Introduction
In multi-organizational disaster events, different organizations and, in some cases, different nation’s governments, are forced to interact in highly complex situations requiring effective collaboration among different professionals with different backgrounds, cultures, and operational systems. In such challenging environments, effective interoperability and adequate collaboration have the potential to spare the human life and to control the economic burden in disaster management (DM). Reference Noran1
Despite the importance, a disaster’s intrinsic characteristics of emergency and contingency makes it difficult to achieve effective interoperability in multi-organizational DM. All health care organizations involved in a disaster need to have effective interoperable systems because it facilitates the exchange of information on health data, improving capability and data analysis. 2
On this perspective, the scope of “interoperability” as “all aspects of collaboration and interaction needed to effectively prepare for, and respond to, disasters and other public health emergencies” Reference Lerner Brooke, Billittier and O’Connor3 is gaining more and more interest because it allows “health care technology systems and devices to exchange, interpret, and store data using common standards.” 4
The interoperable capability may have the potential to influence all the information channels (eg, within participants and organizations and vice versa) because there is an interaction with the innovative technologies and the human factor, the first facilitating the process of information flow and coordination and the second influencing the trust and collaboration enhancing disaster planning, mitigation, and management. Reference Sagun, Bouchlaghem and Anumba5,Reference Sagun, Bouchlaghem and Anumba6
To facilitate a more systematic understanding of challenges in high-risk environments, some authors distinguished between endogenous uncertainty, relating to the inherent challenges of a high-risk incident, and exogenous uncertainty, relating to challenges with the operating system and teamwork. The authors found, during a live counter-terrorism training exercise, that 75% of uncertainties were related to exogenous team issues Reference Alison, Power, Van den Heuvel and Waring7 such as trust issues, competition, poor role understanding, and communication. Reference Shortland, Alison and Moran8
Therefore, the objective of this scoping review is to provide an overview of the multi-organizational problems and solutions on achieving interoperability among health care organizations and other emergency organizations during a disaster.
The research question adopted was: “What are the problems and solutions to achieve interoperability in a multi-organizational approach involving health care systems during a disaster event?”
Methods
The scoping review was conducted according to the methodology of the Joanna Briggs Institute (JBI; Adelaide, Australia). Reference Aromataris and Munn9 Scoping reviews are useful to identify and analyze knowledge gaps in a given field. They can also report on the types of evidence that address and inform practice in the field and the way the research has been conducted. Reference Munn, Peters and Stern10 For both these reasons, this type of review seemed appropriate for this study.
To report the results of the present scoping review correctly, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist was followed. Reference Tricco, Lillie and Zarin11 The selected papers were assessed using the Critical Appraisal Skills Program (CASP) checklists 12 to screen their methodological quality.
According to the JBI scheme, the research question was first disentangled following the Population/Participants, Interest/Intervention, Comparison/Context, Outcome (PICo) mnemonic structure:
Participants: Emergency rescue and health care organizations working together during a disaster;
Phenomena of Interest: Interorganizational interoperability contributing to DM; and
Context: Health care and multi-organizational systems in any country during a disaster event.
Literature published in English from 2000 through 2020 was collected from the three databases: PubMed (National Center for Biotechnology Information, National Institutes of Health; Bethesda, Maryland USA); Google Scholar (Google Inc.; Mountain View, California USA); and Web of Science (Thomson Reuters; New York, New York USA).
Inclusion criteria were set in accordance with the PICo, including:
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- Studies reporting experiences of health care systems and/or organizations interoperable and exchanging information during a disaster; and
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- All research including also grey literature (eg, non-published research reports), if relevant.
The search was performed systematically following the flow diagram represented in Figure1.
Figure 1. Flow Diagram’s Literature Selection Process.
Abbreviation: WOS, Web of Science.
The search algorithms were developed using the three key concepts “interoperability; multi-organizational; disaster medicine” translated into different possible search and Medical Subject Headings (MeSH) terms.
In order to develop the search algorithms, an initial search in the MeSH database was performed to identify the best search terms and additional MeSH terms. A first search in the different databases with the identified algorithms was performed on March 9, 2020 and an additional hand search based on the article’s reference lists was performed on October 29, 2020.
The screening process was done to discard double articles, and according to title and abstract, adherence to the subject and on full-text eligibility. The methodological quality was assessed using the CASP checklist (Table 1, Table 2, and Table 3).
Table 1. Checklist Systematic Review Assessment Results
Note:
Table 2. Checklist Systematic Review Assessment Results
Note:
Table 3. Checklist Qualitative Studies Assessment Results
Note:
The articles were also rated with a zero-to-one score (Table 1, Table 2, and Table 3), taking into consideration if the findings can be transferred to other populations or uses, the study contributes to current knowledge, and if new study areas are identified.
Data were extracted from papers summarizing the relevant information such as phenomena of interest, method/design, participants, author conclusions, and major concepts relevant for the search. This process allowed the reviewers to identify and synthetize the key features of each paper.
All phases of the study were performed by the first author with regular consultations with the second author.
Discussion
From an original total of 2,149 articles, 12 were included. Two of those articles were systematic reviews. The remaining studies included one qualitative study and nine scenario-based studies supported by literature review.
The analysis of the literature showed two complementary, and sometimes opposite, concepts of interoperability: technological interoperability versus personnel interoperability.
This clear distinction is the direct consequence of the human-to-computer (technology component) and human-to-human (personnel component) interactions influencing the interoperability over the DM process.
Moreover, the interoperability needs to support situational awareness, resource allocation, and stakeholder information. Reference Marres, Taal, Bemelman, Bouman and Leenen13
All the studies were consistent that the core problem of multi-organizational DM is an ineffective integration of different systems. The medical, fire, and police departments; civil protection; international teams (eg, foreign medical teams); together with the government chain of command, all have their own systems and these systems are (sometimes) not well interconnected.
Technological Interoperability
Human-to-human communication includes face-to-face communication, wireline and wireless telephones, and computers while human-to-computer interaction includes databases, modelling and simulation technologies, computer assistance, alarms, security systems, and monitoring technologies such as cameras, satellite systems, robotics, and broadcast and print media. Reference Sagun, Bouchlaghem and Anumba6
The technological solutions affecting the interoperability are heterogenous, for example triage by laser scan codes, Global Positioning Systems (GPS), geographic information systems, and Personal Digital Assistants (PDA), to name a few. The wireless solutions are reported to integrate clinical data to other organizations data (rescuers but also administrative, logistic, and financial systems), mobile technologies to alert people (sending individual messages to mobile telephones), and to provide effective two-way communication during relief activities. Reference Marres, Taal, Bemelman, Bouman and Leenen13–Reference Van der Togt, Beinat, Zlatanova and Scholten15
These technologies have applications also in terms of enhancing mass-casualty field care, provider safety, field incident command, resource management, informatics support, and regional emergency department and hospital care of disaster victims. Reference Chan, Killeen, Griswold and Lenert14
The Information and Communication Technology (ICT) focusing on enhancing interoperability is particularly relevant for health staff that should take trainings, compare means of communications, and share protocols with others emergency agencies.
Technology can be also very handy as the case of a dedicated software that provides a system for early, unique registration of victims in the impact site. In this case, the online application is used by the different chains and systems in the disaster relief phase, promotes interoperability, and patient tracking and tracing. It offers a real-time overview of victims to all involved disaster relief partners, which is necessary to generate an adequate disaster response. Reference Marres, Taal, Bemelman, Bouman and Leenen13
It’s important to stress that the information systems which are used with the purpose to support processes during disasters must resemble information systems which are used in daily situations. For the users, it is very hard to switch to other systems when a disaster occurs, especially if not used routinely, and in a moment when they must work under high pressure. Reference Van der Togt, Beinat, Zlatanova and Scholten15
A common belief is that the lack of coordination and communication is linked to technical problems, but even if this sometimes is true, this axiom is not always confirmed. For example, some authors have noticed that information challenges and the lack of communication between the field and the operation center may be due to inaccurate, incomplete, or too much information, which causes, in some cases, delays in decision making as well as insufficient information. Reference McEntire16
A compromise on “human versus technology interoperability” is found with the Intelligent Disaster Collaboration System (IDCS) that aims to support and enhance the collaboration process and information flow during DM, Reference Sagun, Bouchlaghem and Anumba6 and in some way, to fill the gap among the two components.
The IDCS concentrates on three main types of collaboration: collaboration of tools for detection; collaboration in decision making; and collaboration of resources for implementation. Reference Sagun, Bouchlaghem and Anumba6
The ICT tools used in the DM process are declined in an IDCS as a conceptual model for integrating ICT tools into the DM process and improving data interface and collaboration. The IDCS presents a bottom-up approach that can also enable international collaboration if applied by different countries. Reference Sagun, Bouchlaghem and Anumba6
In particular, the presence of suitable data filtering networks offers a means of minimizing common problems with information flow during the DM process. Reference Sagun, Bouchlaghem and Anumba6 The filtering process gives the opportunity to categorize the information as clear or unclear and can ease the decision-making process because reliable information is highlighted Reference Sagun, Bouchlaghem and Anumba6 and the ICT can work properly.
Five critical information categories when receiving and sharing the information were formulated by some authors: incident data, mission status, area status, safety at work, and tactics. It is also highlighted the importance of focusing to essential information needs to obtain and maintain situational awareness. Reference Norri-Sederholm, Paakkonen, Kurola and Saranto17
In addition to ICT, Health Information Technology (HIT) standards address the challenge of integrating information from disparate health care resources (eg, devices, people, and information systems) to support not only the effective handling of emergencies, but also their analysis for long-term resource planning. Reference Chronaki, Kontogiannis, Panagopoulos, Vourvahakis, Koutentaki-Mountraki and Katehakis18
The cooperative use of interoperability standards in HIT are investigated from the Health Level Seven (HL7; Ann Arbor, Michigan USA), the Organization for the Advancement of Structured Information Standards (OASIS; Burlington, Massachusetts USA), and the European Committee for Standardization (CEN; Brussels, Belgium) to harness the power of ICT in emergency preparedness and response. Reference Chronaki, Kontogiannis, Panagopoulos, Vourvahakis, Koutentaki-Mountraki and Katehakis18
While recent advances in information technologies have contributed to enhancing interorganizational collaboration by offering “electronic bridges” and creating “virtual teams,” Reference Reeves, Lewin, Espin and Zwarenstein19 the use of this technology does not always meet the health care professionals’ needs, nor it is considered an effective tool for their specific environment. Reference Karam, Brault, Van Durme and Macq20
Personnel Interoperability
The importance for interoperability is not fully understood by today’s crisis managers. While most grasp the necessity for technological systems interoperability, there is insufficient appreciation of interoperable organizations and personnel. Reference Kevin, Bergethon and Reimer21
Several studies highlighted that the hurdles of interoperability in emergency services and in the humanitarian sector are influenced by the human factor such as lack of trust and competition for funds. Reference House, Power and Alison22 Actually, many government funds are in competition with each other and hinder the establishment of essential relationships to interoperability. Reference Kevin, Bergethon and Reimer21
Interoperable networks are very demanding in terms of collaboration and individual teams tend to focus on agency-specific behaviors (following instructions, guidelines, and protocols) as opposed to coordinated multi-team functioning and, as a consequence, collective interoperability is not achieved. Reference House, Power and Alison22
This factor can be decisive in the health sector, particularly characterized by protocols and hierarchies. The hierarchical command structure may inhibit effective decision making when the global structure requiring interoperability is based on single multi-agency hierarchical systems and the accountability chain often is not clear. Reference House, Power and Alison22
The interoperability challenge is partially achieved when considering the processes and procedures used in the Urban Search and Rescue (USAR) community as tools to improve the operation of humanitarian logistic and interoperability among agencies. Reference Tatham and Spens23,24
The general approach adopted in Foreign Medical Team guidelines deliberately mirrors the International Search and Rescue Advisory Group (INSARAG; Geneva, Switzerland) model to reach a culture of interoperability. Reference Tatham and Spens23
Other elements that can enhance the culture of personnel interoperability are training and educational programs. The training process should include evaluation of thinking systems, mental modeling, and symmetry learning as integral components for any proposed interoperability training process. Reference Kevin, Bergethon and Reimer21 It is introduced the concept of “All Disciplines” trainings (administration, finance, and managerial positions) Reference Kevin, Hallock and Bergethon25 because the joint participation to trainings and drills will enable the management’s organizations to understand the most complex mechanisms of interdisciplinarity and they will facilitate the process to create an interoperable system.
As mentioned, the trainings and drills need to involve all the sectors participating to DM such as managers, liaison officers, health care, and rescue staff. The research centers and universities should be involved to constitute a global grid platform to learn from other countries and to introduce new technologies. Reference Power26 This concept of joint training can, therefore, encourage the creation of new mental patterns and an interoperable language that does not require translation among agencies. Reference Power26 The direct consequence is to create interoperable language and interoperable personnel. Reference Kevin, Hallock and Bergethon25 Training should also encompass all aspects of crisis planning, response, recovery, and mitigation. Reference Tierney27
Due to the emergency team’s tendency to form rapidly during disasters and the involvement of multiple layers of organizations and individuals who are unfamiliar to each other, it is argued that research should primarily focus on identifying solutions to facilitate the team processes that happen during task-related teamwork (eg, an emergency incident). Reference Power26 Team processes enable team members to achieve collective goals by structuring task-relevant behavior, namely: coordination, communication, and cooperation. Reference Power26
To achieve the correct balance between technology and personnel interoperability, training designed to facilitate multi-disciplinary cooperation and trust among organizations would be desirable. A positive example on how team training has progressed in recent years is the UK’s Joint Emergency Services Interoperability Program (JESIP), whose goal was to enhance interoperability among emergency services. Reference Alison, Power, Van den Heuvel and Waring28 They ran a series of multi-agency classroom-based training days, which brought commanders from the emergency services together to run through incidents and discuss the roles and capabilities of different agencies with the aim to develop an interoperable language. Reference Power26
Another human-focused solution to ensure a smooth team network and interoperability is via the use of liaison officers: individuals who are responsible for coordinating information and actions during an emergency and who are trained to understand the roles in different emergency teams. Reference Power26 The use of liaison officers removes the need for other team members to fully understand the team structure as they can rely on liaison officers to provide and share relevant information to the right person. Liaison officers can offer a non-technological solution to team processing and multi-agency coordination Reference Power26 because they are a key enabler in fostering functional linkages that are required to gain situation awareness of complex, multi-faceted events. Reference Harrald29,Reference McGuire and Silvia30
Limitations and Strengths
The limit of this study was that since the theme of interoperability during a disaster has not yet been effectively considered, wide-ranging research of the literature was chosen, including, when necessary, grey literature. This approach has increased the number of articles available, but the studies under consideration do not have a homogeneous quality and strength.
The strength of this study was to take into consideration the two mentioned aspects (technology and personnel interoperability) and to bridge to the hypothesis for hybrid solutions, keeping into consideration both the need for technology and the presence of an interoperable language for all front-line actors involved in a disaster.
Conclusion
In this study, specific problems and solutions were found regarding the technological and personnel interoperability, such as ineffective integration and data filtering networks, technical problems, and lack of an interoperability language.
This study identified two main approaches during disasters: technology versus personnel interoperability. The suggested approach is to develop a hybrid culture of interoperability through compatible technological solutions combined to joint and multi-disciplinary trainings to achieve the development of a common language.
Further research will need a purposeful approach on the culture and language of interoperability as thematic gathering training, socio-technical networks, and policies/procedural guidelines.
Conflicts of interest/funding
The authors have no conflicts of interest to declare.
Acknowledgments
To all staff of European Master in Disaster Medicine (EMDM), as this work is the result of a thesis submitted in partial fulfillment of requirements for the Master’s degree of the EMDM.
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