Chapter 11 Kevin McGinnis Public Law 93-154, the EMS Act of 1973, facilitated a sea change in the organization and delivery of EMS, including its communications system. Communications were identified as one of 15 critical components of a modern EMS system. Prior to that, in the era of EMS as horizontal taxicab, telephone access to the local ambulance base was the most sophisticated part of the communications system. Ambulance attendants in the field had little need to talk to a doctor in the hospital and an approaching siren was the only clue for emergency room staff that a patient was on the way in. The EMS Act not only caused the role of radio communications in EMS operations to be defined for access, dispatch, and medical oversight and coordination, but brought significant grant funding to, among other developments, putting VHF and UHF radios in ambulances. The former enabled communications between dispatchers and ambulance crews and between EMTs and hospital staff for arrival notification and medical direction. The latter were the core of systems to send biotelemetry (ECGs) from the field to the hospital in ALS systems. The development of the EMS communications system has not significantly progressed since that time. The communications capabilities and practices of the 1970s are, for the most part, reflected in most EMS operations today. While cell phones have found their way into most ambulances, 12-lead ECG transmission has taken the place of earlier three-lead systems, and trunked communications systems have improved public safety systems in general, narrowband voice communications still rule the roost. While the average teenager’s smartphone has more broadband data communications capability than the average EMS provider’s communication system, that is beginning to change. The National EMS Information System (NEMSIS), electronic patient care report (PCR) systems, and the concept of the longitudinal electronic health record available to the EMS provider in the field have begun our transition to data communications. Integrated computer-aided dispatch (CAD) and emergency medical dispatch (EMD) systems enable data communications to match resources to needs and to manage resources with increasing situational awareness. In 2012, President Obama signed Public Law 112-96, the Middle Class Tax Relief and Job Creation Act [1]. The law created the First Responder Network Authority, or FirstNet, and funded it to create a nationwide public safety broadband network. It will, in essence, be a wireless carrier like Verizon or AT&T but reserved for the use of public safety providers, including all types of EMS providers and acute care hospitals. It promises to have as much impact on EMS communications as did the EMS Act of 1973. The topic of communications, taken broadly, encompasses all the ways EMS providers communicate among themselves, with the public they serve, and with other health professionals. It includes public education, data and information technology systems, protocols, and standard operating procedures. Recognizing that, and that most of these topics are covered in depth elsewhere in this text, this chapter focuses on information communications technology (ICT), the nuts and bolts underlying how we communicate now and how we will communicate in the future. The 2006 Institute of Medicine report Emergency Medical Services at the Crossroads summarizes the issues facing emergency system leaders, and their patients [2]. A notable recommendation suggested a regionalized, coordinated, and accountable emergency care system and the development of an EMS workforce that can improve the quality of care in the long term. A regional accountable emergency system would provide health service in a more integrated and broad delivery model in the vein of current efforts in community paramedicine and mobile integrated health care. The role is more one of unscheduled health service, of which true emergency responses are a subset. The function of the regional accountable emergency system would be to deliver the right care to the right patient at the right time in the right setting, and then move that patient to the correct site for the next level of care needed [3]. Now and into the future, the EMS system is an integrator of public safety and health care functions. Emergency providers interact with numerous organizations in the provision of unscheduled health services. Ideally, the communications system integrates the various delivery components into the smooth, seamless operation desired and expected by the public. The communication system for EMS must be designed to support these elements: The mission of the EMS system is to prevent injury and emergency illness and, where prevention fails, to reduce their consequences to the patient, family, and society. It does this by bringing the patient together with the appropriate type and level of care, generally following an unscheduled demand for service. The mission of the EMS communications system is to provide timely information to EMS system providers in the field and in the hospital to bring the patient and this care together. The EMS communications system integrates the hardware and software components, service providers, and administrators to provide emergency medical care. An effective communication system uses hardware and software elements for routine daily operations, with flexibility and redundancy necessary for disasters and other special needs. The efficiency of the system for facilitating medical care must be measured locally, as each EMS provider has unique geography, medical service providers, and public expectations to consider in system design. Medical and administrative leadership is required from EMS system medical directors to prioritize those aspects of the communications system that promote optimal care. The communication system sets the stage for high-quality patient care. A needs assessment should be performed on a regular basis, with objectives outlined for the various communication components. As new configurations of system access, dispatch, and medical communications become available, local EMS leaders can design smart radio systems to integrate medical and administrative roles [4]. System status management and vehicle locator systems are other efficiency tools to facilitate medical care and allow administrative oversight [5]. Service providers must develop appropriate administrative information systems that maintain the service available for patient care. Administrative information on nuts-and-bolts issues of vehicle maintenance, equipment and supplies, personnel licensure and education, and facility upkeep are necessary. Human resource issues of due process, health surveillance, and employee recognition are other components of the management information system supporting direct medical care. Billing systems must be developed to address the compliance needs of the payers, especially the federal government which is the largest payer for health services. Some communities have developed models for broad inclusion of communication needs in the health system. A communication system with medical oversight can navigate patients to a broad range of services other than an ambulance ride to an emergency department. Figure 11.1 demonstrates the architecture of such a system, which provides demand management services through a wide array of health care service providers. Community paramedicine and mobile integrated health care resources are increasingly integrated into the access/demand management system to help the health care system better match patient need to resources provided. Figure 11.1 Access/demand management for regional system. Communication leaders have been successful in providing universal access in America through the 9-1-1 system [6]. Other countries have comparable access numbers.. The enhanced 9-1-1 (or E9-1-1) system, activated from a landline, permits automatic caller location and phone number identification to be displayed at the dispatching site. This feature eliminates telephone queries about emergency location in many situations and offers assistance to those callers unable to communicate due to age or nature of injury. This identification can be automatically tied to a system status computer, which will then immediately display the closest available emergency responders. The 9-1-1 system has created challenges in many communities. It has come to be used for almost any request for service from the public (anecdotal stories abound). Concurrently, demand for timely access to EMS has increased [7]. Other three-digit numbers (e.g. 3-1-1 for government service questions and 5-1-1 for travel information) have evolved to aid this. Many systems now have over half of 9-1-1 calls originating from mobile phones. The use of mobile phones has defeated the automatic call location function, and new triangulation and global positioning system (GPS) technology for locating the cell phone position has been implemented over the past several years [8]. “Next Generation 9-1-1” planning recognizes that emergency dispatch centers must be able to receive demands for service from automatic notification systems from vehicles (OnStar® and others), homes (“I’ve fallen and I can’t get up”), medical monitoring devices, and smartphones (texted messages, video, and pictures) among a wide variety of communications devices [9,10]. The emergency medical dispatcher now has the role of call receiving, interrogation, determining response configuration and mode, and delivering any appropriate prearrival instructions to the caller [11]. EMD protocols are now in place and verified to reduce use of “lights and siren” response, decreasing the likelihood of vehicle accidents [12]. Navigating patients to non-emergency resources, through a call center or other resource, is also an increasing role. Following the initial response, the dispatcher supports field operations with additional information regarding scene location, a complete description of the medical complaints, road conditions, potential hazards, special approaches, and simultaneous fire and police response. The dispatcher may designate which channel and hospital to use for direct medical oversight, and may also assist in linking field and hospital personnel. Dispatchers must be knowledgeable about the entire emergency response system, and be able to access all necessary support resources. Any medical protocols used should be reviewed by medical oversight. Properly administered, EMD in metropolitan areas will shorten average response times for urgent patients, decrease unnecessary use of back-up resources, improve public perception of emergency services, and help minimize the inappropriate use of emergency resources [11]. Ideally, one dispatch center should operate in an EMS system with trained emergency medical dispatchers. Central dispatch will usually save money, manpower, and equipment when compared to individual dispatch centers for each community. It will also minimize time delays in coordinating scene responses, particularly near jurisdictional borders. The dispatch center will coordinate activities among responding vehicles, including special rescue units, support services, police, fire, utilities, and tow vehicles. Without timely coordination and communication, the full life-saving potential of the system may not be realized [13]. One of the hallmarks of early EMS development was the initiation of medical communications between trained field providers and direct medical oversight. This development allowed the delegation of complex medical tasks and equipment from a physician to the out-of-hospital scene. Direct medical oversight is best provided by experienced physicians who are immediately available for medical guidance of field personnel. It is the responsibility of the state or regional EMS authority to determine system configuration to provide the communication pathway from EMT to medical oversight. The system will be configured with consideration of the number of receiving hospitals and field units requiring communication channels. Direct medical oversight may be provided by a single resource hospital “base station.” When the EMS system uses a non-receiving base station for direct medical oversight, it may become the responsibility of the base station to notify the receiving facility of the emergency situation, the patient’s condition and estimated time of arrival, the treatment, and other pertinent medical data that will make the receiving facility better able to respond [14]. Direct medical oversight communications between physician and provider may be by telephone (landline or mobile), radio, or combinations of the two. Selection of equipment for hospital-to-ambulance communications must take into consideration transmission interference and distances. The next generation of direct medical oversight communications will allow multimedia exchange between field personnel and physicians, with immediate and simultaneous audio, video, and biodata exchange [15]. System leaders now have opportunities to implement video-recording technologies to link information from the emergency scene to later care. ED personnel found great value in this photographic addition to the PCR [16]. The availability of the FirstNet broadband system will enable enhanced real-time video applications. Telemedicine communications between field providers and the medical director are most likely to benefit community paramedicine and rural emergency medical providers. With data communications in our near future, the information exchange between field providers and the medical director may be very different and more effective. Today, this exchange is voice based, with perhaps some biotelemetry data integrated on a separate device. This requires two parties to be present and focused on either end of a radio or phone system at the same time to exchange that information. In the sometimes chaotic environments of an emergency scene and the emergency department, this does not always work well. In the future, the value of “pushing,” “parking,” and “pulling” information on an as-needed basis will become more recognized. For example, a medic could activate a miniature head camera, speak her basic patient findings and requested treatment plan into a speech recognition application through a throat microphone, while attaching a small multi-vital signs monitor on the patient’s chest and inserting the patient’s health record chip into her smartphone. Simultaneously, four data sets are populated and available to the medical oversight physician, incoming helicopter crew, and others. When the medical oversight physician is available, he can pull in these four sets of data, make a determination, and push out orders to be parked until the medic is ready for them. Future EMS systems will continue to rely on voice communications but field personnel will access real-time information by connecting with information that is parked, and continually updated, in a database. Systems will allow acute “situational awareness” of events that can affect decisions about care and transport of patients, and of the resources available to us to best make those decisions. A “common operating picture” of an event, and the resources available to manage that event and the patient involved, will be shared by all personnel contributing to a patient’s care regardless of their locations.
Communications
Introduction
The context of EMS information communications technology
System readiness/access/demand management
Dispatch
Patient interaction and collaboration with medical direction
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