Introduction
Natural and intentional disasters can unfold quickly and cause a variety of injuries to a large number of affected individuals, necessitating both immediate and sustained medical care. While the timely extrication, stabilization, and transport of injured victims of mass casualty incidents is a cornerstone of emergency medical and trauma care, medical responses are often impeded by overwhelming numbers of patients and the limited number of available medical personnel and resources, resulting in delayed treatment [
25]. Major disasters such as earthquakes or hurricanes may also damage infrastructure within the affected area, such as communications facilities and roads, further impeding the delivery of medical personnel and material resources from external sources, including neighboring communities, humanitarian organizations, and State and federal sources.
The fundamental premise of telemedicine is that voice and data linkages permit medical services to be provided remotely. When equipped with basic telecommunication devices that can be deployed by mobile units, responders at the scene of a disaster can quickly establish telemedicine linkages. This would potentially increase both the speed and the capacity of medical response and make it available when and where it is needed. Applications of telemedicine to disaster response began in the mid-1980s. Following the devastating 1985 Mexico City earthquake, NASA provided advanced satellite communication technology to support the international relief and rescue operations [
27]. After the 1988 Armenian earthquake, telemedicine was employed to provide clinical consultation to several regional hospitals via the U.S.-U.S.S.R. Space Bridge project [
2,
27]. In this decade, telemedicine has been more widely used in various ways in response to disasters including earthquakes, tsunami and hurricanes [
1,
10,
13,
14,
24]. In addition to response to real disasters, numerous telemedicine experiments, exercises and simulations of “staged” disasters have been carried out worldwide to evaluate the usefulness and performance of telemedicine systems [
12,
20].
Many in the emergency medicine and preparedness community believe that, based on the observed value of existing telemedicine capabilities for disaster management, more advanced telemedicine systems will greatly facilitate disaster response. However, support for this belief is mainly based on expert opinions, case studies, or anecdotal examples. Many questions arise as to how to most effectively apply and integrate telemedicine into a regional response framework. For example, what is the role of telemedicine in existing protocols and guidelines for disaster response? How can external physicians and other resources be mobilized in such an incident through the use of telemedicine? What are the appropriate infrastructure and information systems to support telemedicine interventions in the event of a major disaster?
To address these issues in a quantitative fashion, we examined whether the concept of a regional telemedicine hub (TMH) is the best organizational model to enable efficient, effective, and equitable delivery of medical services to a target population in the aftermath of a major medical disaster. The establishment of a telemedicine network with a regional hub has significant policy implications, such as the coordinated selection of communication platforms and information systems, the consolidated management of resources in a target area, and the facilitation of NIMS (National Incident Management System)-compliant centralized command and control centers to direct the healthcare response for disasters. However, while a regional telemedicine hub with an extended network has the potential to alleviate multiple problems during disaster response, there is no consensus about how to quantify the health-related benefit associated with the proposed organization model [
8]. In this paper, we describe a comprehensive quantitative analysis that assesses the benefits of the telemedicine hub concept in emergency response for a hypothetical earthquake scenario.
Discussion and conclusion
The study presents quantitative results of a simulation study testing the concept of a telemedicine hub (TMH) for patient treatment during the acute phase of emergency response. Our results suggest that a TM-enhanced strategy of preserving local management of disaster victims (i.e., not sending large number to the DRC) may improve the coordination of resources between the receiving center and peripheral treatment facilities, resulting in better health outcomes. With essentially the same resources (i.e. local and DRC ED beds and health care providers), health outcomes are typically better when telemedicine is used in disaster scenarios of various scales. We believe the proposed TM Hub model provides a useful planning and training platform for regional disaster response preparations. Previous work has suggested that the potential roles of telemedicine in disaster situations can be categorized as follows:
(1)
Improved situational awareness and communication.
The impact of disasters can be unexpected and extensive, resulting in destruction of ground communications and transportation facilities in addition to casualties. The Mexico City earthquake of September 1985 disrupted all land-based forms of communication in the city, except for a few ham radio operations. Thus the satellite link NASA provided within 24 h of onset of the disaster was vital for the international rescue and relief efforts [
7]. During multiple humanitarian support missions that the SMART Team, a United States military telemedicine team, carried out in Africa and Pakistan in 2005, they observed that sometimes the most critical tasks were focused on providing communications capabilities, while the amount of actual telemedicine activities may be small due to other limitations [
14]. In the response stage of the 2008 Sichuan earthquake, mobile phones and telecommunications equipment were among the first batches of materiel air dropped to the most heavily impacted regions [
19].
(2)
Assistance in field triage.
A large natural catastrophe or disaster often results in an overwhelming number of casualties. In such incidents, priority of medical care is often given to initial patient triage, acute care in the field and rapid patient disposition. The ability to obtain accurate information on the victims in a timely manner is critical to the success of continuing medical response [
11]. Electronic triage tags, as well as other documental and communicational telemedicine facilities such as hand-held first responder devices (PDA’s) and online data centers, have been put to the test in various simulated and actual disaster events [
11,
17,
21]. This new telemedical triage system overcomes many limitations of the current paper triage tags; its advantages include real-time data transmission, improved capability for documentation of injuries, improved accuracy for information transfer, weather resistance, etc. As advances in miniaturization of computing and wireless technologies continue, the use of telemedicine for triage in future mass casualty incidents is expected to grow significantly.
(3)
Augmentation of local medical surge capacity.
When disasters happen, the capabilities of local medical care facilities can be severely compromised. Local hospitals and clinics may be physically damaged or inaccessible, communication with the outside world may be severed or insufficient, and medical care givers may be unable to reach the scene due to the effects of the disaster. Even with infrastructure intact, various types of injuries resulting from the disaster may require medical specialists that are not available in the affected region; in addition, the sudden surge casualties and overwhelming demands for care present a serious challenge to the effectiveness of medical response. Telemedicine can be used to provide external help in a relatively short time frame. In addition to assisting with pre-hospital management such as initial triage, previous reports document other ways to rapidly deploy telemedical capabilities, such as in mobile field hospitals [
14] and via email and video consultations [
10,
20]. In one case, remote physicians were virtually brought to scene via telemedicine to boost the medical capacity of doctors and first responders in the field for providing a range of care including diagnosis, treatment, monitoring, etc. [
3].
(4)
Enhanced planning and preparedness.
The community involved in disaster response activities have come to realize that the effectiveness of disaster relief efforts, including those of a telemedical nature, depends heavily on the availability, accessibility and deployability of various resources including people (such as responders and physicians), infrastructure (such as equipments for communications), information technology (mobile communications devices, base stations, GIS, online databases, expert systems), and reserves of resupply materiel (e.g., batteries). The resources need to be prepositioned or rapidly deployable in order to be utilized at the time of crisis. Numerous planning groups have been formed, and drills exercised, often via advanced virtual reality technologies, to establish and evaluate the resource requirements, data gaps, and the efficacy of process management structures to enable effective telemedicine capability [
7,
20,
29].
(5)
Delivery of post-response support, rehabilitation and education
In the aftermath of a disaster, telemedicine can continually provide post-traumatic patient management and support such as telemonitoring, telepsychiatric care and telerehabilitation education for the affected population. Surveys indicate that applications in this area are most encouraging; they can be more cost-effective for both care providers and patients [
26], and the quality can be comparable to that of the traditional means [
28]. In some reported cases, patient care was considered improved due to customizable telerehabilitation programs [
4]. Existing telemedicine networks and facilities also provide a platform for disaster-related research, such as information sharing, tele-education and e-training for injury types, disaster epidemiology, and medical management strategies.
In all the scenarios we considered, we observe that application of telemedicine helps local EDs serve more patients locally while maintaining lower ED bed occupation rates by reducing patients’ waiting (boarding) times, hence utilizing resources more efficiently. On the other hand, properly functioning TMHs will require rapid access to external specialists for optimal performance. That is, the benefits of telemedicine in heavy demand disaster scenarios require the rapid availability of external specialists, stressing the need to establish and maintain such resources for emergent uses.
For these external remote specialists to contribute to the emergency response operation, they need to be part of a regional telemedicine network that can be quickly accessed and put to use during crises. If such a network has not been established or properly maintained, emergency telemedicine support to local disaster areas may have to be sought manually via coordinators from the center. This working process, however feasible in regular times, may result in aggravated demand on the coordinators and processes at the center, as well as deteriorating system performance, especially for scenarios of major scale disasters with heavy demand at the center already.. We cannot assume that telemedicine without external specialists would still result in improvements in the demand-intensive scenario.
We have developed a model that is generally applicable to the design and functioning of telemedicine systems for disaster response. However, it has several important limitations. First, we did not model the incorporation of, and impact of telemedicine activities on, command-and-control systems such as ICS as well as other disaster response systems such as EMS. Second, the model requires a number of assumptions about patients’ arrival patterns at the local facilities, injury types that may present, scales of patient’s injury severity, as well as representation of various treatment processes and time-dependent mortality. Although the simulation is able to describe the overall medical response process (sequence of events and resource requirements), more complex models will need to be constructed and to represent more complicated issues that arise in reality. Last, the simulation presented here is an analytical tool, but not an optimization tool. It may be used to evaluate the performance of alternatives (such as different queue length threshold values for transfer rules) in various scenarios. However, it is not able to directly provide a solution, or suggest a policy, that can be used to guide the operations and routing directions within the process. This model shows that existing telemedicine technology can be applied to current disaster response activities to enhance surge capacity of the healthcare system and the speed and effectiveness of medical response, to facilitate communications and improve resource and operations planning, and to increase situational awareness within the command and control system and overall community.