PULSE History

Over the past six years, PULSE has evolved into an integral tool for declared disasters and public health emergencies. Looking back on our history of leadership using health information technology in Emergency Response, Audacious Inquiry stands ready to help states respond to these events for the future.

It’s already been one of the most active hurricane seasons on record, which runs from June 1 to November 30, with 23 named storms, including eight hurricanes, spinning across much of the Atlantic basin to date. For perspective, the average formation date of the Atlantic’s 8th named storm is Sept. 24 for the years spanning 1966 to 2009, according to the National Hurricane Center. In addition to battling hurricanes and wildfires, we continue to face the severe challenges of COVID-19, making this a noteworthy time to reflect on the evolution of PULSE and the opportunity to deploy health IT more aggressively in support of emergency response.

Validating the Need with On-The-Ground Experts

In 2014, The Office of the National Coordinator for Health Information Technology (ONC), the federal office within the Department of Health and Human Services (HHS) charged with coordination of nationwide efforts to implement and use the most health information technology (IT), sought to better understand how to leverage health IT to improve the healthcare response during disasters.  They had a keen understanding of the fact that while major investments were being made in interoperability across the country, those investments were not being applied to critical preparedness and response capabilities.  The “sentinel event” that motivated this work was Hurricane Katrina, which made landfall in 2005.  While that national experience amplified the need for better solutions in disaster medicine, we were finally having the discussion about clinical data access nearly nine years later.

Importantly, in the immediate aftermath of Katrina, a national foundation of healthcare stakeholders came together to create a system that would allow licensed healthcare providers to access electronic patient medication histories.  Through this system, known as ICERx, medication records could be retrieved from claims information provided by two large pharmacy benefit managers or from e-prescription data provided by a large, national e-prescribing network. However, it was not a durable solution to remain available into the future.

I distinctly recall the first time I read an HHS Office for Civil Rights bulletin dated September 9, 2005 – it was a jarring call to action. The first paragraph read:

Hundreds of thousands of evacuees from areas affected by Hurricane Katrina have been relocated to shelters across the country.  For many, an important need is to identify and provide prescription medications.  However, medical and prescription records of many evacuees either are lost or inaccessible.

It is important to note that while we interpreted this bulletin as a dire need for solutions to support the preparedness and response community and needs that had gone unmet for nearly 10 years, important foundational interoperability progress was being made. It was the kind of progress central to enabling what would become PULSE.

Under a contract with ONC, Audacious Inquiry (Ai) team members, myself included, traveled throughout California and the Gulf Coast to meet with Emergency Medical Services and disaster response officials. We learned about the nature of their work and where health IT solutions might improve their ability to serve patients more effectively.  Colleagues from ONC, Lee Stevens and Rachel Abbey, participated in these meetings as we learned alongside one another.  As we traveled in California, we were also fortunate to have expert guides from the California Emergency Medical Services Authority (Cal EMSA), including Dan Smiley and Leslie Witten-Rood.

We heard many challenges and good ideas for solutions as we met with state and country-level experts and “on-the-ground” leaders.  They described the importance of day-to-day access to patient information for EMS as well as the broader challenge of treating patients during larger scale disasters where people may be displaced or sheltered away from home for some period.  Hearing the important need to obtain medical histories in real-time to treat patients in medical shelters following disasters, we made recommendations to rely on existing interoperability standards and disaster healthcare volunteer tools to create a solution that enabled medical professionals to have access to clinical histories in alternate care locations.

Applying PULSE for Real-World Use

Following our initial report, the HHS Idea Lab awarded additional funding to ONC to further develop the recommendations therein. We focused on developing a more detailed technical architecture for PULSE. We also partnered with Rim Cothren from the California Association of Health Information Exchanges (CAHIE) to help focus on specific PULSE use cases.

In 2015, CalEMSA pursued and was awarded grant funding from ONC to support the development of the first iteration of PULSE. In partnership with Ai, CalEMSA successfully deployed the first version of PULSE which has been relied upon during multiple wildfire responses. In settings with no access to an electronic health record, such as an alternate care site during emergencies, PULSE has enabled providers to access clinical information in real-time while treating patients.

In 2018, The Sequoia Project, Inc, began collaborating on PULSE initiatives and established the PULSE Advisory Council. Comprised of nationwide representation from state and federal public health and emergency preparedness experts, this body has been valuable in providing guidance on the national-level rollout of PULSE and working closely with states on their planning processes.

PULSE’s National Scalability

In 2019, ONC committed additional funding to help scale PULSE connectivity to national health information networks and develop additional features.  As our team was developing this new version of PULSE, inclusive of the ONC objectives, the COVID pandemic began to unfold.  While PULSE was originally conceived through the lens of earthquake, hurricane, and wildfire scenarios, it was a perfect fit for the evolving crisis we now face. Alternate care facilities were being stood up and epidemiologists were scrambling to access clinical data for case augmentation. The development timeline we were on would not have a production version of PULSE ready until the late summer. Recognizing that timeline was insufficient, our team hustled to develop a lightweight, rapidly deployable solution we call PULSE COVID. While PULSE COVID doesn’t have all the functionality of the full-featured version, it allows clinicians to access information in real-time at the point-of-care and assists public health officials conducting case investigations and contact tracing.  This solution has been successfully contracted in five states and one federal agency to assist with their response. 

Ai has recently launched an advanced version of PULSE, called PULSE Enterprise, a cloud-native, fully hosted and supported solution that includes a series of additional capabilities. For example, PULSE Enterprise offers a consolidated medication view for easier clinical use. Ai will also offer full technical and programmatic support, including access to its 24/7 support desk during emergencies. This solution will allow state and local entities to turn on or “activate” PULSE for use in any declared disaster or public health emergency.

Looking Towards the Future

PULSE is an important tool both now and for future disasters. But, there are many other challenges across the preparedness and response and public health communities that could be improved through health IT solutions. From syndromic surveillance to real-time hospital capacity and resource measurement (see The SANER Project) to family reunification and beyond, closer ties between experts in health IT with peer experts in preparedness and public health communities and a diligent focus on future risks, even when times are smoother sailing, will result in better solutions for future challenges.



Scott Afzal | President
Scott Afzal is the President of Audacious Inquiry and a Strategic Advisor for CRISP, a health information exchange serving Maryland, DC, and West Virginia. Across both roles, Scott establishes organizational growth strategies, delivery system reform initiatives, and technology solutions to support value-based payment models and connected communities. Through Ai, Mr. Afzal advises other states, health systems, and health information organizations on health information exchange (HIE) implementation approaches and sustainability strategy. Previously at CRISP, Mr. Afzal served as the Program Director for the organization’s first 10 years; he managed the roll-out of CRISP’s HIE network while leading the development of new service offerings. Scott is a noted speaker on HIE, having presented at regional and national health IT conferences. Prior to joining Audacious Inquiry, he served as a consultant with Accenture, Inc. out of their New York City office. Mr. Afzal holds a Bachelor of Science in Business Administration (BSBA) from Bucknell University.