Human Factors Considerations in the Design and Implementation of Telemedicine-Integrated Ambulance-Based Environments for Stroke Care

Strokes are the fifth leading cause of death in the United States, with an annual cost of $34 billion dollars in healthcare, medication, and lost work. The time to treatment is critical, as it reduces the adverse consequences from strokes, such as physical and mental disabilities. However, most stroke diagnoses are made outside of the treatment window. Using ambulance-based telemedicine allows the time of transport to be used for patient evaluation and diagnosis, reducing time to treatment by approximately 50 percent.

This research evaluated an existing telemedicine ambulance program that had completed a successful pilot in two ambulances. The system allows 24-hour access to stroke care experts, with time to neurology consult in as little as 9 minutes. The evaluation examined the cognitive demands, workload, workflow, and communication of the care team.

The specific aims of the research were the following:

• Evaluate the demands placed on the caregivers, the usability of the telemedicine system, and the barriers in the workflow associated with a telemedicine-integrated, ambulance-based setting for stroke care.
• Iteratively develop and refine guidelines and recommendations for large-scale implementation of telemedicine systems for stroke care in ambulances.

Simulated stroke sessions with care providers; surveys on workload, usability, and teamwork; and interviews were conducted. A task analysis was developed with a subsequent heuristic evaluation to determine usability issues in the telemedicine user interface. A qualitative analysis determined the sources of disruption and a systematic human error reduction and prediction approach (SHERPA) to determine the possibility of human error while providing care using the telemedicine work system.

The researchers identified barriers to the use of the system, including frustration with the equipment, training of providers, increased cognitive demands, and loss of personal connection of neurologists with patients. The constraints of the physical space in the ambulance were noted as an additional barrier. Facilitators included live and visual communication that led to increased teamwork and efficiency, the ease of access to needed specialists, and increased flexibility. The evaluation identified issues with the systems design regarding the information architecture, error messages, and page formatting. Errors that were predicted included miscommunication, omitted or incomplete steps, incorrect data entry, and insufficient assessment. Consequences of these were predicted to have a limited probability of patient harm. However, the researchers felt that knowledge of types of errors that occur pre-arrival to the hospital have implications for the care of the patient upon arrival.

The researchers proposed several remediation strategies, including automation of task structure and audio and visual improvements to support communication. These remediations will be considered as the research group continues their investigation into the use of telemedicine for prehospital stroke assessment.