Telehealth and Systems Reengineering

To address these issues, there has to be an associated business case that justifies embarking on a telehealth implementation. For telehealth to be a serious proposition as a standard part of the emergency response, it must have clear clinical and economic justifications. Supplementing existing routine and emergency healthcare delivery systems with telehealth is a sophisticated process. It requires major reengineering of current healthcare delivery systems. Redesigning a system involves more than merely adding telehealth technologies and their supportive information platforms to deliver essentially a duplicate version of current services. A “provide the technology and they will use it” approach to telehealth implementation without an accompanying change in management’s agenda is likely to fail. Rather, fundamental changes in clinical and 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, clinical change management, and associated organizational development. Although simulations and pilot projects exist, the widespread investment necessary to implement these changes and maintain the ongoing clinical, technology, and business processes for telehealth networks has not yet been made. Decision-makers should carefully consider this investment before implementing telehealth programs. Once such changes are made to incorporate telehealth into standard practice, there is no easy method for reverting back to implementing the previous technologies. 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 anticipate reversing the process.³ Resources to reverse implementation of this system would include recreating X-ray film archives, reemploying staff, reinstituting radiology storage rooms, and then investing in additional equipment and staff training. This brief description of the business process reengineering that accompanies the implementation of picture archiving illustrates how telehealth application requires a systems approach, one that usually creates multiple interdependencies. Risk management strategies associated with telehealth require the clinical, technology, and business components of the new system to be documented, managed, maintained, and updated. Creating an initial telehealth project or program is complex, and its long-term support and maintenance is infinitely more so. Such support processes for a new program include staff training, quality management, systems maintenance, ongoing contracting, and a continuity of operations plan (COOP). The vital roles of training and maintenance/support are often neglected when considering implementing a telehealth system.

The benefit of connecting local hospitals and their associated clinicians with the site of a public health emergency is well described.³⁷ This chapter assumes general familiarity with such point-to-point approaches to telehealth in disasters and will therefore concentrate on the systems approach to create interoperable telehealth networks.³⁸ The magnitude of public health emergencies, and the challenges they present, require that telehealth provide a sizable and reliable resource that deals with the associated substantive problems in an efficient, effective, and consistent manner.

The will, financing, and focus involved in undertaking a widespread systems reorganization to implement a telehealth program requires that decision-makers embrace change. Which of these drivers is the eventual vehicle of change will vary according to circumstances. In the case of implementing technology-based telehealth solutions, the pace of change typically depends on the baseline level of technology sophistication within the organization.³⁹ In regard to telehealth’s role in supporting emergency preparedness, there are currently some innovators and early adopters, but a preponderance of traditionalists remain resistant to these programs. Given this general resistance to organizational change, and a comfort with the traditional emergency response, there is currently no overarching driver at the operational, policy, or political levels that supports the changes involved in creating and then sustaining telehealth networks. Understanding how these systems will eventually evolve and implementing the clinical, technological, and business systems to support telehealth is neither a conceptual exercise nor a question of fashionable technologies. It must be based on pragmatic considerations of underlying patient care needs in population terms coupled with appropriate support systems. This needs-driven approach to shape systems that support care requires a service-oriented architecture in an organization, something that will be discussed later.⁴⁰

Health Needs as Drivers of Telehealth Implementation for Emergency and Disaster Management

Developing telehealth networks to support public health emergencies requires a clear understanding of population-level patient needs whether voluntarily adopted in the short term or imposed out of necessity in the future. Telehealth must function to: 1) manage these needs more effectively than can be done by the elements of the traditional emergency response; 2) offer solutions at lower cost; and 3) protect healthcare workers. Meeting these stipulations raises the following questions:

A case for creating telehealth networks to systematically support emergency services requires more than a commitment to embracing new technology. The successful creation of telehealth networks 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 mainstream 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 disasters are unpredictable in terms of their causation, timing, occurrence, location, and the damage and disruption they produce. The RAND Corporation defines public health emergency preparedness as:

The main mission for public health emergency preparedness is, therefore, to provide an anticipatory response to unpredictable events. Conceptually, this response prevents, proactively manages, and adapts to the changing way in which most disasters unfold. The traditional emergency preparedness approach has been based on managing this unpredictability by creating systems that seek to impose elements of certainty. Such elements include:

This traditional approach to preparedness of defining certainty in relation to public health emergencies is essentially an exercise in Newtonian physics. This classical physics theory takes a linear view of systems, one in which knowledge of the constituent parts allows its behavior to be accurately predicted. 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 technologies have fostered new approaches to the logistics and management of situations from industrial production to military conflict by enabling the operations of just-in-time systems. This creates a more flexible and adaptable response, one that replaces the Newtonian view of events with one that views situations as part of a complex adaptive system. This changed approach is relevant to the role of telehealth networks in providing flexibility and adaptability to healthcare services in an unfolding public health emergency.

Telehealth offers ways in which population needs for healthcare services can be addressed dynamically. The traditional Newtonian 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. The appropriate resources to meet these needs have been considered and are potentially accessible. It is the logistics of ensuring 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 disaster or to provide urgent support in areas of neglected healthcare delivery. As with the delivery of routine healthcare services, the main benefit of telehealth in emergency and disaster management is that it allows for the reengineering of clinical processes and a flexible response to changing circumstances.

Since 2010, the horizon for telehealth has radically shifted and continues to evolve. The advent of smartphones will significantly change the complex adaptive response that telehealth can offer. Before the smartphone, use of telehealth in emergency and a disaster management response usually required deployment of telehealth assets that were expensive, inflexible, and largely in the hands of emergency responders. Connecting disaster victims to emergency responders required the victims’ physical co-location with the telehealth technologies. However, with the advent of the smartphone, its potential new role in telehealth may facilitate a quantum change in emergency and disaster management. This device could effectively place telehealth technologies in the hands of the affected population and enable a personalized response aimed at these affected individuals. Such changes could replace the current stylized logistic response that is frequently mismatched in size, scope, and specificity for the event to which it is deployed. Apps on smartphones have the potential for:

There are a myriad of challenges that require resolution to reliably use smartphones as part of an emergency response. Apart from creating the necessary apps, data exchange systems, and associated communication policies, telehealth programs must adhere to regulatory privacy and jurisdictional requirements. Although using smartphones in this way may be piloted at the city or state level, it will ultimately require national government coordination and involvement. Standards and regulation will be critical in achieving this result.

A typical emergency response encompasses a wide spectrum of primary, secondary, and tertiary healthcare needs. Such a response usually involves governments at the local, state, and federal levels. It necessitates these bodies working collaboratively with nongovernmental organizations (NGOs) and volunteers. A range of professional and allied staff may be involved at various stages including engineers, aid workers, volunteers, law enforcement, water and sanitation workers, transportation and healthcare professionals, and public health representatives. The public health emergency response includes much more than healthcare services alone. Such services, whether delivered physically or via telehealth, must be considered within the context of the wider response. The information technologies, videoconferencing capabilities, and telecommunications bandwidth necessary to support telehealth is equally applicable for non-healthcare 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 emergencies, 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 during the phases of a disaster, including allowances for unexpected contingencies. Embedding telehealth within current healthcare services systems can be accomplished by introducing it directly into existing strategies and programs. For example, the breakdown of routine transportation services during a disaster can be mitigated by implementing a telehealth program.

The example of using telehealth in situations where there are transportation difficulties is one of many possible scenarios. There are endless combinations and permutations whereby telehealth can be incorporated into an emergency response. In August 2005, Hurricane Katrina illustrated how a sudden loss of critical infrastructure could rapidly render inadequate the ability to deliver healthcare to the population. Telehealth was deployed during Hurricane Katrina, but without a coordinated approach for incorporation into the traditional emergency response.⁴³ Telehealth can assist with the provision of basic emergency response elements as shown in Table 26.1.

Mounting an effective emergency response with telehealth is dependent on attention to detail. Assessments of the disaster response to Hurricane Katrina, the Indonesian tsunami, and Hurricane Sandy in 2012 are prototypical of all such responses.⁴⁴ They suggest there could better coordination of agencies and assessment of needs in the local community to ensure the resources deployed are appropriate, efficacious, and cost-effective. A glimpse of how smartphones can assist in these complex tasks as a telehealth modality was shown in Hurricane Sandy. During this storm, one of the top application (app) downloads was the Red Cross Hurricane App, which combines a storm tracker with emergency functions such as a flashlight and alarm.⁴⁵ The app also features a first aid database and a notification system for quickly and easily informing loved ones of a person’s safety.

As with non-emergency healthcare, progress is being made to standardize the response elements to a public health emergency.^46,47 Since the destruction 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 disasters in the United States has received increased scrutiny by politicians and the general public. As a result, new funding opportunities have arisen, and with them have come enhanced expectations of safety and security for the public. With increasing accountability for a return on investment in emergency preparedness, the issues of dealing with unpredictability and uncertainty receive greater attention.⁴⁸ For example, the elusive search for a solution to containing the threat of pandemic influenza has sharpened the attention of governments on the financial accountability of emergency preparedness systems.⁴⁹ As the following telehealth emergency response scenario shows, managing the consequences of pandemic influenza exemplifies 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 collaboration 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 outpatient locations. Home and community settings (e.g., community centers and hotels) could 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 employing telehealth, fewer healthcare 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 professionals will also become infected, thereby reducing the workforce. Home telehealth-based quarantine systems, if adequately designed and appropriately engineered, offer a solution to the lack of surge capacity. Figure 26.3 depicts a healthcare professional managing a population 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.

Figure 26.3.

Population Management via Home Telehealth.

The most significant benefit that telehealth brings to healthcare delivery, whether providing routine care or emergency care, is that patients can receive care at their location, and don’t need transportation to a specialist. Healthcare decision making often takes place in hospitals. Telehealth makes it possible to move the locus of healthcare decision making from the hospital to home or a local community setting. When the physical locations of patient and practitioner are changed through 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 can provide supportive care during public health emergencies.

Individuals who are being treated for injuries sustained in a disaster may have existing medical histories that impact how, where, when, and even if they should continue to receive care. After the initial patient assessment is performed at the disaster site and health-related problems are detected, patients begin receiving treatment. 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 a prior baseline. If the patient requires evacuation and subsequent care is undertaken at a different location by another clinician, information about the preceding treatment regimen, such as medications or surgeries, should 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 that the necessary processes are in place to coordinate patient management. If these processes are not in place, telehealth can 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 medical 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.⁵⁰ Many telehealth applications have rudimentary 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 with modules for pharmacy and applications that 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. Implementation of EHRs is proceeding to varying degrees, at variable paces, and with differing success rates in healthcare systems worldwide. The EHR is vital to 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 monitoring 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 a population’s needs would allow a dynamic response with coordination of healthcare services within a wider emergency management context at the local, national, and international level. This would help manage the logistics of evacuating casualties to outside regional medical facilities. The EHR also could facilitate consistent epidemiological surveillance of those affected by a public health emergency. If an EHR had existed to assist with patient management during the sarin incident in Tokyo, for example, 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 information technology to coordinate care has been recognized at the policy level.⁵¹ 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 its 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 continuum of care associated with an emergency and disaster response, just as it does in routine healthcare delivery. It facilitates changing 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 visit traditional hospitals in order to receive expert assessment and care. EHRs and telehealth enable a much more flexible approach to the delivery of care. Major changes in healthcare, emergency, and disaster management often follow what occurs on the battlefield. The Korean War introduced the concepts of rapid evacuation and the mobile army surgical hospital that persisted as standard operating procedures throughout the Vietnam War and until the end of the First Gulf War. The acute management of wounded soldiers 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 exemplified by the evacuation process for patients in the New Orleans VA Medical Center who were relocated to other VA centers in advance of Hurricane Katrina in 2005. The EHRs for these evacuated VA patients were available nationally within 48 hours.⁵² 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 chronic care for existing health conditions. In a population that is aging and suffering from an increasing burden of chronic disease, public health emergencies affect the daily 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 technology systems to communicate, coordinate, and evaluate complex undertakings. These systems resolve logistical problems in analogous 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 systems. It is a considerable challenge to implement the hardware and software components of an EHR. Implementing an EHR with the associated training, information technology support, cyber security, interoperability, and other modular components it requires (such as laboratory and blood transfusion packages) is a colossal undertaking. To succeed, an EHR project must be well planned, particularly in developing countries. Key principles are listed in Table 26.2 for the implementation of information technology systems in developing countries to support routine operations.⁵³ These same principles apply to projects in developed nations and to telehealth systems.

Table 26.2.

Recommendations for Implementing Information Systems Nationally and Internationall|y

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