Could ICT Be Harnessed for Prehospital Emergency Medical

Services?

The Case of the Lebanese Red Cross

Nabil Georges Badr

Department of Business Administration, Grenoble Graduate School of Business, Grenoble, France

Keywords: Lebanese Red Cross, Prehospital Emergency Medical Information Systems, Computer Assisted Dispatch.

Abstract: Of particular interest, this paper treats Information and Communication Technologies applied to the

Emergency Medical Services Division of the Lebanese Red Cross. Information for the case study is gathered

via semi-structured interviews with six informants and a database of Secondary data is collected from

available management reports, assessments, feasibility studies, project reporting and documentation. The case

of the ICT implementation investigated in this study offers insight into an implementation of a prehospital

emergency medical services. Though ICT implementations in pre-hospital care systems, are now common

practice, what makes this case particular is that it is starting from a volunteer-based.

1 INTRODUCTION

Dispatch Call 1: “The 1-4-0 national hotline for

ambulance services rings. The dispatcher picks up the

phone, and opens a case in the system with the basic

details of the phone number and the caller details

prefilled with caller data”. The dispatcher asks the

standard questions to the caller, and inputs the

answers on the electronic form. The software then

automatically assigns a priority to that call based on

predefined criteria and links the call to the nearest

available vehicle location. The dispatchers is able to

see the geographical location of the ambulance on an

electronic map on his screen as he sends the call data

to the ambulance and monitors its progress on the

screen. Trained in emergency medical dispatch the

dispatcher begins patient care before the emergency

team arrives to the site. While the call is in progress,

the EMT volunteers in the ambulance complete their

patient care report information on a handheld, the

data is then sent to the dispatcher and forwarded to

the receiving hospital.”

Dispatch Call 2: “As dispatcher “D1” takes caller

details into the system, another phone rings and the

only free dispatcher “D2” is an apprentice, who is

limited to handle non-urgent transport calls. The

supervisor checks his dashboard and realizes that the

latest call that is ongoing is a non-urgent transport

request, whereas all other dispatchers are receiving

either a red code or a yellow code call (High

priority). The supervisor informs dispatcher “D1” to

transfer his call to dispatcher “D2”. The ongoing

case is transferred to D2 freeing D1 up to pick up the

other pending call. The apprentice completes the call

taking procedure, while the supervisor is listening to

the call to make sure that the conversation is

compliant to the local protocols. If necessary, the

supervisor could take over the call from his own

workstation and the case transfers to his screen for

handling. Call recording is automatic and recorded

information is saved in the case for future review. …

Reports on utilization rate, call duration linked to

mission information, are at a press of a button”

(The

Lebanese Red Cross Emergency Medical Services)

Such was the initial envisioning stage of the

Integrated IT solution for the Emergency Medical

Dispatch Services at the Lebanese Red Cross. The

Lebanese Red Cross ICT strategy committee has

recently completed a roadmap for an integrated

solution for its prehospital Emergency Medical

Services (EMS). The solution has expanded from its

initial functional focus on Dispatch to include

supporting functions such as: volunteer management,

training, IT help desk ticketing, logistics (fleet and

equipment management), and other functions such as

blood donation management and financial donor

management with real cost reporting and forecasting.

What were the core drivers to implement ICT at

the Lebanese Red Cross EMS? How was the

Badr, N.

Could ICT Be Harnessed for Prehospital Emergency Medical Services? - The Case of the Lebanese Red Cross.

DOI: 10.5220/0005671902690276

In Proceedings of the 9th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2016) - Volume 5: HEALTHINF, pages 269-276

ISBN: 978-989-758-170-0

269

Lebanese Red Cross EMS able to implement ICT?

What opportunities, challenges and rewards were

observed from ICT? In order to answer these

questions we set out on an in depth case study

exploration of the LRC EMS’ implementation of an

integrated IT solution.

2 BACKGROUND

2.1 ICT Implementations in Non-profit

Organizations

Information and Communications Technologies

(ICT) in humanitarian services have been defined as

the “range of electronic technologies which when

converged in new configurations are flexible,

adaptable, enabling and capable of transforming

organizations and redefining social relations”

(Michiels and Van Crowder, 2001:8). Indeed, ICT

have been argued as essential components in

humanitarian strategies; from poverty reduction for

example (Grimshaw, 2015) to major incident

management where information sharing and

interoperability is cornerstone for realization of the

objectives (Allen et al., 2014). Non-profit

organizations typically operate in such complicated

social environments, due partly to their reliance on

external funds and partly due to different forms of

compromise between multiple stakeholders with

diverse interests. Political climates and drivers are

major determinants in the approach for humanitarian

action (MPC Research Report 2012/13). In general,

ICT implementations in non-profit organizations

must take into consideration such environment

conditions (Thatcher et al., 2006). Though well

documented in research contextual to the for-profit

setting (Zhang et al., 2010), in-depth insight into ICT

implementations in humanitarian and non-profit

organizations is scarcely existent in the literature.

2.2 ICT Implementations in Red Cross

Societies

In the context of the Red Cross societies, the British

Red Cross have exploited ICT in volunteer

management (Waikayi et al., 2012), especially

targeted towards volunteer retention programs that

would be based on data captured and analysed by

systems that model volunteer management processes.

Elsewhere, volunteer portals have been setup to

support the volunteers for the Portuguese Red Cross

and monitor real time relief work management

(Macedo et al., 2012).

The American Red Cross leveraged social media

to build relationships (Briones et al., 2011), other

applications were found beneficial in Disaster

Response (Park and Johnston, 2015) leveraging the

information technology platforms for collection and

dissemination of field information in near real-time.

These platforms would include tools for point-of-care

diagnostics, case management, logistics

management, community mobilization, payment and

financial support distribution, and big data analytics

solutions, etc… as in the case of the Ebola response

in 2014 (According to a Technical Brief: Use of

Technology in the Ebola Response in West Africa,

www.africanstrategies4health.org).

The Finnish Red Cross reported the need for

standard supply chain planning tools and logistics

performance measurement systems to assist in their

relief activities (Leppänen, 2012) reinforcing the role

of ICT in humanitarian logistics (Christopher and

Tatham, 2014). On the other hand, implementations

of ICT in Disaster Risk Reduction (Kelvin and

Innocent, 2012) and crisis management (Meier and

Leaning, 2009) apply technology to crisis mapping

and early warning (Meier, 2011) to help prevent

disasters and manage their capacity to respond

(Mung’ou, 2014).

2.3 ICT Implementations in

Prehospital EMS

Prehospital EMS includes on-site first aid treatment

of injured or ill patients and the transport of patients

from the incident to a hospital in emergency or mass

casualties. For major trauma patients as in the case of

out of hospital cardiac arrest (OHCA) cases for

instance, the speed of response of the prehospital

EMS is critical to the survival of patients

(NHTSA.org). Specific to prehospital care

performance, ICT was shown to be vital (Blackwell

and Kaufman, 2002).

Historically, computer-aided dispatch tools have

provided means of classification and prioritization of

calls (Curka et al., 1993) and measurements of

effectiveness of EMS (Campbell et al, 1995).

Emergency medical services may require a

specialized and unique type of intelligent

transportation system (Kuwata and Takada, 2004)

that must place the ambulance the closest possible to

the patient when the call is received. Geographic

information systems (GIS) have been developed to

minimize response time (Hall, 1999) and patient

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270

survival rates have been linked to different response

time thresholds (McLay and Mayorga, 2010).

Scholars have tackled the incorporation of

simulation-based training for prehospital emergency

care (Alenljung and Söderholm, 2015) to increase the

skill levels of the participants and placed ICT as an

efficiency constituent in EMS (Ahmed et al., 2014).

However, technology offerings are yet to reach a

ubiquitous level in real-time teleconsultation for pre-

hospital emergency medical services (Thelen et al.,

2014). Scholars have suggested that overall, ICT

applied as telemedicine had a positive impact on

emergency pre-hospital medical care (Amadi-Obi et

al., 2014). The use of information tools such as tablets

and medical device integration avail prehospital

information to EMTs during Trauma Resuscitation

(Zhang and Sarcevic, 2015).

In resources constrained countries such as

Lebanon the implementation of an ICT system in

support of pre-hospital emergency care is to be

completed in a graduated fashion dependent upon

resource availability (Sun and Wallis, 2012);

resources could be human, financial and

technological.

2.4 Prehospital EMS in Lebanon

Prehospital emergency medical services in Lebanon

are based on volunteer systems with multiple

agencies (El Sayed and Bayram, 2013). One of which

is The Lebanese Red Cross (LRC), a humanitarian

society established on July 9, 1945 as an independent

national society, to “provide relief to victims of

natural and human made disasters, and help people

prevent, prepare for and respond to emergencies, and

to mitigate the suffering of the most vulnerable”

(Mission of the LRC).

Historically, in 1946, LRC was recognized by the

State as a public non-profit organization and as an

auxiliary team to the medical service of the Lebanese

Army. In 1947, LRC joined the International Red

Cross and Red Crescent Movement and became a

member of the International Federation of the Red

Cross and Red Crescent Societies (ICRC). It wasn’t

until 1964, when the LRC started provisions of

providing Emergency Medical Services (EMS)

established with 12 volunteers serving as the original

first-aid teams.

Today (as of August, 2015), the LRC is staffed by

about 8000 volunteers and members in 32 Chapters

(or local branches); 36 Youth Clubs; 7 Mobile

Primary Health Clinics; 12 Blood Transfusion

Centers; 40 Medico-Social Centers; 6 Nursing

Institutes; 12 local Disaster Management Units for

relief in natural and man-made disasters and an

Emergency Medical Services (EMS) department.

According to a poll issued by INFOPRO

Marketing “Perception towards Lebanese Red

Cross,” issued on August 24, 2012, the LRC Society

(LRCS) derives most of its credibility and public

image from its EMS; services chartered with the

response to life threatening events including home,

work and transportation accidents; medical and

trauma cases; and acts of war casualties.

The LRC Emergency Medical Services (LRC

EMS) runs a fleet of 260+ Ambulances, a team of

2700+ volunteer Emergency Medical Technicians, 46

EMS stations and 4 dispatch centers. The LRC EMS

ensures the only nation-wide comprehensive medical

transport available to all Lebanese. 28 full time staff

provide the professional operational support to run

this large-scale nation-wide multi- million dollar

operation.

3 METHODOLOGY

Of particular interest, this paper treats Information

and Communication Technologies applied to the

EMS Division of the Lebanese Red Cross

(LRCEMS). We will review the core drivers to

implement the Integrated IT Solution as part of the

ICT strategy at the LRCEMS and summarize the

opportunities, challenges and rewards observed,

presenting such study as “lessons learned from

practice” for other humanitarian ICT

implementations. This research into practice takes the

form of a qualitative case study (Eisenhardt, 1989).

Information for the case study is gathered through

semi-structured interviews with six informants from

LRCEMS chosen from the project team, management

team, and stakeholders of the Integrated IT Solution

implementation; namely, statements from the

manager of the dispatch call centers; the director and

assistant director for EMS development; the project

manager; the EMS training manager; the EMS IT

manager, with an added insight of the LRC

undersecretary general, in order enrich the empirical

evidence. Secondary data is collected from available

strategy and management presentations, request for

proposal (RFP) documentation for the Integrated IT

Solution, Telephony and Telecom upgrade, ICRC

reports and assessments (2005 - 2015), feasibility

studies, project documentation for the Integrated IT

Solution, and a review of information on the

LRCEMS portal.

Could ICT Be Harnessed for Prehospital Emergency Medical Services? - The Case of the Lebanese Red Cross

271

4 DISCUSSION

4.1 Strategic Drivers for ICT

In 2005/2007, assessments of the LRCEMS function,

conducted by the ICRC, the dispatch centers were

found to lack appropriate tools to effectively manage

the coordination and communication activities with

the other 4 regional dispatch.

Calls to 1-4-0 (The Dispatch Call Center Hotline)

were going unanswered, in particular during day-

time. This was identified as reputational risk.

The fleet is aging with unclear replacement plans,

the infrastructure, materials and equipment were not

standardized, often sub-standard and outdated with

only a paper tracking mechanism in place to address

this essential requirement.

The changing socio-economic patterns in the

country make it more and more difficult to recruit and

retain the sufficient volunteer base required to meet

the EMS’s ambitions.

Training of EMS volunteers was not standardized,

and there was no recognized certification of their

capacities as pre-hospital emergency care providers.

On the administrative side of the EMS action,

attention needed to be given to reducing the risk of

operating cost explosion. Financial requirements

were indefinite. There was a recognizable need for

effective systems to ensure proper financial

management, actual understanding the cost basis and

funding requirements and a clear transparency for

cost control. The assessments also showed that the

EMS had been chronically underfunded and the

impetus for transparency and real cost budgeting was

clear. “Ambulance response is very expensive

especially during the day when volunteers are not

available, having reliable and precise data about

ambulance response, will enable the LRC to respond

more rapidly to the most urgent cases without

increasing the associated cost” said the

undersecretary general.

Towards the end of 2007, the Lebanese Red

Cross Society, with the support of Red Cross / Red

Crescent Movement and other development partners,

launched a 5 year strategy to upgrade the overall

capacities and general performance of its Emergency

Medical Services in the purpose of reducing incident

response times and increasing the quality of

prehospital EMS.

Key operational objectives of the strategy called

for a solution that automates the EMS dispatch

functions and supporting activities. “One of the

primary goals of the upgrade was to enable the

dispatch function to manage calls centrally. […],

meaning one dispatch centre can talk to ambulances

all over the country” (LRCEMS ass. dir. for

development).

4.2 Integrated It Solution Overview

The integrated IT Solution was scoped around a

computerized aided dispatch module designed to

automate emergency missions, patient transport

mission and mobile First Aid. The dispatch module

incorporates Patient Care Reports into the dispatch

functions with pre-set dispatch triage and decision

criteria, call priority and call type. Complete with

reporting capabilities and a mission dashboard, this

module offers the ability to identify the available

resources at each station at the beginning of each

shift, log their scheduled missions into the dispatch

timetable and respond to events that impede the call

progress.

The automated dispatch function includes a

telephony system facility for the automation of call

routing and recording with correlation to cases for

proper reporting. The ICT strategy comprises a

rebuild for the telecom infrastructure aimed at

improving security, and reducing interference is to be

integrated with the data network for tracking,

recording and statistics.

A set of supporting modules (Appendix- Figure 1)

for logistics and volunteer management are conceived

with specific functionality: (1) the logistics module

covering fleet and equipment inventory is intended to

monitor and report on consumables usage for stock

level management and track nonperishable

equipment location, usage and reporting; and (2) the

volunteer management module incorporates a

dashboard to report on the related activities with

visibility into factors that could improve volunteer

retention. Annexed to this module is a training

component for training requests, approvals, activities,

cancellations and reschedule. Finally, an EMS portal

offers access to information from the public,

volunteers, administrators and national societies.

4.3 Outcomes and Rewards

A phased approach was conceived to deploy the

functionality in sequence in order to emphasize the

proper adoption of the system. Dispatch centers have

transitioned to computer assisted dispatch. The

volunteer management and logistics modules are in

the pilot stage. Databases for fleet management,

finances and tracking of consumables are being

developed and rolled out. Shortly after the

implementation (6 months), the system is starting to

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show rewards in terms of effectiveness & efficiency

improvements and insight to vital information.

“The success of the implementation in the

dispatch centers has led to a decision to consolidate

the dispatch function in two strategic dispatch centers

significantly decreasing our operating costs” adds the

LRCEMS assistant director for development. “This

tool is starting to give us insight into the durations

required for each part of the call management

process” states the Project Manager. Such

information is vital for monitoring and improvement

as necessary. As a source of operational data, this

system is poised to serve as a basis for fundraising

data related to donations and pledges, accounting and

allocation of costs. It has also become clear that

features such as “dispatch call recording” would add

a level of real data capture to strengthen the legal

basis of LRC activities.

Furthermore, the implemented solution has

proven a visible utility for other LRC departments

(e.g. Blood bank, logistics, Psycho-Social support,

etc.) an opportunity for bolstering LRC services to the

community through interfaces with smartphones and

handheld applications that facilitate caller response,

and through integration with social networks for

communication diffusion in state of crisis.

4.4 Challenges

In system implementations of this magnitude,

challenges are abound. Empirical observations from

this case study bear witness to challenges before,

during and after the implementation activities.

4.4.1 Challenges Before Implementation

In preparation for the implementation, the LRC-EMS

issued a comprehensive Request for Proposals (RFP)

for an “Integrated IT Solution” with the objective to

secure funding by January 2011. Full buy-in by the

rest of the LRC Society was slow to come. “A proof

of feasibility was an essential impetus for the donor

support in the implementation process” (LRCEMS

ass. dir. for development). Furthermore, funding, as a

package, was not forthcoming and the RFP was

divided into components, which eventually did lead

to funding for each component separately introducing

complexity into the planning process.

In order to adequately support the project, “an

active IT Committee was engaged” stated the Project

Manager, mobilizing ICT staff resources augmented

by outsourced consultant to plan the required updates

for the infrastructure and prepare for the

implementation of the new systems. “The internet

connection to the stations needed to be improved and

this required the network to be upgraded” (LRCEMS

IT Mgr.). The choice of vendor was made based

principally on their ability to execute on the technical

portion of the implementation as there was no single

source of expertise available for both, the operational

and the technical aspects of the solution. Succinct

functional requirements to build the solution’s

modules were difficult to muster. “The user interface,

field, forms and workflows were in a state of flux as

the information was gathered”. (LRCEMS Training

Mgr.). “A specific focus on usability and speed

scrutinized the structure and flow in a non-call-taking

environment before being introduced into the

dispatch centre.” (Proj. Mgr.).

4.4.2 Challenges During Implementation

Above and beyond the classical guidelines of

security, resiliency and ease of use, the context of the

Integrated IT Solution, imposed tight architectural

imperatives: (1) A bilingual user interface (English

and Arabic) based on a web-based platform that can

be modified centrally and reduces costs; (2) an

“offline mode” functionality resilient to

telecommunication connection outages with the

ability to synchronize offline data automatically when

reconnected without risk of data corruption or

information loss; and (3) a scalability to an unlimited

number of users with an open license for public

access to portal functionality that would avoid the

burden of long-term running costs. On the other hand,

the dispatch software was believed to require

extensive testing. The LRCEMS had to be prepared

for delays. A specific software acceptance checklist

was developed by the project team. Additional

difficulties were attributed to maturity level of the

dispatchers in IT was weak. “We had to get them up

to speed quickly on basic skills first, then train them

on the operational aspects of the software” (LRCEMS

Training Mgr.). The implementation of the solution

lagged behind schedule. Training simulation for

dispatchers had begun too early and without the

software, which required a retraining process nearer

to implementation. Changing in operational processes

necessitated a change in scope. The processes to be

implemented had to be documented first and then

adjusted before they are automated. “As the

implementation date nears, all heads of stations

needed a set of guidelines outlining the expected

changes and the impacts on current processes”

(LRCEMS ass. dir. for development). Finally, the

variable levels of funding during the project presented

a risk on the sustainability of the project as

Could ICT Be Harnessed for Prehospital Emergency Medical Services? - The Case of the Lebanese Red Cross

273

institutional donors “tend to prioritize beneficiary

facing activities over infrastructure and

organisational development” (LRCEMS ass. dir. for

development)

4.4.3 Post-implementation Challenges

The implementation is still in course, however some

post implementation challenges are starting to be

reported and addressed.

The LRCEMS assistant director for development

indicated that “most pre-implementation challenges

are persistent in post-implementation […]

Supplemental funding could be required for added

features, potential changes to scope, or simply to

cover increased training costs” (LRCEMS ass. dir.

for development).

“Infrastructure such as connectivity and power

requirements are necessary for the success of the

system, especially such a 7x24 online system” Says

the dispatch call centre manager. Work was being

done on the internal infrastructure, however, the

required utility based services (telecom, power, etc.)

may not always be up to the required performance

level. This presents a higher risk and higher cost for

the ICT budget to bear as to emphasize opportunities

for infrastructure resiliency; namely, options of

hosting, multiple connectivity methods,

Even at the post implementation stages, buy-in is

a persisting challenge primarily due to the scale of the

national society and the number of stakeholders. “The

leadership team needs to better understand the

“Integrated IT Solution” and its potential for

optimization” (LRCEMS Director).

The post implementation maintenance budget was

strained: Though cost reductions are expected from

the consolidation of the dispatch centre, the

implementation, with the required infrastructure

components (networks, systems and hosting

services), brought additional costs in form of

maintenance and support costs to the budget baseline.

5 CONCLUSIONS

The value of ICT in crisis response has been

recognized (Sharoda et al., 2008). Cases have been

made on the need for an integrated data flow from

computer aided dispatch and patient care reports, into

hospital information systems (Schooley and Horan,

2007) in providing quality prehospital care.

In the literature surveyed, ICT solutions tackle

challenges of prehospital care in a form of specific

objective based point solutions; either in dispatch

(McLay and Mayorga, 2010), training (Alenljung and

Söderholm, 2015), mobility (Zhang and Sarcevic,

2015), or resource management (Waikayi et al.,

2012), etc... In distinction, this study focuses on an

integrated solution implementation in a non-profit

EMS organization and reveals challenges before,

during and after the initial implementation stages of

this large scale ICT solution.

The participants in this in-depth study converged

to three fundamental limitations in the planning and

implementation of this solution. Namely, limitations

of infrastructure, resources constraints and buy-in.

The transformation to a performance based system

requires change that is dependent upon support and

action from both internal and external agencies and

departments, including donors and funders.

Funding and buy-in dominate all the phases of the

implementation with concerns of sustainability in the

cost structure, resources, infrastructure capability.

The complexity of the environment necessitated a

thorough preparation exercise to properly identify the

architectural imperatives, prepare the functional

requirements, with a continued active management of

time and scope of the project.

5.1 A Turning Point in Capability

Transformation

Distinctively, the LRCEMS addressed their

prehospital care services automation as an ecosystem

through the automation of the dispatch functions and

the related supporting services including volunteer,

fleet, equipment, training, and financial management.

This open solution quickly became the focal point of

the LRC at large with integration functions into the

remaining LRC divisions. The integrated IT solution

is destined to build a database of information that

would deliver a source of reliable measurable

achievements. Furthermore, such reports would be

indispensable as a basis for fundraising justification

to motivate wider integration and full range of system

adoption. The assistant director for development at

the LRC, sees a greater value of the information

collected from this system. For instance, the system

would “support the definition of needs for prevention

campaigns (highest incidents of cardiac, etc…)

furthering the role of the LRC in the service of the

community”. Thus, the Lebanese Red Cross is poised

to maximize their impact on the community by using

the data generated to refine their services, adjust their

fundraising efforts, and train their volunteers and

board members more effectively.

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5.2 Research Limitations

The concepts outlined herein are collected from a

single case study; some unavoidable limitations can

be noted in contexts such as culture, organizational

context and industry. Though limited in scope and

generalizability, the research has reached its stated

aim.

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APPENDIX

Figure 1: LRC EMS Integrated IT Solution.

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