When disaster strikes, healthcare providers are usually among the first to arrive, carrying whatever they need to deliver quick and urgent care. Telehealth is now a critical part of the first responder toolkit, giving providers the help they need to create connected care platforms that improve care coordination and management.
EMTs, fire and rescue crews, Red Cross personnel and the military are now armed with technology that goes far beyond the first-aid kits and walkie-talkies of days past. Smartphones and specially-designed rugged tablets can improve communication, clinical decision support and data capture, and wireless devices capture vital signs and other biometric information.
In addition to first responders, hospitals and health systems are now developing telemedicine networks to stay operational during disasters or to facilitate care coordination and management when they’re forced to evacuate patients and suspend operations. These same networks enable health systems to triage care at the scene of a large accident or mass-casualty event, or coordinate care and treatment during a pandemic.
On a more wide-ranging level, the Red Cross and various international relief organizations are using telemedicine platforms to deliver care to regions of the world hit by disasters, ranging from hurricanes and earthquakes to drought and famine. And the US Military and NATO are using the technology to improve care in high-risk areas like battle zones.
“Following a major disaster, there are always victims with new, urgent healthcare needs,” said Lori Uscher-Pines, a senior policy researcher at the RAND Corporation, told Popular Science magazine. “At the same time, the healthcare system is not functioning at 100 percent. So you have greater demand for healthcare resources and less capacity. Given that this is a common problem, it’s exciting when new tools or services emerge, that can address these challenges.”
Preparing for the Coming Storm
Hospitals and health systems not only have to be prepared to treat those involved in disasters – they need to withstand the damage caused by these events.
In a large-scale disaster such as a hurricane, tornado or earthquake, the first priority is to get a power source up and running, so that electricity and light are readily available. At the same time, healthcare providers and response teams need to set up a broadband network to facilitate communications and share data, both inside the disaster area and with health systems providing emergency care from a distance.
“The purpose of telehealth is to be able to create equivalency across all systems,” says David Catell-Gordon, Director of the Office of Telemedicine at the University of Virginia (UVA) Center for Telehealth in Charlottesviille, Va. That functionality becomes especially important, he says, when health systems are overwhelmed by a surge in traffic or damaged or destroyed by a disaster.
The UVA Health System, which houses the Mid-Atlantic Telehealth Resource Center, recently partnered with Cisco to develop a telemedicine network that would keep healthcare services up and running throughout a disaster. The partnership ensures power and broadband connectivity at times and in places where neither might be available.
“You need a distributed communications network that supports emergency services” under any conditions, says Catell-Gordon, who notes the platform was tested earlier in 2018 during riots caused by a white supremacist rally in the city. “The ability to see the smartphone or laptop or even the smartwatch as a communications tool,” he says, gives providers more insight into what’s going on in the field.
“Without a (reliable) network, you can get overwhelmed easily,” adds Karen S. Rheuban, a former president of the American Telemedicine Association and co-founder and director of the Karen S. Rheuban Center for Telehealth at UVA. “And with so many different emergencies nowadays, you never know when” the system will be tested.
As with any telemedicine system, testing is vital to ensure the technology will work when it’s needed.
During the4th of July holiday in 2018, the Veterans Health Administration took advantage of holiday crush in the nation’s capital to test its Telehealth Emergency Medicine program. In the middle of the crowded Mall, the VHA parked a mobile health van in the crowded Mall.
“We had activated a number of satellites and Wi-Fi channels with the goal of understanding what our capabilities were and seeing how many telehealth sessions we could run at the same time,” Dr. Leonie Heyworth, national synchronous lead for telehealth services in VHA’s Office of Connected Care, said in a press release. “The Mall provided a perfect setting to simulate a post-disaster scenario, as there were half a million people drawing from cellular towers in a small area.”
“If we can have six, seven, or more concurrent video sessions running, whether for mental health support or to address other clinical concerns, that would be the equivalent of having seven more providers on the ground providing that care,” she added. “We offer medical support to many patients simultaneously, across a wide range of clinical specialties, by telephone or video in a much timelier manner because of the ability for telehealth to get to a post-disaster area quickly.”
In a 2010 brief, four physicians from the Center for Telehealth Research and Policy at the University of Texas Medical Branch in Galveston laid out lessons learned from Hurricane Ike, which killed 82 people and almost destroyed Galveston in 2009. They noted the hospital’s connected care platform was up and running at a time when the hospital campus was badly damaged.
“Although there were significant disruptions to a majority of UTMB’s physical and operational infrastructures, its telemedicine services were able to resume near normal activities within the first week of the post-Ike recovery period, an unimaginable feat in the face of such remarkable devastation,” the study reported. “This was primarily due in part to the flexibility of its data network, the rapid response, and plasticity of its telemedicine program.”
Frequent testing has its benefits, as staff at Bingham Memorial Hospital in Idaho found out. During a solar eclipse in August 2017, the 25-bed critical access hospital in eastern Idaho suddenly lost power. With no way to accept incoming calls, Robert Weis, the hospital’s director of information technology, used a secure messaging platform that the hospital had put in place for disasters.
“Whether it was coincidental or not [with the eclipse], we still don't know exactly, but at that moment it was like, ‘Wow. Let's try the tool. Let's broadcast to the team,’” Weis told HealthITSecurity. “Obviously within a few minutes, 30 to 40 people had read the message so they knew what was going on.”
Power was restored within 20 minutes, and Weis said the mHealth platform worked as intended.
“We practice on a lot of different scenarios,” including floods, mass casualty events and pandemics, he said in a separate interview. “We want to layer our communications strategy so that when something happens, we can still coordinate care and keep functioning.”
Using Telehealth to Extend Emergency Care Services
When Hurricane Harvey rolled through Texas in August 2017, it left in its wake flooded communities, impassable roads and hospitals damaged or deprived of electricity. Hurricane Irma followed less than a month later, slamming into Florida with the same effect. Both storms had devastating impacts on healthcare networks – and proved the value of telehealth in emergency response.
The Nemours Children’s Health System, with locations in Delaware, Pennsylvania, New Jersey and Florida, was among the first to open its telehealth platform to those affected by Harvey, offering free access through any mobile device to the CareConnect service.
“We all of a sudden realized, ‘Oh, we can help,’” says Carey Officer, Operational Vice President for Nemours Care Connect and the health system’s Center for Health Delivery Innovation. “So we put the word out on social media and got an unprecedented number of shares and feedback. We saw in just one three-day period more [patients] than we typically see in three months.”
In Rockport, one of the coastal Texas communities hardest hit by Harvey, a telemedicine station staffed by Lubbock-based emergency care provider Star ER stepped in to provide on-site care following the hurricane.
“We have the personnel, we have the supplies, we have the training we have the knowledge to go actually make a difference and take care of people in their time of need,” company co-founder Ryan Lewis, MD, told television station KCBD. “I personally feel is our duty to step up and go help our fellow Texans, our fellow health care providers and our fellow safety personal.”
Lewis said residents could also download the Star ER app to “tele-consult back to Star ER with one of our physicians.”
When Irma hit, Nemours once again opened its telehealth program for disaster relief, even as its Jacksonville, Fla. facility was lashed by the storm.
“Telemedicine is absolutely a huge opportunity that our state and our nation needs to look at,” Officer said. “One of the biggest challenges is the realization of what hospitals can and can’t do in an emergency.”
The hurricanes of 2017 produced a watershed moment for telehealth. While Nemours and other health systems used connected health platforms to reach out to patients in need of care following the disaster, direct-to-consumer telehealth companies like Teladoc, American Well, MDLive, LiveHealth Online and Doctor on Demand saw the opportunity to extend their services for free to anyone in need of care.
Those caught in the hurricane could now get immediate medical attention through a smartphone, tablet or laptop, or be directed to the nearest emergency shelter for prioritized treatment.
Direct-to-consumer telemedicine “may facilitate care that would otherwise be inaccessible due to displacement, impassable roads, emergency closures, or increased demand for healthcare services,” The RAND Corporation’s Uscher-Pines wrote in an April 2018 study.
“Our study suggests that direct-to-consumer (DTC) telemedicine is a new way to deliver routine healthcare to people in the immediate aftermath of a natural disaster, although it does require that certain infrastructure like cellular service and Wi-Fi remain intact,” she said in an accompanying press release.
“Relying on direct-to-consumer telehealth services may help relieve the immediate burden on local health care system so that limited in-person care resources can be reserved for those patients with the greatest need,” Uscher-Pines concluded. “Our study illustrates the emerging role for direct-to-consumer telemedicine in disaster response.”
Since Harvey and Irma, DTC telehealth companies have offered their services for free following several major events, including the Parkland School shooting, Las Vegas massacre and California wildfires.
“One of telehealth’s biggest powers is its ability to beam care instantly to where it’s most needed,” says Roy Schoenberg, MD, American Well's CEO. “Often this 'superpower' is used for convenience, but when a disaster strikes, like hurricanes in the southeast, a flood in Houston or area fires in California, telehealth can mean the difference between being stranded and getting the care you need.”
“Telehealth is playing a new role as a 'gatekeeper' for appropriating medical services to areas in need,” he adds. A telehealth platform like American Well's “matches the supply of doctors with the demand coming from patients in a specific region, allowing us to digitally scale up services for a particular area. This is ideal for emergency scenarios where access all of a sudden becomes a challenge.”
These services are especially beneficial in treating emotional distress.
“Keep in mind, the victims’ needs are not limited only to medical care,” says Nathaniel Lacktman, telemedicine chair at the Foley & Lardner law firm. “Natural disasters are emotionally traumatic, and victims can access licensed mental health professionals and psychiatrists to help with the emotional and psychological burden.”
“Moreover, victims who have been displaced to shelters or cities outside their hometown can continue to maintain contact with their treating providers due to the highly portable nature of telemedicine technology. On-site first responders can also bring with them new digital health devices as a small, lightweight substitute for bulky traditional diagnostic tools.”
Putting the Mobility in Mobile Health Response
Healthcare providers and relief organizations have been sending care teams into disaster zones with telemedicine kits and specially designed laptops and tablets for years. But sometimes the situation calls for a bigger solution.
When Haiti was rocked by a massive earthquake in 2010, the University of Miami Miller School of Medicine established several telemedicine clinics in the island country. The largest, a 240-bed tent hospital, saw volunteer surgeon perform more than 1,000 emergency surgeries and, through a satellite link, collaborate with colleagues in the US on long-term care.
The experience led the university to develop an ongoing telehealth partnership with Haiti, providing continuing care in an area where resources are poor and life isn’t easy.
Closer to home, hospitals and health systems are using mobile health units – specially designed ambulances and vans – for a variety of purposes, including telestroke services, community paramedicine and public health outreach. They’ve also been used in disaster response.
Following Hurricane Sandy’s 2013 assault on New York and New Jersey, Northwell Health dispatched its first mobile health unit (MHU) to affected areas. According to Forbes, the mHealth vehicle saw more than 1,000 people, with vaccinations and treatment for upper respiratory infections the most common treatments.
While some health systems have retrofitted large RVs or semis with telemedicine technology, others have developed telemedicine stations capable of being shipped or airlifted into disaster areas where the roads might not be good.
In early 2018, AMD Global Telemedicine and Jenisys Global joined forces to create a rapid response telehealth clinic – basically a specially equipped storage container – that could be either transported on a truck or ship or airlifted into a disaster zone. The so-called “specialized health pods” come with their own power source and satellite-based broadband connection, HVAC and waste disposal units and clean water source. The pods can be set up in 15 minutes.
“When you’re at the scene of a disaster, there’s a different way of operating,” says Eric Bacon, AMD’s president. “You could put all the best equipment in the world there but if you don’t have the power or connectivity, you’re just (exacerbating) the problem.”
Looking ahead, Bacon sees these types of telemedicine units being deployed in other locations, including oil rigs, remote camos and communities, large business campuses and developing countries.
Tackling an Epidemic, Preventing a Pandemic
When the Ebola virus swept through parts of Africa between 2014 and 2016, US-based health systems and relief organizations used telehealth to connect healthcare providers in Africa with specialists. They also sent in laptops and tablets equipped with clinical decision support tools and resources to help those on the ground access the latest in treatments.
With the possibility that the Ebola or Zika viruses could spread to the US, hospitals and health systems here developed telehealth and telemedicine platforms to aid quarantined care teams and connect providers with specialists for immediate consults.
Those tactics are now being applied to a number of potential health concerns, from flu outbreaks to possible incidents of biological warfare – even suicide clusters. Using artificial intelligence, public health agencies can now scan social media channels, communications networks and other online channels to track trends and identify locations where populations are affected.
Health systems have used this technology to identify an emerging flu outbreak and prepare for a rush of patients to the emergency department (or DTC telehealth service). Mental health professionals and school systems have used the system to detect increased levels of depression and anxiety, then sent out mass messages alerting the public to available mental health resources. One community used the technology to identify environmental patterns that could trigger asthma outbreaks.
“Telemedicine adds a completeness to our response to a crisis,” says UVA’s Catell-Gordon. “When you add that technical network on top of the human network, you’re saving lives.”
This article was originally published on August 24, 2018.