Original Research
Moving Toward a Universal Digital Era in Mass
Casualty Incidents and Disasters:
Emergency Personnel’s Perspective in Romania
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Adrian Stănescu, MD,1 Peter Eliot Gordon, MD,2
Sanda Maria Copotoiu, MD, PhD,3,4
and Cristian Marius Boeriu, MD, PhD5,6
1
Department of Radiology and Medical Imaging, Tı^rgu Muresx
Emergency Clinical County Hospital, Tı^rgu Muresx, Romania.
2 Conclusions: Professionals support the implementation of an
Department of Emergency Medicine, Albany Medical Center,
Albany, New York.
3
Department of Anesthesia and Intensive Care, Tı^rgu Muresx
Emergency Clinical County Hospital, Tı^rgu Muresx, Romania.
4
Department of Anesthesia and Intensive Care, University of
Medicine and Pharmacy of Tı^rgu Muresx, Tı^rgu Muresx, Romania.
5
Department of Emergency Medicine, Tı^rgu Muresx Emergency
Clinical County Hospital, Tı^rgu Muresx, Romania.
6
Department of Anesthesia and Intensive Care 2 and Emergency
Medicine, University of Medicine and Pharmacy of Tı^rgu Muresx,
Romania.
Abstract
Background: Despite a recognized need for improved com-
munications and logistics in high acuity situations, the in-
tegration of telemedicine services into the mainstream health
services has been difficult. This study reports on the opinions
of Romanian professional responders to mass casualty inci-
dents and disasters regarding the use and requirements of
specific electronic medical documentation solutions.
Materials and Methods: Doctors, nurses, paramedics, and
fire department officers participated in a customized online
structured questionnaire. To assess factors associated with
the current use of information technology and the willingness
to adopt an exclusive optimized electronic system, a multi-
variate analysis was performed. Logistic regression was used
for free input key elements regarding the most useful tech-
nical and operative improvements and medical documenta-
tion solutions for large-scale events.
Results: A total of 536 respondents provided answers between
the second half of the year 2014 and the first half of the year 2015.
Doctors and nurses were the most frequent users of documenta-
tion techniques, especially if they were employed at a high-level
emergency care center. Professionals’ duties were perceived as
increasingly impaired by the use of current electronic systems as
DOI: 10.1089/tmj.2017.0037 ª M A R Y A N N L I E B E R T , I N C .  VOL. 24
those duties became more complex. All respondents favored an
optimized large-scale event electronic solution, emphasizing the
need for enhanced communications, technical equipment, co-
operation, and workflow mainly by integrating mobile devices,
dedicated software, remote databases, and interlink capabilities.
integrated electronic system for large-scale events if outlined
requirements are met to maximize user acceptance.
Keywords: mass casualty incident, disaster, opinion, elec-
tronic documentation, telemedicine, digital
Introduction
T
elemedicine has proven to be not only a valid alter-
native within the classical healthcare process, but
also a supplementary tool, providing features and
benefits that would otherwise be unavailable locally.
This makes it useful not only for underserved geographical
areas, but also for critical cases where time is of the essence.
Acting as a force multiplier, telemedicine can address com-
plex issues independent of location by interlinking medicine,
public health authorities, civil services, as well as remote ex-
pertise, to assist overwhelmed local resources. Its application
has been demonstrated to be appropriate for real and simulated
mass casualty incidents and disaster (MCI-Ds) scenarios.1–3
Improvements in patient triage, monitoring, medical man-
agement, remote medical assistance, and disaster recovery
support are undeniable benefits in stressful situations, con-
tributing to a structured approach in event management.4–6
In large-scale events, the visual representation of unfolding
processes by using object-oriented modeling tools may opti-
mize medical and operational workflows. Using a field elec-
tronic medical record system makes conventional paper
methods obsolete provided the case that there are no signifi-
cant technological challenges.7 Victim tracking and status
evaluation are significantly improved, while documentation
standards are enhanced.4,7,8
Despite the potential benefit, telemedicine has not met ex-
pectations in terms of in-the-field application.9 Although there
is an acute need to establish telemedicine programs in high-risk
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STANESCU ET AL.

areas,10 acceptance has been slow within the mainstream health
services. This is true despite the fact that its perceived useful-
ness ought to impact the behavioral intention to use it.11 Cited
reasons for unsuccessful deployment of telemedicine refer
mainly to technology, regulations, and licensing and costs, but
there are also concerns regarding physician buy-in and patient
acceptance. This brings up controversies since patients, medical
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nonprofit organization in Romania provided participation
instructions. All participants were informed of their right to
opt out of the study at any time of their choosing. We obtained
approval for the overall project, including the current study,
from the Institutional Review Board of the host institution, the
Tı̂rgu Muresx Emergency Clinical County Hospital.

staff, hospital executives, and cultural issues are also cited not
INQUIRY PROCESS
to interfere with its implementation.12,13
Program enrollment was based upon personal credentials,
Given the diversity of telemedicine solutions that may be ap-
including the participants’ name, e-mail address, agency,
plied in MCI-Ds settings, as well as the multitude of factors hin-
geographical origin, and other specific information requested
dering their application, it is reasonable to investigate factors
by the organizers. The e-mail address was used as a username
impacting variations in clinical acceptance, expansion, and
for all online instructional support. Participants also gave
sustainability.13,14 Before implementing such systems, it is worth
their consent for using the registration credentials for the
investing in studies attempting to identify predictors of success or
purposes of the program, including the current study.
failure to modify their influence.15 Stakeholder participation,
A master questionnaire was developed addressing specific
particularly clinicians, early in the design process is a key element
aspects of large-scale events, interventions, as well as targeted
for success, while pilot projects should be designed with a max-
questions regarding the use of information technology in these
imum degree of integration into the existing care system.9,16–18
settings. The current study refers exclusively to the latter.
Over the last 10 years, the Romanian Ministry of Health has
The survey was implemented by using a dedicated Web-based
implemented various telemedicine initiatives designed to
application, connected to a secured database, which sent e-mail
improve specialist care in distant emergency medical centers
invitations to all trained participants, and collected individual
as well as in prehospital settings for individual selected cases.
responses. An alphanumeric unique identifier was assigned to
The current study reports on the topic of emergency person-
each subject and included in the survey URL. The researchers
nel familiarity and acceptance of electronic documentation
were blinded to personal credentials, exposing only the pro-
methods and their opinions regarding a prospective tele-
fession of the subject (doctor, nurse, paramedic, or officer). This
medicine solution proposed for the MCI-D setting in Romania.
was done for response tracking purposes to maximize response
These results can be extrapolated and integrated across the
rate by reissuing e-mail invitations in case no response was
region and Europe as well as other locations worldwide.
obtained for a certain period of time. This timeframe was set to a
week. In total, a particular subject would receive three e-mail
Materials and Methods invitations at most should no response be received.
This study is a part of a larger research project that aims to
The first invitations were sent in early 2014 and the initial
develop a customized telemedicine solution for MCI-Ds rescue
assumption was that by the end of that year the data collection
efforts as an extension of current emergency management
process would be concluded due to the absence of new input.
operations. The first phase of the project consists of inquiring
However, survey responses continued to arrive through early
upon current procedures followed by inviting study partici-
2015 when the process was terminated.
pants to point out specific requirements and features of a
future system that they would regard as beneficial to their
work and agree to utilize. The study methodology utilized in SURVEY
this study is based on similar work.19 The questionnaire included nine questions regarding partic-
ipants’ demographics, their past participation in a real MCI-D
SELECTION CRITERIA setting, the general utilization of information technology at
The current study recruited all participants to a nationwide their specific workplace, and particularly in an MCI-D setting.
comprehensive MCI-D training course, which took part for the Assessment of a subjects’ opinion regarding a certain topic in-
second half of the year 2013. Each week-long training session cluded the use of a 5-point Likert scale with the exception of a
included doctors, nurses, paramedics, and fire department single three options staged question regarding the exclusive use
officers. Participation was not mandatory but based on an of an electronic data documentation solution. We inquired on
informed opt-in process before the beginning of the program. each participant’s opinion on the implementation of new tech-
Experienced specialists from the largest emergency situations nical or operative solutions as well as their opinion on the best

2 TELEMEDICINE and e-HEALTH A P R I L 2 0 1 8 ª MARY ANN LIEBERT, INC.

 DIGITAL MCI AND DISASTERS: A ROMANIAN PERSPECTIVE

tions where the subject’s opinion was assessed, the ANOVA

Table 1. Study Questionnaire Used
QUESTIONS
Q1. What is your age?
Q2. What is your gender?
Q3. Did you take part in a real mass casualty
incident or disaster rescue effort?
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test to compare differences in age groups, and Pearson’s chi-
ANSWERS squared test or Fisher’s exact test for categorical variables as
Numeric input appropriate. Free text responses were parsed to establish key
Male or female words and concepts provided by responders, which were later on
made subject to logistic regression to identify possible differ-
Yes, simulation only
ences between groups. Statistical significance threshold was set

to a p-value of 0.05. All statistical computations were performed

Q4. What would be the most useful technical Free text
or operative improvements when participating using STATA/MP 14.1 by StataCorp LLC (College Station, TX).
in an event of this type?

Q5. Are you required to use electronic patient Yes or no

Results
data input solutions (by means of computers/ The training program enlisted 1,380 professionals by the
smartphones/tablets) at your workplace? end of all sessions, consisting of 305 doctors, 383 nurses, 562
Q6. To what extend do you consider such an Not at all, somewhat, paramedics, and 130 fire department officers.
obligation hinders your duties? average, a lot, excessively
RESPONSE AQUISITION
Q7. Presuming a complete electronic data input Yes or no
solution would be easy to use (similar to paper During the e-mail invitation process, 122 invalid e-mails
forms), would you agree to use it? (8.8%) were identified. As a result, only 1,258 professionals were
Q8. What effect do you consider an exclusively Leverage, similar, successfully notified of their invitation to the study. The study
electronic data input solution would have or slow down links were accessed by 722 subjects and valid responses were
on your duties? obtained from 536 of them, averaging a 42.6% response rate.
Q9. What patient medical data documentation Free text
solution do you think would be best in terms DEMOGRAPHIC ANALYSIS
of ease of use and offered benefits? The responders were generally young, with a median age of
35 years (30–39 years old interquartile range). Male and fe-
male ratios differ significantly ( p < 0.001) between doctors
practice for patient data documentation in an MCI-D setting by and nurses on one side, which are formed roughly of 2/5 males
allowing free text inputs. The questionnaire is shown in Table 1. and 3/5 females, as opposed to paramedics and officers, where
males make up more than 90% of these groups (Table 2).
STATISTICAL ANALYSIS We observed a significant difference regarding the origin of
We first performed the descriptive analysis of the demo- professionals by the presence of a medical university and/or a
graphic data to describe the population characteristics. The county aeromedical service and/or dedicated disaster resources
chi-squared test for independence was used when examining in the subject’s county—hereinafter referring to such origins as
differences between response behaviors among subject groups. High-Level Emergency Care Centers (HLECCs). Doctors (81.2%)
We used the Mann–Whitney U or the Kruskal–Wallis test of and nurses (78.1%) came more frequently from such centers
variance to compare differences between groups for the ques- than paramedics (68.5%) and officers (45.1%) ( p < 0.001).

Table 2. Demographics of Study Respondents

MEDIAN (YEARS) IQR (YEARS) PROPORTION (%)
PROFESSIONAL
GROUP MALE FEMALE ALL MALE FEMALE ALL MALE FEMALE
Doctors 36 35 35 31–43 31–40 31–40 37.2 62.8

Nurses 35 37 37 31–41 33–41 32–41 39.5 60.5

Paramedics 32 37 32 29–36 34–42 29–37 95.4 4.6

Officers 36 41 37 29–40 38–46 30–41 91.4 8.6

All 34 37 35 30–38 32–41 30–39 66.2 33.8

IQR, interquartile range.

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STANESCU ET AL.

independent factors for either

groups. However, HLECCs ac-
count for a significant difference
between AMC and RMC groups
( p < 0.001)—as shown in Figure 1.
Figure 2 illustrates the Likert
item response distribution for the
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question regarding the hindering

effect of responders’ duties when
required to use an electronic data
documentation system. For the
Likert item point range from 1 (no
hindering) to 5 (extreme hinder-
ing), doctors scored a mean of
2.7 (95% confidence interval [CI]
2.5–3.0), nurses scored a mean of
2.3 (95% CI 2.1–2.6), paramedics
Fig. 1. Current usage of an electronic data documentation system by survey groups. had a mean of 1.8 (95% CI 1.6–
2.0), and officers had a mean of
RESPONSE ANALYSIS 2.0 (95% CI 1.7–2.4), the differences being statistically sig-
Given the differences in their training, when appropriate we nificant ( p < 0.001).
will refer to doctors and nurses as an advanced medical care All respondents, independent of their professional roles,
(AMC) group and to paramedics and fire department officers were found to be in favor of using an electronic solution for
as a restricted medical care (RMC) group. MCI-Ds should its employment be convenient, averaging a
All professional groups reported on an electronic patient 94.1% agreement (95% CI 92.1–96.1%)—Figure 3. There is a
data documentation system already in use for their daily ac- significant shift toward less positive answers regarding its
tivities; however, AMC group subjects had a statistically sig- adoption as respondents report being hindered from their
nificant higher ratio of its use compared with the RMC group duties by current electronic solutions, with a drop from 100%
subjects ( p < 0.001). Age and gender were not identified as to just over 60% ( p < 0.001)—illustrated in Figure 4. Age
and HLECCs did not account for
any other significance; however,
males are slightly more moti-
vated than females (mean 96.3%
vs. 89.9%, p = 0.003). Simulation
versus real events experience had
no impact upon any of the ex-
amined topics.
When questioned on the pros-
pect of an exclusive electronic
data documentation MCI-D solu-
tion, a large majority of respon-
dents considered this would have
a beneficial effect, with signif-
icant differences between AMC
and RMC groups ( p = 0.046) as
depicted in Figure 5. Factors hav-
ing a positive impact on respon-
Fig. 2. Hindering effect of current electronic solutions when required to use an electronic data dents’ opinion of an electronic data
documentation system by survey groups. documentation MCI-D solution

4 TELEMEDICINE and e-HEALTH A P R I L 2 0 1 8 ª MARY ANN LIEBERT, INC.

 DIGITAL MCI AND DISASTERS: A ROMANIAN PERSPECTIVE

FREE INPUT ANALYSIS

Free text input to express
potentially useful technical and
operative improvements of an
MCI-D intervention was provided
by 266 responders (71 doctors, 53
nurses, 101 paramedics, and 41
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officers), averaging a 49.63% in-

put rate while collecting 434 in-
put elements.
The majority of collected ele-
ments were of operative nature,
demonstrating strategies and in-
direct technical necessities, dou-
bled later on by specific technical
elements. Communication opti-
mization under all of its aspects—
Fig. 3. Willingness of using a convenient electronic data documentation system for MCI-Ds by employed technical devices as
survey groups. MCI-Ds, mass casualty incidents and disaster. well as their applied operation—
was the dominant topic (36.18%
were the current use of electronic data documentation by input rate) outlined by all groups, paramedics having a sta-
doctors ( p = 0.011), nurses ( p = 0.042), officers ( p = 0.028), tistically significant lead on the subject relative to other re-
but not paramedics ( p = 0.476), and by males ( p = 0.035), sponders ( p = 0.007).
but not females ( p = 0.074). It was also noted that the per- Detailed aspects of communication improvements were
ception of being hindered by current electronic solutions identified (in descending order of their average input rates): in-
inhibits the positive effect of an exclusive electronic solu- creased interagency communication flow (11.52%), optimized
tion for all professional categories ( p < 0.001), except offi- coordination within the same agency and improved dynamic
cers, as does withholding to use an electronic input system command structure (7.14%), extended information regarding
( p < 0.001). the event scene (13.23%), increased information/time density
and real-time traffic (2.07%), role-
centered filtered communication
(1.84%), standardized commu-
nication procedures (1.38%), and
enhanced knowledge of assigned
resources whereabouts (0.69%).
The remaining operative elements
refer to the need of more fre-
quent unannounced MCI-D sim-
ulations with realistic scenarios
(5.76%), improved customization
with MCI-D intervention proce-
dures (5.76%), and the need to
implement an objective debrief-
ing solution (0.69%).
The most cited technical
topic is the need for individu-
ally assigned communication
Fig. 4. Hindering effect of current electronic solutions over willingness of using a convenient devices—paramedics advocating
electronic data documentation system for MCI-Ds. the most once again ( p = 0.013).

ª M A R Y A N N L I E B E R T , I N C .  VOL. 24 NO. 4  APRIL 2018 TELEMEDICINE and e-HEALTH 5

 
STANESCU ET AL.

for the unfolding event (1.84%),

(6) the deployment of an MCI-
D integrated electronic system
(0.69%), deployment of mobile
devices (0.69%), (7) use of data
and video broadcast features
(1.38%), (8) use of interactive
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maps and GPS localization fea-

tures (0.92%), (9) on site and in-
traffic Internet access (0.23%),
and (10) devices interoperabil-
ity (0.23%). All input rates are
homogeneous among responder
groups, without statistically sig-
nificant differences apart from
the specified exceptions. All tech-
nical and operative input rates
Fig. 5. Perceived effect of using an exclusive data input solution for MCI-Ds over professional duties are illustrated in Figure 6.
by survey groups. In the matter of medical data
documentation, 522 input elements
The technical elements include (1) improved communication were obtained from 295 responders (86 doctors, 61 nurses, 108
quality and decreased error rates (3.92%), (2) increased wire- paramedics, and 40 officers), averaging a 55.04% response rate.
less carrier coverage (4.15%), (3) increased use of radio devices The largest proportion of inputs pointed to an electronic
(2.3%), (4) individually assigned hands-free devices (2.07%), medical data documentation solution with a highly significant
(5) the need for a dedicated radio frequency or data channel 36.78% leading average input rate as opposed to an exclusive

Fig. 6. Input rates for the most useful technical and operative MCI-D improvements.

6 TELEMEDICINE and e-HEALTH A P R I L 2 0 1 8 ª MARY ANN LIEBERT, INC.

 DIGITAL MCI AND DISASTERS: A ROMANIAN PERSPECTIVE
paper-based solution (2.3%) or to a dual electronic and paper-
based solution (3.45%)—p < 0.001. For this last option, all but
two elements were in favor of digitizing a previously hand-
written medical chart versus a simultaneous paper and elec-
tronic documentation effort. The responder groups did not
show any statistically significant differences among input
rates ( p = 0.176).
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In functional terms, responders requested (in descending
order of their average input rates): remote access to the patient
medical history (12.45%) and dedicated staff for the docu-
mentation effort (4.21%)—where the AMC group had a signif-
icant higher demand than the RMC group ( p < 0.001). In
anticipation of future use of a dedicated electronic solution,
responders asked for an easy-to-use application interface
(4.79%), interagency software interfacing (4.6%), location-
independent access to collected data (4.21%), real-time data
visualization among all users (4.02%), MCI-D chart data fields
essentialization (2.11%), standardized medical forms (1.92%),
hospital prearrival medical data receival (1.53%), patient data
and user access security (1.34%), documentation redundancies
removal (1.15%), addition of visual, audio, and location data
meta elements (0.77%), role-centered application interface
(0.77%), and real-time event statistics (0.38%). The most re-
Fig. 7. Input rates for MCI-D medical data documentation solutions.
ª M A R Y A N N L I E B E R T , I N C .  VOL. 24
quested technical element was the use of mobile devices
(8.81%), doctors and paramedics having a significant higher
demand than officers and nurses ( p = 0.044). The remaining
two technical elements included dedicated MCI-D software
(3.07%) and patient bracelets with wireless (radio-frequency
identification [RFID], near field communication [NFC]) and/or
optical (barcode or quick response [QR] code) tags (1.34%). All
input rates are also homogeneous among responder groups,
without statistically significant differences apart from the
specified exceptions. All medical data documentation solution
input rates are illustrated in Figure 7. Controlling for age,
gender, and HLECCs did not expose any independent factors for
any free input topic.
Conclusions
The deployment of telemedicine during a mass casualty
incident or disaster is a challenge, not only because of infra-
structure constraints but also because the available solutions
are still immature.14,20
Even if rescue personnel are cited as not being an obstacle
to implementation of telemedicine projects,13 omitting user
design input and user acceptance studies in favor of technical
concerns can be pitfalls destined to negatively impact a
NO. 4  APRIL 2018 TELEMEDICINE and e-HEALTH 7
 
STANESCU ET AL.
project. To conceive a successful and sustainable MCI-D tel-
emedicine project,15 we started by querying professionals on
their perception of current technology in use and then asked
for specific improvements to establish a general model for the
proposed future project.
Among limitations of the current study, we presumed that
age is proportional to professional experience without spe-
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cifically requesting this information. This may not always be
the case, but we assumed those cases to be rare particularly
considering that the study population is young and that
changing professions is infrequent in Romania. We also chose
not to suggest a list of elements to choose from as an alter-
native to free text input in an effort to encourage spontaneous
input and to avoid social desirability bias. Evening out re-
spondent proportions with larger professional population
groups would ideally be preferable, especially given the rel-
atively low input rates we obtained and which we attribute to
sociocultural factors.
We observed that doctors and nurses are required to use some
form of electronic medical data documentation more often than
paramedics and officers, particularly if they originate from a
HLECC. Higher medical expertise generally relates to a per-
ceived increased negative effect of current electronic docu-
mentation solutions on professional duties. The magnitude of
this effect is not negligible, demonstrating that the current setup
does not act as a natural extension to the staff’s medical duties.
Not surprisingly, this leads to a significant drop in enthusiasm
for the implementation of a proposed improved system.
It was generally conceded that enhanced communication
and an exclusive electronic system for MCI-D data docu-
mentation could streamline staff’s duties. Responders focused
mostly on functionalities that may be supported by technol-
ogy, sometimes exclusively, rather than pointing to detailed
technical solutions, which may exceed their competence.
The ideal model centered on responders’ feedback is an up-
dated communication system based on modern devices, de-
signed to facilitate rescue effort interactions, and teamwork
while streamlining workflow, supporting a dynamic command
hierarchy, delivering a larger amount of exact, reliable data
taking advantage of available advanced technical features. In
this regard, it must compensate for technical shortages like the
absence of a wireless carrier signal. It must also be enabled for
simulation and educational purposes. All of these requirements
need to be available in an ergonomic user-friendly package.21
The user interface has to be adapted to role requirements and
demonstrate filtered data. To allow doctors and nurses to per-
form complex and urgent medical maneuvers, where possible,
specially designated operators should provide data input into
the system rather than the healthcare provider.
8 TELEMEDICINE and e-HEALTH A P R I L 2 0 1 8
In setting up a project with the stated specifications it is vital
to ensure organizational and technical integration into existing
services. While pilot projects are critical, switching to main-
stream operations is known to be far from straightforward.9,22
This requires that, in addition to technical aspects and user-
centered design, the implementers of the project have to plan
and budget for user training, protocol development, technical
support, a business model, and supporting policy and legisla-
tion.14 While ensuring system resilience—as an exclusive state
prerogative—is critical for MCI-Ds, the aforementioned com-
plex requirements may set the need to externalize some of the
above services to private contractors. Failure to ensure an
overall coherent working system may lead to rescue interven-
tion collapse, potentially aggravating an unfolding event. We
thus consider there will always be a need for contingency plans.
Finally, we advocate for the development of a user-centered
and user/task-customized telemedicine system for MCI-Ds.
Although this may be difficult in some settings due to previ-
ously initiated projects, model design, and technical changes
incurred later may not only increase expenditures, but also
decrease user perceived usefulness and acceptance, posing a
substantial risk to the overall success of the project.
Acknowledgments
This study was supported by SC Avant Maris Medical SRL
and the University of Medicine and Pharmacy of Tı̂rgu Muresx—
Research Grant No. 15897/10.11.2014.
Disclosure Statement
No competing financial interests exist.
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