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
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Table of Contents
Sections
Executive Summary
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Use Case
Pre-Teletrauma System
Post-Teletrauma System
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Background
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Benefits
Access to Specialists
Evidence-based Resource Allocation
Knowledge Sharing
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Challenges
Experimental Technological Base
Liability and Privileging
Economic Sustainability
Integration Across Different HIT Systems
Varying Levels of Clinical Expertise & Resources
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Legal and Ethical Issues with Plans for Compliance
Physician Licensing
Credentials and Privileges
Electronic Prescribing
Informed Consent
Malpractice Liability
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Standards
Background
Types of Services
Critical Components and Standards
Relevance of Standards
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Technical Requirements
Data Flow
Integration Elements
HL-7 Message Types
Connectivity
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Projected Development and Implementation Costs
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Training Requirements
Multidisciplinary Team
Technology Training
Clinical and Communications Training
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3
Simulation Training Sessions
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Implementation Plan, Workflow, Organization, and Governance
Project Phases
Workflow
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Critical Evaluation of Teletrauma System
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Summary
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References
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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
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Appendices
Appendix I: Trauma Center Level Designations
Appendix II: Trauma Team Activation Criteria
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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.
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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
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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
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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
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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.
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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
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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
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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
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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
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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
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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.
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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
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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
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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
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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
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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.
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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.
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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.
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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
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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)
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Appendix I
(Sasser et al., 2012)
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Appendix II
(University Medical Center, n.d.)