Could ICT Be Harnessed for Prehospital Emergency Medical
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.
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
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
2016 by SCITEPRESS Science and Technology Publications, Lda. All rights reserved
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.
2.1 ICT Implementations in Non-profit
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
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,
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
( 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
HEALTHINF 2016 - 9th International Conference on Health Informatics
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
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
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
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
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
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
HEALTHINF 2016 - 9th International Conference on Health Informatics
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 costsadds 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 Solutionwith 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
institutional donors “tend to prioritize beneficiary
facing activities over infrastructure and
organisational development” (LRCEMS ass. dir. for
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.
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
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.
HEALTHINF 2016 - 9th International Conference on Health Informatics
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
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Figure 1: LRC EMS Integrated IT Solution.
HEALTHINF 2016 - 9th International Conference on Health Informatics