Appendix C: Existing Systems: Tracking Systems

The proposed National System would be used during multi-jurisdictional mass casualty/evacuation incidents to:

1. Locate, track, and regulate patient sand evacuees.
2. Improve decisionmaking regarding patients and evacuee transportation, resource allocation, and incident management.

A fundamental recommendation (Section 3) for the National System is that, to the extent possible, it be compatible with existing systems and procedures and that development of new systems and procedures be minimized.  In particular, the more information that can be drawn from existing information systems, the more likely the National System will be adopted and used.  For this reason, project staff conducted a review of existing systems, including:

• Tracking systems—i.e., systems designed to record the movement of persons from one location to another.
• Institutional records systems—i.e., systems that contain the current location of persons but are not designed to track their movement from one location to another.
• Resource inventory or availability systems—i.e., databases that contain baseline inventory of a resource or systems designed to solicit the current level of resource availability, from resource owners. 
• Resource requirements models—i.e., planning tools that could be used to estimate resource requirements, which could in turn be compared to resource availability to yield resource shortfalls or gaps. 

The purpose of this review is to highlight the primary examples of existing systems, rather than provide a comprehensive directory of all existing systems.

The remainder of this appendix reviews tracking systems.  Institutional records systems, resource inventory or availability systems, and resource requirements models are discussed in Appendixes D, E, and F, respectively.

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Overview

The primary purpose of a patient and evacuee tracking systems is to monitor the movements of people who require evacuation assistance, so that each is transported to a safe and appropriate location and none "slip through the cracks."  For example, nursing home patients must be transported to a nursing home or hospital rather than a shelter, and intensive care unit (ICU) patients must be transported to a hospital with ICU space available.  For many patients, timely transportation to an appropriate facility is also important—delay in adverse conditions could be life-threatening and transportation prioritization must be based on urgency of health needs. The tracking system will also give facilities (shelters, hospitals) at the receiving end some information about the needs of people who will be arriving.  Finally, family members need to know where other family members are so they can try to make contact and reunify the family (e.g., parents locating missing children).

The patient or evacuee tracking function is not unlike that employed by package delivery companies such as Federal Express or UPS.  Each "package" must be uniquely identified and tagged (e.g. bar-coded), and its whereabouts reported into the central database each time it is moved.  The central database can then generate a tracking record showing each stop along a package's journey from pickup to delivery.  The same can theoretically be done with people being evacuated from a disaster zone; each time a person arrives at a new location their tracking record is amended in the central database. (For example, the table in Section 2.)

People are, of course, harder to keep track of than packages.  They may leave a shelter on their own initiative without letting anyone know, they may insist on waiting in a location for their other family members to arrive, they may remove their identifying "tag," or they may suddenly go from safe residence in a shelter to being in urgent need of medical care. 

Discussed in this section are patient or evacuee tracking systems currently in use at the local or regional level, and at the Federal/national level.  Almost all are for patient tracking; one Department of Defense (DoD) system has been used for evacuee tracking.  

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Systems Used at the Local or Regional Level

Some jurisdictions use patient tracking systems to track the location of victims of all mass casualty incidents (at the local level typically defined as an incident with six or more victims).  While in theory such systems could be used to track movements of people between any pair of locations, patient tracking systems generally are used to track movements only from an incident/accident scene to the receiving hospital. 

Emergency responders assign a unique ID to patients in the field (e.g., via a wristband that contains a barcode, radio frequency identification (RFID) device or handwritten information) and then transport the victim to a hospital.  The unique ID, triage category, and possibly other information about the patient (e.g., location of receiving hospital) are typically uploaded via a wireless connection to a central database, where hospital emergency department (ED) staff can see how many and what type of patients are in transit to their hospital.  When the patient arrives at the ED, his/her location can be updated in the tracking system. 

Authorized users can access tracking data for a variety of purposes: emergency operations center personnel can monitor and track casualties and the number of patients taken to each hospital (to help with load balancing); hospital personnel can track incoming casualties and prepare for specific casualty types.  A public Web site can also be set up so that the public can query the database to learn to which hospital particular evacuees were taken. 

The number of jurisdictions using patient tracking systems is not known, but it is a very small percentage of jurisdictions across the country.  One possible reason for the small number of sites is that there are few compelling reasons for using these systems on a daily basis.  From the emergency responder's perspective, it is easier to contact the hospital via a two-way radio. In fact, the systems were designed primarily to be used in mass casualty incidents or to help prepare for such an incident via periodic refresher trainings (e.g., "Triage Tuesdays").Patient tracking systems include both commercial and institutional systems. For example, the Hospital Association of Southern California has developed an open source alternative to commercial systems—Rapid Emergency Digital Data Information Network (ReddiNet).⁴⁶  Originally built in the 1980s for use in Los Angeles, ReddiNet has been modernized and is extensively used in nearly 250 emergency response organizations throughout 17 California counties, including Los Angeles and Orange counties. ReddiNet connects hospitals, agencies, and service providers within regional health care systems and displays real time, regional, and inter-regional diversion data and available resources.  Special data screens allow for data input on patient capacity, victim identification, and dispatch information to evenly distribute patients to waiting hospitals.  A polling feature allows rapid assessment of bed availability, bed census, epidemic surveillance, and other parameters.

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Systems Used or in Development at the Federal Level

The U.S. Department of Defense uses two systems for tracking and regulating military casualties—Joint Patient Tracking Application (JPTA) and TRAC2ES.  Another system (ETAS) was designed for evacuee tracking and exists as a prototype.  Both the DoD and the U.S. Department of Health and Human Services (HHS) are currently considering different options for expanding their capacity to track and regulate civilian patients and evacuees.  In particular, in response to an initiative from the DoD's Office of the Secretary of Defense and Office of the Secretary of Homeland Defense, and supported by the NORAD-NORTHCOM Surgeon's Directorate, DoD is considering options for establishing a system that will provide information on the movement, regulation, and tracking of all DoD and civilian patients and/or evacuees moved by the DoD during contingency operations resulting from a man-made or natural disaster in the U.S. Northern Command (USNORTHCOM) Area of Responsibility. 

Any new system(s) would be coordinated with the Federal government's National Disaster Medical System (NDMS).  This system augments the Nation's medical response capability by establishing a single integrated National medical response capability for assisting State and local authorities in dealing with the medical impacts of major peacetime disasters.⁴⁷

JPTA. The DoD uses the Joint Patient Tracking Application (JPTA) to track the location of casualties treated in military hospitals around the world.  JPTA was first deployed in January 2004 and, as of June 2006, was used in 25 military hospitals.  DoD ultimately plans to use JPTA in all military hospitals.  JPTA has never been used in a civilian setting; a "disaster relief" version of JPTA was developed for Katrina, but it was not used. 

JPTA has a patient registration module; some of the fields in this module, including the arrival date, are automatically filled in via a link to TRAC2ES (see below).  JPTA records the patient's treatment status, hospital and room number, and disposition/referral destination.  If patients are later transported to another military hospital, the patient's existing JPTA record is updated.  Electronic medical records and other files also can be attached to JPTA records and accessed by health care providers as the patient moves from one military or Veterans Health Administration facility to another.  JPTA users have different access privileges, some being limited to a single hospital while others can view system-wide data and reports.  According to JPTA personnel who have worked with hospitals using the system, JPTA benefits hospitals in three primary ways: (1) patients have "visibility" outside of the hospital, thus reducing the number of phone inquiries about whether a patient is at a hospital, (2) hospital staff have advanced warning about patient arrivals via TRAC2ES, and (3) JPTA is a convenient way to transfer electronic medical records between medical providers. 

TRAC2ES.  As noted above, the DoD has linked JPTA to the Transportation Command Regulating and Command and Control Evacuation System (TRAC2ES) system.  TRAC2ES has a transportation focus: its goal is to effectively use military patient transport planes so that planes arrive to pick up patients in a timely manner and so that they have the necessary resources on board  to care for the patient (e.g., a nurse, blood, a monitor).  Patient movements are associated with an event; in 2005, two such events were Operation Iraqi Freedom and Katrina.  Once an event is defined, a patient movement request (PMR) can be generated. The PMR includes identifying information on the patient, clinical information (in particular, medical resources needed on the airplane), the patient's location (i.e., where the plane will pick up the patient), and the patient's destination (typically a military hospital).  The patient's location is updated once s/he boards the plane, when the patient arrives at the destination airfield, and when the patient arrives at the hospital.  If the patient is subsequently flown to another military hospital, that information is appended to the patient's TRAC2ES record.  TRAC2ES alerts hospitals about incoming patients by sending a message to JPTA.

TRAC2ES was been used to track the movement of U.S. citizens being rapidly evacuated from Lebanon in the summer of 2006.  As such, it is the only Federal/national tracking system that has been deployed for evacuees (as opposed to patients).  It is not, however, fully scaled up and it assumes the presence of "handlers" like the National Guard or other personnel to enter the data on evacuees at each checkpoint; it has not yet been integrated into civilian disaster response.

ETAS.  In addition to TRAC2ES and JPTA, the DoD has developed a prototype evacuee tracking system called Emergency Tracking Accountability System (ETAS).  This system evolved from the DoD's Non-Combatant Evacuation and Repatriation Operations (NEO) Tracking System, or NTS.  First deployed in 1996, in part to support a possible non-combatant evacuation in South Korea, NTS has been used for non-combatant evacuations in Turkey, Lebanon, and other locales.  In 2005, DoD requested development of an evacuation tracking system for civilian evacuation operations in the U.S., which led to development of the ETAS prototype.  ETAS's goals were to: improve the efficiency of evacuation operations; manifest and track evacuees using the FEDEX/UPS model of barcode scanning at departures and arrivals; use robust, redundant communications for transmission of encrypted evacuee data; and enhance coordination, control, and management of evacuees.  ETAS currently does not have a sponsor and is unfunded within DoD.⁴⁸

NDMS.  The Department of Health and Human Services operates the National Disaster Medical System (NDMS) and is considering options for implementing a system to track the movement of patients and transfer their medical records, wherever they are served by NDMS units.  Federal Medical Shelters (FMSs) are temporary medical units deployed inside facilities that have been erected or commandeered to serve as temporary shelters (e.g. airports, army bases, stadiums).  FMSs are staffed by Federal clinicians, or by activated Disaster Medical Assistance Teams (DMATs).  Both the FMSs and the DMAT teams are part of NDMS. At this time, only hard copy records are created by NDMS clinicians and there is no system to track the movement of patients or transfer electronic medical information about these patients.  If, for example, an evacuee arrived at the Superdome and needed medical assistance, s/he would most likely have been seen by the NDMS medical staff on site.  When that patient was then transported to the Houston Astrodome where another FMS was deployed, there was no system to track their movement and assure that medical staff in Houston assumed medical responsibility for the patient and no system to relay medical information from the Superdome to the Astrodome.

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46. http://www.reddinet.com/index.html
47. http://www.oep-ndms.dhhs.gov/
48. Presentation on November 16, 2006, by Mike Masica, Chief, Operations Support Division, Defense Manpower Data Center.

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