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J. Health Inform. 2011 Agosto 3(Especial): 87-99 Relato de Experiência

Interoperability in Disaster Medicine and Emergency Management

Interoperabilidade em Medicina de Desastres e Administração de Emergências

Catherine Eleftherios Chronaki1

Vassilis Kontoyiannis1
Dimosthenis Panagopoulos1
Dimitris George Katehakis1
Dimitris Vourvahakis2
Kyriaki Koutentaki-Mountraki3
Descritores: Disaster Planning; ABSTRACT
Emergencies; Mass Casualty Incidents; Accurate and timely information is critical for health early warning and effective emergency
Information Management management. Health Information Technology (HIT) standards address the challenge of integrating
information from disparate healthcare resources e.g. devices, people, and information systems to
support not only the effective handling of emergencies, but also their analysis for long-term
resource planning. In the management of emergencies, co-operative use of standards facilitates
effective sharing of information among the parties involved in search and rescue, continuous
disaster assessment, and public awareness. This paper discusses the cooperative use of
interoperability standards from Health Level Seven (HL7), the Organization for the Advancement
of Structured Information Standards (OASIS), the European Committee for Standardization
(CEN), and other Standards Developing Organizations to harness the power of Information and
Communication Technologies (ICT) in emergency preparedness and response. The paper reports on
the experience gained from the deployment of ICT in the Satellites for Epidemiology and health
early warning (SAFE) civil protection exercise and interoperability considerations in technical
solutions to be deployed in the “POSEIDON” exercise (earthquake followed by tsunami in the
Mediterranean) still at the planning stage.

Descriptores: Planejamento de RESUMO

Desastres; Emergências; Incidentes Informações acuradas e na hora oportuna são essenciais para a emissão de alertas precoces de saúde
desastre em massa; Gestão da Informaçãoe para a gestão eficaz de situações de calamidade pública. Os padrões de Tecnologia da Informação
em Saúde objetivam resolver o desafio de integrar informações de diferentes recursos de saúde,
como por exemplo dispositivos, pessoas e sistemas de informação para apoiar não só o tratamento
eficaz nas situações de emergência, mas também na sua análise, para planejamento de recursos de
longo prazo. Na gestão de emergências, o uso cooperativo de padrões facilita o compartilhamento
eficaz de informações entre as partes envolvidas na busca e salvamento, de avaliação de desastres
e conscientização pública. Este artigo discute o uso cooperativo de padrões de interoperabilidade
do Health Level Seven (HL7), do Organização para o Avanço de Padrões de Informação Estruturados
(OASIS), Comité Europeu de Normalização (CEN), e outras normas das organizações produtoras
de padões para fortalecer o poder de Tecnologias de Informação e Comunicação (TICs) na
preparação e resposta a emergências. O artigo relata a experiência adquirida com a utilização das
TIC nos satélites de Epidemiologia e de alerta precoce de saúde (SAFE) exercício de protecção
civil e os aspectos da interoperabilidade nas soluções técnicas a serem implantados no exercício
“Poseidon” (terremoto seguido de tsunami no Mediterrâneo) ainda em fase de planejamento.

Autor Correspondente: 1
FORTH-Institute of Computer Science, Heraklion Crete Greece.
Catherine Eleftherios Chronaki 2
Emergency Coordination Center, Heraklion, Crete Greece.
e-mail: chronaki@ics.forth.gr 3
Direction of Civil Protection, Region of Crete - Greece.

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88 J. Health Inform. 2011 Agosto 3(Especial): 87-99

INTRODUCTION on Personal Digital Assistants (PDAs) to be instantly

accessed by the Emergency Coordination Center. In
Time is a critical resource in managing emergencies the earthquake settlement, the transfer of information
that needs to be compensated by high aptitude, sharp from the Electronic Health Record (EHR) system to
judgment and timely information. Education activities an epidemiological investigation system demonstrated
and training within the scope of readiness exercises the ability to provide early warning in public health at
traditionally support the development of skills and the the onset of an epidemic. In this context, we
validation of plans and procedures. The role of ICT experimented with the HL7 Clinical Document
and interoperability standards further supports decision Architecture Release 2 (HL7 CDA R2)(5) using the
making and public awareness by delivering the right International Classification of Diseases, 9th Edition/
information to the right persons at the right time, in a Revision (ICD9II), International Classification of
predictable format that supplies the necessary context. Primary Care (ICPCIII) to code diseases, problems and
In the aftermath of a disaster everybody is looking symptoms. The resulting clinical documents were
for reliable and accurate information. People are exchanged using web services in the frame of protocols
looking for their loved ones. ICT can help them accepted by the World Health Organization (WHOIV)
register to receive updates and note their latest recorded and National Center for Disease Control in Greece
location. Systems like SAHANA used in South East (KEATINOV).
Asia after the Tsunami disaster, as well as social media In POSEIDON, a follow-up civil protection
like facebook are receiving increasing attention(1-3). exercise co-funded by the European Commission, the
Commanders on the field need to assess the scene of theme is severe earthquake following a tsunami in the
the disaster. They ask themselves: Is the area safe? How Mediterranean. Its special focus is collaboration and
many victims are there? What is their location? How coordination among the participating member states
can the available resources assert the highest impact? in the management of disaster and familiarization with
The emergency operation center looks out for an the European Civil Protection (ECP) mechanismVI. The
overall assessment of the disaster, extending its own ECP mechanism was established by the European
capacity through trained volunteers, location of Council in 2001(6) to provide added-value to European
response teams & ambulances, availability of healthcare civil protection assistance by making support available
facilities, and potentially external help. At the regional on request of the affected country to ensure protection
or national level, again assessment of the disaster is primarily of people, their property, but also of the
needed to understand the type of medical & other natural and cultural environment. The need to activate
means, materials and human resources necessary to the mechanism may arise if the affected country’s
support the local population and visitors, transport disaster preparedness is not sufficient to provide an
patients, etc. In this level, decision makers need answers adequate response in terms of available resources. The
to questions like: What is the extent of the disaster? tools set in place for the ECP mechanism include the
What is the extent of damage to infrastructures? What Monitor and Information Center (MIC), the Common
are the needs in medical assistance, food, shelter, Emergency Communication and Information System
support, etc. of the survivors? What is the status of (CECIS), the ECP Training Program, and the Civil
the hospitals and other healthcare facilities? How many Protection Modules explained below.
beds are available? Finally, there are also public health MIC is the operational heart of the ECP
agencies concerned with health issues, such as: Is the mechanism, a one-stop-shop for civil protection means
water supply safe? How many people are in the shelter available amongst participating states through which
and what are their needs in food, beds, medication, all countries affected by a major disaster can make an
etc.? Do we have indications for the outbreak of an appeal for assistance. MIC serves as the communication
epidemic? In all cases, a GIS system providing on a hub at headquarters level between participating states,
digital map summary information and real time the affected country, and dispatched field experts and
updates would help quickly assess the situation and provides useful and updated information on the actual
the development of the crisis. status of an ongoing emergency.
In SAFE(4), a project co-funded by the European CECIS is a reliable web-based alert and notification
Space AgencyI, a civil protection exercise demonstrated application created with the intention of facilitating
the value of satellite-enabled applications in providing emergency communication among the participating states.
health early warning after an earthquake disaster. A local
Wireless Fidelity (WiFi) network supported by a vehicle II
WHO International Codification for diseases: http://
www.who.int/whosis/icd10/
equipped with satellite communications provided III
International Classification for Primary Care: http://
Internet connectivity in the crisis zone and in an www.who.int/classifications/icd/adaptations/icpc2/en/
earthquake refugee camp. In the crisis zone, volunteers index.html
IV
World Health Organization: www.who.int
assisted in triage by entering information about victims V
National Center for Disease Control in Greece: http://
www.keelpno.gr/en/
VI
European Civil Protection Mechanism: http://ec.europa.eu/
I
European Space Agency – ESA, http://www.esa.int echo/civil_protection/civil/index.htm

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Chronaki CE, Kontoyiannis V, Panagopoulos D, Katehakis DG, Vourvahakis D, Koutentaki-Mountraki K. 89

Figure 1 - Operating Zones in the disaster area for POSEIDON: role of ICT

The ECP Training Program is a program that aims Public alerts and warnings: assuring the provision
to enhance the skills of experts involved in civil protection of safety /evacuation tips to the Public across different
assistance operations by sharing best practices through media, and possibly attempt to reduce the anxiety of
training courses, organization of joint exercises, and a people by exploiting the power of social media,
system of experts exchange and to ensure compatibility Situational awareness: providing accurate
and complimentarity between the intervention teams from information to decision makers & the public using
the participating member and associate states. standardized messages and exploring the possibility
The Civil Protection Modules are made of national to visually assess the extent of the disaster presenting
resources from multiple member states on a voluntary on the map update messages from the field as well as
basis and constitute a contribution to the civil protection reports of incidents and available resources possibly
rapid response capability fostering organizational including amongst other hospital beds, ambulances,
interoperability at the level of the intervention teams. So and rescue teams.
far thirteen modules have been specified, including water In the next section, the relevant activities and
purification, urban search & rescue, field hospital, etc.(7). standards from HL7VII, OASISVIII, and CENIX are
POSEIDON will organize in October 2011 an presented as they are at the forefront of the emergency
operational civil protection exercise in the island of management and disaster medicine. Then, Section III
Crete that will engage forces from different European presents in more detail the ICT applications used in
Union (EU) member states through the ECP SAFE and designed for POSEIDON focusing on
mechanism. In the “POSEIDON” exercise, ICT needs interoperability and standardization aspects. Section IV
to address the issue of interoperability standards and discusses the main findings in SAFE and technical
alarms in a global setting, whereas specific ICT design considerations for POSEIDON. Finally, section
applications to be deployed conform to these V presents the conclusions.
standards and aim at testing:
Activation of the European Civil Protection RELATED STANDARDS
Mechanism: providing knowledge and wider
awareness of the underlying processes and procedures. HL7 CDA and IHE Profiles
Management of medical emergencies, triage: HL7 CDA R2 is an HIT standard modeled along
supporting the Emergency Medical Services in effective the concept of Electronic Health Record (EHR) paper
triage and treatment using innovative eHealth technologies
in coordination with the regional health authority (see VII
Health Level Seven www.hl7.org
Figure 1 for an overview of the disaster area in
VIII
Advancing Open Standards for the Information Society -
OASIS, http://www.oasis-open.org/home/index.php
POSEIDON as supported by ICT technologies). IX
European Committee for Standardization: http://www.cen.eu

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90 J. Health Inform. 2011 Agosto 3(Especial): 87-99

forms, useful in the exchange of medical documents Within HL7, besides the Structured Documents WG
among HIT systems. In disaster and emergency which works on clinical document specifications and
management, clinical documents need to be exchanged implementation guides for CDA and the EHR WG
between Emergency Medical Ser vices and the that works on functional specification for different cases
Emergency Department of the hospitals and their of EHR use, Emergency Care (EC)XVIII and Public
EHR systems if operational and interoperable, but also Health and Emergency Response (PHER)XIX are
with public health agencies, regional health authorities Working Groups specifically looking into issues that
and civil protection operation centers. relate to emergency management. The EC WG aims
Integrating the Healthcare Enterprise (IHEX) has to “bring the unique understandings and perspectives of
developed several profiles that relate to prehospital and prehospital care, emergency medicine, and emergency nursing to
emergency care. The Emergency Management Services (EMS) the HL7 standards process”, focusing on the development
Transfer of Care (ETC) Profile supports the exchange of comprehensive EHRs. The PHER WG is focusing
of clinically relevant data between pre-hospital providers mostly on public health issues related to emergencies.
and hospital emergency departments(8). The Emergency S. Renly et al. discuss in(12) the use of HL7 CDA in a
Department Referral (EDR) content profile allows cross-border setting in the Middle East. Schnürer and
clinicians to refer a patient to an emergency department Oemig in(13) support that Aarden syntax, a standard
providing a medical summary that includes besides the produced by the relevant HL7 Aarden Syntax WGXX,
current health problem, past medical history, and can be used along with terminology codes to trigger
medications, structures to provide information on the alerts and reminders to health practitioners in the presence
estimated time of arrival and method of transport. In of specific findings according to the epidemiological
addition, the Emergency Department Encounter Record protocols defined by public health agencies.
(EDER) profile describes the content and format of
records created during an emergency department visit. OASIS-Emergency: Structured Information
These profiles use clinical documents in HL7 CDA to Standards
exchange clinical information or EHR data. OASIS is a non-for-profit consortium for the
The Emergency Responder Electronic Health Record advancement of Structured Information Standards
Interoperability Specification by American National founded in 1993 as Open Standard Generalized Markup
Standards Institute/Healthcare Information Technology Language (SGML Open). The objective of OASIS as it
Standards Panel (ANSIXI/HITSPXII)(9) has selected relates to emergency management is twofold. First is to
specific standards and profiles to track and provide on- accelerate the development, adoption, application, and
site information regarding an emergency episode/victim. implementation of emergency interoperability and
These include the IHE profiles mentioned above, the communications standards. Second is to represent and
OASIS Common Alerting Protocol (CAP XIII) (10) serve the needs of all constituents, from practitioners to
examined in Section II, and several infrastructure technology providers and national, international and
standards that relate to identification and security. The multinational oversight agencies. The emergency
National EMS Information System (NEMSISXIV) is interoperability member section of OASIS was formed
another effort to standardize and make sense of the in 2007 and consists of a steering committee and two
emergency information collected across 50 states in the affiliated technical committees: the Emergency
United States. Its data dictionary reflects more than 400 Management Technical Committee (TC)XXI (2003) that
of the most common terms in the management of creates standards and the Emergency Management
emergencies(11). Table 1 shows elements of the EMS AdoptionXXII TC (2009) that addresses Education and
Transfer of Care IHE profile and their correspondence Outreach. The emergency standards ratified or under
to widely used data dictionaries, such as Logical development by OASIS-Emergency include the following:
Observation Identifiers, Names, and Codes (LOINCXV) - Common Alerting Protocol (CAP) v1.1, an
by the Regenstrief Institute, and Data Elements for International Telecommunications Union (ITU)
Emergency Department Systems (DEEDSXVI) by the Recommendation x.1303 in 2007(14)
Center for Disease Control and Prevention (CDCXXVII). - Emergency Data eXchange Language (EDXL) –
Distribution Element (DE) (2006)(15)
X
Integrating the Healthcare Enterprise www.ihe.net
XI
American National Standards Institute – ANSI, www.ansi.org
XII
Healthcare Information Technology Standards Panel – HISP, XVIII
HL7 Emergency Care Working Group, http://www.hl7.org/
http://www.hitsp.org Special/committees/emergencycare
XIII
OASIS Common Alerting Protocol – CAP, http://docs.oasis- XIX
HL7 Public Health and Emergency Response Working Group,
open.org/emergency/cap/v1.2/CAP-v1.2-os.html http://www.hl7.org/Special/committees/pher
XIV
National EMS Information System- NEMSIS, http:// XX
HL7 Aarden Syntax Working Group http://www.hl7.org/
www.nemsis.org/ Special/Committees/arden/index.cfm
XV
Logical Observation Identifiers Names and Codes- LOINC, XXI
OASIS Emergency Management Technical Committee, http:/
http://loinc.org / w w w. o a s i s - o p e n . o r g / c o m m i t t e e s /
XVI
Data Elements for Emergency Department Systems, http:// tc_home.php?wg_abbrev=emergency
www.cdc.gov/ncipc/pub-res/deedspage.htm XXII
OASIS Emergency Management Adoption Technical
XVII
Center for Disease Control, and Prevention, http:// Commitee http://www.oasis-open.org/committees/
www.cdc.gov tc_home.php?wg_abbrev=emergency-adopt

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Chronaki CE, Kontoyiannis V, Panagopoulos D, Katehakis DG, Vourvahakis D, Koutentaki-Mountraki K. 91

Table 1 - EMS Transfers of Care Data Element Index(8)

Data Element pt LOINC DEEDS NEMSIS
Emergency Contact R2 Not available in LOINC 1.14 to 1.17 E07_18 to E07_26 Closest
Info Emergency Relative
Contact
Chief Complaint R 10154-3 CHIEF COMPLAINT 4.06 Chief E09_05 Chief Complaint
Complaint
Injury Incident R 11374-6 INJURY INCIDENT 5.03 Injury E09 Situation E10
Description DESCRIPTION Incident Situation/Trauma
Description
History of Present R2 10164-2 HISTORY OF 5.15 ED Clinical N/A NEMSIS
Illness PRESENT ILLNESS Finding
Acuity Assess R2 11283-9 ACUITY 4.08 First ED N/A NEMSIS
ASSESSMENT Acuity Assessment
Active Problems R2 11450-4 PROBLEM LIST 5.15 ED Clinical E12_10 Medical/Surgical History
Finding
Current R2 10160-0 CURRENT 5.09 Current E12_14 Current Medications
Medications MEDICATIONS Therapeutic
Medication
Allergies R2 48765-2 ALLERGIES, 5.15 ED Clinical E12_08 Medication Allergies,
ADVERSE REACTIONS, Finding E12_09 Environmental/Food
ALERTS Allergies
Immunizations R2 11369-6 HISTORY OF 5.15 ED Clinical E12_12 Immunization History
IMMUNIZATIONS Finding
History of Past R2 11348-0 HISTORY OF PAST 5.15 ED Clinical E12_10 Medical/Surgical History
Illness ILLNESS Finding
History of R2 10162-6 HISTORY OF 5.15 ED Clinical E12_20 Pregnancy
Pregnancies PREGNANCIES Finding
Advance Directives R2 42348-3 ADVANCE 5.15 ED Clinical E12_07 Advanced Directives
DIRECTIVES Finding
Family History R2 10157-6 HISTORY OF 5.15 ED Clinical E12_10 Medical/Surgical History
FAMILY MEMBER Finding
DISEASES
Social History R2 29762-2 SOCIAL HISTORY 5.15 ED Clinical E12_10 Medical/Surgical History
Finding
Vital Signs R 8716-3 VITAL SIGNS 5.15 ED Clinical E14 Assessment/ Vital Signs
Finding
Pertinent ROS R 10187-3 REVIEW OF 5.15 ED Clinical E09_13 Primary Symptom
SYSTEMS Finding
Physical O 29545-1 PHYSICAL 5.15 ED Clinical E16 Assessment/ Exam
Examination EXAMINATION Finding
Assessment R X-ASSESS ASSESSMENTS 8.30 Patient E09_15 Providers Primary
Problem Assessed Impression
Intravenous Fluids R X-IVFLU INTRAVENOUS 6.02 ED D04_04
Administered FLUID DMINISTERED Procedure E18_04 Medications Given Route,
4205 Intravenous
Medications R 18610-6 MEDICATION 7.04 ED E18_03 Medication Given
Administered ADMINISTERED Medication
(COMPOSITE)
Procedures R X-PROC 6.02 ED E19_03 Procedure
Procedure

- EDXL – Resource Messaging (RM) (2009)(16) - EDXL – Tracking of Emergency Clients (TEC),
- EDXL – Hospital Availability (HAVE) (2009)(17) analysis phase
- EDXL – Situation Reporting (SitRep) work in - The CAP v1.2 Integrated Public Alert and Warning
progress(18-19) System (IPAWS) Profile v1.0 was approved as a
- EDXL – Tracking of Emergency Patients (TEP), Committee Specification in 2009. The Department of
analysis phaseXXIII Homeland Security’s Federal Emergency Management
Agency (FEMA) has decided to adopt an alerting
XXIII
OASIS Tracking of Emergency Patients http://
protocol in line with CAP 1.1 as the standard for Public
www.evotecinc.com/TEP/ Alerts and Warnings(20).
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92 J. Health Inform. 2011 Agosto 3(Especial): 87-99

The OASIS EDXL standards today provide the Disaster and Emergency Management (OASIS
capability to support Alerts and Warnings, seamless projectXXIV), in Reaction to Emergency Alerts using
routing of information, hospital availability to know voice and Clustering Technologies (REACT projectXXV),
where to route patients, and to request, commit, track, a follow-up EU project to facilitate effective electronic
status and return resources. Important standards under communications among operation centers using
development are those for Situation Reporting about standards(22). TSO is the result of CEN Workshop
any incident and its response (SitReps), to track patients Agreement led by the OASIS project to facilitate the
(TEP), and extension of TEP to track any person exchange information in disaster and emergency
displaced, evacuated, sheltering in place, expired, and/ management. TSO consists of message syntax and a
or requiring medical attention in the context of any dictionary(23) and provides information regarding an
scale incident (TEC). EDXL-SitReps aims to emergency episode comprising of context, event,
standardize the operational picture of the incident resources, and associated missions (see Figure 3).
namely information about the situation and cross Different types of events, the resources engaged in the
agency/jurisdiction response between responders, operation, and the tasks in progress are reflected in
government officials, coordinating entities and the TSO terms (i.e. Context, Event, Resource, and Mission).
public(21). The REACT project used CAP with the TSO
dictionary and its successful approach was adopted by
the Italian Firecorps(24).

HIT IN THE MANAGEMENT OF EMER-

GENCIES

Experience from SAFE

The Satellites for Epidemiology and health early
warning project (SAFEXXVI), set out to demonstrate
the value of satellite-enabled applications in the acute
phase of the disaster as well in a settlement of
earthquake victims. A vehicle equipped with satellite &
local WiFi communications accompanied by a mobile
biochemical laboratory provided the supporting
infrastructure on the field within 30 mins of arrival,
while a number of satellite terminals provided auxiliary
telecommunication capabilities to key locations
including the Operations Center of Civil Protection, a
regional Hospital, and the Emergency Coordination
Center. Dedicated power generators provided
autonomy to each of these sites and a WiFi network
provided the mobile teams with a live connection to
the civil protection operation center, independent of
the conventional telecommunications infrastructure,

Figure 2 - Basic entities of the Common Alerting

Protocol(10,14).
XXIV
OASIS EU project: Open Advanced System for Disaster and
Emergency Management, http://www.oasis-fp6.org/
XXV
REACT EU project: Reaction to Emergency Alerts using
In Europe, CAP (Figure 2) has been used along voice and Clustering Technologies, http://www.react-ist.net/
XXVI
SAFE - Satellites for Epidemiology and health early warning
with the Tactical Situation Object (TSO) developed in project: http://www.medes.fr/home_fr/telemedecine/
the EU co-funded Open Advanced System for teleepidemiologie/safe.html

Figure 3 - Components of TSO object used in the REACT project(23).

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Chronaki CE, Kontoyiannis V, Panagopoulos D, Katehakis DG, Vourvahakis D, Koutentaki-Mountraki K. 93

which may be damaged or severely overloaded by to the office, triggered an alert to report the incident,
the disaster. Thus, despite the disaster each of these by presenting the appropriate form with selected fields
sites was able to communicate through the Internet were automatically retrieved from the EHR. After the
along horizontal and vertical lines of command. physician digitally signed the form, the latter could be
submitted through a web service, in HL7 CDA format
to the epidemiological surveillance system. Additional
reports from the mobile clinical laboratory were linked
to the original report based on a unique id. The HL7
CDA implementation guides used in this context have
been adapted from ones developed for the US
realm(25).

POSEIDON: Resilient & Robust

Interoperable Systems
Building on the experience gained in SAFE, efforts
concentrated on creating open resilient and robust
applications that address the information needs of
different groups including decision makers, civil
protection teams, emergency workers, and the public
targeting the efficiency of the underlying processes. In
Figure 4 - Triage application used by Red Cross particular, application focus areas that were selected
volunteers in SAFE. to be supported with appropriate interoperability
standards were:
In the acute phase of the disaster volunteers with - Situational Awareness for civil protection agencies
PDAs entered triage information (Figure 4) that was and informed decision about the activation of the ECP
immediately conveyed to the Emergency Coordination mechanism
Center through the Satellite/WiFi network. - Management of Emergencies, Triage, and
In the emergency ward of the hospital, a screen Telemedicine
listed the emergency episodes transferred in ambulances - Alerts and Warnings to the Public.
en route to the hospital (Figure 5). In the earthquake Each of these areas is described in the paragraphs
settlement, a group of volunteers with PDAs supported below.
the management of the camp by recording the health
needs of the population, facilitating the creation of Supporting Situational Awareness
reports on the status of the settlement and requesting Situational awareness is a process rather than a state
medication, and other needs. The use of open where people are aware of emergency situations, and
standards was limited, since both applications were pending risks, and take measures to address them
dedicated clients to the legacy emergency information (Figure 6). Recent advances in ICT can support
system. The use of non-standard unstructured reports situational awareness by providing up-to-date
via email worked at the local level, but overall scalability information to collaborating civil protection agencies
was limited in relation to the exchange of information on the unfolding emergency incidents. Digital maps
with third-party systems, a capability that was not showing with clear marks information on the severity
exploited in SAFE. of incidents, the status of the infrastructure and the
In the medical office of the earthquake settlement allocation of resources would facilitate not only
an EHR system was deployed, and was extended to decision making, but also horizontal and vertical
support selected protocols of the National Center for coordination and communication. SmartPhones with
Disease Control. The symptoms (in ICPC) and diseases Global Positioning System (GPS) and Geographical
(in ICD9) that were recorded during the patient visit Information System (GIS) support will provide

Figure 5 - An application in the Emergency Department providing advance information on the episodes
about to arrive.
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94 J. Health Inform. 2011 Agosto 3(Especial): 87-99

Figure 6 - Types of Situation Information from in EDXL-Sitops(18).

Figure 7 - Emergency Network infrastructure in the field area supported by satellite and wireless communication.

updates to commanders over the hybrid emergency used the TSO dictionary together with CAP to
satellite/WiFi network. In POSEIDON the CAP communicate information on the status of the crisis in
protocol will be evaluated as the message format. different languages. In POSEIDON we need to use
However, specification of the data dictionary is custom codes in Greek, which need to be translated in
pending as TSO, EDXL-SitOps, RM, TEP are English and French to support intervention teams from
analyzed together with relevant medical dictionaries in other EU member states. Recent developments in
the specific POSEIDON context. The REACT project OASIS-Emergency for EDXL standards as SitOps,
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Chronaki CE, Kontoyiannis V, Panagopoulos D, Katehakis DG, Vourvahakis D, Koutentaki-Mountraki K. 95

as well as HL7 Domain Analysis Models and IHE Interoperability is quite important if the EHR is
profiles for emergency are quite promising and of perceived to evolve as the central repository for all
potential use to POSEIDON that addresses the specific citizen related health data. Figure 7 shows a supporting
use case dealing with Earthquake and Tsunami. auxiliary rapidly deployable network infrastructure
based on Satellite communication (a satellite equipped
Management of Emergencies – Triage- van), a local WiFi network, and optionally sensing
Telemedicine devices and actuators equipped with Radio Frequency
Significant part of the data feeding situational Identification (RFID) designed for POSEIDON. What
awareness is provided by the actual emergency workers is particularly important in this emergency setting is
on the field, doing triage, engaging in emergency that each of these telecommunication links does not
treatment, or transferring victims to a healthcare facility constitute a single point of failure. Global System for
or a shelter. The transfer of information on the Mobile Communication (GSM) & Satellite
number, type, and severity of emergency episodes communications, RFID and traditional PDAs/
from the crisis area to the Operation Center of the Smartphones should work interchangeably to provide
Civil Protection, the Emergency coordination center robust ser vices facilitated communication and
and the receiving hospitals can help take important coordination among decision makers and emergency
decisions about the management of resources and response teams.
possibly the request for external assistance. Additional The form shown in Figure 8 has been designed by
issues related to the use of interoperability standards emergency management personnel to be used during
at the site of the crisis concern information on hospital secondary triage-treatment in the field hospital area
resources and the use of telemedicine services to and upon arrival to the hospital (area indicated by box).
support emergency health workers in field hospitals. If standardized and widely adopted not only for

Figure 8 - Form provided upon delivery of episode to the hospital Emergency Department by EMS ambulance
personnel.
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96 J. Health Inform. 2011 Agosto 3(Especial): 87-99

disasters but also daily practice, it could improve to areas. As far as standards are concerned, CAP provides
accountability, resource management, and eventually the right standardization framework. However, the
patient outcome. actual message format and content need to be analyzed,
An area where the HL7 CDA seems to be confirmed with, and endorsed by the national civil
particularly useful is the exchange of data between the protection authorities for limited experimental use and
Emergency Coordination Center and the Emergency evaluation by exercise participants. Currently in Greece,
Department component of the hospital information there is no legal framework for the use of electronic
system. The IHE ETC content profile has been communication in alerting the Public on the occasion
analyzed to examine whether it suffices to of pending natural disasters such as tsunamis. Thus,
accommodate the information. In addition to IHE the evaluation results of this public alert service in the
profiles elements of the ongoing work on EDXL TEP POSEIDON exercise will be reported to relevant
need to be taken into account. authorities.
If the ability to evacuate the patients is limited, In the USA, National Oceanic and Atmospheric
telemedicine could be a viable alternative, in the absence Administration (NOAA), already produces tsunami
of specialized health professionals. From a standards alerts using CAP on the Internet (Figure 11). In Europe,
perspective, clinical documents in HL7 CDA based a tsunami alert service is provided on subscription basis
on different templates could form parts of a
teleconsultation folder, presenting an overview of an
episode to be shared with experts. Additionally, patient-
connected health monitoring devices can provide
volunteers with important insight on their progress,
while they can also support telemedicine.
Another important aspect of our work relates to
the EDXL- HAVE standard(17), which specifies an
XML document format that allows communicating
the status of a hospital, its services, and its resources.
These include bed capacity and availability, emergency
department status, available service coverage, and status
of a hospital’s facilities & resources (Figure 9).

Alerts, Warnings and Guidance to the public

Alerts and Warnings for the public traditionally use
different media, e.g. sirens, loudspeakers, radio, internet,
television, short messages. In addition, customized
maps may provide evacuation routes and concentration Figure 9 - EDXL-HAVE message example(17)

Figure 10 - Map showing graphically the tsunami alert, shelters, and evacuation routes. The map will be
automatically updated to reflect updates from the field and facilitate communication and coordination.
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Chronaki CE, Kontoyiannis V, Panagopoulos D, Katehakis DG, Vourvahakis D, Koutentaki-Mountraki K. 97

Figure 11 - NOAA is using CAP in tsunami alerts

to interested individuals (http://www.tsunami-alarm- usability and productivity in the backdrop of
system.com). The CHORIST27 project is another effort fluctuating network infrastructure. Moreover, while
supported by the European commission to develop delivering integrated services is helpful, a reliable and
modules for risk assessment, public warning, and a robust solution requires redundancy so that occasionally
rapidly deployable telecommunications system that is unavailable service components do not hinder
using TSO and CAP. As already mentioned CAP is an emergency communications. Disconnected operation
XML-based data format for exchanging public is quite important, while flexibility and alternative ways
warnings and emergencies between alerting of use are keys to an effective ICT-enabled
technologies. CAP allows a warning message to be communication and coordination mechanism. Finally,
consistently disseminated simultaneously over many the availability of HL7 CDA implementation guides
warning systems and media including internet, radio, available at the HL7 portal, were very helpful in the
SMS, TV, etc. Thus, CAP increases warning effectiveness process of creating the specific clinical document
and simplifies the task of activating a warning. templates for a predefined standards-compliant way
of communicating accurate health data.
RESULTS - DISCUSSION For POSEIDON, the challenges are higher as we
try to bring ICT applications to work much closer to
The “SAFE” exercise demonstrated the value of standards from HL7, OASIS and other relevant SDOs,
ICT in the management of disasters. However, in a while addressing the interoperability issues present both
larger European or global context, interoperability at the technical and the organizational levels.
issues turn out to be quite critical in providing timely Information that flows in from different sources has
information to decision makers, emergency workers, to be cross-checked and leveraged based on standard
and the public. procedures. This is a quite challenging task as
ICT applications built for emergencies need to be information and messages should be developed in
primarily usable, robust, and resilient. In SAFE, despite Greek and translated in English and French. Moreover,
support for disconnected operation, security and the legal framework needs to be reexamined reflecting
privacy provisions were deemed quite unfriendly to on the experience gained and the evaluation results of
users with PDAs that were facing repeated disruptions the POSEIDON exercise.
of network connectivity. The high overhead of security Although selection of applications and configuration
and privacy mechanisms has to be weighed against in POSEIDON is still in the adaptation stage, early
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98 J. Health Inform. 2011 Agosto 3(Especial): 87-99

indications show that cooperative use of standards Organizations (SDOs), interoperability initiatives and
through predefined protocols and guidelines consortia is to work together to cultivate a spirit of
appropriate to the disaster scenario considered is cooperation and collaboration that will bring out
feasible. However more work lays ahead: bridging effective robust and usable services built on global
gaps and harmonizing partly overlapping standards in agreed standards to advance interoperability not only at
emergency management and health information the technical but more importantly at the organizational
technology would certainly improve our capacity for level leading to more effective and informed Disaster
rapid situation assessment and emergency response. Management and Emergency Response.

CONCLUSIONS ACKNOWLEDGEMENTS

Situational awareness, resource availability, and timely Project POSEIDON has been co-funded by the
response are the most critical parameters for effective European Commission, DG Environment, under contact
disaster management. The grand challenge for engineers 070401/2009/534360/SUB/A3 “POSEIDON:
in service design and implementation is to cooperative Earthquake followed by Tsunami in Mediterranean Sea.”
deploy standards from different organizations to create The authors would also like to thank George Ioannis
robust, resilient and flexible integrated services, and Tzikas, Evangelia Flouri, Nikos Kampanis, and Costas
leverage information from different sources to support Sinolakis collaborators in the POSEIDON project, as
decision making. The pressing need for HL7 well as Jussara Macedo Pinho Rotzsch for helping with
International and other Standards Development the translation of the abstract to portugese.

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