sup- port in areas of healthcare delivery that have been neglected. As with the delivery of routine healthcare services, the main bene- fit of telehealth in emergency and disaster management is that it allows for the re-engineering of clinical processes. Telehealth does not necessarily generate innovative new programs of care. It does facilitate creativity and improvisation that is often the hallmark of success when the unpredictable happens.

Emergency response encompasses a wide spectrum of pri- mary, secondary, and tertiary healthcare needs. Such a response will typically involve governments at the local, state, and fed- eral levels. It necessitates these bodies work collaboratively with nongovernmental organizations and volunteers. A wide range of professional and allied staff may be involved at various stages of a public health emergency. This staff includes, but is by no means limited to, engineers, aid workers, volunteers, law enforcement, water and sanitation workers, and transportation and health- care professionals, including public health. The public health emergency response includes much more than healthcare ser- vices alone. Healthcare services, whether delivered physically or via telehealth, must be considered within the context of the wider response. The information technologies, videoconferenc- ing capabilities, and telecommunications bandwidth that is nec- essary to support telehealth is equally applicable for nonhealth- care professionals use in other aspects of assessing and managing the emergency response. The current discussion will be limited to the healthcare services response to public health emergen- cies but recognizes that this is only one component of a broader system.

The effectiveness of the public health emergency response depends on the adequacy of logistics and communications. Detailed plans must provide sound and effective strategies for managing the variety of situations that may be encountered

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Table 23.1: Basic Management Elements for the Response Phase of the Public Health Emergency

1 Ongoing surveillance/monitoring to detect the threat to the public health

2 Verifying the existence, associated location(s) and determining the extent and cause of a public health emergency

3 Mobilizing the appropriate local, state, federal, nongovernmental organization, and voluntary responses to the emergency

4 Ascertaining the legal milieu and enforcing laws and regulations to protect health and ensure public safety

5 Instituting existing policies and plans that verify, manage, and contain the emergency

6 Informing the public about the emergency and the appropriate actions they need to take

7 Providing the appropriate triage, preventative, curative, palliative, and investigative services to protect and treat people and animals affected by the public health emergency

8 Depending on risk and exposure related to the nature of public health emergency, evacuate, quarantine, or shelter in place the affected/exposed population

9 Transitioning from the initial emergency response to routine operational management to deal with the aftermath of the immediate emergency situation

10 Reviewing the outcomes, opportunities for improvement, and need for revision of laws, regulations, policies, and procedures

through the phases of a public health emergency and these must include allowances for unexpected contingencies. Embed- ding telehealth within current healthcare services systems can be accomplished by introducing it directly into existing strategies and programs. For example, the breakdown of routine trans- portation services during a public health emergency can be mit- igated either temporarily or permanently by implementing a telehealth program.

The example of using telehealth in situations where there are transportation difficulties is one of many possible scenarios. Telehealth use for a variety of needs, array of situations, and differing responses associated with a public health emergency creates endless combinations and permutations of how it might be incorporated into an emergency response. In August 2005, Hurricane Katrina illustrated how a sudden loss of critical infra- structure could rapidly render inadequate the ability to deliver healthcare to the population. Telehealth was deployed17 dur- ing Hurricane Katrina, but without a coordinated approach for incorporation into the traditional emergency response. Tele- health can assist with the provision of basic emergency response elements as shown in Table 23.1.

Mounting an effective emergency response with telehealth is dependent on attention to detail. Assessment of the disaster response to Hurricane Katrina and the Indonesian tsunami18

is prototypical of all such responses. It suggests there could be better coordination of agencies and assessment of needs in the local community to ensure the resources deployed are appropri- ate, clinically effective, and cost effective. As with nonemergency healthcare, progress is being made to standardize the elements of the response to a public health emergency.19,20 Since the destruc- tion of the World Trade Center in New York on September 11, 2001 and the anthrax attacks in its aftermath, the need for an effective response to public health emergencies in the U.S. has come under the spotlight politically and in the public conscious- ness. As a result, new funding opportunities have arisen and with them have come the accompanying expectation of enhanced safety and security for the public. With increasing accountabil- ity for a return on investment in emergency preparedness, the issues of dealing with unpredictability and uncertainty rise to the fore.21 For example, the elusive search for a solution to contain- ing the threat of pandemic influenza has sharpened the attention

of governments on the financial accountability of emergency preparedness systems.22 As the telehealth emergency response scenario below shows, managing the consequences of pandemic influenza is a concrete example of how telehealth should be applied within this framework of financial awareness.

Telehealth Emergency Response Scenario In the event of a high virulence pandemic, there will likely

be widespread contagion and loss of life without an effective vaccine for protection. In the evolving public health emergency, engagement of national governments and international collab- oration will be necessary to mount a humanitarian response of unprecedented complexity. From a practical perspective, there will be insufficient hospital capacity to care for infected patients and it would be better to manage many of the victims in out- of-hospital locations. Home and community settings (e.g., com- munity centers and hotels) would probably be used to house those affected and segregate those who have been exposed but have not yet become ill. Home telehealth devices offer one option for monitoring people and helping to manage their treatments remotely, such as via telephone. By using telehealth, fewer health- care professionals would be needed to monitor and manage a population of patients (100 or more patients can be managed by each nurse). In the event of a pandemic, healthcare profes- sionals will also become infected, thereby reducing the work- force. Home telehealth-based quarantine systems, if adequately designed and appropriately engineered from a clinical and tech- nology perspective, offer a solution to the lack of surge capacity. Figure 23.3 depicts a healthcare professional managing a popu- lation of patients who are being monitored on home telehealth systems. The monitor provides population-level data that are viewable on a simple Internet browser–based application that enables expanded viewing to the level of individual patients.

The most significant benefit that telehealth brings to health- care delivery, whether in providing routine care or emergency care, is that patients can receive attention at their location and need not be transported to a specialist. Healthcare decision- making often takes place in hospitals. Telehealth makes it pos- sible to move the locus of healthcare decision making from the hospital to home or a local community setting. When the phys- ical locations of patient and practitioner are changed through

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Figure 23.3. Population Management via Home-Telehealth. See color plate. Used with permission from Kimberly Boltom.

the use of telehealth, it is particularly important to pay close attention to the continuum of care. The purpose of monitoring a patient at home in the routine delivery of care is to facilitate treatment in the home or arrange for care in a more appropriate setting. Logically such monitoring activities lend themselves to providing supportive care during public health emergencies.

Individuals who are being managed for injuries sustained in a public health emergency may have existing medical histories that impact how, where, when, and even if they should be treated. After the initial patient assessment at the disaster site(s) and real or potential health-related problems are detected, patients begin a journey of care. They may need ongoing monitoring and if so, it is important to have medical information available for clinicians to compare any change in patient status with the baseline. If the patient has to be evacuated and subsequent care is undertaken at a different location by another clinician, information about the preceding treatment regimen, such as medications or surgeries, needs to be available. Telehealth enables the virtual management of patients across the continuum of care. Telehealth is a safe and effective addition to the delivery of care, provided the elements of this continuum are recognized and the necessary processes are in place to coordinate clinical care. Otherwise it may result in further fragmentation of care and make it less safe. Although aspects of a written patient record can be verbally communicated, sent by fax, or physically attached to the patient, the optimal way to support patient management across the continuum of care using telehealth is to implement an electronic health record (EHR). In the absence of an EHR there are major limitations to how widely telehealth can be used.

It is difficult to build a viable business case for telehealth in the absence of an EHR.23 Many telehealth applications have rudi- mentary EHR systems that can support continuity of care but fall short of a comprehensive EHR. These limited software packages lack the advantages of well developed systems, including applica- tions to link with laboratories, operating rooms, and emergency departments. The creation and implementation of EHRs into healthcare systems is a major socioeconomic issue for any nation and has implications for payment systems as well as privacy and confidentiality of personal healthcare information. Implementa- tion of EHRs is proceeding to varying degrees, at variable paces, and with differing success rates in healthcare systems worldwide. The EHR is vital to the creation of telehealth networks; the two systems are synergistic in public health emergencies. An EHR provides more than just a tool for the management of individual

patients. Aggregated information from an EHR can offer valuable data for assessing needs, planning services, and patient monitor- ing and evaluation. If data were available from those who are triaged and assessed, this would transform the management of public health emergencies. Real-time data on the needs of the population would allow a more dynamic response with coor- dination of healthcare services within a wider emergency man- agement context at the local, national, and international level. This would help manage the logistics of evacuating casualties to local/regional/national or even international medical facili- ties. The EHR also could facilitate the ongoing epidemiologi- cal surveillance of those affected by a public health emergency. Regarding the sarin incident in Tokyo, for example, if an EHR had existed to assist with victim management, it would have been much easier to understand how long-term symptoms related to initial exposure.

The Electronic Health Record and Telehealth

In the routine delivery of healthcare services, the use of infor- mation technology to coordinate care has been recognized at the policy level.24 A health information system is a clear prerequisite to providing safe and effective consultations via telehealth. The success of organizations such as the U.S. Department of Veterans Affairs (VA) in implementing telehealth is, in part, attributable to the presence of an EHR. The EHR facilitates the ability to change the location of care. In public health emergencies, there is a critical health information need to support 1) monitoring, surveillance, and planning; 2) managing the care of those with health problems resulting from the emergency situation; and 3) caring for patients with existing health problems that may have been exacerbated or compounded by the emergency situation.

The EHR offers tools to manage patients across the contin- uum of care associated with emergency and disaster response, just as it does in routine healthcare delivery. It enables changes in the location of care because it allows the process of healthcare decision making to move closer to the patient. It removes the necessity for the patient to travel to large capital assets such as traditional hospitals to receive expert assessment and care. EHRs and telehealth enable a much more flexible approach to the deliv- ery of care. Major changes in both healthcare and emergency and disaster management often follow what happens on the battle- field. The Korean War introduced the concepts of rapid evacu- ation and the mobile army surgical hospital, which persisted as standard operating procedure throughout the Vietnam War and until the end of the first Gulf War. The acute management of the combat wounded totally changed with Operations Enduring Freedom and Iraqi Freedom. Initial triage and stabilization now take place closer to the site at which the injury occurred and definitive treatment may happen in another country or even on another continent. Patients need only be “stabilized” prior to transport rather than “stable.”

The value of an EHR in a public health emergency was exem- plified by the evacuation process for patients in the New Orleans VA who were relocated to other VA centers in advance of Hurri- cane Katrina in 2005. The EHRs for these evacuated VA patients were available nationally within 48 hours.25 Impressive examples such as this show the value of the EHR when used for routine care delivery in emergency situations, both for patients affected by the acute event as well as those who require ongoing care for existing health conditions. In a population that is aging and suf- fering from an increasing burden of chronic disease, public health

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Table 23.2: Recommendations for Implementing Information Systems Nationally and Internationally

Ensure information technology system can support the individual, organizational, and institutional needs of users

Avoid simultaneous implementation in an entire large country in one overarching project

Avoid implementing state-of-the art technology with unskilled professionals

Limit the number of project components

Ensure clear ownership of the project and buy-in by users

Ensure compatibility of systems and collaboration among participants

emergencies affect the ongoing care of these patients in ways that can be life-threatening, such as the separation of diabetic patients from their insulin supply. Many other areas of human activity, such as commerce and industry, already use information technol- ogy systems to communicate, coordinate, and evaluate complex undertakings. These systems resolve logistical problems in anal- ogous ways to the emerging use of the EHR and telehealth in healthcare.

Although an EHR is of particular importance to telehealth, it must be kept in perspective and viewed cautiously to avoid overzealous and uncoordinated efforts to introduce such sys- tems. It is a considerable challenge to implement hardware and software components of an EHR. Implementing an EHR with the associated training, information technology support, cyber secu- rity, interoperability, and other modular components it requires (e.g. laboratory and blood transfusion packages), is a colossal undertaking. To succeed, an EHR project must be well planned, particularly in developing countries. Key principles for the imple- mentation of information technology systems in developing countries to support routine operations26 are listed in Table 23.2. These same principles apply to projects in developed nations and to telehealth systems.

Basic requirements for an EHR are even more complex than for other systems. Therefore, even if there were unanimous sup- port for an international EHR system to coordinate emergency responses, the challenges of implementing an integrated system offering public health benefit would severely impede its creation, even in developed countries. Nascent elements of a future solu- tion can be seen in projects like the common alerting protocol, which is an attempt to standardize alerts in the event of disas- ters.27 The rudimentary nature of the information systems that can be deployed widely in a developed country was shown by the experience with KatrinaHealth in the U.S.28

Telehealth logically builds on health information systems for two reasons. First, the EHR provides necessary information that is needed for continuity of care and assists both the referring practitioner and the teleconsulting practitioner in making appro- priate treatment decisions. Second, the telecommunications infrastructure required for distributing an EHR helps provide the business case and routine operational telecommunications backbone for a telehealth network. The routine exchange of an EHR on the local area networks and wide area networks (WANs) of healthcare organizations sustains the network and ensures basic interoperability, cyber security, and privacy requirements. These same items apply directly to other systems on the network,

such as telehealth. If the organization’s information technol- ogy infrastructure is not sophisticated enough to implement the requirements of an EHR, it will restrict the development of a tele- health network. An adequate telecommunications infrastructure is as important to the development of telehealth services, as water is to a hydroelectrical power generation project.

Telecommunications Technology Support of Telehealth

Telecommunications technologies are changing the lives of peo- ple worldwide. Developing nations that lack impediments to innovation from vast legacy systems, such as public telephones that use copper wire, are leapfrogging over developed nations in their use of new technologies for commercial, leisure, and enter- tainment purposes. The legacy that current telecommunications systems impose on developed countries means that developing nations may lead the way over developed nations in creating the preeminent technology-based healthcare delivery systems of the future. These nations may also decide how these systems will par- ticipate in the emergency response to public health emergencies.

The availability of traditional telephone service and inte- grated services digital networks (ISDN) as well as cellular, radio, and satellite communications are the basic building blocks for data exchange that can support telehealth services. The ability to use standard telephone service, ISDN, broadband, or satellite communications to connect a patient at one point with a clini- cian at another site is known as point-to-point telehealth. This will be described in more detail later. Given access to the neces- sary finances and political willpower, it is possible to purchase the equipment and telecommunications bandwidth necessary for establishing a telehealth project that can support routine healthcare delivery almost anywhere in the world. The step-by- step addition of new participants on point-to-point telehealth networks is unlikely to create systems of the size and complexity needed to assist in routine healthcare delivery, much less support services needed during public health emergencies. The reason for this relates to the nature of telecommunications networks and fundamental systems requirements that can be traced back to the development of the telephone.

After its invention, the telephone was of limited use to the general population because the connections were all point-to- point. The worldwide network of telephone services that is now supported by standard telephone service, wireless, satellite, and the Internet was made possible by the development of tele- phone exchanges and common dial planes that allow direct dial- ing. The key developments needed so that telecommunications infrastructures can support telehealth depend on similar tech- nology solutions and standards to ensure they are interopera- ble. It is outside the scope of the current discussion to describe international efforts associated with telecommunications stan- dardization; however, there are efforts underway to standardize the emergency response to public health emergencies. Although telecommunications needs have been recognized, telehealth is not yet a supported application.

Telehealth and the Standardization of Support Services for the Emergency Response to Public Health Emergencies

The Sphere project is an attempt to define a Humanitarian Char- ter and Minimum Standards for Emergency Response.29 It lists contingencies to consider when managing disaster situations,

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from monitoring clinical conditions such as goiter to logistical issues such as burials. However, it only references telecommuni- cations and does not mention telehealth. Telecommunications are a vital part of disaster relief. By their very nature telehealth services are based on a telecommunications infrastructure. A robust interoperable telecommunications network is a prerequi- site for telehealth. The need to develop this telecommunications network for emergency and disaster relief has long been recog- nized at the international level, but it has been slow to evolve. The Tampere Convention30 was unanimously adopted on 18 June 1998 by the delegates of 75 countries. Its elements require countries to facilitate the provision of prompt telecommunica- tion assistance in the event of a disaster. The convention covers the deployment of reliable, flexible telecommunication services. Regulatory barriers that impede the use of telecommunication resources for disasters are waived during a public health emer- gency. This waiver includes licensing requirements for allocated frequencies, restrictions on the import of telecommunication equipment, and mobilization of humanitarian teams. The Tam- pere Convention also eased restrictions for the use of life-saving telecommunication equipment but did not aid its standardiza- tion. The relative inertia in attempts to harmonize telecommuni- cations platforms globally is due to commercial and political con- siderations coupled with the relative inflexibility of large legacy systems. These issues lie outside the current discussion of the role of telehealth in public health emergencies; however, as a conse- quence of this lack of standardization, there are problems with interoperability of communication systems, including telehealth. The functional continuity of function of telecommunications systems is vital if they are to support the delivery of health and other services in public health emergencies, as illustrated in Case Study 23.3.

The vulnerability of telecommunications networks to disas- ters was exemplified by this situation in which it took 48 hours to restore paging services to the areas most affected by Hurri- cane Katrina.31 Rescue attempts during Katrina were plagued by problems with nonoperability of telecommunications systems. To help rectify this deficiency in the U.S., part of the telecom- munications spectrum has been dedicated to emergency and disaster management services.32 Considerable work remains to secure land-based telecommunications infrastructure and stan- dardize it in ways that are necessary to support the safe and robust networking services needed for widespread telehealth expansion.

Satellite-based services provide the most reliable and con- sistently available telecommunications systems in the event of

CASE STUDY 23.3

On August 29, 2005 Hurricane Katrina made landfall in southeast Louisiana and Mississippi. As a consequence of the hurricane and subsequent flooding, 1,577 people died in Louisiana, Mississippi, and Alabama. Hundreds of thousands of people were left homeless and a massive humanitarian relief effort was mounted. The event was a severe test of emergency preparedness in terms of logistics and readiness. It took 48 hours to restore even the most basic telecommunications services on a widespread scale.

a public health emergency. A disaster such as an earthquake, hurricane, flood, or cyber terrorist attack can disrupt land-based telecommunications systems. Despite the theoretical back up and redundancy of telecommunications fiber in WAN topographies, there are often situations where critical points of failure can occur with damage at a single site. Any design for telecommuni- cations systems that support telehealth should contain back-up arrangements that involve a contingent WAN based on satellite communications.

The need to have a contingent WAN applies to both the routine delivery of healthcare and to telehealth networks that support public health emergencies. The value of using telehealth to provide services at a distance is that existing care delivery systems are redesigned to make care more accessible. Usually the physical provision of certain services can either be reduced or completely curtailed because telehealth offers care more eco- nomically and effectively. The end result is that information technology–mediated services replace services that were once delivered directly and in situations where the ability to physically provide services may not be possible. This makes it vital to ensure that telecommunications back-up and redundancy plans exist in the event of failure of the primary technology. Telehealth-based services will likely never replace the need to provide direct care during a public health emergency, but telehealth should be con- sidered part of the emergency response armamentarium, with the aim of providing a flexible and adaptive response. In mount- ing this flexible and adaptive telehealth response, a critical issue is determining how clinicians and responders at the scene(s) will be connected via telehealth networks. This will require the development of a common telecommunications dial plan33 for telehealth services, whether limited to the emergency response or applied to telehealth provision generally.

Telephone and cell phone networks have a standardized sys- tem to assign numbers and support connections between indi- viduals on the basis of dialing the requisite number(s). This organized system of interconnectivity is known as a “dial plan.” A dial plan to connect telehealth clinicians over telecommunica- tions networks must have a standardized structure and must link remote healthcare responders into a prioritized telecommunica- tions infrastructure. It would be pointless to have a widespread network of clinicians available to respond urgently to a public health emergency and then rely on a publicly available telecom- munications system to support them. Questions related to the dial plan and access issues emphasize the need for improvement in the human aspects of telehealth networks and how they are organized.

Telecommunications standards for video functions that con- nect clinical workstations are rapidly changing as point-to-point services are evolving toward multipoint services. The H.320 video protocol34 for point-to-point over ISDN is evolving to the H.32335 protocol that allows multipoint connections and many individuals to connect into a videoconference. The future of video services over large telecommunications networks is Inter- net Protocol36 (IP) based. There are constraints on the expansion of web-based services to support IP video on the scale that large telehealth networks will require. These should be resolved with the newest version of IP – Internet Protocol Ipv6. The use of IP as the basis for telecommunications connections raises the pos- sibility that large telehealth networks may assemble from smaller existing systems as a network of networks and not as a separate undertaking.

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Clinical Care Networks to Support a Telehealth Response to Public Health Emergencies

A single provider who personally knows the on-site clinician and is linked by satellite-based videophone can improve care and decrease mortality. A relationship-based initiative like this illustrates a benefit of telehealth, but it is not readily scalable beyond a certain size. A systems approach to telecommunica- tions networks is necessary to support large-scale public health emergencies. Emergency managers must assemble and connect the various components of the clinical care network that pro- vide such support. This network is likely to constitute a core of practitioners that have competencies in

1) Trauma and orthopedics 2) Emergency and critical care 3) Neurosurgery 4) Plastic surgery 5) Infectious disease 6) Public health 7) Pediatrics 8) Psychiatry 9) Care of burns

In the event that such a network must be assembled rapidly, it might be possible to use on-the-spot volunteers. The planning and processes necessary to construct a reliable telehealth network require that the appropriate systems are already in place to

1) Verify that staff (volunteer or otherwise) are trained and fit to practice

2) Establish a registry of staff that identifies their appropriate credentials, their clinical specialties, and contact details

3) Ensure that staff have access to equipment that is compatible and interoperable and can link via the necessary telecommu- nications bandwidth

4) Develop operations guides for staff that focus on explicit processes and communication

5) Train staff in the systems and ensure they are aware of the limitations of telehealth and the support on which they can rely at the patient site

6) Develop and implement quality assurance and outcomes measures as well as the systems to monitor them postevent

7) Construct the necessary systems within emergency response teams to manage and coordinate a telehealth-supported healthcare initiative

The processes 1–6 all currently exist in healthcare but must be adapted to the emergency response. To support the clinical and technology arrangements that make telehealth possible, associ- ated business processes are needed.

Business Processes that Support of Telehealth Networks

Healthcare systems vary worldwide in terms of management style and reimbursement or funding allocation strategies for care. Telehealth facilitates the provision of healthcare irrespective of how it is delivered. The two main approaches to the provision of care are dedicated services and service lines.

Dedicated services are implemented through traditional hierarchies that are professionally based and represent distinct

silos, for example orthopedic surgery, emergency medicine, physical therapy, and occupational therapy. This construct bases the delivery of care on the expertise of those providing it rather than on the patients who receive it. Telehealth can readily fit into this arrangement, assuming the clinical activity can be coded on associated information systems and the workload captured by individual professional discipline and subspecialty.

A service line arrangement is one in which the services pro- vided dictate the managerial arrangement. An example is mental health services. Telehealth itself can be managed as a separate ser- vice line. This pattern of service delivery is more reflective of the care given to patients. In this arrangement of services, telehealth can be coded for workload purposes as its own entity.

The workload supported by telehealth services is accurately captured, whether delivered as a dedicated service or a ser- vice line. Telehealth is distinctly different from other healthcare practice in that there are two separate episodes of care associ- ated with each telehealth encounter. The first is the support of the patient at the site and the second is the consultation ser- vices of the clinician who is providing advice from a distance. This duplicative coding requirement can present challenges in some healthcare systems in which the concept of two separate episodes of care occurring simultaneously at two separate sites is anathema.

The arrangements for reimbursement or supplemental fund- ing after a public health emergency is complex and variable within and between nations. The ability to systematically code for telehealth activity means that it is possible to accurately capture workload data and thereby ensure that an accurate reckoning is made for the costs of providing services. Telehealth relies on electronic technologies and it is possible to automate the pro- cess of capturing workload activity by using standard codes. One example is the use of Health Level 7 generated by the technologies instead of relying on manual coding of information by clinicians. The ability to track clinical activity and associated costs of tele- health encounters is a vital part of developing telehealth-based services. The nature of large networks that rely on electronic technologies is that they need a stream of high-volume low-cost applications to sustain them. Telehealth networks are sustain- able up to a certain size by the variable types of grant funding and barter that often typifies the development of innovative new services in healthcare. However, to achieve a critical mass of per- manently sustainable funding, the processes of workload capture, clinical coding, and financial recompense should be as clear and explicit as the clinical and technology processes associated with telehealth.

CURRENT STATE OF THE ART

Introduction

The current state of the art with respect to the use of telehealth in public health emergencies is varied and somewhat rudimentary. Within the wider healthcare arena, telehealth is an innovation that is emerging but lacks the information systems necessary to support it in ways that will transform it into a full-fledged healthcare activity. In many situations, telehealth activities are fragmented and it is difficult to gauge its effectiveness. It is typ- ically a separate endeavor undertaken within an existing clinical service in an informal way, not supported and coordinated at the enterprise level.

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Although the current role of telehealth in public health emer- gencies is limited and variable, there are several telehealth modal- ities in use, including

1) Real-time clinical videoconferencing 2) Home telehealth 3) Store-and-forward 4) Public telephone systems 5) Amateur radio 6) Web-based information

State of the Art for Real-time Videoconferencing Applications

The Telemedicine Information Exchange37 provides information on telehealth activity worldwide with sections on

■ Africa ■ Antarctica ■ Asia ■ Australia and New Zealand ■ Canada ■ Caribbean ■ Central/South America ■ Developing countries ■ Eastern Europe ■ France ■ General Europe ■ Germany ■ Global ■ Greece ■ India ■ Italy ■ Middle East ■ Netherlands ■ Scandinavia ■ Spain/Portugal ■ Switzerland ■ United Kingdom ■ United States

Therefore, expertise from all these countries is potentially avail- able to assist in the event of a public health emergency. The cur- rent status of telehealth deployment in emergency preparedness situations is largely that of a single or small group of clinicians providing variable support. There are organizations seeking to develop a clinical network of physicians who can offer humani- tarian assistance via telehealth. Humanitarian Emergency Logis- tics & Preparedness (HELP)38 is one such organization. It main- tains a website39 through which it strives to mediate ISDN- and IP-based video consultations. This initiative and others like it are works in progress. These are grassroots efforts that are attempt- ing to develop an international network of telehealth providers. There is a tremendous willingness and enthusiasm among indi- vidual clinicians to participate in humanitarian assistance via telehealth. Despite this enthusiasm, there are logistical issues that limit implementation. The goal of voluntary, governmen- tal, and international agencies is to harness the volunteerism of clinicians into telehealth networks. Progress by such agencies toward achieving this goal is hampered by the lack of interopera-

ble registries to certify the credentials of these volunteers and the cost of satellite communications, which provide the only current assurance of telecommunications operations continuity.

Satellite Communications for Synchronous Telehealth in Emergency and Disaster Management

There are upward of 150 communication satellites that could be used for telehealth.40 However, at the time of this writ- ing, the cost of satellite communications is approximately 7.50 USD/minute for only 64 kbit/second transmission (Inmarsat Air- time by KVH). The costs of satellite bandwidth make it pro- hibitive to use in third world situations where the total per capita annual expenditure may amount to 15 minutes of satellite time.

Despite these constraints, when the United Nations Scientific and Technical Subcommittee of the Committee on the Peace- ful Uses of Outer Space41 met in 2007, it noted the programs that were contributing to the increasing availability and use of space-based solutions to support disaster management. These included

■ Italian-Argentine Satellite System for Emergency Manage- ment (SIASGE)

■ RADARSAT-2 to reinforce the ability to detect potential disasters

■ Use of IRS images ■ Indian National Satellite System (INSAT)-based commu-

nications and telemedicine services for postdisaster relief operations

■ Advanced Land Observing Satellite (“Daichi”) of Japan ■ ISRO satellite-based search and rescue network (this helped

save 30 crew members on board the ship Glory Moon in 2006) ■ International Satellite System for Search and Rescue

(COSPAS-SARSAT) mission control center of Nigeria, which had been supporting search and rescue operations in aviation-related disasters

Although the U.S. military is similarly bound by cost consider- ations regarding satellite usage, it participated in the Pakistan earthquake relief effort in 2005. The military demonstrated that a robust consultation service for infectious disease, trauma, pedi- atrics, and dermatology could be established via satellite com- munications.42

Land-based Communications for Synchronous Telehealth in Emergency and Disaster Management

The PROACT43 system (Preparedness & Response On Advanced Communications Technology) is a synchronous telehealth pro- ject based at the University of Kentucky. It was established to bring public health, medical, and other experts together from anywhere within the U.S. via interactive videoconferencing. Its aim is to supplement other elements of the emergency response by

1) Bringing the regional coordinators together on a regular basis 2) Delivering disaster preparedness and response educational

programming to communities 3) Engaging communities in statewide planning and response

efforts

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4) Reaching out across state lines to other PROACT-like net- works for regional and national disaster response

5) Providing a channel to connect victims of disasters with spe- cialists from anywhere in the world, including the U.S. Cen- ters for Disease Control and Prevention in Atlanta

The activities of PROACT mirror those outlined by the Southern Governors Association. This group called for the inclusion of telehealth in emergency preparedness44 and seeks to develop a network of networks to evolve telehealth capacity for emergency preparedness.

Bandwidth, logistics, regulations, and other constraints mean that the status of real-time clinical videoconferencing (and store-and-forward telehealth) has been relatively unchanged since the Telemedicine Spacebridge to Armenia.10 During oper- ations between March and July 1989, the use of Spacebridge resulted in more appropriate diagnoses being made in 26% of the patients seen. Anecdotal experience repeatedly shows sim- ilarly improved outcomes when telehealth is used in this spo- radic way. Proponents of telehealth see its value in public health emergencies and call for the development of the telehealth net- works that are necessary to support its widespread operational deployment. Opposition to creating these telehealth networks stems from the lack of scientific evidence to support them. Tele- health use in public health emergencies is therefore in the classic dilemma that besets many new innovations in healthcare. Delay in creating the networks that will demonstrate the widespread benefits of telehealth are the norm until scientific evidence for improved outcome can be shown.

To show the benefits of telehealth and provide evidence of effectiveness, telehealth network simulations have been devel- oped.

Real-time Simulations Using Synchronous Telehealth

1) Operation Strong Angel.45 The United States Navy Third Fleet organized this simulated humanitarian response in Hawaii in June 2000. It took place within the umbrella of the concurrently occurring Rim of the Pacific Exercise46

2) North Carolina Domestic Training Exercise.47 This training exercise took place in June 2002 at Camp Lejeune Marine Corps Base in Jacksonville, North Carolina. It used existing telehealth networks supplemented by rapidly deployable sys- tems like satellite to show how telehealth could enhance the traditional emergency response to a disaster

3) Shadow Bowl.48 In January 2003, the U.S. Super Bowl sport- ing event was used as the backdrop to a simulated homeland security exercise that examined community readiness and medical response. Telehealth was used as part of this medical response

There is a commonality of findings from all these simulations. The first and most important is that it is possible to mount an effective telehealth response within the wider emergency response. Even with the advantages of forewarning and planning, it is a complex undertaking to develop the telecommunications infrastructure to support telehealth. Integrating the telehealth response and the use of information technologies into the exist- ing emergency response is challenging. Operational details that reflect the clinical, technical, and business considerations high- lighted in the overview section can be problematic. Telehealth networks should be based on realistic simulations.

State of the Art for Home Telehealth Applications

Patient monitoring and telemetry has been featured in simula- tion exercises but the use of home telehealth technologies to man- age public health emergencies has not occurred in real events. Home telehealth technologies have the potential to provide surge capacity, such as during pandemic influenza. The current status of home telehealth services and networks is at an early stage and needs to evolve. Currently relevant issues for the development of home telehealth networks and the provision of surge capacity are

1) The home telehealth industry is an emerging one but still in its infancy, although rapidly increasing in sophistication and interoperability of technology

2) Strategy for technology distribution 3) The telecommunications capacity needed to support such

networks 4) Where the necessary clinicians would be situated 5) What protocols and procedures these clinicians would use 6) How home telehealth services would interface with other

services 7) How staff would be trained and retrained 8) Whether the necessary patient self-management and fam-

ily/community caregiver tools could be developed

Without resolution of these issues, the use of home telehealth will likely be sporadic and show limited benefits. In the aftermath of Hurricane Katrina, the care provided to veterans via telehealth in areas not devastated by the hurricane continued uninterrupted. The only exception was the need to transfer support for this remote care from clinicians at hospital sites that were destroyed to other hospital sites.

State of the Art for Store-and-Forward Applications

The Swinfen Charitable Trust,49 a United Kingdom–based char- itable organization, has provided routine medical services to third world countries and shown the great value of store-and- forward technologies. However, such initiatives are fixed in terms of the “people networks” on which they depend. They rely on relationships that are not easy to expand in a complex public health emergency unless the necessary practices, processes, and procedures have been detailed in advance and embedded in the emergency response.

There is increasing use of informal telehealth modalities to provide support in emergency and disaster situations. Examples include the use of e-mail and transfer of digital images over a variety of telecommunications platforms, including cameras in cell phones. These activities are usually ad hoc, poorly docu- mented, and use the general public telecommunications systems. They are, therefore, vulnerable to failure if these networks cease to function. Instead, they need to function as part of dedicated networks to support emergency and disaster management.

The current status of store-and-forward technologies is, therefore,

1) Sporadic and mostly informal 2) When formal, part of the real-time videoconferencing

response 3) Subject to the vagaries of telecommunications support 4) Lacks access to accompanying health record systems

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5) Has major privacy and cyber security deficiencies in its infor- mal usage

State of the Art for Public Telephone Systems

By definition, there is ubiquitous use of telehealth in both rou- tine healthcare and emergency and disaster operations when the public telephone system is accessed. However, this resource is subject to disruptions from network damage and to inadequate capacity due to sheer call volume in a public health emergency. Despite its limitations, the public telephone system is a main- stay in healthcare delivery. Its use is routine and understood and cell phone technology makes it mobile. It does not lock indi- viduals to set locations in the way that the old copper-wired systems did. The telephone system is often the way in which telehealth systems are deployed that involve clinical videocon- ferencing. Important initiatives in relation to an expanded role for the telephone in providing healthcare are: 1) to work toward prioritization of users on public telephone systems to ensure that emergency responders get priority and 2) to use the telephone and telephone call centers as sources of public information and epidemiological surveillance.50

The Current Role of Amateur Radio Networks in Providing Telehealth

There is a danger with telehealth, as with all new innovations, of not recognizing existing capabilities. An invaluable part of telecommunications support in public health emergencies has been amateur radio.51 Amateur radio users are often trained and skilled communicators. The emergency management commu- nity recognizes these competencies when discussing the Amateur Radio Service. Amateur radio users are a resource that can act as a conduit to help agencies exchange information. They may not understand the medical and health terminology, but the ability to transmit the information accurately makes them an invaluable communications bridge.

The Current Role for Web-based Information

The use of the Internet to provide web-based information and resources is a worldwide phenomenon. The volume of health- related information on the Internet that may be pertinent in the event of a public health emergency is so great that it could not all be synthesized and verified.

The Internet may itself be a target of a terrorist or hacker- induced event. The effect of this could be local, national, or con- ceivably worldwide. If a patient’s EHR were purposely altered, this could lead to a well-meaning telehealth provider inadver- tently administering a fatal treatment. In addition, ongoing access to the Internet requires electricity services that despite generators, batteries, and solar energy can be finite. Furthermore, bandwidth capacity might be inadequate to accommodate large numbers of users simultaneously. Thus, a total reliance on post- ing information on the Internet is unwise and written materials that are published or printable are needed as a backup.

The veracity of Internet information is a critical issue. There have been large purchases or liquidations of stock and other financial instruments triggered by planted rumors on the Inter- net. The propagation of misinformation in the form of urban legends is well known. Web-based information sources must be

credible, authoritative, accessible, and usable by those with dis- abilities, such as visual impairment.

Examples of credible information sources valuable to emer- gency responders and the public are the sites for the the U.S. Armed Forces Institute of Pathology Anthrax Education and the Center for Disaster and Humanitarian Assistance Medicine. The anthrax education web site52 provides information about the pathogenesis and imaging of inhalation anthrax. It is intended to improve the understanding and recognition of inhalation anthrax by diagnostic professionals. The content represents the combined efforts of the Armed Forces Institute of Pathology and the American Registry of Pathology, Washington DC and INOVA Fairfax Hospital, Fairfax VA. The Center for Disaster and Humanitarian Assistance Medicine is supported by the Uni- formed Services University of the Health Sciences, Bethesda, MD. Its web site is a resource53 intended to provide information about chemical and biological warfare and terrorism. Information con- tained on the site is derived from the organizations’ 25 years of instruction on management of weapons of mass destruction events.

Using the web to distribute information requires resources and expertise to maintain the data and keep it scientifically cor- rect and valid. There is also concern that by publicly posting information about the emergency response on the Internet, one may be providing information to terrorists as well as the intended audience.

Web-based resources that provide information to the gen- eral public at the local, national, and international levels are currently grossly inadequate with regards to content and quality. Web-based training modules are increasingly providing infor- mation for emergency responders. This information, however, is often parochial to individual organizations and not linked with common standards and the operational policies and procedures of other organizations.

Recommendations for Further Research

In the previous sections of this chapter, it has been stressed that the use of telehealth in public health emergencies is at a rudi- mentary and formative stage. To move forward and use telehealth as a tool to transform elements of the healthcare response, the following areas of research, investigation, and development are important.

1) Policy considerations 2) Organizational strategic considerations 3) Networks of networks 4) Research on the clinical effectiveness of telehealth in public

health emergencies 5) Robustness, standardization, and interoperability of tech-

nology 6) Understanding that telehealth is a complex adaptive sys-

tem54

RECOMMENDATION 1 – POLICY CONSIDERATIONS

Central governments and healthcare services should consider telehealth in formal policy terms.

The role of telehealth has not yet been formalized into policy in terms of the routine delivery of healthcare services, let alone for public health emergencies. Governments and health services are notoriously reactive when it comes to policy development in

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healthcare. The EHR and telehealth are simultaneously transfor- mative and disruptive technologies and organizations. Health- care professionals worldwide are reluctant to embrace the EHR and telehealth for these reasons. The crisis that affects the deliv- ery of both routine and emergency healthcare services in terms of access equity requires a focus on the patient. Telehealth is a tech- nology that benefits patients by taking services from healthcare facilities to the home and local community. Lack of support from hospitals and the existing healthcare infrastructure is a powerful barrier to change.

ORGANIZATIONAL STRATEGIC CONSIDERATIONS

Similar reservations exist in healthcare and emergency response organizations to adopting telehealth in their approach to managing public health emergencies. In part, this is because healthcare organizations do not plan ahead in a strategic man- ner and consider the impact of new technologies. This strategic approach requires incorporation into the broader consideration of health informatics and telecommunications implementation and mandates innovative new methods for reimbursement.

RECOMMENDATION 2

Telehealth should be part of the emergency and disaster man- agement strategies for all healthcare organizations.

NETWORKS OF NETWORKS

Healthcare organizations develop their own intranets based on evolving information and communication technologies. Busi- ness, technical, and privacy/confidentiality/cyber security con- siderations make these intranets self-contained offering limited access to the Internet and connectivity with other healthcare entities. Access to the breadth and volume of healthcare services needed in a public health emergency requires that networks of networks aggregate and self-assemble in an organized and cohe- sive way to offer integrated and interoperable services.

RECOMMENDATION 3

International agencies, central governments, and healthcare organizations should link telecommunications networks and clinical services that provide both routine services and emer- gency and disaster management.

Research on the Clinical Effectiveness of Telehealth

The use of telehealth in public health emergencies must be based on scientific evidence that it is clinically effective and cost effective. Although there is accumulating evidence for the effec- tiveness of telehealth in certain areas,55 such evidence is cur- rently lacking for its application in public health emergencies. A research agenda should be developed and should include ethical dilemmas in disaster research. There are special research consid- erations in a fast moving technological area like telehealth.56 For example, the approach of the traditional randomized controlled trial is rarely appropriate.

RECOMMENDATION 4

A comprehensive research agenda should be developed and funded at the international and national levels to generate the evidence necessary to support the use of telehealth networks for emergency and disaster management.

Robustness, Standardization, and Interoperability of Technology

Telehealth in general, and the home telehealth industry in par- ticular, is an emerging enterprise. The future use of telehealth depends on creating robust technologies that are standardized and interoperable. The experience of cellular technologies in public health emergencies shows the dangers of nonoperability. The electronic components required to support telehealth must be engineered to exacting specifications and developed under the necessary standards for interoperability. Wherever possible these new assets should be compatible with existing technologies to maximize the function of older systems (backward compati- bility).

RECOMMENDATION 5

Governmental bodies and international/national technology standardization agencies must develop robust and interoperable telehealth technologies that enable the widespread deployment of these assets in public health emergencies.

Telehealth Requires a Complex Adaptive System

The implementation of telehealth by emergency and disaster management in ways that can improve response to contempo- rary threats and address risk security57 need to embrace rather than deny uncertainty. Telehealth should be developed within the context of building networks of organizations committed to a process of continual inquiry, informed action, and adaptive learning. This approach is one that recognizes complexity and is different from the traditional anticipatory response to emer- gency and disaster management that is linear. The emergency response to a public health emergency is, above all, a logistical response. Using a scientific approach to logistics management, investigators are beginning to examine the emergency and disas- ter response.58 By considering the key participants, phases, and logistical processes of disaster relief, the parallels with business logistics are identifiable and each can learn from the other. Infor- mation systems are key to both.

RECOMMENDATION 6

Organizational development should encompass both linear and complex adaptive approaches as appropriate in developing and implementing telehealth networks.

Conclusion

Telehealth has many applications in the management of pub- lic health emergencies. With technologic advances, heightened emphasis on efficient allocation of scarce resources and cost- effectiveness, and protection of emergency responders, telehealth will become an increasing important tool for the emergency managers of the future.

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