My name is Josh Hehner, I'm a Paramedic working in Toronto, Canada, and am Director of Community Medicine Programs for a Peruvian-Canadian charity called Para el Mundo (PaM). We work in northern Peru in the areas of community medicine, education and social services.
We work closely with the Peruvian Ministry of Health (MINSA), and have many contacts there.
I was moved to become involved after thinking about the OLPC project, its implications for children and the lowering of barriers to access to education and the means of information processing, and finally their application to the work that we have been doing. For a long time I have had an interest in the applications of portable computing and new media to pre-hospital emergency medicine, having written a paper in 2001 during my paramedic program about point-of-contact informatics, researching the future of the emerging adaptation of those tools to facilitate our job (see below).
In 2005, my wife and I moved to a small town in northern Peru and helped form a community development organization that has created the town's first free medical program and medical clinics visiting more remote and isolated peasant communities in the area. I work as Director of Community Medicine.
The medical program is among a variety of community projects we have initiated in the areas of education and social services. We work with the schools in our town, both primary and secondary, in strengthening teaching capacity, particularly having been deeply involved in areas of sexual health education, english, math & computers. We hope to involve our local high-schools in Peru's participation in OLPC pilot projects.
A "One Laptop Per Doctor" that I imagine would be ideal technological support for the model that I have been developing. It is one which uses the Paramedic's model of one (or more) base-hospital physicians whose reach is extended out into the community through protocols, delegated acts, training and continuing medical education. This is combined, in our Peruvian context, with the "Health Promoters" model of community health workers, of less formal training where institutional support is unavailable, of home-visits and 'healthy community' models.
This could obviously be facilitated enormously by the distance medicine revolution that is just on the horizon. An OLPD device could assist in so many vital ways, ones which I imagine you have already or can envision without having to be in the medical field. Some examples that I dream of are data entry + gps tagging; video-conferencing to docs back in the city for consultations or even providing instruction to nurses,paramedics or health workers; telemetry; images & a/v for patient education; maybe translation for patient interactions, etc..., etc...
I am currently involved in the OLPC health project, particularly in the areas of theory & philosophy development, planning and project development, and hope to implement health methodology research initiatives and test the effectiveness of these ideas and technologies in the region we're involved with (Peru's northern coastal region, Piura & Tumbes provinces, Mancora & the surrounding communities).
I can be contacted via e-mail at josh at paraelmundo dot org
Some background on work I've been involved with and how they variously inform my thinking about these areas:
I'm a former Toronto EMS Paramedic, working as a 911 emergency responder. Through this I developed a keen interest in the area of pre-hospital emergency medicine. There are a lot of commonalities between the domain of pre-hospital medical service in wealthy countries, on the one hand, and community development medicine in resource-poor areas, on the other (the second being "pre-hospital" by definition because there simply is no hospital close by).
As well, as I became more involved with the field, I developed a strong interest in point-of-contact informatics and how they would come to transform the way paramedicals engaged in their work. Being a devout technophile at the time I was in the Paramedic program at Humber College, I wrote a short paper on it for one of my courses (see below).
I am a founding member of PaM, a small international development project in Peru's northern coastal region. We work in community development projects in medicine & public health. This forms part of a larger, holistic community development program that includes the two other pillars of education and social services. We also run a volunteer program to provide a wealth of workers and knowledge resources for our projects.
Through this work I have been developing new models for community medicine in rural & remote areas that bear similarities to pre-hospital medicine in the use of base doctors with paramedicals radiating around them. This is added to the idea of health-promoters as valued members of the health-care chain. This would be done through the use of a base-hospital, training, delegated acts & standing orders, and readily available consultation.
Before becoming a Paramedic, I ran a small business specializing in graphic design and web design. I also taught information design at the University of Toronto's McLuhan Program in Culture and Technology. I'm also a Yoshinkan Aikido instructor. I have a strong interest in the role of education, in formal and informal settings, as a central need of progressive and transformative social action. In particular I'm interested in anti-authoritarian and anti-oppressive educational forms which differ from traditional indoctrinational models.
Point of Contact Informatics Paper
Note: I wrote this in December, 2001. At the time it was meant to be forward-looking; since then some of this has come to pass, while other aspects are only just now being explored. While this was meant to examine the applications of these technologies for applications to pre-hospital emergency medicine, it is obvious that these tools could have enormous impact in the areas of community development medicine. I apologize for the pedantic tone; it was written for a non-technical audience.
Paramedics, by the nature of their profession, are constantly working with vast bodies of knowledge and large volumes of information, and they must be able to communicate effectively with many people, from patients to nurses, doctors and administrators. Like other health care workers, paramedics must be proficient in medical science, pathophysiology, pharmacology, and trauma and medical emergency management. They must be able to apply this knowledge in a timely fashion and to a wide range of problems.
Paramedics work on the front lines of the health care profession, carrying with them a host of standing orders and guidelines, as well as relaying information back to the hospitals and other community health facilities. In emergency medicine, they have been described as extensions, out into the community, of the eyes, ears and hands of emergency room doctors. Paramedics must also be social workers, working to reduce the harm of disease, poverty or misadventure by networking with a host of community organizations. In the past, paramedics had only their memories and communication skills, in addition to a small amount of dispatch information and the ability to make a radio patch to base hospital doctors if needed, to help them in this endeavor.
A new host of informatics tools is now becoming available to assist with these and similar tasks. In order to be useful, these tools must be mobile, working wherever the paramedic does, and must function even in the most difficult of conditions. This paper will examine these tools and the various software applications that might be used on them. It will also discuss problems that might be associated with their introduction and make recommendations as to their potential usefulness in the near future.
Information: Data which conveys meaningful ideas, in the form of text, drawings, images, video, sound, etc...
Network: A group of people and their computers in communication with each other, working together and sharing information between them.
Information Technology (IT): Tools which facilitate interaction with information and between individuals and networks.
Informatics: The study of the practical applications of information technology to various fields. Medical informatics could be used as a tool for reference, as a memory refresher or medical textbook, or for public education, and could transmit information, such as patient records or vital signs, between the hospital and the paramedic.
Mobile computing: The use of portable and wirelessly networked devices to help communicate and access information, regardless of where the user happens to be. Includes devices like PDAs (Personal Digital Assistants), such as the PalmPadÅ, cellular telephones and pagers as well as portable or "laptop" computers.
Point of Contact (POC) tools: Mobile computing tools which allow the paramedic to access information, as well as communicate with networks and people, at the patient's location, such as at the scene of an accident, the patient's bedside, or in the ambulance en-route to the hospital.
In paramedicine, any tool used must directly aid in the delivery of effective patient care. Too often, new technologies are introduced simply because they are new and exciting. Point of contact informatics tools will need to be shown to be valuable additions to, rather than fancy distractions from, the paramedic's ability to render aid and to communicate between members of the health care team. The high cost of new information technologies will need to be justified through cost/benefit analyses.
General requirements of point of contact informatics tools include the abilities to view information, such as on a small display screen, and to input data, through the use of buttons, a keypad, or pen with character recognition (software which turns handwriting into editable text). Mobile computing devices intended to be used as reference tools must have storage space for large volumes of information, such as a pharmacopoeia or medical encyclopedia. Those working as communications tools or for accessing networked databases must have some form of wireless communications system, such as those found in cell phones and pagers. Wireless network infrastructure, for example cell phone towers and radio antennae, will also need to be in place in the community.
In pre-hospital emergency medicine, space and time are at a premium. In order to be effective, point of contact informatics tools must be portable and lightweight, and must not add excessive weight or bulk to the large volume of gear already needed at the patient's side. They must be conveniently accessible and uncomplicated to use, particularly if required in an emergency situation.
Paramedics must work in a variety of uncontrolled settings, and any gear used must be able to cope with a diversity of circumstances. Examples include the use of backlit screens for poorly lit areas and buttons large enough to be worked by gloved hands. Mobile computing tools must also be durable, able to handle shocks and bumps without breaking or malfunctioning, and must be protected from rain, mud or bodily fluids. There must be a way to disinfect the outer shell without ruining the device.
Mobile computing devices offer a host of capabilities that make them likely to be valuable additions to the paramedic's tool kit. These devices are currently being tested by individual paramedics, as well as some Emergency Medical Services, across North America. The abilities to look up and view large amounts of stored information, to connect to databases such as patient hospital records, to digitize records and forms like the Ambulance Call Report (ACR), and to function as portable communications devices, all from the patient's side, will transform emergency medicine over the next decade.
Four major categories of capabilities likely to be of value to the paramedic, and some of the specific applications associated with each, are presented here.
Information Storage and Retrieval
Mobile computing devices which can store information, for example from a diskette or CD-ROM or by being connected to a desktop computer, allow the user to access large volumes of information in a highly portable form, from anywhere. The amount of information that can be carried on typical PDA today is equivalent to that of a dozen multi-volume encyclopedias. Not only is this form much easier to carry, but the ability to program in an "interface" (a group of menus, icons and windows), makes it quick and simple to search for the right information.
Digital information can take the form of text, drawings, images, video and audio clips, flowcharts or other "multi-media". However, as the complexity of the information increases, so too does the amount of storage space required, and the more expensive the display capabilities needed to view it become. Most information will be stored in the form of text that is navigable through the use of directories, lists and search functions.
1. Pharmacopoeia of Drug Information: Allow the paramedic to look up information from the Compendium of Pharmaceuticals and Specialties (CPS) such as generic and trade drug names, contraindications, drug interactions, and so on, as well symptom relief standing orders.
2. Medical Information: Including a medical dictionary or encyclopedia, a pathophysiology text and anatomy images and diagrams. This is less likely to be used, one would hope, in an urgent setting, as paramedics will continue to be expected to have an active and current knowledge of emergency medicine rather than simply having good reference materials at hand. However, the information could be used for continuing education (CE), to refresh one's memory after a call, or perhaps most interestingly, for public education. It may be valuable on many occasions to have diagrams and images available to help explain a particular anatomical problem or physiological process, as in when trying to convince a patient that it is in their best interest to come to the hospital.
3. Language translation, phrasebook: In a city as diverse as Toronto it is common to encounter language barriers that interfere with patient care. PDAs could serve as a portable phrase book for every language one is likely to come across, offering pronunciation of key phrases, or maybe even playing pre-recorded sound clips, that aid in history taking and patient care. Another possibility is the display of text, in a wide array of different languages, that a patient could point to in assisting to identify which tongue they speak.
4. Protocols: PDAs could allow the paramedic to view and navigate complicated protocols, and could offer tools to assist in note taking. These could include things such as event markers and forms, noting the time and pertinent information in activities like defibrillation and Advanced Cardiac Life Support (ACLS) medication administration.
Personal Data Assistant devices are now also being outfitted with wireless network capabilities similar to those of cell phones. This will allow them to connect, via the Internet, to databases of information stored on the computers of various hospitals, government and community agencies, and allow the paramedic the opportunity to view this material remotely as well as enter data to update records.
Users can view public websites as well as access private networks using security measures such as passwords and encryption (a method of digitally garbling the information so that it can't be decoded by anyone but the intended recipient).
Networked databases, unlike printed documents, are always up-to-date: when a change is made, it is instantly available to all interested parties, since only the most current version is viewed. This works particularly well with forms that may be filled out or viewed by a number of parties, such as patient charts, and for information that may be changing regularly, such as lists of phone numbers.
1. Patient records: This includes hospital records, medic alert information and police database information. It would allow the paramedic to supplement their dispatch information with knowledge of a patient's specific conditions and past diagnoses, medications and doctor's orders. Examples include information about complicated medication regimens, pertinent medical history and the presence of communicable diseases. Police databases could also provide information about past violence or abuse of the system, though clearly some form of legislation will need to be created to address this capability's implications for privacy. This application could also provide a text-based version of the Medic Alert directory, whose information is currently accessible via telephone operator at a toll-free number.
2. Directory of community services: Many times, paramedics must play the role of social workers, helping clients to be aware of, and make use of, a variety of social agencies. This function would allow the paramedic to carry with them a large directory of available community services, providing contact names, phone numbers and addresses. This capability may even allow them to interact with the agency, for example via a website, to book appointments or check on the availability of resources such as shelter beds or rehabilitation programs.
3. Maps: Map systems may be implemented in a variety of ways, but at their most basic would allow for a searchable and scrollable version of the map-books carried on the vehicles. One could also "zoom" in and out to view the map at various scales. When connected with dispatch information, this would allow the paramedic to instantly locate destinations on the maps.
This system could also be connected to a Global Positioning System (GPS), which identifies the exact location of vehicles through the use of satellite triangulation. The maps could then show, through the use of small icons, one's own location as well as those of other vehicles on the system, such as response cars and Advanced Life Support (ALS) vehicles. Another exciting possibility is the ability to incorporate up-to-date weather and traffic information to aid in planning routes or avoiding trouble spots.
Bureaucracy and Office Work
Paper work and day-to-day office tasks could also be helped by portable computing devices. Digital forms allow for easy dissemination of multiple copies, as well as automatic tabulation of data for research and statistical purposes.
1. Day-timer, calendars, organizer, address book: This software is currently in use in many places and is basically an automated version of a personal day-timer / FilofaxÅ type book. Applications that have been standardized across a whole service and are connected to a network, however, could allow the paramedic to receive timetables and updates right to his or her PDA, as well as request days off, adjust scheduling with another paramedic, etcä In addition, these could include an updated directory of important service numbers and contact information.
2. Ambulance Call Reports (ACR), incident reports, personal notes: Could allow the paramedic to fill in forms and take reports right on their PDA, automatically sending a copy to all the relevant places. This process would also facilitate things like research and statistics, since all the material is already digitized. The paramedic would also be able to search through back records of forms, and cross-reference material with previous calls. A well-designed system would create a simple interface for this process and would prompt the paramedic to fill in all the relevant information in the appropriate places.
Real-time communications, Wide-Area Networks (WAN)
Another exciting possibility is incorporating cell phone and pager-type capabilities into a point of contact device. This would allow for real time communications with people and networks, and the ability to send text and diagrams, and possibly even still images and video, along with voice transmissions. In addition, network programs could send real-time information updates to the paramedic's PDA or allow the transmission of live data from the ambulance to triage nurses and emergency room doctors.
1. Dispatch system, Central Ambulance Communications Centre (CACC): Currently, dispatch information is sent to the paramedic via an initial phone or radio call, followed by small text updates sent to a pager. This new system would allow for ongoing dispatch updates, as well as giving the ability to receive further clarifications, or, as discussed above, to cross-reference information with maps and patient records. Dispatch updates would no longer be limited to a single, heavily abbreviated sentence, but could instead include all relevant information available at the time. Whenever the paramedic looked at their PDA, it would show the most current and up-to-date information available, based on, for example, the evolving 911 call.
As well, as has been previously discussed, the use of GPS systems could allow all paramedics to be aware, much in the same way that dispatch workers at the CACC are, of the state of the EMS system as a whole. This feature could be very useful for self-dispatching response cars, multi-patient units (MPU), ALS crews and for supervisors. In addition, a networked communications system such as this could facilitate load balancing between adjacent EMS services (such as between Toronto EMS, Peel, York, New York State, etcä) and coordination between the different emergency services, including ambulance, fire, police and public works.
2. Communications with base hospital, destination hospital, doctors, nurses: Would include useful functions like sending patient status updates and estimated times of arrival (ETA) from the ambulance to the receiving facility. It could also involve an extension of the Canadian Triage and Acuity System (CTAS) to include ambulances, allowing triage nurses to be simultaneously aware of all patients they are responsible for triaging, both in the waiting areas of the hospital and those in-bound in ambulances within the hospital's catchment area. Conversely, paramedics would not only be aware of the current state of a hospital, such as whether they are open or on critical care bypass (CCB), but would also see the current load on any given hospital or ward, as it evolves.
In addition, mobile computing devices allow for communication in a variety of media, from voice transmissions, to data, text, diagrams and more. One useful feature of having a small digital camera incorporated into a PDA would be to send digital photos of an accident scene, such as a motor vehicle collision (MVC), to the hospital along with the patient. Point of contact informatics devices could also transmit live data, called telemetry, from a variety of monitors such as cardiac and oxygen saturation monitors, which may help base hospital doctors to evaluate patients and authorize procedures.
Problems and Recommendations
The incorporation of point of contact informatics tools will present wonderful opportunities for new methods and practice. These tools will also bring with them a host of new problems that need to be addressed before being widely deployed. A few such problems, and suggested solutions, are discussed here.
Security and Privacy
Any device which is capable of accessing confidential patient records, as well as those which can remotely influence the entire Emergency Medical System, will need to be kept in the tightest security. One method of addressing this is through the use of passwords and other codes which allow only the designated operator to perform the specified actions. Only those empowered by law to access confidential information would be able to do so. This is similar to the protections in place for police dashboard computers.
In the near future, devices such as these will incorporate some form of biometric identification, that is, systems that identify the operator on the basis of unique and unforgeable characteristics such as thumbprints or retinal scans. This increased security will, however, mean a trade-off in ease-of-use, and in some cases could slow the use of the application down to the point where it is no longer practical.
Another aspect of security to consider is the use of wireless communications, which must necessarily involve the transmission of signals through the air. These signals could theoretically be picked up by any other wireless device in the vicinity and capable of receiving them. This problem is already being addressed in the cell phone industry with the use of digital encryption, which prevents anyone but the authorized recipient from decoding the signal.
Memory and Dependency
The basic function of many of these applications is to externalize knowledge and mental processes that previously would have been memorized. One special interest group website for medical Palm/PDA enthusiasts even calls itself the "Ectopic Cortex". Though it may be handy to have this information available as a reference, in many cases the paramedic will continue to need a current and active knowledge of the field, particularly of those things necessary for the management of emergency situations. It would be impossible, for example, to be looking up ACLS protocols, medications and dosages and still administer them in a timely fashion.
Technology also has a habit of breaking down when you need it most, so an EMS system would be well advised to avoid becoming dependent on a particular application, and should maintain alternate methods of performing any task.
Cost and Infrastructure
Information technology is notoriously expensive. When evaluating the cost of a particular solution, the provider must consider not only the direct cost of the tools themselves, but also things such as software applications, technical support, repair and retraining time.
Infrastructure is also an enormous issue, particularly with respects to wireless communications. These devices will only work when they have access to a strong enough cell tower signal (e.g. the Toronto subway disaster), and when the network itself is not overloaded with calls, as can be the case during large-scale emergencies. Many events which place heavy demands on the emergency response system will also affect public infrastructure, such as wide-area power outages and snow storms. Again, it would be advisable to maintain backup systems and to continue training in their use.
Continuity of legal documents
One final challenge to discuss is the ramifications that digital reports have on the continuity of legal documents. Administrators and legislators will need to establish methods of insuring that digital documents are not tampered with and still retain legal integrity for things such as inquests and court cases. This may involve measures such as secure storage and transmission of documents, timestamps and server identification codes to establish exactly where and when it was created, stored and who has had access to it. Keep in mind that paper documents themselves are not completely secure, but only offer a reasonable degree of assurance due to consistent bureaucratic procedures and conventions for filling out legal forms and taking notes. Similar measures will need to be adopted for digital documents.
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