Ambulance by Smartphone
The sound of sirens reaches your ears and you glance in the rearview mirror to see flashing red lights. You frantically jerk the car to the right side of the road as an ambulance races by. As you continue, you come upon the same ambulance stopped behind a crumpled car. This familiar scene captivates your four year old in the back seat who wants to know all about the flashing lights. You explain 911 and how your cellphone can call these numbers so someone on the other end can send help, like the ambulance that just passed. But what if they can’t wait that long, she asks innocently?
What if. Trauma is the leading cause of death for individuals 46 and younger, costing the US $670 billion in medical care and lost productivity annually. Even more shocking, an estimated 30,000 deaths per year might be preventable.[i] How can we use that same smartphone that today simply summons the ambulance to do more?
Civilian emergency medical services (EMS) began in the United States in the 1960s when it was determined that more lives were lost due to traffic crashes in the previous year than in the Korean War. President Johnson received a report that stated, “if seriously wounded … chances of survival would be better in the zone of combat than on the average city street.”[ii] Since the 1960s, the drugs and equipment have changed but the need for expedient pre-hospital care remains and the ambulance remains the primary delivery mechanism for this care. With today’s technology however, there is an incredible opportunity for breakthroughs in the provision of pre-hospital care that will empower the public, improve patient outcomes, and reduce waste.
Technology has changed everything about the practice of medicine. Virtual healthcare or telehealth/telemedicine allows doctors to examine patients without requiring them to come to an office. Surgeons can conduct virtual consultations mid-procedure. Patients have electronic medical records that can be accessed by their insurance companies, other physicians and sometimes by the patients themselves. Prescriptions are sent electronically to the pharmacy. Appointment reminders come to your email or by text to your smartphone. Combine this new environment for medicine with the incredible technology in smartphones and now anyone can participate in telemedicine- from anywhere.[iii] Return to the question of your four year old, what if someone can’t wait for an ambulance: what if they don’t have to.
A Vision for the Future- Ambulance by Smartphone
Capitalizing on technology available through smartphones potentially revolutionizes the delivery of emergency medical services. Smartphones are mini computers with instant access to all the other computers connected to the internet. In a new system for pre-hospital care, the smartphone becomes an essential user interface that connects patients to medical consultation immediately and also supports the efficient monitoring and diagnosis of patients en route to the hospital. Reimagined pre-hospital care looks like:
· Next generation 911 that incorporates the ability to accept cell phone monitored vitals and video links through features such as Skype and FaceTime connecting patients to medical providers prior to EMS arrival;
· Regional health dispatch (call centers) where video diagnosis can take place in a secure environment that meets current HIPAA standards;
· A software package that connects user apps, Computer Aided Dispatch (CAD) systems, and hospital electronic medical records securely and in real time;
· A user (patient) app that allows smartphones to alert first responders when monitored vital signs suggest a crisis and offer to connect the user to medical dispatch;
· Reduced vehicle stock for EMS and a shift of focus to Advanced Life Support (ALS) care as non-emergent calls are self-transported or scheduled for follow-up after video consultation.
A New Way to Deliver Pre-Hospital Care
A reimagined system centers on the patient and the patient’s data, leveraging enhancements to the smartphone and portability of health records to deliver pre-hospital care efficiently and expediently. Read more about how the system will work on the next page.
How the System Works
A 911 call comes into the dispatch center; it’s routed to a trained paramedic (or equivalent) who accepts the video feed and begins diagnosis by talking to the patient and/or bystanders, reviewing incoming vitals, and looking at the patient’s health history. Based on this information, the call taker can select from one of several responses. When the emergency warrants transport, either an emergency medical technician (EMT) or paramedic will be sent with a ‘traditional’ ambulance. However, many EMS calls do not require transport and for those patients who will not be transported but still need expedient care, a smaller vehicle such as an SUV with an EMT will be sent. Finally, in the case that no emergent response is required, the call taker will direct the caller to a non-emergency clinic, their physician, or to a health specialist who can spend additional time assisting the patient with questions or access to needed services, such as a taxi ride to their doctor.
At every step in the process, the patient’s vitals and medical history follow them and are shared securely with the appropriate healthcare providers.
Problems to Solve
Access to Patient Health History and Data
While the sharing of health information is improving among cooperative health providers, the majority of information remains in silos. What if, there was a software that could simply link the existing databases together? Rather than create new proprietary programs, how can the existing databases speak to each other so the user interface is seamless? The foundation of next generation EMS is this ability to make all health records portable. Portability of medical data will have dramatic and immediate impacts on patient outcomes.
From the initiation of service, various persons need access to the patient’s complete or partial medical record which requires HIPPA compliant management policies. HIPAA is frequently cited as an obstacle to attempts to share medical information but in reality is fairly limited in scope. Education is needed for hospital attorneys and a national standard for HIPAA compliance should be developed to provide for both appropriate patient confidentiality and system efficiency.
In today’s legal environment, this universally portable record requires patient consent that must be obtained in advance and could be encouraged through a campaign and registry. The campaign can start with insurance companies and then advance through direct outreach to those patients that EMS responds to frequently and the more ‘at-risk’ populations like the elderly or other functional needs patients. As a strictly voluntary option, contingency plans are needed for maintaining equivalent levels of care for those who do not choose to share their data.
Unnecessary Transport
Virtual consultation and wearable/portable diagnostic tools can also address a major problem facing EMS: frequent utilization of ambulances for non-emergency care. In every community, providers can identify regular patients who have chronic conditions or mental health conditions that cause them to overuse/inappropriately use EMS. If these patients are assisted in managing their chronic conditions by their smartphone app it will reduce emergency care from preventable or manageable issues. In addition, virtual consultation via next generation 911 will allow medical providers to divert these users to their regular physician or a non-emergency clinic where they can receive appropriate care. An additional benefit of better management of chronic users is likely to be reduced wait times in emergency rooms for those who have legitimate medical emergencies but self-transport.
Access to Care
In a serious medical emergency, every second counts. While the average EMS response time is about eight minutes, in rural areas it can be up to twenty or more.[iv] Serious bleeding can kill you in just minutes. Next generation EMS can empower bystanders to provide life-sustaining care until professional medical arrives. Apps already exist that notify people nearby when someone goes into cardiac arrest so they can respond and begin CPR. Take this a step further: imagine that your smartphone notifies you when ANYONE nearby is having a life threatening emergency and needs your help. This can happen by user choice or by automatic notification when the patient’s smartphone detects changes in their vitals and they are unable to alert on their own. When you arrive and call 911, video feed from your smartphone back to medical dispatch will allow the call taker to guide you through necessary life-sustaining interventions. In this new system, life-saving care is at the patient’s side within seconds to minutes of wounding.
Opportunities to Seize
Video Diagnosis
Technology is currently transforming healthcare in one way that can benefit EMS, allowing video appointments to be made with healthcare providers. Most smartphones have or can access a video conferencing app such as FaceTime or Skype. In the EMS context, this video conferencing capability will allow the 911 call to be routed to a healthcare provider for consultation. With video consultation, the right resources can be sent to the patient for the level of care they need or they can be connected to their physician or directed to a non-emergency clinic. In cases where a patient calls and then becomes unconscious or non-responsive, the phone camera can still be accessed remotely. For bystanders, the video consultation can be used to provide pre-arrival care instructions such as stopping bleeding, repositioning an airway, closing a chest wound, or providing CPR.
Programs like this are already in place; one example is called “E-ICU” which places a doctor on the other end of a live stream camera to look at a patient physically, along with their vital signs and make medical decisions in real time.[v]
Early Vital Signs
Every time you go to the doctor for a routine appointment, they take your temperature, blood pressure and pulse. In an emergency, additional data points such as blood sugar and oxygen concentration become important. Currently, EMS personnel have the ability to capture this data using traditional tools but what if they could get this information prior to arrival and then transmit your real-time vitals to the receiving emergency physician? Imagine if the attending physician could examine a patient’s medical records while they were en route to the hospital and simultaneously review their real-time data; tests could be pre-ordered and procedures scheduled just-in-time improving efficiency and patient outcomes.
Using Fitbits and other personal health monitoring apps/devices, medical dispatch will direct vitals to the ambulance for review en route. This will take additional technical development for current apps to allow for blood pressure, body temperature, blood sugar, and EKG readings. Technology already exists for obtaining a blood pressure without a cuff but it would need to be modified for a smartphone application.[vi]
As an added feature, these tools can automatically call 911 if for example, a person’s blood oxygen level drops below a prescribed percentage. Adding a sensor that measures this will aid in identifying hypoxia in patients experiencing trouble breathing. This would be life saving for unwitnessed cardiac arrests, diabetic comas, or opioid overdoses. Real-time blood lab analysis can be obtained, and can alert healthcare professionals before a patient experiences signs and symptoms of a medical emergency.[vii] Diabetics suffering from hypoglycemia or ketoacidosis can be alerted; along with cardiac patients who begin to produce increased levels of Troponin, indicative of myocardial ischemia will be notified they are having a heart attack. This alert could also be automatically tied to the 9–1–1 system and receiving hospital, lessening the time from initial cardiac injury to definitive care.
Enhancing the Training
Increasing the ability of the everyday smartphone for use as an EMS tool will result in a re-balancing of skills among personnel but does not significantly change the current training needs or requirements. Training may need to be expanded to include new tools and protocols. For example, training in video diagnostics is needed for medical dispatch and potentially at the receiving hospital.
Background: Pre-Hospital Providers and Levels of Care
EMS responders possess one of four different levels of certification with increasing scope of practice. The lowest two tiers are the Emergency Medical Responder (EMR) and Basic Emergency Medical Technician (EMT). Providers at these levels provide non-invasive patient care and transport with EMTs providing more advanced care than EMRs. The next tier is the Advanced EMT which has low-risk invasive care in his/her scope of practice. The final level is the Paramedic who can perform invasive and pharmacological intervention care. In some areas of the country, an EMR or EMT is the most advance care available outside of the hospital.
Implementation Plan
In order to bypass the traditional government procurement process, hospitals and insurance companies will be the primary target for pitching the technological improvements. Both of these entities have strong incentives to improve performance: streamlining operations reduces costs and improves patient outcomes which results in improved reimbursements. Because many hospitals also have non-profit status, they have an obligation to serve the public that extends beyond profitability.
Assuming that funding is available, adoption of a new system for delivering pre-hospital care will be most successful if implemented in phases beginning with a pilot.
Exploration/User Experience Design and Testing
In this system there are multiple users who have different needs; the first phase of design is to understand what each user needs from the system and to work with them to frame essential design requirements. Once all the user needs are understood, a project plan can be developed that maps how the various system components will work with and talk to each other. Performance benchmarks should be established and subsequently tracked throughout development, piloting, and implementation.
Development/Piloting
After the technology is developed, it needs to be piloted. Pilots cannot be run independently once in advanced stages of testing; a set of communities needs to be selected to test the system holistically. A sponsor insurance company and health system, preferably combined, should work to identify pilot communities within their network.
Security Considerations for Development
By linking all the components of the system together, there could be serious security risks to both individual components and the overall system. Security needs to be designed into the technology from the beginning to potentially include biometric security, two-factor authentication, compartmentalized access to data, need to know access to data, chip-card login, and secure devices (i.e. work cell phones, laptops). In case of a breach, the system should allow sections to be locked down to prevent any malicious code, ransomware, etc. from spreading and infecting the entirety of the system. This system is a piece of critical infrastructure and should be treated and secured in accordance with appropriate industry standards.
Training
Prior to implementing the pilot, various trainings are needed by the different user groups. Presumably, the lay public (bystander) facing portions of the system will not require training but medical dispatch, EMS providers, and receiving hospital staff will need to be trained on any new software or procedures.
Redesign and Launch
After a series of pilots, any system re-designs should be undertaken and then the system can be launched. Without results from the pilot, it is not possible to know how best to implement the launch but presumably it will become clear what opportunities there are for simultaneous verses phased roll-out. During launch it is essential to establish appropriate mechanisms to collect feedback from the system so it can remain adaptive to user needs as new opportunities and challenges arise.
[i] National Academy of Sciences, “A National Trauma Care System: Integrating Military and Civilian Trauma Care Systems to Achieve Zero Preventable Death After Injury,”(June, 2016), http://nationalacademies.org/hmd/~/media/Files/Report%20Files/2016/Trauma-Care/Trauma-Care-RiB.pdf.
[ii] Edgerly, Dennis. “Birth of EMS: The History of the Paramedic,” Journal of Emergency Medical Services, (Oct. 8, 2013), http://www.jems.com/articles/print/volume-38/issue-10/features/birth-ems-history-paramedic.html.
[iii] This will require phased implementation as not all persons have access to smartphones and internet.
[v] http://searchhealthit.techtarget.com/definition/Electronic-Intensive-Care-Unit-eICU
[vi] http://www.vsigntek.com/a-new-cuff-less-blood-pressure-monitor-device/
[vii] https://www.pointofcare.abbott/us/en/offerings/istat/istat-handheld
