The Telemedicine Response to Homeland Safety and Security Developing a National Network for Rapid and Effective Response for Emergency Medical Care

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1 The Telemedicine Response to Homeland Safety and Security Developing a National Network for Rapid and Effective Response for Emergency Medical Care The unprecedented and growing threats to the safety and security of the U.S. population from physical, chemical, and biological terrorist acts range in scope from the general and massive to directed and local. The nation is now struggling to develop a systematic, coordinated, comprehensive strategy to deal with these threats. The strategy must address all aspects of the problem, including prevention, early detection, containment, and treatment of victims. Successful implementation requires an integrated approach utilizing existing medical and public health communities working in consort with other officials and agencies in addressing homeland security. This document proposes a framework for utilizing the available telecommunications, medical and healthcare infrastructures in the nation, leading to the development of a seamless, hierarchical network that links health information and medical treatment at the national, regional, and local levels. Effective medical and public health responses to current threats require immediate response capability in four critical areas: 1. Prevention and surveillance Risk assessment Communication regarding emerging threats Education for providers and the public at large Implementation of risk avoidance measures 2. Early detection Real time health monitoring Local, regional and national data assessment Education 3. Crisis response Rapid assessment and identification of medical need Diagnostic, therapeutic, contamination containment Coordinated response Optimization of logistics 4. Treatment Centers of excellence providing specialty care instructions to front-line providers and officials Timely consultations Supervision of treatment at regional and local levels Referrals to specialty centers National Expertise Leading U.S. government health agencies, as well academic, public and private health care institutions are world-renowned repositories of expertise and information regarding the diagnosis and treatment of the vast majority of conditions that may result from these threats. The Defense Department, Centers for Disease Control and Prevention and other federal agencies, private companies, and academic centers

2 are developing new technologies and programs in surveillance, detection and response individually and cooperatively. Still other federal and national agencies maintain enormous expertise in responding to emergency and disaster situations. Local Needs and Limitations Despite the availability of these first-rate resources and expertise at the national level, it is the local and regional health care providers and public agencies that are the first responders in this new war. In addition, local and regional providers typically serve as the collection and access points for information and reporting, as new threats are manifest. Hence, it is necessary to develop and maintain a network that links the resources available at the national level with local and regional providers to deal with routine problems and emergency situations. Unfortunately, many local health providers are geographically and functionally limited in the existing infrastructure. Currently, for example, there are only two effective ways for evaluating and treating a patient suspected of exposure to biological or chemical agents: (1) the physical transfer of the patient to the specialist site or (2) the transport of the specialist to the patient. A time delay in either case is likely to compromise the patient's health. Equally important, each scenario severely limits containment measures, which may result in unnecessary secondary exposures. Telemedicine technologies are uniquely suited for providing essential links between the national and regional resources with first responders. However, the deployment and implementation of these technologies and systems require a national coordinated network and level of expertise, which are not available throughout the country today. Little exists to allow for interactive, real-time telecommunications on a national level that includes sharing of situation, threat and patient information from the point of need to the point of expertise. Existing Telemedicine Infrastructure There are more than 200 local and statewide telehealth/telemedicine networks in the United States, which are operated by leading medical centers. These networks connect more than 2,000 existing health and medical centers including major medical centers, rural hospitals and other facilities such as clinics and schools within their respective networks. The typical network consists of a consultative resource located at a hub site such as a VA hospital, an academic medical center, a military health facility or a comprehensive community hospital that provides consultative and educational resources via a telecommunications infrastructure to a group of outlying health facilities, inner city clinics or remote military bases. Some are statewide. Many major academic medical centers are already using telemedicine facilities to provide education and training for health providers throughout the state, coordinating their activities with VA, military and other health facilities. A typical telemedicine program uses the system for such relevant medical services as pathology, pulmonary/critical care, dermatology, teleradiology and emergency medicine. Many use these networks to provide infectious disease diagnostic services. Some integrate the provision of emergency medical services through linkages with EMT personnel serving as first responders. The federal government has played an active role in the deployment of telemedicine by (1) authorizing over 10 federal grant programs to support local and statewide telemedicine programs; (2) reimbursing telemedicine services under Medicare; and (3) using telemedicine to provide direct medical care for the military, veteran, Indian and correctional care populations. Several federal offices have played a significant role in the development and deployment of telemedicine, including: The Telemedicine and Advanced Technology Research Center (TATRC), at the US Army Medical Research and Materiel Command, Ft. Detrick The Office for the Advancement of Telehealth (OAT), at the Department of Health and Human Services

3 The Veterans Health Administration, at the Department of Veterans Affairs The National Library of Medicine, at the Department of Health and Human Services Telemedicine programs have already been used in responding to the new threat of terrorist action. This response is not surprising given that the functionality of any existing telemedicine system is effective in evaluating the skin and pulmonary manifestations of anthrax, the skin lesions of small pox, the neurological presentation and sequelae of botulism, etc. For example, over the past month, several telemedicine systems have taken the lead in training local health workers in identifying and dealing with biological pathogens as well as preparing for other terrorist incidents, using information available from the Centers For Disease Control and Prevention and other national and regional resources. Creating a Network of Telemedicine Networks Operating telemedicine networks that link health resources within defined geographic areas come together at the American Telemedicine Association (ATA). With over 1,500 members, ATA is the national focal point and world leader for collaboration, education, and peer networking for those working in telemedicine. The ATA has served as the catalyst for developing this proposal. The ATA proposes that the existing vertical telemedicine networks connecting major hospital centers with outlying hospitals and clinics be expanded and connected together to form a comprehensive horizontal network. Such a network would provide immediate seamless access to expertise that exists at key national centers (CDC, NIH, MRMC or other centers of excellence) for any health and medical provider, regardless of their location. As a network of existing medical and health facilities, it will be available to complement and build upon other existing efforts related to public health, emergency response and threat detection, such as CDC's Health Alert Network. Working in cooperation with the Federal Communications Commission, White House National Communications System, Department of Health and Human Services, Commerce Department and other relevant federal authorities, a new "network of networks" termed the National Emergency Medical Communications Grid (NEMCOM) will be established to connect these existing networks. NEMCOM will serve as a frontline network for medical response to threats of terrorism throughout the United States. The functions of the grid include: Collecting health information leading to the early detection of emerging threats Educating first-line responders regarding initial diagnosis indicators and treatment options Facilitating early medical intervention and specialist consultation Protecting personnel and resources by optimizing the number of personnel that respond to the scene. To encourage rapid deployment the Grid could be configured using 5-10 coordination sites that are able to connect local and statewide systems within their region. As the need arises, mobile telemedicine units (already developed and in use by military and civilian medicine) can be quickly used to supplement the existing network at key sites. Linking such telemedicine services, operating through established health facilities, is a cost-effective approach to the creation of a national health response network and enables almost immediate implementation. A special urgency presently exists to have such an emergency response system in place. The reality is that victims of targeted pathogens have characteristic signs and symptoms that are easily transported and identified over a telemedicine network. Therefore, the ATA proposes that the Office of Homeland Security take immediate steps to establish such an integrated horizontal and vertical network. Once in place, NEMCOM will become a national asset for response to both man made and natural disasters.

4 Proposal Given the special urgency that presently exists to have such a health and medical emergency response system in place, the ATA proposes the establishment of a Telemedicine/Telehealth Task Force within the Office of Homeland Security. The Task Force should include representation from: Military telemedicine a. Telemedicine and Advance Technology Research Center Federal telecommunications agencies and programs a. Federal Communications Commission b. Universal Service Administrative Corporation c. National Communications System Federal Health Centers a. The Institute of Medicine b. Centers for Disease Control and Prevention c. Office of the U.S. Surgeon General Federal programs supporting telemedicine activities a. Office for Advancement of Telehealth b. Veterans Administration Federal emergency response agencies a. Federal Emergency Management Agency Representatives of state governmental agencies a. Nationals Governors Association National associations such as a. American Telemedicine Association b. American Association of Medical Colleges Private sector representatives The Task Force should be charged with the following : 1. Conduct an immediate inventory of all public and private civilian and military telemedicine programs in the USA. The inventory will build upon existing databases maintained by the Federal Office for the Advancement of Telehealth and DOD's Telemedicine and Advanced Telecommunications Research Center. The inventory should include not only the specific location of each network component but also the medical, technological and communications functionality. 2. Create a telecommunications blueprint to interconnect all of the existing individual networks into a National Emergency Communications Grid - a "Telemedicine Internet." 3. Develop procedures and protocols to address interstate licensure restrictions that may currently prevent a patient from being diagnosed and treated through this anti-bio-terrorism network by a specialist licensed in another state. 4. Identify existing telecommunications barriers to the effective implementation of such a network. 5. Determine the budgetary requirements

5 Precedents to the Development of a National Emergency Medical Communications Grid In 1919 a young lieutenant colonel in the U.S. Army accompanied the Army's first transcontinental motor convoy from Washington, DC to San Francisco, California. Encountering traffic congestion, poor road conditions and narrow passes, the eighty-one vehicles, including nine motorcycles, traveled 3,251 miles in 62 days to test the mobility of the Army under simulated wartime conditions. The often-primitive state of the roads exposed the convoy to what one historian called an endless series of difficulties: "Vehicles stuck in mud or sand; trucks and other equipment crashing through wooden bridges; roads as slippery as ice or the consistency of 'gumbo.'" Later, as President, Dwight Eisenhower recognized the inadequacies of two-lane state roads that meandered indirectly to their destinations and could not handle the weight and size of the military traffic. He worked with Congress to craft legislation that provided a new highway system with adequate federal financing and practical design and engineering. These essential elements have ensured that motorists today can journey unimpeded across vast distances in a relatively short time. Eisenhower noted that without a reliable, dynamic transportation system, the United States would be a mere alliance of many separate parts. Instead, the interstate highway system has united the nation economically, culturally and financially in countless ways. It has, in Ike's words, literally "changed the face of America." (Adapted from Creating The Interstate System by Richard F. Weingroff) Similarly, in the 1970's the nation's leadership became aware of the danger of having a major communications failure within the country if the nation comes under attack, especially a nuclear attack. A priority was placed on maintaining telecommunications in operation among the many national research centers located at major academic institutions. The Defense Advanced Research the Projects Agency (DARPA) was tasked with responding to this need. The Agency responded by developing a multi-modal telecommunications network providing multiple interconnected pathways that would survive the destruction on individual node. The network, termed "DARPA-Net" was later renamed the Internet.

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