A Multidisciplinary Teletrauma Program: Connecting Regional Level I Trauma Expertise To Community and Rural Hospitals Jenna Barber James Murray Ruchi Thanawala Northwestern University MED-INF 498: Capstone Project June 4, 2014 2 Table of Contents Sections Executive Summary 3 Use Case Pre-Teletrauma System Post-Teletrauma System 4 4 5 Background 6 Benefits Access to Specialists Evidence-based Resource Allocation Knowledge Sharing 8 8 9 10 Challenges Experimental Technological Base Liability and Privileging Economic Sustainability Integration Across Different HIT Systems Varying Levels of Clinical Expertise & Resources 10 10 11 11 12 12 Legal and Ethical Issues with Plans for Compliance Physician Licensing Credentials and Privileges Electronic Prescribing Informed Consent Malpractice Liability 13 13 14 14 15 16 Standards Background Types of Services Critical Components and Standards Relevance of Standards 17 17 17 18 20 Technical Requirements Data Flow Integration Elements HL-7 Message Types Connectivity 20 21 23 24 24 Projected Development and Implementation Costs 25 Training Requirements Multidisciplinary Team Technology Training Clinical and Communications Training 25 25 27 28 3 Simulation Training Sessions 29 Implementation Plan, Workflow, Organization, and Governance Project Phases Workflow 31 32 33 Critical Evaluation of Teletrauma System 33 Summary 36 References 37 Figures and Tables Figure 1: Teletrauma project participants Figure 2: HL-7 Messaging Standard Figure 3: Mysis Data Transmission Figure 4: View Clinical Data Screen Figure 5: Clinical Data Points Figure 6: HL-7 Patient Data Figure 7: Operational Costs Figure 8: Trauma Workflow Figure 9: Teletrauma Display Figure 10: Implementation Team Figure 11: Project Phases Figure 12: Performance Measures Table 1: Clinical Quality Measures 4 21 22 22 23 24 25 26 30 31 31 35 35 Appendices Appendix I: Trauma Center Level Designations Appendix II: Trauma Team Activation Criteria 40 41 4 Executive Summary Premier Health Center (PHC) is a 720-bed, 57 bassinet, Level I trauma center (see Appendix I), tertiary care center located in Johnson City, MA with a population of 153,552 people. PHC is also an academic teaching hospital with fourteen residency and training programs for physicians, physician assistants, and nurses. The catchment area for PHC is approximately 1,000,000. PHC is a member of the larger health system, Premier Health System, and serves as its flagship hospital. Two smaller community hospitals are part of the Premier Health System. Assent Hospital (AH) is 90-bed hospital, Level II trauma center and is located 20 miles from PHC. Community Care Center (CCC) is a 25-bed hospital, Level IV trauma center and is located 25 miles from PHC. In addition to these small community hospitals, three non-affiliated rural hospitals fall within PHC’s catchment area. Rural Hospital A (RHA), Rural Hospital B (RHB), Rural Hospital C (RHC) are 125-bed or less hospitals, and Level III and IV trauma centers. The objective stands at establishing a multidisciplinary, telemedicine trauma management program connecting the affiliated hospitals, AH and CCC, the non-affiliated rural hospitals, RHA, RHB, and RHC, to the dedicated trauma center in the region, PHC. This telemedicine and telepresence system aims to bring real-time access to trauma management specialists to the affiliated and non-affiliated hospitals outlined. The projected benefits are improvements in morbidity and mortality associated with trauma management directed at lower level trauma centers and patient transfers between hospitals, reductions in length of hospitalization, variations in care, and improvements in the quality of care delivery overall. Figure 1. 5 Use Case Pre-Teletrauma System SN is a 77-year-old male who presents via ambulance to Community Care Hospital at 2030 hours following injuries sustained when he was hit by a motor vehicle while he was crossing a residential street. He remains confused and hypotensive (low blood pressure) after 5 minutes of loss of consciousness. Additionally, he has facial injuries along with bruising on the chest, abdomen, and pelvis. The general surgeon on-call is on his way to the hospital. The ED physician and her team have started the trauma protocol to stabilize SN. His airway is intact at the moment but he breathing is labored with decreased breath sounds over the left chest. This indicates a likely pneumothorax (lung puncture and deflation). They put him on high-flow oxygen. A chest tube is warranted immediately. The ED physician has not placed a chest tube for many years but the patient is deteriorating. The physician places a chest tube in the left chest successfully. The patient immediately desaturates (low oxygen levels) and the nurse at the patient’s head notes that 6 she is unable to ventilate him. A surgical airway is required. The facial injuries have caused the patient’s airway to be compromised. The patient soon goes into cardiac arrest and is pronounced dead at 2130 after many implementation of the advanced cardiac life support protocol. Post-Teletrauma System SN is a 77-year-old male who is en route via ambulance to CCC at 2015 hours following injuries sustained when he was hit by a motor vehicle while he was crossing a residential street. While en-route to CCC, the PHC teletrauma surgeon, Dr. Smith, has viewed the patient and discussed his status with the EMTs via the ambulanced-based video communication system. They have determined that the patient likely has a left sided pneumothorax based on the decreased breath sounds the EMTs described. Dr. Smith has recommended that SN be stabilized at CCC with airway evaluation and chest tube placement and then considered for transfer to PHC. The CCC ED physician, Dr. Carter, has been informed of the patient and the evaluation by Dr. Smith. The teletrauma system encounter is started. Dr. Carter and Dr. Smith discuss the patient over the videoconferencing function as they await his arrival at CCC ED. The team has pulled the appropriately sized chest tube and a surgical airway kit. It has been a few years since Dr. Carter has put in a chest tube, but the recent skills sessions lead by the teletrauma team at PHC have helped her to feel more confident about putting in the chest tube. Dr. Smith reviews the steps briefly. Most important is the possible need for a surgical airway if SN cannot maintain his airway and Dr. Carter cannot place an endotracheal tube. Dr. Smith talks Dr. Carter through the surgical airway as well. SN arrives at 2030. He remains confused and hypotensive (low blood pressure) after 5 minutes of loss of consciousness. His has facial injuries along with bruising on the chest, abdomen, and pelvis are obvious. Immediately, Dr. Smith uses the video camera, which he can control at the PHC teletrauma station, to view the patient’s face and body. The team at CCC is moving quickly to put the patient on the monitor while evaluating his airway. Dr. Smith sees the 7 data on the monitor immediately. Another team member at CCC is opening up the chest tube kit. Dr. Smith and Dr. Carter note the labored breathing and gurgling sounds from SN’s airway. They decide to attempt an oral intubation (breathing tube in throat), but Dr. Carter cannot see past the large amounts of blood. Dr. Smith and Dr. Carter promptly decide upon a surgical airway. Dr. Carter uses the scalpel to incise the skin over the trachea as Dr. Smith looks on via the teletrauma video communication system. Dr. Smith’s voice is transmitted over speakers throughout the trauma room. He guides Dr. Carter through the process. A surgical airway is successfully placed less than 2 minutes later. SN is now oxygenating well. A chest tube has also been placed successfully and attention is now turned to the abdominal and pelvis injuries. Dr. Smith and Dr. Carter decide to transfer the patient to PHC for further evaluation and management of a pelvic fracture. Background Health care delivery in the modern era is marked with resources extending beyond the four walls of a single hospital. Advances in technology and communications have supported the electronic exchange of data across geographical locations. Some examples include medical data through health information exchanges and voice data over voice-over-IP applications. The use of communications technologies for telemedicine have been in place since the 1900s with two-way radios (Wesson & Kupperschmidt, 2013). In 1978, Dr. R. Adams Cowley demonstrated the use of telemedicine for trauma resuscitation in real time for a staged disaster exercise at Friendship Airport. He used an old satellite technology for the data transfer (R. Latifi, Ong, Peck, Porter, & Williams, 2005). In the United States and similarly in other countries, the majority of specialized trauma centers and specialists in trauma management are based in urban settings. This framework leaves rural areas vulnerable to the management of severe traumas without adequate and timely access to resources (R. Latifi et al., 2005; Wesson & Kupperschmidt, 2013). In fact, while only a quarter of 8 the population in the US lives in rural regions, 56.9% of mortalities due to motor vehicle collisions occur here. When patients are matched by severity score of injury, those who are treated in rural regions have twice the mortality rate (R. Latifi et al., 2005). Reasons for the vast discrepancy in mortality rates between urban settings with immediate trauma management capabilities and rural settings include lack of timely access to the subspecialty, adjunctive care (neurosurgery, orthopedics, vascular, cardiothoracic, trauma surgery) needed in comprehensive trauma care (R. Latifi et al., 2005). Additionally, with infrequent exposure to injuries requiring activation of trauma management protocols, the rural health care providers often lack the competencies to manage these injuries. The lack of adept knowledge and resources in trauma management can result in higher patient morbidity and mortality, length of hospitalizations, patient care costs, and transfers to other hospitals (Wesson & Kupperschmidt, 2013). Currently, most rural health care providers and trauma specialists in dedicated trauma centers rely on phone communication to assess and determine the plan of care for a patient suffering from traumatic injuries. The trauma specialists must rely on the assessment of the rural health care provider to determine whether the patient should be transferred to the dedicated trauma center, managed locally, and/or suggest a plan of action (Wesson & Kupperschmidt, 2013). In an era where we are gathering and have access to vast amounts of data which support clinical decision making (human-based and computerized), telemedicine and telepresence modalities should be used to connect rural health care settings with dedicated trauma centers in the management of traumatic injuries. This potential power of this interconnected web of healthcare providers with immediate access to each other, supplemented with innovative methods to share data surrounding patients such as shared cardiac monitors, radiology image viewing applications, and laboratory values could make the absence of telemedicine in trauma management seem arcane in the next few decades. 9 Benefits Access to Specialists Trauma management is principled on care provided in the “golden hour”, which is the hour during which rapid trauma assessment and resuscitation of the patient reduces mortality. Trauma deaths fall into a trimodal distribution. The first group dies from injuries usually on-scene of the event within seconds to minutes. The second group dies within minutes to hours following the traumatic event. Lastly, the third group will suffer death many days to weeks following injury (Zunder, n.d.). The proposed teletrauma project targets the management of patients in the second group who may present to rural and community hospitals. Transferring the patient, once at a rural facility, often consumes valuable time that may be better dedicated to management of the traumatic injuries. A real-time teletrauma management system connecting PHC to the aforementioned affiliated and non-affiliated hospitals would provide these hospitals with the support and knowledge of specialists who are off-site. Comprehensive trauma management is a multidisciplinary process. The health care providers engaged in this process include trauma/critical care surgeons, trauma nurses, anesthesiologists, neurosurgeons, orthopedic surgeons, vascular surgeons, plastic surgeons, and radiologists. These individuals are essential to the immediate assessment of a trauma victim, management, and subsequent treatment plan development. Through our teletrauma program, they are theoretically able to participate in all aspects of this trauma protocol remotely in collaboration with the on-site team at the rural or community hospital. The utilization of existing infrastructure and technology, acquisition of and innovation on new technologies, along with process development will be necessary to realize the full potential of the multidisciplinary teletrauma program. Evidence-based Resource Allocation Health care resources are finite in availability. With the rising cost of health care, cost consciousness is a guiding principle in the delivery process high quality patient care. The trauma 10 bay is stocked with many resources such as cardiac monitors, airway equipment, radiology equipment such as ultrasounds, intravenous fluids and blood products, and surgical kits for the placement of chest tubes, central venous catheters, open the chest. At times, in addition to the trauma team, specialists such as anesthesiologist, obstetricians, and neurosurgeons may be called in before the patient arrives. A level 1 trauma activation (see Appendix II) can cost approximately $5,000 (Rifat Latifi, 2013). A call from the transferring hospital or emergency medical technicians (EMTs) may suggest that immediate stabilization of injuries associated with those specialties is required. Teletrauma connecting PHC to the smaller affiliated and non-affiliated surrounding hospitals could help provide PHC important information on the resources immediately required upon patient arrival into the trauma bay. Tailoring the equipment and specialists made available for immediate use based on solid evidence could reduce medical waste in the form of physical items and clinician time. Telephonic transfer consultations between the other hospitals and PHC can be supplemented with direct video feed of the patient during the primary and secondary survey of injuries, sharing of available radiographs and laboratory values, and real-time, two-way communication during the process (R. Latifi et al., 2005). Extending the teletrauma program to ambulances transporting patients from the site of injury and between hospitals in the PHC catchment should be a future consideration of significant benefit. With the new availability of wireless infrastructure in the catchment area, a program similar to that rolled in the city of Tucson can be considered in Johnson City, MA. University Medical Center (UMC) and the Tucson Fire Department deployed an ER-link system in 2007. This system allows the ED physicians at UMC to see the patient in 20- to 30- second video “snap shots” while the ambulance was stationary and while in motion. This video data has helped the receiving physicians at UMC anticipate the state of the patient when he patient arrives in the ED or trauma bay. Their system includes a camera that can be moved and zoomed within a fixed range for improved visualization of the patient by the physician. Additionally, 12-lead 11 electrocardiogram data is also shared with UMC. Plans are underway to provide hand-held cameras to allow for transmission of specific video feeds not within view of the stationary camera (Rifat Latifi, 2013). Using all the data available to optimize a patient’s outcomes and the responsible allocation of healthcare resources are core goals in today’s health care delivery system and the proposed teletrauma system. PHC can move to the forefront of innovation and quality of healthcare by using teletrauma to connect PHC will the local, smaller hospitals. Additionally, a future phase of the project should include provisioning ambulances with video and communications equipment to allow for a virtual physician to enter the ambulance with the highly qualified EMTs (Rifat Latifi, 2013). Knowledge Sharing A teletrauma system, bridging the gap between rural and community hospitals and PHC, can lead to effective dissemination of trauma management knowledge. Learning in the active clinical environment is the long held practice in medical training. Consistent and reliable access to knowledgeable educators can influence the delivery of care in time-sensitive situations such as acute trauma. As collaboration in the management of these patients increases through the teletrauma system, the rural and community hospital physician will likely feel more comfortable and confident in administering varying degrees of care at their own facility. Using the teletrauma system for training mock trauma scenarios can create ease of use with the system for all parties, provide education in a safe, simulated environment, and identify areas for improvement (knowledge, process, system) outside of the real-life setting. Challenges Experimental Technological Base Many challenges in the implementation of teletrauma are centered on the different technologies upon which the system can be based. Since telemedicine is a developing field, all of the implementations are in some experimental phase. Without a strong model with a lengthy 12 history upon which to develop our teletrauma system, we anticipate challenges requiring innovative thinking to arrive at solutions. Existing telemedicine programs have used dedicated T1 lines, integrated services digital network (ISDN), Internet protocol (IP) technology, or even satellites for connectivity (R. Latifi et al., 2005). A broad analysis of current implementation of technologies for telemedicine and new approaches will guide the development of the teletrauma program connecting PHC to the rural and community hospitals locally. Liability and Privileging Health care provider licensure is provided by individual states. While PHC and the affiliated community hospitals are all within Massachusetts along with Rural Hospital A, Rural Hospital B and Rural Hospital C are in Connecticut. PHC’s location near the border between Massachusetts and Connecticut presents a unique challenge with licensure considerations in the teletrauma program. The requirement to obtain licensure in Connecticut for all the physicians who may be engaged in the acute management of a trauma patient through the teletrauma system could be difficult. Similarly, all the participating hospitals must agree on the privileging policies for the teletrauma physicians (Wesson & Kupperschmidt, 2013). As this is a multidisciplinary project, the physicians that will require coverage for licensure and privileges span many departments (trauma surgery, radiology, orthopedic surgery, neurosurgery, critical care, etc.). The presence of clear processes to manage these issues is necessary to protect the hospitals, physicians, and patients medico-legally. Economic Sustainability The technological infrastructure needed for telemedicine programs can vary in the cost of implementation and maintenance, ranging from low-cost, smaller programs, to large satellitebased programs, which can span nationally and internationally (Saliba et al., 2012). The US Department of Health and Human Services (HHS) has grants available to support telemedicine programs in rural areas. They also do not require quantitative outcome studies that evaluate the 13 impacts on the quality of care, role of this technology in the delivery of care, and cost efficacy of the program. While the grants and technological infrastructure can be financed in various ways, the billing of services rendered by a telemedicine physician is a challenge. The HHS has established policies that can guide the decisions related to this. A requirement is that all the communications in the teletrauma program be two-way, real-time, audio-visual data feeds. Collaborative program development between the technology and economics planning teams is necessary to ensure the economic sustainability of the teletrauma program. The commitment of clinical time by physicians at PHC has to be matched with appropriate reimbursement for care provided. Integration Across Different HIT Systems While the hospitals within the Premier Health System use the same electronic health record system (EHR), Rural Hospital A, Rural Hospital B, and Rural Hospital C are using a single different EHR system, which is unlinked between the hospitals. An interface will need to be developed which can interact with both EHR and billing systems. While this interface will be able to display the laboratory, radiology, and other tests gathered at the teletrauma receiving hospitals (e.g. Rural Hospital A, Community Care Center), the documentation of the interaction originating from PHC providers should become part of the patient medical record. This is a critical consideration if the patient does not get transferred to PHC for management. An electronic medium is necessary to share the documentation across hospitals and maintain a complete record for each patient managed through the teletrauma system. The upcoming implementation of the health information exchange in the region should further solutions to this challenge. Varying Levels of Clinical Expertise and Available Resources An additional obstacle to the fluid use of the teletrauma system is the variability in available clinical expertise to perform emergent skills such as chest tube insertion or emergency thoracotomy. The resources available in each hospital vary. For example, the trauma bays at PHC are fully equipped with multiple thoracotomy trays, differing chest tube sizes, fiberoptic 14 laryngoscopes and rapid blood infusion pumps. A smaller hospital such as Rural Hospital A may not have immediate access to the same equipment. It is necessary to have clear knowledge of the resource and expertise availabilities and limitations prior to a teletrauma management case with a live patient (Saliba et al., 2012). The use of detailed, up-to-date inventory of resources in the trauma management area in each hospital facility can help prevent delays in patient care. Similarly, a list of competencies of the physicians on service at every shift who could be part of the management of a teletrauma patient can help the consulting teletrauma physician at PHC gauge the amount of care that can be provided before recommending transfer to PHC. Given the high pressure, complexity, and time constraints in the management of acute trauma, leaving minimal questions surrounding resources and capabilities will help the teletrauma program succeed in providing improved care to trauma patients across the region. Legal and Ethical Issues with Plans for Compliance The advancement of telemedicine technologies is eliminating barriers that distance has posed on access to medical care and expertise. As this development is being streamlined, there has been increasing discussion on unique and new ethical and legal concerns raised by telemedicine care delivery. These concerns span the state and federal level. Topics requiring direction and policy include: physician licensing, credentials and privileges, electronic prescribing, informed consent, and malpractice liability. Physician Licensing With improved high-speed connectivity, physicians are expanding the ways in which they participate in patient care, including web-based communication and consultations. Variations in state medical licensure policies allow some doctors to cross state borders while providing care and other states do not. Since PHS, with its flagship hospital PHC, the two affiliated community hospitals, and Rural Hospital A reside in Massachusetts, telemedicine is permitted under the state licensure as long as the deductible, copayment, or coinsurance do not exceed that of an in-person visit. This law supports telemedicine amongst the Massachusetts teletrauma project partners. 15 Similarly, Rural Hospital B and C in Connecticut can provide telemedicine services to each other. But, in order to have PHC serve as the core teletrauma consulting center for the community and rural hospital partners, the participating physicians must hold licenses in both states (ATA Wiki, 2013a, 2013b; Federation of State Medical Boards, 2013). As a result, the PHC physicians providing teletrauma consultation will obtain Connecticut medical licenses. The teletrauma program will cover payment for these licenses. Credentials and Privileges Telemedicine has created many challenges for credentialing agencies and organizations. The National Telemedicine Policy Resource Center points to the May 5, 2011 Centers for Medicare and Medicaid Services (CMS) final rule that makes changes to CMS’s Conditions of Participation (CoPs) as they pertain to the credentialing and privileging of telemedicine providers. The final rule permits both hospitals and critical access hospitals (CAHs) to utilize a new process to credential and privilege telemedicine providers (National Telehealth Policy Resource Center, 2013)).” As this rule may conflict with specific state policies, the teletrauma project will establish is a plan and methodology to guide the privileging and credentialing process. Since all of the participating hospitals in the teletrauma program are Medicare-certified, a written agreement between PHC and the other hospitals will be established. This agreement states that (Massachusetts Medical Society, 2011)(Mass Med 2011; Credentialing for Telemedicine): The distant site is a Medicare-participating hospital The physicians participating in the teletrauma program have privileges at this hospital The physicians participating in the teletrauma program hold a license recognized in the state of the receiving hospital The receiving hospital reviews the physician’s performance and reports on adverse events and complaints to the distant site. Electronic Prescribing 16 E-prescribing has become a cause for concern for medical boards across the country due to the influx of sites that are allowing “supposed physicians” to order prescriptions through the use of medical questionnaires, without previously examining the patient or establishing an existing physician-patient relationship. While the vast majority of telemedicine encounters are legally within the law, quality and inappropriate misuse of prescribing are also being examined. Like credentialing, e-prescribing policies also vary across states. In the context of the proposed teletrauma program, any patient who is deemed safe for discharge from the emergency department and trauma bay will be discharged by the on-site physician, even if the teletrauma system was utilized in the course of the care. As a result, electronic prescribing policy should be restricting to that of the individual participating hospitals. Informed Consent Medicare does not require informed consent for those patients seeking medical treatment/consultation through telemedicine. This is in comparison to Medicaid, where the informed consent policy varies by state. The policies range from written consent before the start of treatment to verbal consent and up to no clear specification on the type of consent required. Unlike Medicaid who’s policies vary from state to state. The doctrine of informed consent is based on the notion that “every human being of adult years and sound mind has a right to determine what shall be done with his own body…” (Hartman, Liang, Exceptions to Informed Consent). Exceptions to this doctrine arise in the emergency medical setting where the physician is not under a duty of disclosure of the diagnosis, proposed treatment, alternatives, and consequences of the treatment because it could pose a serious threat to the patient’s well being. The case Canterbury v Spence established this exception to informed consent (Hartman & Liang, 1999). Trauma care is emergent by nature. State statutes indicate that: A [physician] shall not be liable for civil damages for injury or death caused in an emergency situation occurring in the [physician’s] office or in a hospital on 17 account of a failure to inform a patient of the possible consequences of a medical procedure… (Hartman, Liang, Exceptions to Informed Consent). The three scenarios where implied consent is employed in emergency care are with unconscious patients, conscious patients with questionable competence, and minor patients. With regarding to minor patients, physicians are generally not held liable for delivering treatment without parental consent in the emergency setting where death or permanent injury could result from delay in care. Court decisions are split on situations where the minor’s injuries are life-threatening but do not warrant immediate treatment allowing for time to obtain parental consent. Another scenario where court decisions vary is for minor patients who are able to comprehend and participate in care decision-making. Some courts permit the minor to provide consent for himself (Hartman & Liang, 1999). As the teletrauma program focuses on the care provided in the emergency setting, the physician managing the trauma patient will obtained informed consent for care at that institution and via the teletrauma system when appropriate. If the patient is unconscious or conscious with questionable competency, implied consent will be assumed for use of the teletrauma system. The minor patient case will be managed based on the judgment of the lead on-site physician (Hartman & Liang, 1999). Many argue that requiring consent prior to treatment does not represent a true picture of what telemedicine is or the tool it is meant to be. While telemedicine is still in its initial stages there is the potential for mistakes and inaccuracies in care just like any new technology platform. And because of these possibilities, it may be essential for patients to be informed of the risks of telemedicine treatment. Malpractice Liability Currently there is little to no policy around malpractice liability and the use of telemedicine. As issues/cases arise, policy will have to be developed so that disputes can be 18 identified and addressed. In the meantime, hospitals or physician organizations may want to draft their own policy and procedures in the event a situation arises. Telemedicine has the potential to transform medical practice and treatment. However, even with all the benefits, many physicians or healthcare organizations are reluctant to engage in its practices due to unknown legal and ethical concerns. Standards Background Healthcare has become and interconnected organism that grows and changes shape at the micro level, for an individual patient, and the macro level for an entire population. The efficient exchange of data is essential for the success and continued evolution of this organism. Centuries of medical care have been coordinated by human-to-human communication. Our current era is marked by the addition of machine-based communication through health information technology (HIT) systems. High fidelity modeling of human-to-human communication and comprehension is a challenging problem in HIT systems and interoperability. The standardization of how data is structured along with vocabularies has provided the foundation for HIT infrastructure supporting EHR and clinical decision support systems (The American Telemedicine Association, 2006). Telemedicine is a unique application of HIT used to enhance healthcare delivery because of the combination of human-to-human communication and machine-to-machine data exchange. Our proposed teletrauma project for Premier Health System must support both of these communication forms to realize the objectives of bringing advanced multidisciplinary trauma management expertise to rural and community hospitals in the area. Types of services to be supported The multidisciplinary teletrauma program provides specialist referral services, whereby a healthcare provider at PHC assists a local healthcare provider at a rural or community hospital in the diagnosis of an acute trauma patient (The American Telemedicine Association, 2006). The “golden hour” in trauma management represents the critical time for intervention to save patients 19 following traumatic injury (Zunder, n.d.). By including direct patient care and remote patient monitoring services, remote healthcare providers at PHC can participate in the treatment plan development and care administration when the patient is en route via ambulance or at a referring hospital. Lastly, the ability to provide medical education, training, and mentorship is a service of critical importance to the proposed teletrauma project. Premier Health System’s ability to ensure high quality care delivery during acute trauma management through the telemedicine system requires the participation of healthcare providers educated on the system’s abilities, strengths, limitations, and functionalities. This is in addition to determining effective ways to administer and deliver care via remote management systems (The American Telemedicine Association, 2006). Simulated scenarios via the teletrauma system will provide clinical users and the IT system developers with semi-real life use data. Both groups can find ways to improve upon the teletrauma system itself and how to better use it to achieve the goals. Critical components and standards of teletrauma system Networking program The networked connection of PHC to the affiliated community hospitals and nonaffiliated rural hospitals is necessary for the teletrauma system. All telemedicine systems currently are considered experimental since standards specifically for telemedicine are lacking (R. Latifi et al., 2005; The American Telemedicine Association, 2006). Options for the network structure include either a hub-and-spoke system or an integrated networked system. We propose the use of a network of T1 and T3 lines to create an Integrated Services Digital Network (ISDN), which is based on ITU-T standards. This allows for data exchange at 1.544 megabits per second to 43.232 megabits per second. These digital lines can more reliably transfer data than analog systems. The reliability of the data exchange is essential to the teletrauma project. TCP/IP standards are selected connect individual hosts to transmit the data over networks and the Internet. 20 Videoconferencing Simultaneous audio and video communication through videoconferencing capability is the most basic part of the multidisciplinary teletrauma project. It serves as a critical component to allow for the consulting healthcare provider at PHC to communicate with the providers at the community and rural hospitals and to view the patient and care setting. While the relatively immature telemedicine market has not attracted major industry attention for the development of unified standards, telemedicine has repurposed standards developed for related industries. The American National Standards Institute (ANSI) H.32x standards support wide-scale videoconferencing interoperability. The H.32x standard addresses the obstacles experienced by early telemedicine programs where software and hardware incompatibility have hindered program implementation, adoption, and growth. This standard allows for videoconferencing equipment from various vendors to exchange data with integrity (The American Telemedicine Association, 2006). Medical data exchange Standards such as Digital Imaging and Communications in Medicine (DICOM) and HL7 messaging language will be utilized for the exchange of medical images and clinical data. The Picture Archiving and Communications Systems (PACS), currently utilized in all of the hospital in the project, will be the integrated radiological imaging solution managing the DICOM formatted files and communications protocols. HL7 and DICOM will be the main data message standards connecting the EHR systems between PHC and the other hospitals. All of the participating hospitals in the teletrauma program will soon be part of a local health information exchange system. We will use accepted industry standards across the project, from technical aspects to operational ones. SNOMED-CT is our selected standardized clinical vocabulary to be used in exchanging clinical data via the teletrauma system. Logical Observation Identifiers Names and Codes (LOINC) codification system will be 21 used for discrete data surrounding the patient’s care such as vital signs, laboratory test, and electrocardiogram tracings (Huff et al., 1998; Purkayastha, n.d.). Relevance of standards The development of Premier Health System’s multidisciplinary teletrauma system will be based on accepted standards where and when available. Transmission of video, audio, and clinical data with high integrity between healthcare providers and HIT systems is likely the most crucial aspect of the teletrauma system. Standards allow for acceptance that the files, protocols, hardware designs, etc. have undergone rigorous testing. The telemedicine project supports the creation of patient encounters that can be incorporated into the patient record and shared between providers and institutions in the acute setting and onward. Standards allow for this to be achieved. Technical Requirements While the PHS EHR system is integrated throughout the health system’s multiple hospitals, the Rural Hospital A, B, and C EHR systems are from another vendor. The integration and interoperability of the necessary EHR components across all of the participating hospitals serves the foundation of the teletrauma system. Telemedicine vendor options have been selected based on their ability to integrate across the two EHR systems and satisfy the needs of the proposed teletrauma system. The goal of the telemedicine vendor integration (see Figure 9) is to display the data captured by telemedicine device in a comprehensive display for the clinician. Both of the EHR solutions in this project utilize HL-7 messaging. These systems will send and receive patient data from the telemedicine vendor using the same HL-7 messaging standard. Message Standards All messages must adhere to the following HL-7 Standard: Figure 2. 22 The HL-7 standard calls for an acknowledgement record to be returned to the sender when the receiver has successfully accepted the message. This indicates ownership of the message. Each EHR vendor requires an acknowledgement to be sent for messages sent from their solution to the Telemedicine vendor. The EHR will send an acknowledgement when a message is received from the vendor. Data Flow The overall data flow structure is a bi-directional exchange of information between the HER systems and the telemedicine vendor. The EHR will send Admission, Discharge, Transfer (ADT) patient information to the vendor, so the vendor can, in return, send, ORU R01 or Clinical Reading information messages that will be processed and stored within the EHR teletrauma solution. The following is an example of how the data is transmitted via the Mysis Homecare product. 23 Figure 3. Below is an example View Clinical Data screen within the Mysis system. This display is provided by our EHR’s Clinical Monitoring screens. Below is an example of the View Clinical Data Screen within this collection of screens. Figure 4. 24 As the teletrauma system is interactive on both the consulting hospital’s (PHC) and the referring hospital’s (all other hospitals) sides, a clinician may want to enter clinical data such as place an order, document a diagnosis, or write a clinical note. An Add/Edit Clinical Data screen allows for entry of clinical data directly into the EHR solution. The data supplied by the telemedicine integration cannot be edited; it can only be marked erroneous, which presents a visual indication of a disqualification. Clinical notes can be stored via the interface and presented in the Clinical Monitoring screens. This allows for a healthcare provider using the teletrauma system to start a clinical document during the care and complete it at a later time. The Revision History screen, which works with the View Clinical Data and Add/Edit Clinical Data screens, provides a complete audit of all data related to the patient teletrauma encounter. This includes data provided via the Telemedicine Interface. Integration Elements The following clinical data points may be exchanged between the telemedicine vendor and the HER systems for the proposed teletrauma project: Figure 5. Units of Measure Both of the HER systems in the teletrauma project support all units of measure coming from the teletrauma interface messages. They also support user selection of units of measure for 25 presentation on screen. For examples, this provides the user with the option to display temperature in Fahrenheit or Celsius on the screen display while the temperature data transmitted through the interface is agnostic of temperature scale. The same principles apply to measurement conversions between the Metric system and the US/Imperial systems. Within the set-up for the interface, a mapping is created that contains the message reading unit of measure to, the type of reading, and the unit of measure for the reading stored within our solution. HL-7 Message Types Figure 6. Connectivity The telemedicine vendors must have their solution installed on the client’s network for secure communication via Transmission Control Protocol/Internet Protocol (TCP/IP). If the vendor solution is hosted outside or must travel outside of the client’s network, then Hypertext Transfer Protocol Secure (HTTPS) is required as the communication protocol. During configuration of the EHR solution, the telemedicine vendor’s server connection information will be inputted be entered to assure connectivity. 26 Projected Development and Implementation Costs Figure 7. Training Requirements For our multidisciplinary teletrauma program to be effective, each healthcare providing group and each team member must be appropriately trained with the equipment, teletrauma interface, and the delivery of care via this medium. The time sensitivity of care delivery in the acute trauma setting requires that workflow not be impeded by the teletrauma technology and interface, but be enhanced by it. In order to accomplish this goal, familiarity with the technology, software, and hardware is important for the healthcare providers. The simulation center available at PHC will be used to run through many simulations using the teletrauma system. Additionally, mock on-site trauma cases will be utilized to test the teletrauma system across the project coverage area. For example, a mock trauma patient will arrive at Rural Hospital A, and the trauma team there will contact the multidisciplinary teletrauma team at PHC. Multidisciplinary team The teletrauma project for PHS is focused on provided multidisciplinary trauma care throughout the region by extending expertise located at PHC to local community and rural 27 hospitals. Effective acute trauma care requires the coordination of various medical and surgical disciplines. Figure 8. (1) Patient arrives in the trauma bay and the EMTs verbalize the events at the scene, patient condition en route, and treatment administered. The trauma team asks questions to clarify as needed. (2) Primary survey of the patient commences promptly to determine if the patient has an intact airway, can breath effectively, and maintain blood circulation. Treatment to stabilize the patient is initiated. (3) The secondary survey starts with a more thorough physical exam. Laboratory tests and imaging studies are obtained. Further treatment is administered to the patient. Decisions are made regarding advanced imaging studies. (3.a) If clinically indicated and the patient is stable, he is transported to get advanced imaging such as CT scans. (4) Once that patient is stabilized and injuries are identified, specialists are consulted as needed. The trauma team in the trauma bay receives the patient. The team consists of the trauma surgeon, surgical and emergency department residents, and trauma nurses along with the transferring emergency medical technicians (EMT). Exchange of verbal information begins nearly immediately between the EMTs and the trauma team. The patient is quickly assessed for any breathing difficulty, circulation failures, and bleeding. Once a first-pass understanding of the patient’s injuries, called the primary survey, is obtained, the trauma team turns their attention to other tests and specialty care need to treat the 28 patient. This secondary survey includes laboratory test and radiographs of areas likely sustaining immediately life-threatening injuries such as the chest or pelvis. Once a patient is deemed stable enough to be transported to another room or down the hall, advanced imaging such as computed tomography or other radiographs can be performed. At this point, diagnostic radiologists are introduced as members of the trauma management. Their interpretations of the imaging studies are conveyed to the trauma surgeon or resident in person in the reading room or over the phone. This versatility lends itself to inclusion in the multidisciplinary teletrauma system. The system proposed allows for the sharing of radiological images across the network. The radiologist can interpret the imaging remotely and convey the information to the local trauma team in real-time. Remote radiology has been present in clinical practice for many years. The use of advanced image sharing through DICOM and PACS, without the degradation of image quality by projection of the image via a secondary video feed, allows for the radiologist to view images as if obtained at the home PHC institution. Findings on the physical exam in the trauma room and on the imaging studies guide the inclusion of specialists such as neurosurgeons, orthopedic surgeons, vascular surgeons, plastic surgeons, critical care physicians, and interventional radiologists, to name a few. The majority of these evaluations by specialists are not critical in the “golden hour” of trauma care, but become important in the short-term and long-term treatment plan. If our teletrauma system is to help support the rural and community hospitals treat trauma patients within their own institutions, the availability of these specialists over the teletrauma system is crucial. Technology training Training the teletrauma team on the use of the technology will encompass building familiarity with the software interface and control over the videoconferencing hardware in the system. Many aspects of the training will be staged along with the project development. Ensuring usability of the software and hardware is important to the success of the project. As the software interface is being developed, regularly feedback will be obtained from the healthcare providers 29 using the system. This feedback will be used to iteratively develop the interface. An inclusionary project development plan, whereby the users are engaged in the development process at each step, will help develop a deep understanding of the system by the teletrauma healthcare providers. Clinical and communication training The clinical training will be staged in a step-wise fashion. An assessment of each hospital’s local expertise level and privileges for trauma care and procedures will guide the clinical training. For example, hospitals affiliated with PHS are staffed with Advanced Trauma Life Support (ATLS) trained surgeons and emergency department physicians on call for acute traumas. The three rural hospitals have a few surgeons who are ATLS trained but they are not on-call for traumas regularly. We are requiring ATLS training and certification of all physicians and Advanced Trauma Care Training (ATCN) for all trauma nurses who will use the teletrauma system. Ensuring a strong trauma management foundation is a prerequisite for this project. Two to three, in-person training sessions will be coordinated where all healthcare providers participating in the teletrauma project will meet to practice trauma management on mock patients. The goal of this training is to address potential issues in working with team members who are unfamiliar with each other (Wesson & Kupperschmidt, 2013). As the multidisciplinary teletrauma team at PHC may not have a current working relationship with the health care providers at the regional hospitals, personal introductions and mock trauma management can identify potential communication and collaboration issues in a safe environment. Structured training plans will be developed to resolve communication and teamwork obstacles. The in-person mock trauma management session will also act as a skills assessment in an individual provider’s ability to perform basic and advanced trauma procedures and tests. While everyone is ATLS or ATCN certified, providers may want further training in chest tube insertion and management, emergency thoracotomies, central venous access placement, Focused Assessment with Sonography in Trauma (FAST) exams (Brohi, 2006). Advanced training areas will be set up with expert providers for each of these skill sets during the sessions. 30 Simulation training sessions Once we have provided a solid clinical, communication, and technology training foundation, our next goal will be to integrate all three components in the live simulation center. PHC houses an American College of Surgeons Program for Accreditation of Education Institutes accredited simulation center. This center has been developed to improve patient safety and the quality of healthcare through simulation-based training and education (American College of Surgeons, 2012). Teams of healthcare providers from the community and rural hospitals participating in the project will be constructed. A high-fidelity medical simulation manikin will be used as the patient. These manikins have physiology that mirrors that of humans and it can be modified to reflect disease processes such as acute blood loss secondary to a stab wound to the chest, respiratory failure, or a spinal cord injury (HealthSimulation, n.d.). The community or rural hospital’s, or referring, team will be placed in a simulation room that is set up similarly to their trauma-receiving room. The multidisciplinary teletrauma team from PHC will be in a separate room in the simulation center, ensuring that both teams are visually and audibly isolated from each other except for via the teletrauma technology. The simulated patient scenarios will be treated as if they were real-life events. The referring hospital team will be brought into their simulated trauma room to assess and manage the trauma patient. The manikin’s physiology will follow that of the human patient suffering the injuries that have been described to the team. The team will manage the patient and call in the teletrauma team when they feel assistance is needed. When the PHC teletrauma team is called via the system, they will visually assess the patient with the videoconferencing equipment, which includes a joystickcontrolled video camera. A separate video camera with microphone is available to communicate with the referring health care provider face-to-face. Other viewable data feeds on the teletrauma system screen include the cardiac monitors, radiology imaging, and laboratory values. The PHC trauma team can select which of these is the most relevant during the phase of care. 31 Figure 9. 32 (a) Consulting hospital teletrauma screen with multiple data feeds. Face-to-face video feed in bottom left corner shows the referring physician from the community hospital with inset of consulting PHC teletrauma physician. (b) Referring hospital teletrauma screen shows similar data feeds with face-to-face video feed of consulting PHC teletrauma physician and inset of referring physician from community hospital. Both of the teams will work together to decide on the acute management of the trauma patient, identification of injuries, and development of treatment plan. Successful management will be determined based on the survival of the simulated patient, communication performance, degree and ease of collaboration, and usability of the technology to enhance care delivery. These simulated training sessions will be the most valuable tools in the training process as they emulate the real-life acute trauma scenarios the teletrauma system has been developed for without the high-stakes. In this environment, we can adjust the technology and communication and collaboration methods and measure the effect on mock patient survival promptly. Implementation Plan, Workflow, Organization and Governance The Implementation team will be made up of representatives of each of the following areas: Figure 10. Both treatment and referring locations must be represented in the project leadership group. The implementation will be lead by co-sponsors from both the medical and the technology teams. Clinical workflow and logistics will be presented and approved by the sponsors. Each team will report back to the PMO in order to maintain consistency and allow for tracking against budget and timeline. Project Phases 33 The project will be divided into 5 phases: Figure 11. The timeline of the project will be 270 days from kick off to post live support. The teletrauma platform will be integrated into the electronic medical record system to enable a seamless patient and provider experience. The system will be deployed in stages with hardware and network connection validation happening first. Hardware will be delivered to individual sites. Remote sites will receive Consult stations for videoconference capabilities. These stations consist of an all in one unit supporting both audio and video connectivity included access to peripheral equipment feeds. Local sites will receive Referring stations. Referring stations consist of a rolling computer cart, medical device interface unit, and video conferencing equipment. Sites will be inspected and network connectivity approximately 15 business days 34 prior to go live. Delivery of equipment, assembly, and technical testing will occur approximately 10 business days prior to go live. Workflow Treating providers will work through an on call schedule as determined by their departments. When a patient scenario arises that can be covered by telemedicine, the referring provider will initiate a telemedicine request from within the EHR. The provider will select the services needed and generate a request which will look up the call schedule for the department and send a message to the EHR inbox of the on call provider as well as a SMS message to the on call’s mobile phone alerting them to the request. The consulting provider will need to login to the medical record, review the chart and accept the request. By accepting the request, the Consulting station will initiate a videoconference with the Treatment station allowing for the clinical exam to take place. Both sites will be able to access the patient medical record during the course of the consult. They will be able to see each other via video and the relevant clinical devices for vital signs (refer to Figure 9). Integration of medical devices and videoconference feed into the single screen with the medical record will require specific hardware which is documented in the Figure 9. Critical evaluation of teletrauma system after implementation The teletrauma project will be tracked and evaluated against a series of measures established by the Institute of Medicine. In order to properly assess the impact of telemedicine services, an organization must examine the quality, access, impact on outcomes, and cost of the services provided. There are several methods for looking at the impact of diagnostic technology on the quality of clinical care. Fineberg et al. (1977) identified several processes and outcomes for making this assessment and those include: · Technical Capacity—Is the technology safe, accurate, and reliable? (e.g., how do transmitted digital images compare to films?); 35 · Diagnostic Accuracy—Does the technology contribute to a correct diagnosis (e.g., was an initial dermatology diagnosis by a primary care clinician corrected after review by a dermatologist?); · Diagnostic Impact—Does the technology provide diagnostic information that is useful in making a diagnosis (e.g., after the telemedicine consult, is a face-to-face consultation still necessary?); · Therapeutic Impact—Does the technology influence patient management or therapy (e.g., do paramedics perform better when they have access to emergency cardiac telemetry?); and · Patient Outcome—Does the technology improve patients' health and wellbeing (e.g., are postsurgical patients telemonitored in a nursing home more or less likely to develop wound infections than patients remaining in the hospital?). The proposed teletrauma project will include processes and quantitative metrics to evaluate the impact of the project on trauma care delivery throughout the region with the participating hospitals. The teletrauma information technology system will include mechanisms for system generated error reports on connectivity, data speeds, errors in data transmission, and similar metrics. User generated error reports will be embedded in the system so that error information not captured by the system and user experience data on the errors can be used to improve the system. All of the hospitals in PHS participate in the American College of Surgeons National Trauma Data Bank. As a result, data on adverse events in the course of acute trauma management, time to diagnosis of injuries, time to disposition of the patient, mortality rate, and such measures are available for comparison before the teletrauma project implementation, during, and after. For the three participating rural hospitals, a team of nurse researchers and clinicians will review acute trauma cases that have presented at these organizations and manually obtain the same metrics for the past two years (American College of Surgeons, 2011). Figure 12. Clinical quality measures will be further evaluated through peer review of medical records, clinician interviews, patient interviews, and observation of encounters. The following five questions, introduced by the Institute of Medicine’s Telemedicine guide (1996) will be considered: Table 1. 1. What were the effects of the application on the clinical process of care compared to the alternative(s)? 2. What were the effects of the application on patient status or health outcomes compared to the alternative(s)? 3. What were the effects of the application on access compared to the alternative(s)? 4. What were the costs of the application for patients, private or public payers, providers, and other affected parties compared to the alternative(s)? 37 5. How did patients, clinicians, and other relevant parties view the application, and were they satisfied with the application compared to the alternative(s)? NOTE: Each question assumes that an analysis of results will control for or take into account severity of illness, comorbidities, demographic characteristics, and other relevant factors. It is important to include patients in the feedback but consideration must be given to their health status when reviewing the results. A multi disciplinary team will be assembled to discuss results and determine overall success of the program for future planning. Summary Premier Health can differentiate itself even more as a leader in quality and efficiency of health delivery. By connecting the network of facilities PHC can improve mortality and morbidity. In addition, PHC can better support the community by creating a system that can manage trauma resources to improve access and overall efficiency. Getting the right care to the right patient no matter where in the network that patient presents will help to raise proper utilization of resources and improve the quality of care delivered. In our current environment we sometimes see inefficient use of strained resources, which has a direct impact on the success of patient care. Teletrauma services represent an important component to deliver better, more efficient, outcome focused care and will further showcase PHC's leadership in the community. 38 References American College of Surgeons. (2011, July 18). National Trauma Data Bank. American College of Surgeons Trauma Programs. Retrieved from http://www.facs.org/trauma/ntdb/ American College of Surgeons. (2012, October 23). Welcome to the American College of Surgeons Program for Accreditation of Education Institutes. 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Retrieved April 14, 2014, from http://smhs.gwu.edu/urgentmatters/news/innovationsmobile-video-systems-link-ed-ambulances-jump-start-triage Latifi, R., Ong, C. A., Peck, K. A., Porter, J. M., & Williams, M. D. (2005). Telepresence and telemedicine in trauma and emergency care management.(Author abstract). European Surgery, 37(5). Massachusetts Medical Society. (2011, October). Credentialing for Telemedicine. Vital Signs. National Telehealth Policy Resource Center. (2013). Legal Issues. Retrieved May 31, 2014, from http://telehealthpolicy.us/legal-issues Purkayastha, S. (n.d.). Standards for telemedicine, infrastructure and financing. Retrieved from http://www.searo.who.int/entity/health_situation_trends/events/09_Saptarshi_Standard_f or_Telemedicine.pdf Saliba, V., Legido-Quigley, H., Hallik, R., Aaviksoo, A., Car, J., & McKee, M. (2012). Telemedicine across borders: A systematic review of factors that hinder or support implementation. International Journal of Medical Informatics, 81(12), 793–809. doi:10.1016/j.ijmedinf.2012.08.003 Sasser, S. M., Hunt, R. C., Faul, M., Sugerman, D., Pearson, W., Dulski, T., … Galli, R. L. (2012). Guidelines for Field Triage of Injured Patients (Recommendations and Reports No. 61(RR01)) (pp. 1 – 20). CDC. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6101a1.htm 40 The American Telemedicine Association. (2006, May). Telemedicine, Telehealth, and Health Information Technology. Retrieved from http://www.americantelemed.org/docs/defaultsource/policy/telemedicine-telehealth-and-health-information-technology.pdf?sfvrsn=8 University Medical Center. (n.d.). Trauma Team Activation Criteria. Retrieved from http://www.umchealthsystem.com/downloads/ems/ActivationCrit.pdf Wesson, J. B. A., & Kupperschmidt, B. E. (2013). Rural Trauma Telemedicine. Journal of Trauma Nursing October, 20(4), 199–202. doi:10.1097/JTN.0000000000000012 Zunder, I. (n.d.). Initial Trauma Assessment - The Anaesthetist’s Role. Trauma.org. Retrieved from http://www.trauma.org/archive/anaesthesia/initialassess.html Image Sources For Teletrauma Screen Views Trauma room: http://upload.wikimedia.org/wikipedia/commons/5/58/US_Navy_021029-N0000W001_A_U.S._Navy_ER_General_Medical_Officer,_provides_trauma_training_to_a_team_of_Em ergency_Medical_Technicians.jpg Cardiac monitor: http://de.wikipedia.org/wiki/Monitor_%28Medizin%29 Chest radiograph: http://upload.wikimedia.org/wikipedia/commons/thumb/2/2f/Pneumothorax_CXR.jpg/522pxPneumothorax_CXR.jpg Surgeon with dark blue scrubs: DFAT photo library / Foter / Creative Commons Attribution 2.0 Generic (CC BY 2.0) Labs/EHR: http://www.asp.md/electronic_medical_records.php Surgeon with light blue scrubs: edenpictures / Foter / Creative Commons Attribution 2.0 Generic (CC BY 2.0) 41 Appendix I (Sasser et al., 2012) 42 Appendix II (University Medical Center, n.d.)