April 23, 2011
The Development of a Region-Wide EMS Telemedicine System Fully Integrated With Day-to-Day EMS and Disaster-Related Activities
Mayor Melvin L. “Kip” Holden
East Baton Rouge Ambulance
Telemedicine, or the ability to provide health care at a distance, has been in use since the advent of the telephone. EMS has a long history with telemedicine, starting with voice communication by radio, then simple ECG telemetry, and more recently, the common use of digitally communicating 12-Lead ECGs along with an ever increasing array of vital signs. With the introduction of broadband wireless systems, 4G cellular and the internet, all possessing the ability to manage vast amounts of data, the sending of video images from ambulances to hospitals is now a practical reality. BR Med-Connect, a new system in Baton Rouge, Louisiana, utilizing this technology is the subject of this article.
In late 2008, under the direction of Mayor Melvin “Kip” Holden and his EMS staff, the parish of East Baton Rouge, Louisiana decided to explore the use of a (wireless) telemedicine system for EMS. The goal was to have a scalable system that could be used for day-to-day EMS, meet special telemedicine needs, and also be incorporated into the parish’s disaster-related activities. The proposed system, to be named BR Med-Connect, was to be test trialed in the City of Baton Rouge and was the product of the far-sighted vision of Mayor Holden, Dr. Cullen Hebert, MD and EMS Director Chad Guillot. Together, they set into motion the start of this advanced, parish-wide EMS/ED system with the mission of improving pre-hospital health care delivery throughout the 472 square miles of urban, suburban and rural population centers.
By addressing all aspects of pre-hospital patient care in one fully integrated system as opposed to a stand-alone telemedicine system, East Baton Rouge EMS expects to lower initial and ongoing costs of the telemedicine system; decrease medic and nurse training, and improve EMS documentation, while, at the same time, create a system that is easy for nurses and medics to use.
The initial phase, conducting a pilot trial, and the second phase, equipping all the hospitals in the parish with the system, has been successfully completed. The remaining phase, equipping the parish’s ambulances with full telemedicine capabilities, is presently awaiting funding.
Phase 1 – Pilot System Testing:
For the Phase I pilot trial, East Baton Rouge EMS contracted General Devices, of Ridgefield, NJ, to supply an e-Bridge Telemedicine System, which was installed in two city ambulances. A General Devices’ CAREpoint Workstation was installed in the emergency department (ED) of Our Lady of the Lake Regional Medical Center to serve as the hospital end of the system.
The system used an existing broadband wireless system within the City of Baton Rouge to provide high-speed connectivity between the ambulances and hospital, permitting bi-directional transmission of video, voice and data. BR Med-Connect was inaugurated on March 12, 2009, with the event being televised on three area TV stations and noted in the major EMS journals.
Over the following year, the telemedicine system was found to meet the operational requirements outlined by the city’s EMS agency, allowing the project to move closer to parish-wide deployment.
Phase 2 – Parish-Wide Deployment in the ED:
By mid-2010, funding was approved for Phase 2 of BR Med-Connect, whose objective was to equip all five of the region’s hospitals and the Office of Emergency Preparedness (OEP) with the ED elements of the system. These hospitals are: Our Lady of the Lake Regional Medical Center, Ochsner Health Center, the Blue Bonnet and the Mid-City campuses of the Baton Rouge General Hospital, and Lane Regional Medical Center. The Baton Rouge Office of Emergency Preparedness also received an EMS/ED system to address disaster-related issues.
BR Med-Connect’s bi-directional video, voice and data system consists of General Devices’ CAREpoint Workstations; Rosetta–DS Data Translators; the hospital component of the e-Bridge EMS Telemedicine system and the e-Net Messenger secure messaging system.
The CAREpoint Workstations integrate all ED-EMS activities, communications, documentation and information management, that takes place in the emergency department. The Rosetta-DS is a laptop or tablet-based component for transmission of pre-hospital 12-Lead ECG reports from the ambulance monitor to the hospital over digital radios, cellular air-cards, cell phones or any IP network. The hospital e-Bridge components allow interfacility telemedicine and teleconferencing and the e-Net Messenger system provides a fast and secure means of exchanging voice, text, data or multimedia messages between the hospitals, OEP and standard PCs.
The hospital equipment was fully installed, tested and operational by the end of February, 2011. Once installed, the BR Med-Connect system began managing all day-to-day EMS activities and ECG transmissions. For communications, the system uses existing radio and landline and cellular telephones. 12-Lead reports are sent from existing ZOLL monitors using existing laptop PCs running Rosetta-DS. As reports are received, they are displayed, archived and reviewed on the CAREpoint Workstation and then forwarded by e-Net Messenger to the cath lab or the physicians’ offices or mobile phones.
When initially asked if they were interested in receiving 12-Lead reports from the field, some of the cardiology groups were skeptical because of concerns about the possibility of patient mix-ups. Once the cardiologists understood that the Rosetta/CAREpoint system allowed a secure, fast and simple means for medics to solve this problem by adding the EMS crew number to the report, they quickly lent their support to the program. e-Net Messenger was chosen to distribute the reports because of its security, speed, surety of delivery, tracking, and, most importantly, message arrival notifications.
The scope of this phase of the BR Med-Connect project was considerable, requiring EMS, hospital and General Devices personnel to coordinate the installations and testing of the equipment at the five locations, the training of EMS, ED and OEP staffs at the various EMS agencies and at all five hospitals and the OEP, as well as training of the ED physicians and multiple cardiologists. General Devices personnel were responsible for the initial training of hospital and EMS personnel using a combination of on-site and WebEx “train-the-trainer” sessions for EMS and hospital supervisors and staff who, in turn, trained their staff. The use of WebEx proved not only convenient to all concerned, but was also extremely well received.
At present, all day-to-day EMS operations in the parish are managed by the five EDs on the BR Med-Connect CAREpoint Workstations, with all calls automatically documented by the system’s digital logging recorder. After completion of their training, East Baton Rouge EMS’ medics began acquiring and sending 12-Lead reports from their ZOLL monitors, through the GD Net secure server and to the EDs’ CAREpoint Workstations. After review by an ED physician the reports are electronically forwarded by e-Net Messenger to the cath lab and/or other destinations as needed. Upon the 12-Lead’s arrival in the cath lab, a distinctive audio/visual alert notifies cath lab personnel of the incoming 12-Lead reports, and the ED is automatically notified when the report is opened. Should the report not be opened, the ED is automatically alerted.
In addition to managing the regular activities of EMS, the system’s e-Net Messenger also provides inter-facility messaging capabilities for everyday and disaster-related communications. This allows ED personnel to quickly and easily send fully encrypted text, voice, data and images to any or all of the other hospitals, the OEP, or to other destinations, and be notified when these messages arrive. This capability is of particular importance in Baton Rouge because of the constant threat of man-made and/or natural disasters that may affect the enormous petroleum and gas facilities in both Baton Rouge and the outlying regions. The region not only possesses the largest oil refinery in the United States, but it is also the distribution point for all the major gas pipelines coming from the Southwest. The ability to use a secure messaging system allows for improved coordination of multi-agency activities ranging from complex disaster related activities to simple everyday tasks such as locating and securing supplies.
Phase 3 – BR Med-Connect’s Next Steps:
The third phase of the BR Med-Connect project will be to equip all of the parish’s ambulances with the mobile components of the telemedicine system (cameras, Rosetta-VC controllers, etc.) for which funding is presently being sought. When fully operational, BR Med-Connect will represent one of, if not the, largest deployment of EMS Telemedicine systems in the world. The arrival of the Verizon 4G cellular system in BR Parish in the second or third quarter of 2011 will provide connectivity of sufficient bandwidth to support image and data transmission throughout the Parish without the need for a special broadband wireless system. This type of “off-the-shelf” connectivity without the need for an extremely costly infrastructure will prove pivotal in the world of EMS and, in particular, EMS Telemedicine.
With BR Med-Connect telemedicine in place, East Baton Rouge EMS will be able to implement programs such as: physician-guided and fully documented treat-and-release; advanced forms of early stroke assessment; firefighter rehab; documented refusals; physician involvement in difficult cases; paramedic protection from false claims; burn patient assessments, and many other forms of advanced prehospital care. Baton Rouge EMS leaders are also considering extending BR Med-Connect telemedicine capabilities beyond the ED and directly onto the physicians’ hand-held devices or office desktop PCs.
Much like the two phases already accomplished, equipping all of the Parish’s ambulances with telemedicine capability and incorporating it into regular practice will be a considerable effort, involving not only the installation and testing of the equipment, but also having the medics, nurses and physicians learn how and when to use these advanced capabilities. Within telemedicine circles, the term “disruptive technology” is used regularly to describe the far-reaching effects of telemedicine on existing medical practice. How far will these changes affect EMS Telemedicine? Some of the issues that will have to be addressed include patient confidentiality, privacy and record keeping, as only some of the new policies and procedures that will have to be developed by EMS and each of the participating hospitals. Because the trust and support of the medics is essential to success of the system, their concerns, including the “big brother” aspects of EMS Telemedicine will have to be addressed. To insure that the system works when it is needed, a regular test and maintenance program, much like other daily or shift-based equipment and vehicle checkouts, will have to be instituted. Similarly, ongoing training programs for both EMS personnel and nurses will be required. Budgetary issues, including who will pay for operating costs, will have to be resolved. Management of telemedicine related ED activities such as when and how physician involvement is required is yet another matter that each of the participating hospitals will grapple with. These are only some of the many issues that will arise as BR Med-Connect moves closer to its final goal and, without question, many more will surface before, during and well after the system is implemented.
It is hoped that the coming year, despite the many budgetary cutbacks we are seeing across the nation, we will see BR Med-Connect continue to progress all aspects of patient care and with new EMS Telemedicine applications identified, implemented and studied. It is expected that the improvement in EMS, disaster response and related ED activities already seen from the system will be expanded to include the full benefits of EMS Telemedicine and that this system will become a model for others to learn from and follow.
*Content carried over from prior GD website: Published dates may not be accurate.