E-Health Care: A Multimedia Inter-Organisational System to Support Emergency Care Process Chains

Dr. Wolfgang Röckelein 1, Dr. Ronald Maier 2, Ulrich Schächinger 1

1 University Hospital of Regensburg, Dept. of Trauma Surgery
2 University of Regensburg, Dept. of Management Information Systems III

Contact address: D-93040 Regensburg, Germany
Email: wolfgang.roeckelein@wiwi.uni-regensburg.de


1. Introduction: German Emergency Care: Context and Application

Scenario

Eastern Bavaria is a rural area associated with deep forests and its national park "Bavarian Forest". Yet it is on the technological frontier with regard to communication and co-operation n medicine: The "Telemedicine Network Eastern Bavaria" links all the hospitals in the area and the NOAH project employs mobile PCs with wireless communication links for the on-scene physicians. This paper presents the findings of the latter project. The emergency medical services in Germany are provided by ambulance cars, vehicular emergency life support, and by helicopters making it one of the best systems world wide (see Mahgsudi et al. 1999). The overall philosophy of the German emergency care system is "Stay and Treat" as opposed to "Scoop and Run" in several other countries. Due to technical and medical progress during the last years and the continued efforts to increase the educational guidance for on-scene physicians, the emergency medical services improved significantly. Despite the existing good overall medical care, there is considerable potential for improvement concerning the management of the emergency care process, communication between the parties involved (e.g. doctor-on-scene, dispatch centre, hospital) and the documentation of emergencies.

This is all the more important as the German emergency care system involves a considerable number of organisations in the treatment of emergencies. Several non-profit organisations as well as a few commercial ones run the ambulance cars and the paramedics. On-scene-physicians are affiliated with hospitals or run their own practice. The government and health-care insurance companies share the funding of this rapidly growing sector. These organisations and the persons involved all have their valid interests, which provide a "natural" barrier to changes involving the whole process.

This paper describes the NOAH project, which is seen as a case study for the design and implementation of a multimedia inter-organisational system in the health-care sector. NOAH stands for "Emergency Organisation and Administration Aid" ("Notfall Organisations- und Arbeits-Hilfe" in German). In chapter two a detailed description of the NOAH solution is presented. Chapter three focuses on the NOAH project. Costs and benefits of an implementation of the NOAH solution are reflected, the project context is outlined and the most important experiences drawn from the project are discussed. Chapter four concludes the experiences gained in the NOAH project and gives a short outlook on the future development of the system and the project’s integration into a more holistic inter-organisational system for the emergency care sector.


2. E-Health Care: The NOAH Solution

2.1.Goals

At present it is difficult for on-scene rescue teams to obtain quick and reliable information in order to select the most advantageous hospital. Additionally, the hospital is not properly informed of incoming patients. The ideal scenario would be that the patients arriving in the emergency room meet a pre-informed, prepared team, consisting of not only the emergency room crew, but also of e.g. laboratory personnel, CT operators, a surgical team or additional specialists. Incomplete information about incoming patients can result in a waste of resources in cases of overestimation or in avoidable damage to the patient in cases of underestimation.

Therefore, the primary goal is to optimise the information flow between all the different organisations participating within the rescue chain starting with the emergency call until admission to a hospital. Specifically, NOAH should help to improve the following areas:

The following general requirements for the new inter-organisational system were found: easy to handle, beneficial to all participants, integration of information systems in use at the various organisations participating in the emergency care process chain and avoidance of repetitive data collection.


2.2.The Organisational Solution: New Emergency Care Process Chain

Pre-NOAH:

Without NOAH the on-scene physician and paramedics and the dispatch-centre use analogue wireless communication on reserved radio frequencies (BOS-radio). There are substantial communication problems due to technical and system related inadequacies, such as radio shadows (communication dead space) as well as distortions and the need for short messages due to the shared radio channel (see Maghsudi et al. 1999). Once the physician and the paramedics have arrived at the emergency location and have left the ambulance car or helicopter, there is no communication link to the dispatch centre any more. The information flow also is unstructured and sometimes involves for example paramedics to hand off information to the operator who in turn contacts emergency physicians in the destination hospital. This can result in the loss, change and/or delay of information concerning the medical condition of the patient to the destination hospital (as experienced in the children’s game "Whisper Down the Lane/Gossip").

Also, the selection of the destination hospital is based on insufficient information. On the one hand, the operator in the dispatch centre (and all the more an emergency doctor in a hospital) does not know the exact condition of the patient. On the other hand, the doctor-on-scene does not know the current availability of medical services in the different hospitals. These evident deficits on the intersection between rescue system and hospitals sparked headlines like "tourism of emergency patients’. In some cases hospitals could not handle the patients any more and emergency ambulances had to take the patient to another hospital hoping that this one would have free capacity to treat the patient.

Figure 1 The basic structure of the inter-organisational system NOAH


With NOAH:

Figure 1 shows the most important persons and organisations involved in the NOAH system.

The on-scene physician is alarmed via NOAH and obtains all the details of the emergency (e.g. the location, a description of the emergency situation, the patient’s name if known etc.) while approaching the emergency location. He can enter the status codes ("on the move", "arrived at the emergency scene", "arrived at the patient", etc.) with NOAH. Upon arrival on the scene, the physician can take pictures and send them to the dispatch centre to elucidate what is actually happening at the scene. The on-scene physician might feel the need to call for additional support (emergency vehicles, doctors or a helicopter). He can use NOAH to call for support and subsequently NOAH will provide information about the status of all other emergency units assigned to this particular emergency case including their current status (e.g. "alarmed", "on the move", "arrived at the emergency scene"). Thus, the doctor is continuously informed about the current status of other emergency units and about what support he can expect.

During the first minutes of the treatment of the patient the physician enters a so-called "First Message" which requires only 10 to 15 seconds. This message contains basic information such as: gender, age class and a categorisation of the patient’s injuries. The dispatch centre in turn uses this information to make an informed recommendation where to bring the patient (if the on-scene physician desires). This message is also forwarded to the emergency room of the destination hospital, where the information can help to start appropriate preparations for the patient. The First Message can be augmented with pictures of the patient, e.g. an open fracture before it is bandaged, and with ECG sequences obtained from semi-automatic defibrillators.

When the on-scene physician finds time she can bring up the documentation screens and give further information to the emergency room. Pictures and ECG data can also be added to the documentation.

Figure 2 NOAH provides a means for efficient emergency care through parallel processes

Figure 2 shows the time gained through the parallel processing of information on the scene, in the dispatch centre and in the hospitals. The NOAH system supports the whole process chain. In the following, a short overview of the technical solution is provided.


2.3.The Hardware Solution

Each on-scene physician is equipped with a mobile PC with a digital radio modem. It provides a direct, digital communication channel between on-scene physicians and emergency physicians in the hospitals. 

There are two types of hardware equipment used at the moment: a hand-held unit and a wearable unit. The hand-held unit is equipped with an internal radio modem and a patient card reader. The model currently used is the Fujitsu Stylistic LT with the Nokia CardPhone 2.0 and a SCM SwapSmart card reader . The Stylistic LT can be recharged inside the ambulance car. A picture is shown in Figure 3.

Figure 3 NOAH hand-held unit

The second type of hardware is a wearable computer inside the physician’s warning and protective waistcoat (so called "NOAH Vest"). The vest allows for the addition of multimedia features, including a video camera in the breast pocket and a connection cable to the defibrillator in another pocket. A microphone (Labtec LVA-7370 collar microphone, connected via the Telex P-500 USB digital Audio converter) is mounted on the collar, currently used to experiment with speech control of the NOAH application in addition to pen control. The wearable computer used in the vest is the Xybernaut MA IV. The camera is the Nogatech USB Micro Cam, the patient card reader is a USB reader from SCM and the radio modem is also the Nokia Card Phone 2.0. This second type is shown in Figure 4 and Figure 5.

  

Figure 4 NOAH Vest with speech control      Figure 5 NOAH Vest with camera in the breast pocket

Figure 6 NOAH set-up in the ambulance car

Figure 6 shows the set-up in the ambulance car. The physician can make a USB connection from the mobile computer (either the hand-held or the wearable solution) to the equipment inside the ambulance car with the silver cable in the middle of the picture. The connection is made to a USB hub, which is in the middle of the figure under the silver cable. On the top of the picture is the printer (Pentax Pocket Jet II). On the right hand side of Figure 6 there is a second, more powerful GSM modem (Siemens M20 Terminal) with an antenna usually mounted on the roof of the ambulance car providing better GSM connectivity inside the moving ambulance car. On the bottom of Figure 6 there is a GPS (Global Positioning System) 12-channel receiver (GPS mouse by Globalsat Technology), providing accurate position information for automatic position reports of the ambulance cars to the dispatch centre and for aiding the driver during the approach to the emergency scene. The latter is supported by a map displayed with markers for both the current location and the emergency scene. All the equipment in Figure 6 is powered by the 12V car power system.


2.4.The Software Solution

The NOAH software is developed by an interdisciplinary team consisting of the authors, trauma surgeons, MIS specialists and programmers from the company "Kratzer Communications, Munich", an expert in wireless vehicle management solutions. The NOAH software runs on industry standard hardware and operating systems (Windows 95, Windows 98, Windows NT 4.0, Windows 2000). The NOAH software uses a pen-based user interface, thus no physical keyboard is required (for text input a virtual keyboard is displayed on the screen). The following screenshots give some ideas on how the software looks and works.

Figure 7 Screen shot of the status screen while physician approaches the scene

Figure 7 shows a screen shot with the alarm instructions. The toolbar on the top left represents the processes involved in the emergency process chain:

The upper right corner is reserved for information about the status of the patient(s). The physician can see at a glance whether he has already sent a First Message for a patient or whether he has already selected a hospital for another one. In the lower right part of the screen is a standard four button block used to initiate radio transmission of the user inputs, to cancel the transmission and to provide a guided navigation through the NOAH screens according to the standard emergency process. Additionally, it is possible to navigate with the toolbar at the upper left part of the screen.

The main part of the screen in Figure 7 shows the alarm instructions. Thus, they are available throughout the approach to the emergency scene. In the lower part, the physician can send status codes on the progress of the emergency care process to the dispatch centre.

Figure 8 Screen shot of the "First Message"

Figure 8 shows the "First Message" screen. The current status code sent with the status screen (see Figure 7) is shown beneath the top toolbar. A First Message was entered indicating a traumatic brain injury of a male adult patient. The emergency physician will put the patient on ventilation. Thus, the patient is in need of intensive care at the hospital which should receive a pre-registration. The two buttons "in need of intensive care" and "pre-registration" are automatically activated once the "on ventilation" button is pressed. The physician has further indicated that he wants the dispatch centre to suggest a destination hospital.

Figure 9 Screen shot of the screen for the "First Message" with camera

In Figure 9 the physician adds a picture to the First Message. The sub-screen shows continuous output of the video camera (the video in the figure shows the first author of this paper). The physician can take snapshots from the video which can be added to the First Message. This sub-screen also enables the physician to attach ECG readouts and data from the patient card to the First Message.

Figure 10 Screen shot of the main screen in the dispatch centre with the First Message

Figure 10 shows the arrival of this First Message in the dispatch centre (the user interface in the dispatch centre is at the moment only available in German). On the bottom of the screen the ambulance car with the call sign "R3212" is selected, which according to the top second row has the status "arrival at the patient" and is manned with the physician named "Dr. Superschlau". On the left hand side the next rows contain six buttons used to display corresponding information in the middle part of the screen as transmitted by Dr. Superschlau (e.g. First Message, status codes). Next to the buttons the time stamp is shown on which new data from this mobile unit arrived. On the right hand side the alarm instructions which were sent to the physician are shown. They can also be changed and sent out again. For the middle part of the screen shot the button "First Messages" is selected. The tabs show two First Messages concerning one adult man and one girl. The destination hospital was selected for the adult which in turn already accepted the patient.

Beneath the First Message the operator in the dispatch centre could select a different hospital and recommend it to the physician on scene. In that case, the operator would work with the screen shown in Figure 11 which presents the status information from the hospitals next to the buttons on the left to select the desired department. The colour coded screen indicates that after accepting the patient as described above the emergency intensive care room and the surgery station can take no more patients (red) while the surgery intensive care station might have some free beds (perhaps only without ventilation facility; indicating colour is yellow).

Everything else is available (green). The next tabs continue with the rest of the hospitals in the city of Regensburg and in Regensburg County and the last tab gives non-hospital destinations, e.g. an ophthalmologist in Regensburg.

Figure 11 Screen shot of the selection screen for the destination hospital with capacity overview

Figure 12 Screen shot of the documentation screen for burns

The physician is obliged to document every emergency care case. The NOAH solution provides an easy-to-fill-out variant of the DIVI protocol – the standardised form recommended for documentation of emergency care cases (see DIVI 1989). Figure 12 shows an example of a documentation screen. The complete DIVI protocol can be printed either on a mobile printer inside the ambulance car or at the emergency room of the destination hospital. Figure 13 shows a printout of the DIVI protocol made by NOAH.

Figure 13 Printout of the documentation form (DIVI protocol)


2.5.The Communication Solution

For the link between NOAH’s mobile units and the dispatch centre a wide range of radio networks can be used. The wireless communication network currently used is GSM (Global System for Mobile communications) with V.110 data transmission. In the past MODACOM (with the RD-LAP 9.6 protocol) was used. GPRS (Generalised Packet Radio Service) will be used as soon as it is available, it will provide a packet-oriented network (which is more suitable to the NOAH communication needs), like MODACOM, instead of the line-oriented GSM V.110 data transmission. 

For the link between the dispatch centre and the emergency rooms in the hospitals a VPN (Virtual Private Network) is used, built on lines of the "Telemedicine Network Eastern Bavaria" (see Röckelein et al. 1999) and on a variety of other lines.


3. The NOAH Project – Lessons Learned

3.1.Costs and Benefits

The Department of Trauma Surgery at the University of Regensburg did a series of studies about the applicability of such an approach (for the following see Maghsudi et al. 1999). The studies used a previous prototype (NOAH I) to determine benefits which could be expected from the application of such a system. The mobile unit was tested in the Regensburg area with one emergency ambulance, one dispatch centre and one destination hospital participating in the field trial. The results can be summarised as follows: The usage is practicable. The main concern of emergency physicians was that it would be difficult to enter the "First Message" within the first minutes after arrival. As the field tests showed the First Message can be entered in less than 15 seconds. The data is available at the dispatch centre only a few seconds after its initial submission.

Practical application of this system showed a significant improvement in time and in the information content submitted to the destination hospital (see Figure 14). The unit of measure (information level) was determined by a quantified information ranking derived from the answers to an anonymous questionnaire of 26 emergency medical assistants and doctors who rated the importance of the transmitted data of incoming patients. The destination hospital is informed earlier and more thoroughly of incoming patients.

Figure 14 Comparison of information levels in the destination hospital with and without NOAH

There was an average time saving of 20 minutes in comparison to conventional data transfer. The time gained could be used to inform all the specialists in the hospital needed and to prepare for the following situations: preparation of the emergency room, transfer of patients from the intensive care unit and information transfer to on-call physicians.

As to date the NOAH prototype is still awaiting its second field trial, it is hard to estimate the final costs of the system. Currently, the notepad computer costs about 5.100 Euro, but the price is likely to decrease (by the time a number of 30 or 50 notepads will be bought). Kratzer, the company providing the software, has not yet calculated the cost of selling and maintaining a system for e.g. a region like Regensburg. The hospitals in the Regensburg area participate in another research project ("Telemedicine in Eastern Bavaria"), so they are already well equipped with the necessary hardware and software platform as well as the communication links for running the NOAH hospital module.


3.2.Project Context and Procedure

The first and in the view of the authors the most important step in the design of an inter-organisational system like NOAH is to get all the parties to talk to each other and focus on joint improvements of the emergency care process. This is provided in Regensburg by "RESCU - Regensburg Emergency Services Centre at the University" (Rettungszentrum Regensburg – RZR in German). The symbol of the RZR is the round table. Its general aim is the improvement of emergency care and communication in Eastern Bavaria including neighbouring states and countries. Figure 15 shows some selected organisations which participate in or exercise influence on the emergency care process chain. Another critical factor is to guarantee a win-win situation for everybody involved. The RZR has provided the platform where every organisation involved will profit from the implementation of the NOAH solution.

Figure 15 Organisations participating in the RESCU - Regensburg Emergency Services Centre at the University (Rettungszentrum Regensburg – RZR in German)

The integration of all parties involved in the emergency care system provides a unique chance to optimise the system. Several study groups within RESCU have been established to focus on different topics in the field of emergency medicine and management. NOAH has been developed and implemented under the auspices of the RESCU. 

The NOAH project is divided into several phases. As mentioned above "NOAH I" was used to study the feasibility of the concept and the proposed advantages. NOAH I was started by the end of 1992 (project manager: Prof. Dr. med. Michael Nerlich). In 1994 and 1995 128 individual cases (emergencies handled with the help of the NOAH I prototype) were evaluated, field tests were carried out to ensure the technical quality of the system and several questionnaires and interviews were conducted with people and organisations involved.

The authors joined the project group by the end of 1995. In 1996 numerous meetings led to the refinement of the project concept for a second NOAH project. "NOAH II" started in 1997. Its goals have been to create a usable product and to introduce broadly the NOAH system as a pilot study in the Regensburg area. A thorough process and data analysis of the emergency care process was done which, together with the experiences from "NOAH I", provided the basis for a redesign of the inter-organisational emergency care processes and the NOAH software. This work has been almost finished in the middle of 2000 and NOAH is expected to be introduced into the whole area of the dispatch centre Regensburg for all on-scene physicians by autumn 2000.

"NOAH II" is a joint project between the RESCU, the department for trauma surgery of the University Hospital Regensburg, the MIS department of the University of Regensburg and "Kratzer Communications". One of the authors has been project co-ordinator of NOAH II. The other two authors consulted the project team in project management, requirements documentation and selection of a systems house and generally about information and communication technologies and their use in inter-organisational systems. The authors were responsible for systems analysis and parts of the systems design as well as the definition of interfaces to other systems used by the organisations involved in the new emergency care process chain. Since November 1998 two of the authors have had part time jobs in the "NOAH II" co-ordination team. One of them became a full time employee in July 1999.


3.3.Experiences

As the authors have been directly involved in all the phases of the NOAH II project from requirements engineering to the test installation of the system, this case study has provided a great opportunity for evaluating the following main areas of systems development for inter-organisational systems:

  1. technological challenges and applicability of hardware and software,
  2. project management issues for the design of an inter-organisational system by an inter-organisational project team,
  3. funding.

In the following the authors provide a short description of their experiences in each of these areas:

  1. One of the biggest challenges in a long-term research project like NOAH II, which uses state-of-the-art technologies, are the incredibly fast technological changes. The NOAH project saw several new waves of mobile technology, which were better and better suited for the needs of the project. In the middle of the project it was decided to use two separate types of hardware, a more conservative hand-held computer and a progressive wearable computer to cope with this fast pace of development. The same is true for the software platforms (operating system, data base management system, communication system). The management of the technological infrastructure and the observation of market developments requires considerable efforts in such a project. Almost every other month the project team had to decide whether to continue the development of the solution on the technological basis as used up to this point or to switch to a new, promising platform. However, often new developments looked very promising, but could not deliver products robust enough for the tough working conditions as encountered by emergency physicians.
      
  2. As mentioned above, the single most important factor in the design of this inter-organisational system was to bring together the different groups participating in the emergency care processes and to provide a win-win situation for all the participants. It soon became clear that it was necessary to change the emergency care processes substantially. This not only involved a redesign of the process chains, but it was also a substantial "political issue" to be addressed frequently during the project. 
    The ideal phases in a software project – requirements engineering, systems design, implementation, test, installation, maintenance – can be found in almost any project. However, in most projects the phases are somewhat blurry and interrelated, so that e.g. during software design, there are still new requirements being generated. This is applicable in this case. Due to the fact that all the participating groups are constantly trying to improve their own processes and tools, new ideas arise almost every week. which could have significant impact on the project. As one of the project’s main goals was to integrate NOAH with all the information systems currently in use at the various participating organisations, it soon became clear that in order to be able to deliver a solution, there had to be a "freezing" of requirements. 
    Another key challenge was to ensure a smooth co-operation between the departments at
    the University and the company "Kratzer Communications". The physical separation (over 100 km by car) had to be overcome by a variety of communications solutions, mainly through frequent use of email and telephone conferences. Nevertheless, physical meetings were necessary. Smaller meetings were held approximately once a month and bigger rounds involving e.g. department heads were held approximately twice a year. Similar to many other software projects NOAH is behind the schedule. This is partly due to the shortness of computer experts on the German labour market which made it difficult for "Kratzer Communications" to assign adequate person power to the project. More lags were introduced by delays in the funding procedures. The organisation of the project consisted of a project manager, a project co-ordinator of the medical part (one of the authors) and a project co-ordinator of the technical part. The roles of the MIS members in the project management were also those of co-ordinators, advisors and mediators between the medical and the technical parts. The "terminological gap" between the medical and technical parts was considerable. Therefore, the authors spent a lot of time learning the details of the emergency care processes and to "speak the language" of the participating organisations. This seemed to be another key success factor of the project.
      
  3. Funding was provided by the program "Bayern Online II" of the Bavarian state government (this program also involves money from the Structural Fond of the European Union), by "Kratzer Communications" and by many of the organisations involved. Thus, there were quite a few stakeholders who exerted their influence on the project. On the other hand, many organisations, which will be affected by the system, took part in its design. Therefore, the project team found many "open doors" and there was no need to convince the participants of the usefulness of the project.

4. Conclusion and Outlook

In the light of MIS research the NOAH project provides a very interesting case study for the analysis of the suitability of the modern set of processes, methods and tools of systems analysis and design for the application in the design of inter-organisational systems. The main results of this analysis can be summarised as follows:

Figure 16 shows the planned expansion of the NOAH system in the near future covering the entire emergency care process chain. The NOAH system is an interesting and positive example for the joint effort of many organisations to propose a useful solution for all the participants.

Figure 16 The future: an inter-organisational system to support the whole emergency care process chain


Acknowledgements

The Bavarian State Government and the Structural Fund of the European Union support parts of the NOAH project.


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