Feature Story

FIRST RESPONDERS NOT FIRST FOR IT BUT CHANGES ARE COMING AS VOICE, DATA CONVERGE AND DISCUSSIONS GET

After 32 years as a paramedic, Kevin McGinnis is still waiting for the information technology revolution to make inroads into his profession. "Our communications technology has not changed significantly in the past 30 years," says McGinnis, who works at Winthrop (Maine) Emergency Medical Services.

But McGinnis, a former state emergency medical services director and currently a program advisor at the National Association of State EMS Officials, sees big changes coming to the field soon.

Today, he estimates 98% of communication between paramedics, dispatchers, hospitals and others is by voice. Industry research, however, suggests that number will fall to 70% within five years, with 30% of communication being done via electronic data, he notes.

In recent years, a number of software vendors have offered information systems that enable the creation of the "run reports" emergency service personnel need to complete after every patient encounter. Run reports generally are done on paper forms with a copy left at the hospital and a copy brought back to the paramedic's base office.

Now, some ambulance services have software on computers in the office and on paramedics' laptops, enabling completion of the reports and downloading to a database. But in many cases the hospital still gets a paper copy. In other cases, the hospital has the software on a dedicated computer, which enables the information from paramedics to go into the patient record, and the base office gets a printed copy.

So, while progress is being made, the software often is automating only part of the manual report creation process. What excites McGinnis is the potential for I.T. to play an integral role in the field treatment of patients. "Now is a tipping point for the EMS industry," he says. "EMS is going from paper to electronic data collection and there will be pressure from hospitals to transmit the data to them."

In Congress, there is movement to bring emergency medical service workers and other first responders into the information age (see story, page 48). The American Health Information Community, a federal advisory group chaired by Health and Human Services Secretary Michael Leavitt, is encouraging development of a standards-based electronic emergency health record. Further, standards development organization Health Level Seven, Ann Arbor, Mich., is developing applicable standards for that health record.

McGinnis' message to the first responder community: "It's a watershed moment."

Bridging the gap

For decades, voice and data have been separate entities in the emergency department medical services field, McGinnis says.

But efforts to bring first responders into the information age are leading to work to converge voice and data communications.

For instance, McGinnis' ambulance has a VHF radio, UHF radio, cell phone and satellite phone, the latter of which he calls "extremely expensive" to use.

McGinnis uses whatever device he needs to get a good connection to dispatchers or an emergency physician from wherever he is. What he wants is a single, all-in-one device with all four technologies embedded and with buttons that provide direct links to various hospitals. "During a cardiac arrest, I want to hit a button that says 'Hospital X' and a single radio searches for the best means of transmission."

Work is being done on several fronts to bring such technology to paramedics and other first responders. The SDR Forum, an association that promotes the development of software defined radio technology, is bringing together stakeholders to develop next-generation radio communications.

Within the forum is a group of radio engineers and public safety responders trying to make McGinnis' wish come true. "They are meeting to design the radios of the future that will enable us to talk to whomever we need at the moment we need to, with no second thought of interference or lack of signal," he explains.

Information on SDR Forum is available at www.sdrforum.org. Other sources of information on next-generation voice communications for first responders include the National Public Safety Telecommunications Council, at www.npstc.org, and the SafeCom Interoperability Program of the Department of Homeland Security, at www.safecomprogram.gov.

In recent years, a growing number of first responders have started using medical reference software loaded on PDAs to help treat patients in the field.

Each of the 40 medical professionals at Boston MedFlight, for instance, have PDAs and reference content from Skyscape Inc., Marlborough, Mass. Bill Cyr, a flight nurse/paramedic and operations manager at Bedford, Mass.-based MedFlight, suspects use of PDAs remains the exception rather than the rule, but adoption is becoming more common, especially in New England.

Today, half of paramedics hired at MedFlight already have PDAs, and the organization pays for reference titles that they need. Some personnel just want a few reference sources, like a drug database and general critical care guidelines for children and adults. Others have a dozen or more titles. All the PDAs include MedFlight's proprietary standing orders and protocols.

MedFlight has three helicopters, one fixed-wing aircraft and two critical care ambulances. "We transport patients from one hour old to 100 years old with any possible medical problem you can think of," Cyr says.

The organization started the PDA program six years ago by putting a device in each unit and over time started distributing them to each professional. The investment isn't small but it's not huge either, Cyr says; it helps that hardware and software prices have fallen in recent years, he adds.

But the return on investment has been substantial. "The feedback we receive from each individual who uses the PDA is it is an indispensable tool," he adds.

When a MedFlight transport is ordered, clinicians initially have limited information about the patient's conditions and needs. They may know, for instance, that the patient is a newborn with a congenital heart problem. Before arriving on the scene, Cyr will pull up research on the condition to assist in planning a course of treatment. If the initial examination of the child indicates treatment plans need to be revised, he immediately can look up additional information on the PDA.

Indeed, the PDA-based reference content is especially useful when treating newborns, Cyr says. "We don't see newborns often, but when we do they are very sick."

The use of field-level computing devices in emergency medical services may still be low, but Cyr sees rapid adoption coming soon. For example, many EMS organizations are starting to use mobile devices to support electronic charting implementations, he notes. MedFlight, for instance, last month outfitted all its transport units with Tablet PCs loaded with charting and reference software.

The next step

Other organizations also are working toward moving beyond the PDA stage, and not just for charting purposes.

A half-dozen fire departments serving communities north of Seattle are testing whether mobile computers are effective at collecting and transmitting patient data from the field.

The departments, in Snohomish County, use the Incident Response Information System of Seattle-based Iomedex Corp., running on Dolphin 9500 mobile computers from Hand Held Products, Skaneateles Falls, N.Y.

The goal of the one-year pilot, paid for by a grant of about $300,000 from the Department of Homeland Security, was to determine if the computers are rugged enough and easy to use in tough environments. The pilot concluded earlier this year. "The question is whether the software is intuitive enough to navigate easily under stress and not take away from patient care," says Greg Macke, assistant fire chief for support services at the Lynnwood (Wash.) Fire Department.

In Macke's view, the computers and related software passed the test. "The software is very intuitive," he says. "It can easily be learned in 5 to 10 minutes."

But the devices use cellular technology to transmit data to a secure Web site hosted by Iomedex for hospitals to access, and cellular coverage during the pilot was not always optimal. "We still have to get over that hump," Macke notes.

During the pilot, the mobile computers were used during regular emergency runs and in a mock evacuation drill. The devices were used not only to collect and transmit patient data, but also to track patients-and first responders.

The computers, which can be held in one hand but are considerably larger than a PDA, also can take a digital photo of a patient. The software then assigns a unique identifier to the patient and prints a bar code on a wristband.

The photo, triage information and transit status information were transmitted to the hospital via the secure Web site either immediately or when a cellular connection was established. All data was encrypted during transmission. "It's a viable solution, but it remains to be seen how to most effectively use it," Macke says.

For instance, he's not yet convinced mobile computers with such capabilities are needed in all first responder vehicles. The real value, Macke believes, may be in better response to mass casualty events.

That's because when working with small groups of patients, paramedics typically are engaged in one-on-one conversations with emergency physicians via cell phone, he adds. "There's certainly value in getting a record started on every person in a disaster-where they are and how seriously they're hurt. It can easily be done with something like this."

While open to other options, Macke suspects that strategically placing mobile computers throughout a region for use in a mass casualty event may be the most appropriate use of the technology.

Besides tracking patients, making it much easier for loved ones to get information, the computers and secure Web site also can track responders and their capabilities. For instance, a regional system could have identifying information on emergency personnel and clinicians in a database, available for instant recall during a disaster.

"If someone shows up in civilian clothes claiming to be a doctor, you could verify who they are and what type of training they have," Macke says. "You could put everyone to work in the right place."

An early stage initiative to establish a countywide, broadband public access Internet service in Snohomish County in northern Washington could form a reliable infrastructure for using the mobile computers.

While the computers transmitted data via cellular technology during the pilot program, they also can transmit using Wi-Fi technology over the Internet. In that case, cellular would be a back-up transmitting option.

The county-driven Internet program has commitments from most local cities. Whether the infrastructure would be completely open to the public or a mix of public and private access hasn't been decided. Security, however, would have to be paramount to protect patient medical and law enforcement investigational data, Macke says.

Some first responders see public Internet access programs as an attractive way to get the communications network they need, says McGinnis, the Maine paramedic.

But first responders need to be wary about signing on to use citywide or countywide systems, he cautions. "These are unlicensed systems that anyone can get in. If you use them, you darn well better make sure they are secure."

Pinpoint positioning

Air ambulance crews often have a hard time locating the geographic reference points they use to guide them to an accident or disaster scene, delaying arrival time.

Use of global positioning systems can connect first responders on the ground with those in the air, giving the exact latitude and longitude locations of the scene.

In 1999, air ambulance service Northwest MedStar began giving GPS devices to emergency agencies in its service area for use by paramedics, search and rescue units, and police and firefighters.

The devices, compatible with equipment in MedStar's three helicopters, help the pilots pinpoint where they are needed. Previously, "We spent a lot of time spinning in the air looking for the scene," recalls Steve Harris, program operations manager of MedStar, operated by Inland Northwest Health Services of Spokane, Wash.

The GPS giveaway ended in 2005 after distributing a total of 379 devices. The goal, Harris says, was to put a device in nearly every responding vehicle in the service area. The costs-about $45,000-were paid by several grants from state government agencies, corporations and private foundations.

MedStar serves Eastern Washington, Northern Idaho, Western Montana and Eastern Oregon and is responsible for providing fast transport of critically ill or injured patients to local hospitals.

The GPS devices also help lessen the anxieties of patients and first responders, Harris says. Pilots can give an estimated time of arrival based on distance and air speed. This lets patients know that help is coming soon and also lets first responders know how much time they have to prepare a landing site, such as setting up lights at night.

During the initiative to distribute the devices, MedStar officials learned they could be advocates for first responders, Harris says. Local agencies often don't have the means to pay for information technology or know how to use grants to underwrite equipment needs.

Many first responders may only deal with MedStar's helicopters a few times a year. But they have learned the devices can be used for multiple purposes, and many of the local dispatchers and search and rescue units now routinely use the technology.

In the next year or so, Harris hopes to survey the first responder community to determine if updated devices are needed or if more devices should be provided to local agencies. "Time is the most precious commodity we can give to patients."

Sidebar

Congress explores first responder I.T. aid

The Bush administration is moving too slowly to award $1 billion in grants to assist community-based first responders in purchasing interoperable communications, some members of Congress believe.

In congressional testimony on February 8, Department of Homeland Security Secretary Michael Chertoff acknowledged the government likely will not meet a statutory deadline to award the grants by Sept. 30.

Chertoff told the House Committee on Homeland Security that his agency and the Department of Commerce's National Telecommunications and Information Administration had not yet even completed a memorandum of understanding on how to administer the grant program. He pledged that task would be completed soon.

In response, leaders of the House Committee on Homeland Security sent a letter to Chertoff and Commerce Secretary Carlos Gutierrez asking them to speed the entire grant-making process.

"Last June, the committee staff was briefed by representatives of the NTIA and told that a memorandum of understanding was forthcoming and would be completed by Sept. 30, 2006," according to the letter sent to the department secretaries. "To date, the memorandum of understanding has not been completed, and neither department has provided this committee with an explanation for the delay. After repeated requests, NTIA informed the committee staff on Feb. 1 that the Department of Commerce is still in the midst of 'ongoing discussions' with the Department of Homeland Security regarding implementation of the program and adherence to the Sept. 30, 2007, deadline. The delay in the coordination of the grant program flies in the face of two Acts of Congress and the recommendations of the 9/11 Commission. Meanwhile, first responders are left in limbo while federal agencies and departments delay on establishing the billion dollar interoperability grant program."

Early this year, the U.S. Senate also was moving to get interoperable communications in the hands of first responders. Commerce, Science and Technology Committee Chair Sen. Daniel Inouye (D-Hawaii), with bipartisan support, introduced S. 385 to enact the Interoperable Emergency Communications Act.

The bill would mandate awarding of the aforementioned $1 billion in grants by the Sept. 30 deadline and establish additional grant programs. It also would eliminate provisions in federal laws that hinder interoperability.

The committee further began debate on a development of a national broadband information network for first responders. In February testimony before the committee, Charles Werner, chief of the Charlottesville (Va.) Fire Department, explained the benefits of such a network.

"A hardened public safety network would make possible nationwide roaming and interoperability for public safety agencies at the federal, state and local levels," he noted. "It would give public safety access to satellite services where terrestrial services either do not exist or are temporarily out of service. The national build-out would give rural areas-for the first time-broadband coverage and provide public safety a communications tool that would be virtually impossible because of cost under any other scenario."

The wireless communications frequency for a public safety network would come from 24 MHz of spectrum previously allocated by the government for public health.

Werner, representing the International Association of Fire Chiefs, encouraged the Senate committee to further set aside another 30 MHz of spectrum scheduled to be auctioned by next January. "Without legislation taking this out of auction and allocating it for the public safety trust, this one-time opportunity will be lost forever," he said.

But other needs are competing for the 30 MHz of spectrum. CTIA, an association representing the wireless communications industry, contends that the 24 MHz of spectrum already set aside for public safety is more than adequate.

That 24 MHz to serve 3 million first responders is a ratio of 8 MHz per million users, testified Steve Largent, president of CTIA. "National wireless carriers in the United States, on average, use 1 MHz of spectrum to provide service to 1 million customers."

Sidebar

Change is on the horizon

Paramedics and other emergency medical services personnel collect data in the field to complete reports. But for the most part there is little data messaging between field workers and hospitals, the exception being use of wireless electrocardiogram devices to transmit heart data to the hospital.

The lack of data transfer could change in coming years as the National Association of State EMS Officials spearheads development of the National EMS Information System.

In the pilot phase, a number of states are transmitting EMS data to a national database and starting to conduct analysis, says Kevin McGinnis, a program advisor at the association. He's also a paramedic at Winthrop (Maine) Emergency Medical Services.

Further, a total of 53 states and U.S. territories have committed to adopting the pending national network's model data set when they update their pre-hospital data sets that paramedics collect.

"The potential is a system where field providers are creating patient databases and tapping into other databases for information in the course of treatment," McGinnis says. "They can see if a helicopter is available or call in the hazardous materials unit."

He also envisions a time when paramedics, police and other responders can tap into the OnStar vehicle communications system-and similar systems-and talk to victims of a car accident before getting to the scene. Responders also could have access to data in those systems-such as the car's speed and whether air bags deployed-that indicate the severity of the accident. "It will enable us to call a helicopter or extraction team much sooner than we can now," McGinnis says.

Within five years, McGinnis sees himself and other responders dictating descriptive records of the patient during treatment using PDAs wirelessly connected to computers in responding vehicles. Speech would be converted to text and text files wirelessly transmitted to hospitals.

All wireless

At the same time, vital signs monitors would be sending data through PDAs to the computers and on to the hospitals. "We'll be able to create databases for each patient with text notes, graphs of heart rates, vital signs, video and ultrasound diagnostic tests, and send them wirelessly."

McGinnis hopes use of this technology will become common in urban and suburban regions within five years and then expand to rural areas.

But for that vision to become reality, first responders and physicians must work together to ensure they are on the same page. For instance, "We have to decide as an industry how useful video is before setting up broadband networks," McGinnis contends. "We have the technology, but the doctors have to say 'This is something we want to do.'"

The military's current practice of using PDAs to wirelessly access decision support content in the field, and collect patient data and transmit it via a central computer to a hospital, could very well be the model for a national EMS network, McGinnis believes. "If it gets licensed for civilian use, it can take off," he adds. "I and colleagues think this is what our future looks like."

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