Modernizing the Ambulance Service is Less about the Ambulance and More about the Service

When approaching the question of “redesigning the ambulance,” it would be understandable to think about the ambulance itself. Maybe a new vehicle platform is needed, or autonomous vehicles could reduce the burden of the Emergency Medical Service (EMS) team, or maybe an ambulance could be a “mother ship” that engages a broad sensor net that relays heath-related telemetry, then deploys airborne and ground-based drones as the immediate response. These are all interesting ideas, but when our design team first met to discuss this challenge, it was striking how little the conversation was about the ambulance itself, and more about the services that the ambulance is expected to provide.

This line of thinking might seem to diverge from the original problem; however, a conversation about the ultimate purpose of the ambulance, and the obstacles that EMS faces in delivering that service, was perfectly aligned with design thinking, and a digital mind set. By using design-thinking principles, we were able to put the end-user, who is the patient, first. This helped avoid the pitfalls so often encountered when the public sector turns to technology. By considering the patient, we were able to avoid using technology for technology’s sake, and instead, select the technologies that were most appropriate for the problem.

Our team was comprised of three practitioners who are closely involved with EMS — the chief of a city fire department, an emergency manager, and a city police officer. Together, they described a dire situation that was jarring to hear. Together, they described a general state of EMS that was overburdened by non-emergency calls from repeat users, struggled to recruit and retain personnel, could acquire state-of-the-art equipment and training, and were often called to address problems that may have been medical on their face, but belied broader problems that extended beyond their capabilities.

As industrial designer Tom Brown says in Change by Design, “Behaviors are never right or wrong, but they are always meaningful.”[1] These behaviors, many of them troublesome, framed our proposals, which were increasing less about the technologies that are less about the technologies that could be deployed, and more about the people who use them: patents and EMS personnel.

These solutions begin with the journey of the EMS, and the patient. In an era where the population is aging, and general medicine has become scarce, EMS and its

Ambulance services are increasingly burdened with non-emergency calls. The endpoint of some EMS calls is the transport to a hospital emergency room, which also struggles to meet demand as patients overwhelm a finite number of caregivers and space with demands for non-emergency services. This chokepoint would also affect the capacity of EMS, who would have to remain until the emergency room was prepared to administer care.

This journey was consistent with the stories told by the team, who described a consistent issue of capacity and load. Research points to the adverse consequences of load on the EMS system. One paper conducted a study of EMS in Santa Barbara, California, and found that “calls preceded by other calls within 20 km and within the previous hour are significantly more likely to result in violations [slow response times].”[2]

The problem of increased demand faces has been met with an equally troublesome problem of supply. Public services in general, and the EMS in particular, struggle to recruit and retain qualified personnel. Scarcity of revenue stretch EMS resources, which are mostly public enterprises. General medical services are scarce and inefficiently delivered, reducing the baseline heath of the community and making calls for EMS services more likely. Finally, EMS faces physical constraints, such as traffic congestion, which interfere with a rapid response.

The coinciding rises in EMS demand, and decline in EMS capacity, amplify the problem of load. This presents load as the most pressing problem to address in Ambulance services. Time to response is the most critical measurement of performance of EMS, which is strongly correlated with patient survival in emergencies.

Innovators in EMS delivery service have taken novel approaches to the problem of load. In one case, an EMS manager examined ambulance load in a geospatial context. Using heat mapping techniques and predictive analytics, ambulances were pre-deployed to high-demand areas instead of responding from central locations such as firehouses. This technique of “fluid deployment” reduced response times to calls.[3] This positive effect also aggregated, increasing supply (called Unit Hours of Utilization) to better meet demand.

This analysis of data is an excellent example of Delivering Digital’s assertion that data can increase efficiencies in real time through gaining a better sense of where public services are needed.[4] The original use of fluid deployment only used one dataset — from the fire department itself. Through analysis against other datasets that have location parameters, such as traffic information, demographics, weather, and ultimately, sensors, this analysis could be further enriched.

This use of correlation information to yield unexpected trends is explored in Seth Stephens Davidovitz’s Everybody Lies. His research used Google search data to find social trends that, he argues, would not be revealed through traditional data collection methods. This book espouses the four powers of Big Data: offering up new types of data, providing honest data, zooming in on small subsets of people, and allowing

many causal experiments.[5] These potentials are explored in the following study I conducted on the San Francisco Fire Department:

About the Data

This data was downloaded from the data.sf.org website.[6] Taking the data for 2016–2017 yielded aver 500,000 separate calls. Filtering for calls that required advanced live support the following initial trends were found:

Average Time to Respond: 0:08:45

Average Time on Each Call: 0:43:48

Total Calls: 343,203

Responses Greater Than 9 Minutes: 122,372, 36%

These numbers present an early indication that the system has a high load.

Uploading this data into the ARCGis mapping website allowed for more analysis. The calls data also had location information, which allowed for the creation of a heat map, which illustrated the locations where class occurred most often, much like the fluid deployment method. Using Census Department demographics data, I was then able to overlay data that mapped neighborhoods that were most socially vulnerable. Viewing these images together illustrates that many of the EMS hotspots were in socially vulnerable areas — places that were older, more poor, were more violent, and used drugs more than other places in San Francisco.

This analysis speaks to all of the following components of this study. Recognition that certain neighborhoods use EMS more than others can inform how and where those services are provided. Government can deploy detection arrays, such as sensors or more discrete data analysis, to deliver EMS services. Recruitment can be tailored to the communities that are most in need of EMS, and specialized service. Procurement can use this data to pinpoint what technology to acquire.

In the truest spirit of leveling silos, other government agencies can be engaged to delivered more tailored services, such as public health or sanitation services, which will increate the baseline health of troubled neghborhoods, decrease their demand for EMS, and ultimately, reduce the load on the EMS system.

Hacking Hiring and Training

Emergency Medical Services agencies have a huge opportunity to hack hiring and training to deliver better services to the public. EMS teams have largely followed traditional government hiring methods without much thought of leveraging the digital ecosystem that could not only make hiring easier, but also improve EMS services to the public. The following sections provide a glimpse into a few areas where EMS can leverage the power of the digital ecosystem.

Talent

William Eggers, author of Delivering on Digital, discusses how successful organizations are able to offer “the best candidates something beyond compensation and benefits.”[7] The EMS profession is naturally aligned with offering employees something far beyond what compensation provides; EMS work provides the opportunity to help people in need. In fact, the value proposition of EMS services is so powerful that about one third of states use voluntary EMS agencies.[8]

Now imagine the possibilities if EMS agencies looked beyond recruiting drivers and EMT’s alone and hired people with the technological skills to improve services and transform the agency. If a small rural agency was able to attract a volunteer with technology talent, the technologist could help unlock the power of crowdsourcing emergency services apps and link them to their own systems. The possibilities of modern technology are endless, but it takes having employees who understand how to utilize technology to improve services for citizens.

While hiring technologists will help digitize EMS agencies, they also need to think about hiring people from the different silos that are involved in the process. EMS agencies interact with hospitals, medical device makers, drug makers, automobile companies, doctors, nurses, and several other members of society. By employing people from these different silos, EMS agencies would be able to develop better approaches across the spectrum on how to improve services. A quick example may be working with an ambulance manufacturer to include Bluetooth technology that automatically reads a person’s wearable device upon entering the ambulance and providing a visual readout of pertinent information to the EMT.

Retention and Turnover

EMS agencies cannot only focus on hiring, but also need to think about retention. In a field such as emergency services, it is easy to emphasize the value of medical professionals over other members of the team, but it is important to show that the tech geek is an equal member of the team and may even have more opportunity to save lives using technology. EMS agencies need to consider what people want in an employer and understand that younger generations are staying in jobs for shorter periods of time. This may seem like a detriment, but it provides an opportunity to have a steady flow of new ideas and also have more people trained in helping others. The more people who know CPR, the more lives that will be saved.

Diversity and Inclusion

EMS agencies must develop diverse and inclusive environments. EMS agencies serve all members of communities and in order to provide the best care to all members, they must strive to have their own workforce represent the community, are aware of the unique cultural sensitivities of that community, and in some cases, can speak the language commonly used there EMS agencies can hack hiring and training to use digital technologies to focus recruitment efforts or even look for volunteers who may be able to fill certain gaps.

Partnerships and Training

EMS agencies are in a unique position to form partnerships with other organizations. For instance, EMS agencies could serve as a pipeline for nursing schools. The development of tools, methods and databases between these disciplines would greatly enhance the ability to start partnership programs. Another partnership may be an exchange program between technology companies focused on emergency medicine and EMS agencies. Technology companies would be able to get a firsthand look at how EMT’s use their products in the field and could adapt them to better meet the needs of both EMS personnel and patients.

Collaborative technologies could encourage sharing of best practices and offer training videos that could help defray some of the costs of individual training programs. EMS agencies could collaborate with biometric wearable companies to offer services to communities and for EMS agencies to help analyze trends in neighborhoods and tailor care to those neighborhoods.

Digitization of training may take another form as well. There could be assessments of different training programs by comparing vast amounts of data that collected by EMS agencies, but not necessarily put into usable databases. Think of the value of understanding how a certain medical approach helps save more lives that you could then share with other agencies. EMS agencies have worked hard to save lives without knowing whether data supports their decision-making, but that can all change.

Reserve Corps

EMS agencies are in a unique position to develop a reserve corps. that they could activate in a time of need. A reserve corps of former EMS personnel could receive notifications to their smartphones of an emergency that required additional personnel, or could be “surged” in advance to meet the needs of a large-scale public event.. The possibilities are endless!

Hacking hiring and training is not a difficult task, but it does necessitate having a better understanding of how technology can improve current processes for both employees and customers. One suggestion for agencies would be to develop their own digital playbook on how they can remake their hiring and training processes. The US Digital Services’ Playbook, https://playbook.cio.gov, offers an example of processes to follow in deploying new technology in the government that can be adapted to the EMS world. The most important recommendation for hacking hiring and training is to for agencies to build an innovative culture where leadership encourages new ideas and focuses on improving services for the user.

Ambulance: Emerging Technologies to Improve Healthcare Delivery

Emerging technologiespenetrate the healthcare environment gradually. New equipment and technologies are being introduced to medicine sto improve the delivery of services, increase productivity and efficiency, as well as provide more holistic and timely care.[9] The digital mindset has also affected the current ambulance services, inducing healthcare providers to invest in advanced technologies. Innovative use of technology includes automated ambulances, telemedicine, and wireless devices for monitoring patients’ condition. These technologies have changed the face of the ambulance services and set high standards for all providers.[10] They bring immense opportunities, and although their introduction may be faced with skepticism due to the high cost and associated technical issues, it is evident that they will gradually replace outdated and inefficient services and technologies.

Current Ambulance Services: Processes and Challenges

Current ambulance services work according to the standard scheme. All 911 calls are made to a public safety answering point, where a call taker performs triage/medical priority screening and decides on the solution. In some cases, immediate instructions are given to the patient until the medical team reaches the place. The dispatcher receives call information using the computer aided dispatch system (CAD) and assigns a basic or advanced life support ambulance depending on the client’s needs. Then, the ambulance is sent to the location with CAD data, and the medical team performs the standard assessment (interview, triage, stabilization, etc.).

The problem is that people abuse ambulance services for non-emergency needs, for example, when they do not have a medication or need help with a chronic issue. These calls strain the capacity of the ambulance service, and leave them less able to respond to critical conditions. Available units sometimes cannot meet all the requirements, which puts clients in danger or makes hospital ERs overloaded.[11] Given these challenges, new technologies should be introduced that would lower the burden on EMTs and hospitals and make healthcare delivery more efficient.

New Technologies to Transform the Ambulance Space

With so many promising technologies and devices in place, we can transform everything we know about the ambulance services and make them more effective, cost-efficient, and client-friendly. Scientists have recently presented the idea of driverless ambulances — it is believed that these vehicles could help EMT teams to focus on the patient rather than driving and help avoid situations when drivers get lost and cannot take the patient to the hospital quickly.[12] Although the initial cost of these advanced ambulances can be high, hospitals can save the expense drivers, who are not directly engage with the patient during transport.

Another innovative approach to the delivery of ambulance services involves the principle of shared economy, which implies active cooperation of resources (human, financial, etc.) to address some pressing issues.[13] The sharing economy can help optimize intellectual, human, and physical assets and combine them with technological capacity to enhance healthcare delivery services.[14] For example, many enthusiasts have recently argued that the use of Uber-like ambulances could help address rising demand for EMS. SUVs can be equipped to provide on-demand services or help clients reach the hospital quicker.[15] Regular citizens can respond to non-critical calls, thus lowering the burden on paramedics. This sharing principle could extend to the endpoint of this service, where spare rooms could be used for hospital services, thereby reducing the current problem of emergency room overload.[16]

Several other technological know-hows can make medical services more sophisticated and efficient. For instance, various augmented reality apps can help citizens find defibrillators or clinics nearby or even help paramedics scan patients to perform life-saving procedures.[17] Remote diagnostics could also be of much help to paramedics and dispatchers, as it provides an opportunity to assess the patient’s condition quickly and decide on the most suitable response. Finally, healthcare providers can use wireless telemetry devices, which have already been approved by the U.S. Food and Drug Administration.[18] These devices allow monitoring patient physiological parameters from a distance, thus saving vital human and financial resources of the hospitals. In general, while some of the mentioned innovations still seem too unrealistic, some of them may change the way ambulance services are currently delivered.

A Plan to Transform the Ambulance Services

Based on the existing opportunities and outlined challenges, we suggest considering a plan for transforming local ambulance services in Philadelphia. To begin with, healthcare providers need to introduce autonomous ambulances to allocate human resources more effectively. Instead of finding and retaining qualified and experienced drivers, hospitals could invest in driverless vehicles with only EMTs on board, which could become cost-effective in the long run. Naturally, the implementation of this ambitious project should be preceded by the preliminary research and project evaluation to determine potential risks, infrastructural limitations, patients’ response, legal implications, and many other aspects.[19]

Negotiating data sharing systems to connect EMRs and response would also be the right decision given the current slow and inefficient transmission of data.[20] Not only medical data can be shared but also information on traffic to avoid unnecessary delays. Finally, it is suggested to adopt cheap wearable health data collectors for those who opt-in. These wireless telemetry devices can monitor the condition of chronically ill patients, thus allowing healthcare providers to allocate resources according to the emerging needs. It would be possible to incorporate this data with the rest to identify areas for community (but provider-subsidized) mobile clinics to visit. Over time, this approach can help provide more timely and holistic care to eliminate chronic-issue 911 calls.

Technological innovations will soon transform the face of the medicine and replace out-of-date, inefficient services and devices. While some of them like Uber-ambulances or augmented reality apps can look too surreal and unrealistic, others have already proven their effectiveness in the medince. These innovations can be gradually incorporated into the current ambulance services system. Many risks and limitations should be considered to initiate changes, but providers’ commitment and willingness to improve can make a big difference for millions of patients.

Hacking Procurement

Traditional procurement in government is best described as a slow fumbling elephant stuck at the 50 yard line of a football field, usually headed in the wrong direction. The slow pace of the procurement process often leaves government agencies with outdated technologies and services that lag behind the private sector. In preparing to create a disruptive technology infusion in the service delivery of ambulances, an important component will be to reorganize how procurement is conceived to maximize performance and take advantage of emerging technologies.

While still working within the traditional framework of soliciting requests for proposals, the time cycle for product presentation would be greatly shortened. Reducing these cycles will accelerate the assessment of the utility and capability of what the vendor can offer, and will determine which technologies are most compatible with the current EMS service. Utilizing these quick turnarounds allows for different models to be evaluated. It also opens up the call for proposals to multiple vendors, which will encourage creative and efficient models for evaluation.

In addition to shorter request for proposal times, the procurement process needs to incorporate a modular approach to adapting new operating methods, rather than waiting for a broad overhaul that is designed to fix everything, but may not necessarily work with other existing networks and agencies. A modular approach allows for pilot projects to be quickly implemented and evaluated for its suitability with service delivery. As a pilot project that is implemented on a small scale, adjustments can be made easily and evaluated for its continued suitability in being implemented as a new technology. In much the same way, those technologies found not to be capable of performing the necessary task or providing a technological benefit can be quickly removed or replaced and the process again re-evaluated. Applying a modular approach will bring innovators to the table with the opportunity to present the representative ideas of a model that can be reworked and adjusted to fit the needs for service delivery. This flexibility allows for innovators to better understand the intricate needs of delivering a service, while adapting the technology to in small steps for a more robust product.

Silos and New Opportunity

Many disciplines in public safety are well known for silos: protected, department-use only data sets that are shielding from sharing through bureaucratic barriers or the outmoded scope of well-intentioned legal protections. Emergency Medical Services (EMS) are a unique component of public safety in that the life cycle of an incident begins with government operation and then all control and accountability are shifted to private enterprise, which operate at a scale that often dwarfs municipal departments. These complimentary, sequential missions are an opportunity for new data sharing across silos to change the scope and location of service delivery.

This unique custody arrangement has also seen parallel or least analogical private health sector capability increase substantially. Notably, these expansions include deployment of electronic medical record (EMR) systems in hospitals, increased attention to and use of healthcare provider analytics, and wide adoption of wearable devices that collect biometric data. In parallel, EMS departments have seen improvements in dispatch data, in-field data collection, and response histories.

A Review of Current Silos

Examining these datasets individually illustrates a comprehensive perspective on not only a holistic perspective of community health interlaced with geographic data:

Electronic Medical Records:

• Institutional data exploring frequency and variability of acute care needs
• Potential feedback on preventative / stabilizing care measures prescribed
• Local public health disease surveillance reporting

Health Care Providers:

• Individual health histories on individuals
• Risk metrics and other actuarial data
• Some forms of algorithmic analysis

EMS Services:

• Dispatch frequency history, GPS real-time location information[21]
• Patient contact information, informal medical history
• Final disposition data through information platforms[22]

“Wearables,” a variety of smart watches, bracelets, and other items:

• Fitness application data, including daily activity tracking
• Real-time heat rate and respiration data
• Location data
• Cellular internet connection or wireless connection smartphone
• Often two-way communication capable

Represented in a simplified tabular form and qualitatively ranked by color/column criterion, this analysis indicates in green the potential ability to combine real-time individual biometrics, with data indicating areas of increased acute medical need, with known risk factors, and profit motivation. These combinations can support the formation of intermediate care services, mobile community health resources, to identify areas of individual engagement. The intent of this data sharing is that it reduces EMS call volume for chronic complaints, brings accessible care to the community with greater frequency than fixed clinics, and inherently reduces healthcare provider benefit expenditures.

Several barriers remain: healthcare data protections[23], interoperability and incentive. With regards to HIPAA, a common data schema and compliant data-sharing framework must be established. Central to this solution is the formation of a central repository of the aggregation of data. Recently Microsoft Azure, a cloud-computing competitor, recently received Criminal Justice Information System approval and has been audited for compliance with HIPAA.[24] In the initial phase of the development of this system, the primary brokers of access and control would be healthcare providers and hospitals. Levels of information sanitization must be universally agreed to in consideration of both private entity and public sector data integration.

Cybersecurity — Keeping the New Technologies of a Modern Ambulance Service Safe

Like any other smart technology, the digital ambulance will be a target for malicious actors, whether they are motivated by criminal, exploitative, espionage, or other malicious purposes. Deterrence by denial, the use of protective measures to improve security of networks and systems, is the optimal solution to addressing the vulnerabilities posed by a digital ambulance. The digital ambulance should use endpoint and network sensing, threat detection analytics, and automated countermeasures to interrupt cyber kill chain, once it is determined. [A1]

The key to addressing and remedying these vulnerabilities is to build cyber defenses into the digital ambulance, rather than onto. In other words, protections against cyber threats must be considered as essential as a tire, a door, or a stretcher. These protections are not a nice-to-have, but a need-to-have. The digital ambulance’s design must reflect a consideration of the hacker kill chain: where might a malicious actor first look for an access point?

Autonomous vehicles are powered, in part, by electronic control units (ECU’s). Suppose a hacker were to gain control of the ambulance’s ECU as they did in 2015.[25] Or consider the vulnerabilities inherent in an interconnected and broad network of shared patient data. How many layers of encryption is sufficient to protect that data? Or the risks attendant to wireless telemetry devices, which rely on radio systems? The design should include several layers of protection for each of these points. Options include the introduction of biometric technology, ensuring that only authorized EMS staff have access to critical systems, and also ensuring that devices that may be used as data access and entry points such as fit bits and smart phones, are secure; treating critical and personal data as secured compartmentalized information so that only those that need-to-know can access it; and ensuring the integrity of the attendant technology necessary to the operation of the ambulance.

[1] Tom Brown., Change by Design: How Design Thinking Transforms Organizations and Inspires Innovation (New York: Harper Collins, 2009), 39

[2] Joshua C. Chang, MS and Frederic P. Schoenberg, ScB, PhD, “A Statistical Analysis of Santa Barbara Ambulance Response in 2006: Performance Under Load,” West J Emerg Med. 2009 Feb; 10(1): 42–47.

[3] Dale Loberger, “Dynamic System Status Management ,”Ems, Technology August 8, 2011

[4] William D Eggers, Delivering on Digital: The Innovators and Technologies That Are Transforming Government. (RosettaBooks: 2016.) Kindle edition. Location 211

[5], Seth Stephens-Davidowitz, “Everybody Lies: Big Data, New Data, and What the Internet Can Tell Us About Who We Really Are.” ( HarperCollins, 2017) 53–54

[6] For the specific link, go to https://data.sfgov.org/Public-Safety/Fire-Department-Calls-for-Service/nuek-vuh3

[7] William D. Eggers, Delivering on Digital, 1st edition (New York, NY: RosettaBooks, 2016), 1018.

[8] National Highway Traffic Safety Administration, “EMS System Demographics” DOT HS 812 041, no. The 2011 National EMS Assessment (June 2014), https://www.ems.gov/pdf/National_EMS_Assessment_Demographics_2011.pdf.

[9] Josh Newby, “The Future of Autonomous Emergency Response,” 2015, https://designmind.frogdesign.com/2015/11/the-future-of-autonomous-emergency-response/.

[10] Juliet Van Wagenen, “The Next Generation of Ambulance Technology Hits the Road,” HealthTech, 2017, https://healthtechmagazine.net/article/2017/04/next-generation-ambulance-technology-hits-road.

[11] Adrian Boyle, Kathleen Beniuk, Ian Higginson and Paul Atkinson, “Emergency Department Crowding: Time for Interventions and Policy Evaluations,” Emergency Medicine International 2012 (2012): 1–8.

[12] Julia Eddington, “Forget Cars — Would You Ever Trust a Driverless Ambulance?” The Zebra, 2016, https://www.thezebra.com/insurance-news/3621/forget-cars-ever-trust-driverless-ambulance/.

[13] Eduardo Alvarado Vásquez, “What Does the Sharing Economy Mean for Medicine?” Financial Times, 2016, https://www.ft.com/content/15a7940e-6eed-30cf-a5fd-8fec1f730d34.

[14] Amr Mohamed Alsayed Metwally, “What Will the ‘Sharing Economy’ Mean for Health Care?” https://www.arabhealthonline.com/magazine/en/latest-issue/Issue-4/What-Will-the-Sharing-Economy-Mean-for-Healthcare.html.

[15] Clive Riddle, “Healthcare Startups Capitalizing on the Sharing Economy and More,” 2015, http://www.mcolblog.com/kcblog/2015/4/1/healthcare-startups-capitalizing-on-the-sharing-economy-and.html.

[16] Ibid.

[17] TMF, “Augmented Reality in Healthcare Will Be Revolutionary,” http://medicalfuturist.com/augmented-reality-in-healthcare-will-be-revolutionary/.

[18] Food and Drug Administration, “About Wireless Medical Telemetry,” 2015, https://www.fda.gov/radiation-emittingproducts/radiationsafety/electromagneticcompatibilityemc/ucm116574.htm.

[19] Eddington, n.p.

[20] Paul Barr, “Equipping EMS: New Technologies Help Improve Patient Care, Ease Burden on Staffers,” Mod Healthc. 18, no. 42(25) (2012): 28–9.

[21] See http://www.firehousesoftware.com/, for example.

[22] See for example, Knowledge Center Health Incident Management System (KC-HIMS) at https://padoh-kc.org/Account/LogOn?skipUsage=Y and https://knowledge-center.com/our-industries/.

[23] https://www.hhs.gov/hipaa/index.html

[24] https://www.microsoft.com/en-us/trustcenter/Compliance/HIPAA

[25] Greenberg, Andy. “Hackers Remotely Kill a Jeep on the Highway — With Me in It | WIRED.” Wired Magazine, 2015. https://www.wired.com/2015/07/hackers-remotely-kill-jeep-highway/.

[A1]This came directly from the professor’s power point, FYI.