The US has recently experienced devastating fires in California and hurricanes that have struck the gulf and east coasts, as well as domestic terrorism. Disaster plans need to be formulated based on risks an area may experience, including those that can impact the flow of information and data. Control over a disaster scene must be established in minimum time to ensure that everyone knows what is happening and to maintain safety. However, confusion may occur because the responders in a disaster bring differing levels of expertise, responsibility, hierarchy, and may use different procedures and terminology.1
Telecommunication infrastructures and services are often severely impacted when a disaster strikes, preventing the flow of information. It is critical that communication and coordination of accurate information be uninterrupted or restored as quickly as possible. A lack of information negatively impacts the victims and responders, increasing their stress levels and decreasing safety. To restore and maintain communication, a coordination of efforts by the different disaster management agencies and disaster relief organizations is essential at all levels. The faster the lines of communication can be secured, the sooner recovery actions can proceed.2
However, there is one significant issue with these varied and new communication technologies: cost. Many of the organizations that respond to disasters are volunteer organizations or governmental agencies, and what they can afford to purchase is limited by budgetary constraints. Regardless of the tools available and utilized in the field, they need to be operationalized quickly, so all stakeholders share accurate and effective information in real time, resulting in a communication system that is reliable and resilient.2,3
The key to sharing information is directing, coordinating, and analyzing the data, which requires a telecommunication infrastructure that provides accurate and timely information. However, a plethora of data can result in data overload, making it difficult to integrate all the data in such a way that they are actionable and accurate. Further, the increase in communication platforms and tools has led to “competitive and parallel initiatives,” which interfere with data sharing.2
The disaster environment
Situational awareness is the ability to be aware of and understand one's physical surroundings. For the disaster team, this requires complete awareness and visibility of the common operating picture (COP) of the disaster event. Visibility is achieved by sharing and integrating data to form a COP capturing the who, what, why, when, and where of a situation. All of this must be done in real time and rapidly communicated to the responding team members so decisions can be executed. The benefits of having data drawn from various sources not only facilitate rapid actionable responses in disasters but also provide data to help improve future responses.4
The three communication challenges present during a disaster include organizational, sociological, and technological issues. Organizational issues arise because of the hierarchical or centralized nature of the groups involved in the response.5 These include government responders (such as the FBI, local law enforcement, and state agencies) as well as volunteer organizations (such as medical emergency response teams, the American Red Cross, and various religious organizations).6 Each has its own systems and methods for communicating, which can lead to confusion as agencies share information. Because flat organizational structures are not scalable, they cannot increase or decrease in size as needed and hierarchical organizations may be so broad that valuable information is lost. Consequently, a better model is a hybrid organizational structure because it allows a more efficient flow of information and communication, and it can be scalable as required.5
Another important issue is the emotional volatility among the stakeholders that can be compounded by a lack of communication, which frequent updates can help mitigate. Also, a mismatch in available technologies can increase communication problems. For example, some agencies or relief organizations may not have the resources to purchase certain communication technologies, or there may be a lack of adequate training to learn to properly use the technologies. Lastly, there may be lack of a common language used to communicate between and among responders and victims; for example, not everyone may be using the same icons or abbreviations.5
The initial technologic challenge entails mobilizing communication systems used by the responders managing the disaster. This must occur regardless of the degree of communication loss from having no power, phones, or network connectivity infrastructure to the lack of communication between different responding agencies. Another significant issue is the problem of interoperability due to the presence of varying types of technologic communication devices and platforms that do not share information readily.5 The Department of Homeland Security (DHS) and the Science and Technology Directorate (S&T) have addressed this issue in their guide, Next Generation First Responder Integration Handbook.7
Legislation and regulation
The Office of the National Coordinator for Health Information Technology (ONC) established an incentive for healthcare organizations to share patient information. It promotes the adoption of health information technology (IT) and the exchange of information. This initiative has been a significant step in the formation of nationwide health information exchanges (HIE), which are critical to the sharing of patient information during disasters.8 The sharing of information has been evolving well within the states, but nationwide sharing among HIEs is still in the future. By 2024, the goal of the US Department of Health and Human Services (HHS) is to have a nationwide fully interoperable health IT network.9
Having functional telecommunication infrastructures and services is an essential aspect of disaster response as well as recovery efforts. In 2016, the Centers for Medicare and Medicaid Services (CMS) issued a regulation requiring organizations to plan for IT downtime regardless of the cause to ensure continuity of patient care. ONC and HHS developed a Health Insurance Portability and Accountability Act (HIPAA) Security Risk Assessment Tool that provides organizations guidance as they develop IT plans, ensuring patient data are available and secure during downtimes, including disasters. ONC also has the Safety Assurance Factors for Electronic Health Record Resilience (SAFER) guides, which provide the tools for organizations as they assess their IT systems' ability to ensure patient safety.10
HIPAA requirements exist for how organizations safeguard data during downtimes, regardless of cause. The requirements' state policies and procedures must be in place to protect electronic health data. Specifically, these requirements include:
- a data backup plan
- a disaster recovery plan
- an emergency mode operation plan
- testing and revision procedures of contingency plans
- applications and data criticality analysis to determine the most critical data in an emergency.11
The HIPAA Privacy Rule has provisions that guide healthcare entities as they share patient information during disasters. Fortunately, to help facilitate the flow of patient information during a disaster, healthcare organizations and law enforcement always have access to these data. Information is also shared without a waiver in the following situations during a disaster: a patient requiring treatment; communicating with family, friends, or others involved in a patient's care; preventing a possible threat; and media or others not involved in care (but only with certain restrictions). The information released should be kept to a minimum and only in the best interests of the victims.12
Issues that impact communication
Several legal, ethical, and social issues can impact how information is shared. Large amounts of data are produced, and they need to be authenticated, organized, and analyzed before they are useful. The examination of these data may be impacted ethically during disasters by attitudes or bias of authorities or relief organizations. Mismanagement of the disaster and the focus of the media can cause problems with discrimination, interference with personal rights, and unequal resource allocations.13 Privacy and legal concerns regarding information sharing can negatively impact information exchange, so it is essential that the analyzing and sharing of data follow legal, ethical, and social norms.2
Electronic health record and health information exchange
Healthcare organizations need to be prepared for events that may compromise their health IT regardless of cause. Fortunately, with the expansion of electronic health records (EHRs), this capability has improved. Having patient data stored in the cloud or in offsite and out-of-state physical locations enables timely access to the data from anywhere.14 An example of how loss of medical records can impact patient care in a disaster was seen during Hurricane Katrina in 2005. Paper records, which most organizations used, were destroyed, leading to the inability to provide healthcare to victims once initial emergent healthcare was provided. Responders were unable to access patient data, especially medication lists, which greatly hampered their ability to treat victims.15
Organizations that participate in health information exchanges can share patient data between EHRs, a critical advantage in widespread disasters where victims may be in many locations. Such exchanges allow for the sharing of patient data among different facilities, helping maintain continuity of patient care.16 However, prior to a disaster these connections need to be in place for this sharing to occur. Consequently, an HIE must be integrated into the organization's disaster plan. Healthcare organizations' staff must know what HIE serves their area so they will know what data are accessible and how to access it. Prior to a disaster, these connections between EHRs and HIEs need to be tested before a disaster occurs so they will function as designed when a disaster strikes.17
Information communication resources
A plethora of resources are available to healthcare providers, emergency responders, and healthcare organizations on what to do to keep communication lines open during a disaster. The specific ones used in a geographic region should be known to all healthcare agencies, organizations, and volunteer disaster groups. NPs should check local public health and disaster agencies for more information on what is available in their areas. One example is telehealth, which can provide a vital link to patients during disasters when the usual avenues of care are limited or nonexistent. If there is intact cellular service and/or wi-fi, these networks can remain operational during disasters to assist with the coordination and management of patient healthcare.18
Mobile healthcare technology (mHealth) includes wireless and mobile devices that are easy to use, convenient, and accessible; improve accuracy of triage; provide disaster victims with faster processing and transport to emergency care centers; and monitor more patients at one time. However, the transmission of data depends on available networks and cellular or wi-fi connectivity, which may be unreliable due to greater demand than the networks can support or damage to cell towers.1 (See How mHealth supports improvement of communication.)
Measures to improve or facilitate disaster response
Another means of facilitating the flow of information is information communication technology platforms. These hardware and software tools permit communicating and sharing of information between stakeholders. Because there may be many platforms in use during a disaster, synchronizing the various platforms may not be optimal, leading to confusion.2
The Sequoia Project, North Atlantic Treaty Organization (NATO), RPM platform, and emPOWER Initiative are four examples of these platforms. In 2017, the Sequoia Project developed the California-Patient Unified Lookup System for Emergencies (PULSE) platform that authenticates the credentials of healthcare disaster volunteers and provides them access to patient data. The system allows volunteers access to patient data from HIEs, hospitals, and other sources; there are efforts to have this platform utilized nationwide.20 The Emergency System for Advanced Registration of Volunteer Health Professionals is also available for registering volunteers.21
In 2017, NATO made available a multinational interoperable remote medicine program that could be used during disasters.22 This program gives providers the ability to assess patients, diagnose, and make real-time recommendations for treatment, all completed away from the disaster site. This process accelerates the ability to respond to disasters more quickly.22
A mobile remote patient monitoring (mRPM) platform provides data on community members throughout disaster events. This platform can provide information on patients who may need assistance at some point during a disaster. This service can also provide information about social determinants of health, such as available food and housing, gathered from questionnaires sent to mobile devices. All these data can assist officials as they make decisions about vulnerable populations during disasters.23
HHS and the Assistant Secretary for Preparedness and Response (ASPR), along with CMS, developed the emPOWER Initiative, which provides data and mapping tools to responders, health departments, and their associates to “anticipate, mitigate, plan for, and respond to” potential requirements of at-risk populations prior to and throughout a disaster.24 (See HHS emPOWER Initiative.)
Information communication technologies
Information communication technologies such as the internet, wireless technologies, mobile phones, two-way radios, and social media are important tools for coordinating and sharing information during the management of a disaster. Regardless of which technologies are used, it is critical that first responders understand how to use them.
Consequently, adequate training sessions for all responders are essential. Without this understanding, confusion and misunderstandings can arise that can lead to a loss of valuable time and incorrect decisions.2 Many different communication devices can be used during disasters (see Communication tools available during a disaster). Disaster apps and additional resources are also available that expand information to the NP (see Disaster apps and additional resources).
Implications for NPs
Disaster-prepared medical personnel, including NPs, are critical to effectively deal with the healthcare requirements of victims and first responders. Disasters may ruin the communication infrastructure to the affected area, forcing providers to rely on alternative means for communication and collaborations. As key members of the interdisciplinary team, NPs need to participate in disaster planning efforts to lend their expertise regarding their community and facility.
NPs know how to access and interpret data and need to be aware of the telecommunication technologies and apps used in their geographic areas. They need to take an active role in educating other healthcare providers, their patients, and community members during their routine activities as well as participate in annual disaster drills. NPs should have situational awareness of the types of disasters that may occur in their area and what responders and responses will be required. How an NP's practice site may be used in a disaster is also a consideration, if the site is the closest healthcare facility to a disaster. NPs responding to a disaster understand and utilize the principles of ideal communication with local healthcare agencies, law enforcement, and other organizations in order to maintain collaboration and proper coordination of care.
To fulfill their mission, NPs must have access to data so victims are treated in a timely manner. This means assessing and evaluating the type of disaster; affected populations, especially vulnerable individuals; factors impacting the health of the affected population such as sanitation, food, and shelter; and human and equipment resources needed to care for victims. Furthermore, having access to EHRs and HIEs permit NPs access to patient data wherever victims are located, enabling the provision of healthcare in a timely manner.
Many new and useful information communication technologies are positively impacting the outcomes of disaster responses, but many are costly. Coordination and sharing of information regarding a disaster with all stakeholders are critical to an effective response. Having fully functional communication systems is a significant factor in effectively managing disasters and delivering appropriate healthcare in the field. NPs need to be familiar with the information communication technologies used in their geographic areas and be ready to use them when, not if, a disaster strikes.
How mHealth supports improvement of communication19
Management of the disaster scene
Triage systems of victims, with resulting data being used to allocate resources and determine transport to appropriate hospitals.
Remote monitoring of victims
Involves monitoring victims' vital signs, allowing disaster responders to focus on other victims while still being alerted to a previously assessed victim's real-time status and any changes.
Permits evaluation of radiologic images at a distance from the disaster site.
Decision support systems
Assist clinicians making triage decisions using patient physiologic parameters, the appropriate triage category, and including such things as exposure to hazardous materials.
Field hospital IT systems
Permits the use of laptops to access patient records, radiologic images, and the location of patients in the hospital.
HHS emPOWER Initiative24
HHS emPOWER Map
Links deidentified Medicare billing data, real-time National Oceanic and Atmospheric Administration severe weather tracking and geographic information system mapping of high-risk individuals who are dependent on electricity for healthcare and/or assistive medical equipment in a geographic area.
HHS emPOWER Emergency Planning
Provides deidentified Medicare data for individuals who are using durable medical equipment, oxygen, dialysis, and need home health in a geographic area.
HHS emPOWER Emergency Response Outreach Dataset
Provides data on individuals who need contact prior to and/or throughout a public health emergency.
Communication tools available during a disaster25-31
Used with intact cell towers or wireless networks; USB battery-powered charging cables have increased their usefulness.
Tablets and laptops
Function like mobile phones if connectivity is available.
Land mobile radio
Wireless system that enables voice and low-speed data transmission; lasts 8 to 12 hours and functions in extreme conditions, during long periods of power outages, and off network in line of sight; uses dedicated channels.
Two-way radios or walkie-talkies
These have global positioning system capability so everyone can identify the location of team members (do not work in buildings); they have their own channels so will not be affected by outside interference or competition from others; coverage can extend up to 300 miles; durable and lightweight.
Voice over internet
Texting and tweets require little network resources; 140 characters permit essential information be sent. The public is encouraged to use this mode of communication.
Cell on wheels or satellite internet communication trailer
These trailers are self-contained and provide high-speed communication anywhere and anytime.
Wearable alert and monitoring system
Being developed by DHS, S&T, and NASA. Provides physiologic monitoring of first responders in real time with data shared with onsite commanders; data enable critical decisions to be made about the health status of the responders. Wireless, wearable devices provide physiologic monitoring of the responder (vital signs, oxygen saturation, ECG plus biomarkers to include saliva, blood, urine, and sweat). Responder's environment can be monitored for oxygen and carbon dioxide levels.
Disaster apps and additional resources31-37
Federal Emergency Management Agency
Preparation for hurricanes and other disasters
Facebook's Crisis Response: Used to inform friends and family of status during crises
White House Innovation for Disaster Response and Recovery apps and other tools that can provide resources for responders and victims as they respond to emergencies of any kind
Geographic information system (GIS) artificial intelligence (AI)
Having the ability to identify areas at risk for a disaster is becoming a reality with drones, satellites, and GIS technology. These technologies plus AI analytics are critical in identifying areas in which people may need to be evacuated. Drones supply footage that along with satellite mapping and identify the impacted areas in real time, which in turn can be analyzed by AI allowing for immediate decision-making.
Social media (Facebook, Twitter, Instagram, Flickr, YouTube, Snapchat, WhatsApp)
Used to share and receive information to and from the public and assist with the management of the disaster: Used to issue warnings; as a conduit for victims asking for assistance; to help establish situational awareness; and to upload images of the scene.
Provides valuable information that can be added to other data to provide a more complete common operating picture once it is verified as accurate.