Ebook: A Multinational Telemedicine Systems for Disaster Response: Opportunities and Challenges

In the aftermath of a disaster the medical infrastructure of the affected zone is often significantly impacted or destroyed. Over the past several decades, telemedicine has been an effective tool used in disasters. Several years ago, the Emerging Security Challenges Division within NATO's Science for Peace and Security Program (SPS) initiated a program with Romania and Russia to develop a multinational telemedicine system (MnTS). Such a system can improve access to health services and increase survival rates in emergency situations that spans both geography and time zones. A MnTS can further the concept of cross border collaboration and meet the mission of the SPS Program.

The planning phase brought together subject matter experts from industry, government, and academia to discuss the integration of telemedicine into an effective system that could be deployed in a disaster. The initial planning involved a number of meetings in Bucharest and Moscow, to outline the approach to the MnTS. In 2014, the MnTS program was formally kicked off with Romania as the key partner country and Dr. Raed Arafat as the program director. Although Russia was involved initially, NATO decided to continue in an Alliance format and select partners only as active participants. Over the next several years, the MnTS program developed a Concept of Operations (CONOPS) document and built a system that included management, clinical and information technology (IT) infrastructure. Following a detailed and robust schedule, the MnTS and the assembled expertise participated in a simulated disaster scenario in the Ukraine in September 2015. In early 2016, the MnTS was expanded to include Finland, Moldova, and Ukraine as full partners.

The MnTS has a number of components and the participants are cognizant of the challenges that are faced in deploying telemedicine in a disaster. These include such areas as IT, language, culture, and legal issues. Each of these has been addressed by expertise in the MnTS program. This book has been assembled as a review of the NATO-funded MnTS and serves as an excellent reference on telemedicine and disasters. It is organized in 14 chapters that follow a thematic approach to the development of the MnTS.

Each chapter, written by subject matter experts, includes a vast array of experiences in MnTS. It includes an historical review of telemedicine and disasters in Chapter 1 and historical perspective of NATO's efforts in the field of telemedicine in Chapter 2. While these two chapters provide a foundation for telemedicine in disasters, Chapters 3–12 provide an excellent summary of how the MnTS was developed out of NATO's SPS Program. These chapters address the important and critical components of the MnTS such as the program's overall organizational structure, the integration of information technology, the legal and regulatory considerations, outreach and public awareness, and the culminating experience of evaluation of the MnTS in a field exercise. The book closes with final thoughts that summarizes the overall MnTS and provides a template for future work in bringing telemedicine as a tool for international disaster response.

Charles R. Doarn

Raed Arafat

Claudiu Zoicas

Rifat Latifi

The integration of telecommunications and information technology in healthcare is referred to as telemedicine. While there may be numerous definitions, its application in disaster response has been well documented. This chapter is meant to introduce the reader to what has been done historically and how this historical context will help build the foundation for a Multinational Telemedicine System (MnTS). The application of telemedicine in disaster is neither new nor novel. With the advent of satellite communications and the introduction of real-time communications, other than telephony, medical personnel could interact with first responders and populations impacted by disasters. From the early uses of telemedicine in the aftermath of an earthquake in Armenia to the development of the MnTS, an historical summary is provided.

In 2000, NATO created the Telemedicine Expert Panel (TMED-EP) when few nations had deployed telemedicine systems to support military field operations. This group and its successor the Telemedicine Expert Team (TMED-ET) have been encouraging the nations to deploy telemedicine (TMED) in support of their forces, and have continued developing the doctrine and technical standards which will facilitate the use of TMED within NATO. This has been a highly successful effort, and TMED is increasingly being used within the military medical structures of some NATO and Partnership for Peace (PfP) nations to provide medical care to deployed military personnel. This chapter describes the history and accomplishments of the TMED-EP and ET which include development of Telemedicine Interoperability Standards for use among deployed NATO forces and doctrine to support TMED use. Also discussed are more recent efforts to include NATO sponsored Advanced Research Workshops in 2012 and 2013 to discuss a multi-national telemedicine system to be used in response to disasters involving both NATO and PfP nations, and the follow-on 2015 NATO Science for Peace and Security (SPS) telemedicine project in the Ukraine which demonstrated the potential role of telemedicine in disaster response among NATO nations.

The Science for Peace and Security (SPS) Program is a policy tool that enhances cooperation and dialogue with all partners, based on scientific research, innovation, and knowledge exchange. Founded in 1958, the Program contributes to NATO's objectives and promotes regional cooperation through scientific projects and activities. Over time, the SPS Program has continuously adapted to new demands and in 2013 the focus shifted on larger scale strategic activities which go beyond purely scientific cooperation. The SPS Program now promotes civil, security-related practical cooperation, and focuses on a growing range of contemporary security challenges, including terrorism, defense against chemical, biological, radiological, and nuclear agents, cyber defense, energy security and environmental concerns, as well as human and social aspects of security, such as the implementation of United Nations Security Council Resolution 1325 on Women, Peace and Security (UNSCR 1325). The Program provides the Alliance with distinctive, non-military communication channels, including in situations where other forms of dialogue are difficult to establish. Accordingly, SPS often serves as the first concrete link between NATO and partner nations.

The development of an international or multinational telemedicine system has been discussed several times over the past 30 years or so. The integration of telecommunications and information technology in the aftermath of a disaster can be of tremendous value in addressing acute and chronic medical needs. The growing consequences of disasters increase the need for more medical support in response actions. The financial realities of recent years however have led to a decreased level of expertise and size of the medical “footprint” on-site. Effective use of telemedicine can close this gap by allowing provision of clinical healthcare from a distance. In 2012, the NATO Russia Council was asked to setup a telemedicine project funded by NATO Science for Peace and Security (SPS). In 2013, SPS Program funded a project to develop and demonstrate a Multinational Telemedicine System (MnTS) for Emergency Response. This project aimed to address the identified shortfalls with multi-national pre-defined emergency measures and augment disaster response care with telemedicine technologies based on agreed procedures with trained personnel and interoperable equipment. In February 2014, the inaugural MnTS conference was convened at NATO Headquarters in Brussels with teams of telemedicine experts assembled to develop a Concept of Operations (CONOPS) for this 3-year project. Topics identified and described in the CONOPS included Governance, Medical Care, Legal Issues, and Information Technologies. Subsequent meetings were held in Romania, Belgium and the United States to further develop the plans and programs for the MnTS. The system also participated in a proof of concept disaster response field exercise in September 2015 in Ukraine.

Telemedicine describes the exchange of medical information between different sites using telecommunications and information systems. Telemedicine helps to improve health status and medical care for those who live in remote areas and who do not have easy access to medical services. In the event of a disaster, telemedicine can enable physicians located in different parts of the world to provide healthcare services remotely, to those found in disaster zones. Disaster management makes use of multiple technologies to provide services in the disaster zones. The idea of using telemedicine in disasters has been around for more than four decades. During the last several decades, there have been many initiatives from the military, space programs, and various governmental agencies to test and evaluate modern telemedicine applications in real and simulated civilian disaster scenarios. The aim of this chapter is to discuss telemedicine applications and how there can be integrated into disaster scenarios, and more specifically, the application and use of technology in the Multinational Telemedicine System (MnTS).

The use of telemedicine across national boundaries requires an understanding of the legal and regulatory challenges that we face in addressing application of telemedicine in disaster response and other humanitarian activities. This chapter focuses on multiple legal and regulatory considerations related to providing telemedicine services across international borders. While clinical standards of care across medical and surgical disciplines are fairly well-defined and generally accepted across the globe, there are various legal and regulatory laws, policies and procedures which limit physicians from openly engaging in the practice of medicine across international borders.

NATO Euro-Atlantic Disaster Response Coordination Center's consequence management field exercise (FX) Ukraine 2015 was co-sponsored by Ukraine and its State Emergency Service. Over 29 nations committed resources, equipment, exercise participants, directing staff and/or observers. Planning was compressed, with 2 formal planning conferences and an in-progress review in less than 4-month to plan an event that consisted of 2 days of academics, a 2-day command post exercise (CPX), a day-long 18-hour FX and a capabilities demonstration day for invited dignitaries. The lead-in scenario used seismic activity resulting from an underground sulfur mine accident to generate broad-spectrum emergency management response requirements: Urban Search and Rescue, restoration of public services, toxic industrial chemical releases, decontamination, environmental impact surveys, medical triage/treatments and a recovered radiation source. The Multinational Telemedicine System (MnTS), which is being developed under the NATO Science for Peace and Security Program, was successfully tested during a field exercise in Lviv, Ukraine in September 2015, attended by NATO Secretary General Jens Stoltenberg and the President of Ukraine, Petro Poroshenko. The exercise permitted the first time use of the MnTS, an independent multinational telemedicine system, to enable provision of medical support in a disaster situation. While telemedicine/telehealth services do not replace real medical personnel, they do augment the teams on the ground with expertise that is not present at the scene of the disaster. Often case the medical infrastructure gets damaged, destroyed or otherwise compromise during disasters. This chapter describes how the multinational telemedicine system was used in simulated disaster conditions.

Disasters present a world-wide problem that requires systematic, methodological preparation, and response by multiple partners. The disaster management cycle includes mitigation, preparation, response, and recovery. To effectively respond to major disaster crises and engage in management of disasters, often a multi-national coordinated system is implemented. Telemedicine technologies should be incorporated into these systems based on the effectiveness of mobile technologies and capabilities of providing remote expertise in crisis situations. Multiple projects and organizations are engaged in testing the effectiveness of training, preparation, and simulated responses in order to better manage disaster response and recovery. NATO has recently tested the effectiveness of a coordinated Multinational Telemedicine System (MnTS) that provides a model for effective disaster management using telemedicine technology. The solution for effective disaster management is to create telemedicine technology prior to a disaster that can be incorporated into the management phases. This solution will ultimately save lives and reduce costs associated with disaster response.

Recent technological developments have made possible the application of telemedicine in the management of trauma and emergency situations, especially in remote areas and isolated communities. What has not been tested effectively remains the use of telemedicine in major disaster management, despite a few examples previously reported. The biggest promise of telemedicine for disaster management is the intervention in the ‘golden hour’, which is the 60 minutes immediately following a traumatic event. While transformation of a chaotic situation caused by a disaster through the use of telemedicine has been demonstrated, the use of a multinational telemedicine system (MnTS) in the management of these situations has not been fully demonstrated. Furthermore, what is truly attractive is the use of the multinational telemedicine concept as an intervention method in major disasters and catastrophes across the different countries or regions, where a number of elements are tested, including language, expertise, communication, licensure and other components. While there are a number of challenges in the application of the MnTS, the opportunities and potential benefits outweigh these challenges. In this chapter, we review both challenges and opportunities in application of telemedicine in the disaster management. Establishing a nationwide program of telemedicine in one country is complex and has its own challenges. Efforts in Albania, Kosova, and Cabo Verde serve as examples to illustrate these challenges using established telemedicine programs to manage disasters in a structured pre-planned way, provides a foundational process. Aside from a few demonstrations over the past several decades, there is limited data on how existing systems are applied. Telemedicine efforts in Albania have been utilized at a high level for administrative management of flooding in 2010. There are a number of challenges in developing and deploying a MnTS to a country or region affected by disasters. These will be reviewed in this chapter.

In 2000, NATO created the Telemedicine Expert Team (TMED ET) when few nations had deployed telemedicine systems to support military field operations. This group and its successor has been encouraging the nations to deploy telemedicine (TMED) in support of their forces, and has been developing the doctrine and technical standards which will facilitate the use of TMED within NATO. This has been a highly successful effort, and TMED is increasingly being used within the military medical structures of some NATO and Partnership for Peace nations to provide medical care to deployed military personnel. This chapter describes a general overview of telemedicine evaluation measures and contrasts civilian measures with the outcome measures used to assess the effectiveness of military and NATO telemedicine programs in austere overseas locations. It provides important examples of the U.S. military telemedicine programs in Iraq and Afghanistan and their outcome measures many of which are shared in NATO telemedicine programs. The evaluation measures describe the unique military and NATO uses for telemedicine such as impact on medical evacuation and types of medical problems encountered in deployed settings critical for future military and NATO manpower planning and staffing. The chapter further describes a multinational telemedicine study conducted in 2005 called the Telemedicine Interoperability Study (TIOPS) that showed the usability and clinical comparability of diagnoses made by consultants from different nations. The TIOPS provides an important framework for future NATO telemedicine evaluations for demonstration projects that can establish long-term measures of effectiveness in NATO missions.

Telemedicine and communications are global companions – often sharing the same digital highways, platforms, and codecs to deliver various forms of data including video and graphical images from one person to another in a different county, country, or continent. During a disaster, both telemedicine and telecommunications have the potential to support a positive response. However, there are fundamental differences – telemedicine can bypass many political, economic, social, technical, legal and organizational barriers so that someone from a deprived background who has been injured and lost everything during a disaster can have access to a medical consultation from the most expensive and highly qualified physicians anywhere in the world. But communications, such as traditional and social media, are often limited by location, social, economic, technical and demographic factors and most importantly the content of the message is subject to the vagaries of personal perception, emotional distortion or false propaganda. Therefore, in order to show the benefits of the NATO Multinational Telemedicine System (MnTS) and share the findings of this project with a global audience we needed to take great care about the content of our outreach and public awareness program as well as the media platforms we chose to disseminate our message. The objective of this chapter is to share the methodology and ethics that underpin the outreach and public awareness strategy. Over the course of the MnTS, 3 videos were created. There are 4 appendices at the end of this chapter – one showing the 3 scripts which were used for creating 3 films and the other showing some Videographer Guidelines: these are provided as a record of the video content and also because they might be of use to those of you who want to make videos of your own to showcase your own projects.

Now that the concept of the Multinational Telemedicine System (MnTS) was been tested and proved to be operational, the need to go ahead and transform the research project into a functional multinational telemedicine system is the next logical step. We face several challenges and we need answers as soon as possible so momentum is not lost. Who will oversee the whole system? Who will be the main beneficiaries? How will reliable satellite communications be provided during a disaster to operate the system? How will we overpass the legal challenges regarding the practice of medicine by the physicians providing advice at a distance crossing borders virtually? All these are questions we need to answer and find solutions that allow us to transform an idea and a project to reality.

The integration of information and telecommunications technology in emergency situations that result in trauma, injury, and significant loss of life and economic stability has been successfully developed, deployed and used in disasters. This book represents a collection of materials about how telemedicine has been applied in disasters over the past 40 years and how subject matter experts from across the international community came together and developed a Multinational Telemedicine System (MnTS) for disasters. This NATO-funded concept was evaluated and determined to have utility in disasters. It also has laid the ground work for taking telemedicine and disasters to a new level. The ability to project knowledge and healthcare delivery modalities across great distances is no longer a challenge. It is an expectation. It is something that is now a tool in the arsenal for us to respond. As technology and ICT continue to march forward, we will be able to project a wide variety of medical specialties, including surgical care and advanced trauma support. Each of these capabilities will reinforce our ability to respond and further our MnTS concept.