Digital Design and the Next-Generation Ambulance
Transformation and the Digital Mindset
Like many young boys of my generation, I couldn’t wait to turn on the television each week and watch Gage and DeSoto speeding to the rescue on the television show Emergency! The things they did seemed exciting and meaningful. That television show was my first exposure to the world of both the fire service and emergency medicine, and it was fascinating. What I find interesting now however, is how little ambulances and the provision of emergency medical care in the field seem to have changed since that show aired forty years ago. Certainly there have been incremental changes brought on by improved diagnostic and trauma care technology among other things, but many of the foundational components of EMS on that show seem remarkably similar to the things we see in the field today.
The ambulance services of today remain primarily reactive emergency response resource. They may use more modern vehicles than were available in the 1970s, but ambulances are still manually driven transport devices staffed by a paramedic and/or EMT who can provide initial on-scene medical care and take a patient to the emergency department of a hospital for more complete diagnosis and treatment. That said, modern ambulance services are not standardized across the nation, and may operate under different models with different capabilities. Emergency medical services may be provided either by a local government, a private corporation under contract with the government, or both. Today, the ever-increasing pace of technological advances and use of data to design consumer-focused practices make the ambulance service ripe for disruption in several areas. The question this article will try to answer is how we can transform the future of ambulance services through the use of digital design and innovation.
We are living in a time when technology drives both our capabilities to deliver services and the expectations of customers in many industries. We bank online, shop online, study online, and communicate online. Innovation drives successful business models in the era of digital design, but government bureaucracies are, by nature, not places one typically looks for innovation, agile practices, or digital design. As one former high-level government employee recently put it to a class of Naval Postgraduate School master’s degree students, bureaucracy is designed to stifle innovation. This speaker pointed out that most people don’t want to be audited by the most innovative IRS Agent, or ticketed by the most innovative state trooper. Despite his assertion, governments can and should use the principles of digital design to create better situations and services for our consumers: the citizens we work for. To do so, we need find out what digital design is, how we can apply it to a field, and what it can do to help make our cities, counties, states, and country a better place for the people government serves. Digital design and strategy provide a way for governments to innovate and can provide both immediate and long-term transformations to the way we provide emergency medical services to patients in the field. But before we talk about how we make this happen, we need to define the methods.
Digital design, digital strategy, and the digital mindset are all frequently used terms in the study of business, but how do we define them? They require business or government leaders to ask themselves a number of questions. The first of those is whether or not they are in the right business.[1] They shift competition, so that businesses not traditionally associated with a field are now able to enter and succeed in new areas. They are a way of thinking about a product or service that runs counter to the traditional waterfall method of project management. In a digitally designed service, the user experience is paramount, and molds the design, delivery, and operations strategies. Digital design relies on data to inform our decisions, provide customized experiences, and drive the delivery of efficient, effective services. Digital designers explore a problem or process from the viewpoint of the end-user to discover the true experience of that person. They eschew focus groups or other artificial settings and prefer to make their observations from the field. Those observations are a more reliable way of learning how real improvements can be made than conducting surveys or meetings.
There is a quote that is frequently, though perhaps wrongfully, attributed to Henry Ford in which he stated, “If I’d asked people what they wanted they would have said a faster horse.” Whether or not Henry Ford actually said this is less relevant than the idea behind it. People often don’t know what they want because they haven’t yet imagined it or haven’t articulated the things they imagine. In Delivering on Digital, Dave Eggars provides a number of examples of digital design in action and the importance it places on actual observation of user experience. One such example came from designers in Finland visiting parks after a snowfall to look at the patterns of footprints.[2] In this way, they can actually see patterns of use and decide where to pave pathways for park patrons. These same ideas and practices can help transform the ambulance services we operate today into a next-generation emergency medical system that embraces the innovative use of technology and data to enhance the user experience of patient and provider.
The Digital Redesign of Ambulance Services
In this article a team of homeland security professionals, from police and fire managers to officials with the Department of Homeland Security will examine the ways in which digital design can help us create the ambulance of the future. To do so, we will look at how data and user feedback can inform decisions about technological innovation for the physical design of ambulances and the equipment they carry. We will also review how that same data can influence the service delivery model in general. We will cover how to “hack” procurement strategies, hiring and training practices, and the silos that frequently exist in government services. Finally, we will spend some time on how not to get “hacked” ourselves as we go digital with the next-gen ambulance. The recommendations we provide will be presented in a layered format. Some recommendations could be implemented today to improve our patients’ experiences, and some may not be feasible for years to come.
So how can digital design help us create the next generation ambulance? It can help us determine what technology can do to deliver the services that matter most to patients. It can help us change the stereotypically plodding government procurement processes. It can be used to examine and streamline our hiring and training practices to ensure we have the right number of qualified employees serving our patients. Through better use of relevant data, it can also help us review and perhaps change the very way we measure success and allocate resources.
Digital design first requires us to understand our customers. In the case of ambulance services, customers can be both patients and medical providers like emergency room physicians and nurses. Both groups of stakeholders offer unique perspectives of what they need to improve their experience with ambulances and the emergency medical system, and a good digital design process would involve observation of and feedback from both groups to determine how we can improve our services and provide a better experience. Digital designers need to get out in the field with ambulance crews to see what it is like to be a patient receiving care in the emergency medical system. They need to speak with doctors and nurses in the emergency rooms to identify opportunities for improvement and areas of inefficiency.
As noted above, the first question to ask in the digital redesign of ambulance services is whether or not we are in the right business. Put another way, are we providing the services our patients most need? Ambulances have been traditionally reactive and viewed as an emergency service, responding to 911 calls for medical help. When those calls come in to an emergency dispatch center, regardless of the type of medical call, a typical response in the author’s city would be to send an American Medical Response ambulance with a crew of 2 and a fire engine or ladder truck with a crew of 4. In an emergency situation this can be a reassuring and appropriate response, but is it what the patient, or taxpayer, needs in the majority of medical aid calls?
Ambulance services, whether public or private sector, should consider the use of both call for service and workload data to study whether they are staffing and deploying resources effectively and efficiently. This will require a micro-level examination of data to determine not just how many calls for service an agency handles, but when those calls come in, how many people and how much equipment is needed to resolve the incident, what level of training and medical intervention is required, and how long each employee spends on each incident. By conducting a comprehensive workload study based on readily available data, the ambulance service provider can make better decisions about resource allocation, training needs, and even their business model. Do we need to send fire engines to every medical call, or would we be better off reallocating resources and changing our response model entirely? In my city, approximately 1.6% of the Fire Department’s calls for service in 2016 were related to fires, while approximately 75% were for medical calls of various types.[3] Even so, the Fire Department does not operate ambulances, and sends their paramedic equipped firefighting apparatus to every medical call along with an ambulance operated by American Medical Response. With that type of imbalance, it seems like there could be greater efficiencies achieved with an updated business model relying on data to inform staffing needs and resource allocation.
In some places both here and abroad, ambulance services are starting to change their service delivery models to better serve both their patients and hospital emergency departments. A number of ambulance providers, like the South Metro Fire Rescue Authority in Colorado, have moved to more of an emergency care practitioner role, treating patients in the field and potentially eliminating costly and unnecessary trips to the hospital. Digital designers need to examine data sets and think of new ways to operate our emergency medicine and ambulance services to create a vision, set a strategy, and innovate an improved business model for the ambulances of the 21st Century
In addition to the core question of whether or not our ambulances are still in the right business, we will examine a number of ways digital design can transform ambulance services. Some will be changes that could be rapidly implemented, and others may not be feasible for a number of years due to immature technology, regulatory problems, health insurance restrictions, privacy and data security concerns, etc. Some of the items worthy of consideration in the digitally designed next-gen ambulance are:
· Greater integration of diagnostic and communications technology in ambulances
· The use of autonomous vehicles and/or drones to provide more rapid, efficient responses
· The use of app-based systems similar to Uber for non-emergency medical transport
· The use of mobile apps and devices to collect and transmit data that improves the patient and provider experience.
· Exploration of alternative models of care including proactive or preventive care in the field
· Greater use of data to inform patient care along with staffing and deployment models
To preview how the greater integration of technology and data in ambulances can improve both the patient experience and the workload in emergency rooms, Kaiser ER physician Dr. Josh Kucker talked about immediate improvements that could be made in the EMS system. The first thing Dr. Kucker mentioned was the use of diagnostic tools like the ISTAT blood testing machine (https://www.pointofcare.abbott/us/en/offerings/istat/istat-handheld) currently used in his ER.
The device, about the size of an IPad Mini, provides rapid results to blood tests and can give information about blood chemistry, blood counts, levels of lactic acid, and troponin among other things. It allows a doctor to rapidly diagnose many kinds of health problems, from infections to heart attack, and if paramedics had them in the field, they could save time for patients and ER staff, improving the patient care experience by providing better more rapid medical interventions through the use of better data.
Another technological improvement Dr. Kucker noted would to equip and train paramedics to use a machine called the focused abdominal sonogram for trauma (FAST). This small and rugged device is already in use in the trauma care of military personnel in the field, and can provide rapid diagnosis of internal bleeding or pneumothorax in trauma patients. Dr. Kucker noted that if a paramedic could provide him with an EKG, ISTAT, and/or FAST results prior to or upon their arrival at the ER with a patient, it could cut 90 minutes or more off the patient’s time in the ER.
Finally, Dr. Kucker mentioned the use of currently available technology like health apps for mobile devices or wearable biometric sensors as a way for patients to take a greater role in their own health car. As an example, he spoke of an arrhythmia patient who came the emergency room several times after a cardiac event, but much like the car that makes a noise until you bring it to the shop, doctors could never observe or record the man’s problem with in-hospital tests. To solve the problem, the man installed an app on his phone that allowed him to record his own heartbeat when he felt an arrhythmia episode coming on. By bringing his phone and the data in to the hospital, doctors were finally able to see the issue and determine the need for a pacemaker.
The idea of apps on mobile devices is especially intriguing in creating an ambulance as a digital service, and one that holds great promise for the emergency medical system. As a parallel, municipal police departments are now using either commercially produced or self-developed apps on Apple or Android operating systems that allow them to write citations, document citizen contacts, write collision reports, and more. The use of these apps allows the mobile devices in the field to connect with the departments’ records management systems and automatically transmit data back and forth, eliminating the need for manual data entry at the station and improving the workflow for the officer, records staff, and the courts. With these apps, an officer’s mobile device can be used to capture and attach photographs to entries, and automatically populate data fields by scanning drivers’ licenses or matching information already found in the agencies’ records systems. These same benefits could be realized in ambulance services, allowing EMTs and Paramedics to more rapidly and accurately assess patient needs and history, and promoting the better use of data in patient care. Mobile apps could also rapidly replace the type of equipment highlighted in the paragraphs above, dramatically impacting service delivery, procurement processes, training of personnel, and system vulnerabilities.
These technological innovations are examples of small steps we can take on the way to digitally designing a next-gen ambulance service, and also highlight the disparities in ambulance services across the country since some jurisdictions have already implemented similar ideas. For example, the previously mentioned South Metro Fire Rescue Authority in the suburbs of Denver already operates ambulances with mobile laboratory capabilities, and fields crews with nurse practitioners who can provide a higher level of care to patients than a traditional paramedic/EMT team could. This kind of response, and use of improved diagnostic data, may eliminate the need to take many patients to a hospital. South Metro’s “mobile care units” are more station wagon or SUV than ambulance and carry equipment that the typical ambulance does not, like wound closure kits for suturing or stapling lacerations.[4] South Metro’s crews also have greater access to electronic medical records for patients so that an ambulance visit can be more like a trip to the doctor’s office. A patient under this model can be diagnosed and treated for their fever at home for about $500 rather than paying the greater expense of an ambulance trip to the hospital.[5]
The use of data can also be used to make short-term improvements in the way we deploy and allocate EMS resources, as noted here by Mark Timpf of the Tucson Police Department in Arizona.
In providing emergency medical services to the public, one of the most critical requirements is the timely response of paramedics and other emergency medical assistance to medical emergencies. Response times have long been a challenge for agencies with growing demands but restricted budgets. In examining this aspect of emergency services, the issues of available staffing and resources, asset allocation, and technology have always been a primary area of emphasis in meeting the needs of the community. Although agencies also engage in analysis on call loads and other demands, this analysis has usually been historical in nature and it considers past activity in the allocation of assets. There is additional opportunity to use data driven models to better identify future trends in service needs. Using artificial intelligence and the comprehensive analysis of data from several sources, a model can be developed to strategically identify future needs of medical emergency services so that medical personnel can be placed in close proximity to call demand thereby significantly reducing response times. These models can literally change on an hourly basis as conditions are often very dynamic and incidents occur requiring the movement of deployed assets.
In using this strategy, algorithms must be constructed using data from numerous sources all of which needs to be utilized in the modeling. These would include a lot of open source data such as traffic conditions, local weather conditions, ongoing civic events, protests or demonstrations, working incidents, and historical trends. However, other more obscure data sources can provide vital information in this modeling. This would include crime statistics, health department data, more specific climatological data such as pollution levels, Center for Disease Control (CDC) statistics, Environmental Protection Agency (EPA), Occupational Health and Safety Administration (OSHA), census data, and even demographics. All these systems will have to be hacked and integrated into the system for analysis. These sources can provide indicators of where public health issues may occur. The following paragraphs will summarize the potential value of the given data source.
Traffic Conditions
Local traffic conditions can yield information valuable to emergency medical providers. Heavy congestion, ongoing road construction, known hazards, and historical information can be predictive of accidents, many of which will involve injuries in need of medical response.
Local Weather Conditions
Although weather systems can impact large geographical areas in urban centers, isolated weather events can impact specific areas within cities. These can include severe thunderstorm cells, isolated wind events, and heavy rain, snow, or icing. In extreme weather conditions such as excessive heat or cold, more medical response needs may be experienced in areas where poverty or low-income residents reside because of the lack of air conditioning or heat.
Ongoing Civic Events
In known civic events, a large gathering of citizens will most often require additional medical services. But several other factors are relevant such as the venue, available facilities, context of the event, and duration, all of which can be analyzed to forecast medical response.
Protests and Demonstrations
These events are very volatile depending on the participants and the context of the event. They often result in conflict and confrontation, which result in injury of participants. In addition, exposure related illness can occur along with stress induced health events.
Working Incidents
Incidents being worked by public safety personnel or others often draw crowds, congestion, and often the displacement of citizens. These events increase demands on medical providers which in many cases are already present at these scenes.
Historical Trends
Using past data and trends is commonly used to allocate resources however this information may lose value if the specific environment has changed or the conditions have otherwise been modified.
Crime Statistics
Crime statistics can be very indicative of where medical resources should be deployed. This also changes depending on the season, day of week, and the time of day. Police agencies have been very successful in predictive policing strategies and many of the incidents they track involve injuries to victims. Certain areas are more prone to crime and also include poverty and other conditions leading to the need for medical resources.
Health Department Data
Health Department data includes information related to public health in specific geographical areas. There are also environmental conditions they track that have specific health implications. Although somewhat controversial, they will have data on populations that can be categorized by region and provide a picture of where medical events are more likely to occur.
Other Climatological Data
Other data such as pollution data, allergy risk levels, and other atmospheric conditions such as ozone alerts, etc. often lead to respiratory illness which often require medical response. These are often felt worse in geographical areas where citizens may not regularly have access to healthcare such as poverty stricken or low income areas.
CDC Statistics
CDC has data on specific populations more prone to health issues. These can be regional illnesses, genetic based illnesses, and known regional threats which may be specific to conditions existing within parts of some urban areas. This data can be used to identify chronic issues in populations that would prompt calls for emergency medical services.
Environmental Protection Agency (EPA)
The EPA has data and information of environmental conditions is various cities in the U.S., many of which have particular areas with known contamination and risks. These locations also have populations which are more susceptible to illness or already have a higher percentage of the population afflicted with cancers or disease.
Occupational Health and Safety Administration (OSHA)
OSHA has data on not only workplace injuries but also locations that have been previously cited for hazardous working conditions, all of which may be indicative of workplace injuries that with require emergency medical response.
Census Data
The U.S. Census Bureau keeps data on almost every aspect of the population, all of which can be used in the modeling of populations most in need of medical assistance. Population density, family structure, educational background, income levels, etc., all have statistical implications on public health which ultimately is correlated with emergency response.
Demographics
This is a controversial one but nonetheless is relevant to identifying populations most in need of emergency medical response. Age, gender, race, ethnicity, sexual orientation, etc. are factors in identifying populations that may be frequent users of emergency medical services.
Other Factors
There are numerous other factors and traits that can be used in developing algorithms in developing a model for resource placement to improve response times. Additional data from economic sources, utilities, tax records, and even medical records can be used. The list is nearly endless, as long as it can be integrated into a singular system for analysis and modeling. Predictive policing programs effectively use these systems to accurately predict crime trends so that resources can be effectively and efficiently deployed. In emergency medical response, these same models can be constructed to provide faster response to emergency medical situations and ultimately save lives.
The principles of digital design, including the use of technology and data to challenge and disrupt the status quo, offer great potential for improving patient experience and transforming emergency medical care in many ways. Whether we are examining the technologies hinted at above, or talking about disrupting the way our emergency medical services operate, the improved collection and use of data will be the key to making smart changes. The use of improved technology in diagnostic equipment, vehicles, communications systems, workload management, and more will allow the next generation ambulance service to collect, secure, disseminate, and use data in ways that will allow forward-thinking leaders to transform emergency medical services in ways that could dramatically change how those services operate. In the next section, we will go into greater detail about how digital design can transform the delivery of services by crews in a next-gen ambulance.
Next-Gen Service Delivery
Modern emergency medical services are delivered in a myriad of ways and processes. There is no one good or better way to provide higher-level care during an emergency. However, there are basic tenets and best practices that are accepted nationwide. We aim to hack this vanilla model with agile development. Instead of a one-size fits all model, our group questioned the norm. For example, why does an ambulance need to have a large box on an expensive chassis, what other modes of transportation can be used, and what other technologies or resources are available that meet the mission but are not readily deployed due to a variety of reasons (political, ethical, cost, etc.)? We quickly realized that there were opportunities for advancement and problems that we must account for.
For example, nationwide, the response to on-scene time standards is no longer acceptable. Because of the lack of a federal standard, agencies are able to set their own standards for response times to medical emergencies. In some areas of the nation, it is acceptable to arrive between 8 and 15 minutes.[6] Unfortunately, from a life saving point of view, many deaths occur well before the arrival of an ambulance or life saving personnel. The cost associated with emergency medical transport is equally important as the time the medical provider spends with the patient, barring the patient is conscious and can provide information.[7]
Accordingly, we aim to hack the problems connected to emergency medical treatment; rapid assessment and triage, and networked vehicles so that a better services can be provided. There are three solutions that make up this digital hack:
1. The BIO-CARD:
Each citizen will be provided with a digital/biometric ID card that will link the person to the 911 operators for basic medical records, emergency contacts, and more. This same information can be developed within an application and can include a QR code that is enabled with a locked screen. Within the ID card, or applications, the user will have a personal identifiable number (PIN) that will enable the dispatcher to access critical services and contacts, such as the patients’ doctor, etc. before the patient is even treated or transported. Users of this mobile app/ID card will benefit from the geo-location function associated with mobile devices currently in use as a way to enable the more rapid and precise allocation of services. Patient files and medical history remain secure and are sharable with other medical teams that have a need for the information. This hack counters the current systems, which include a lengthy interview with the patient (again, the patient may be unconscious or there may be a language barrier), or another piece of technology such as an Ipad or Toughbook. Unfortunately, neither is connected to the hospital and physicians must wait until the ambulance and EMS personnel physically arrive at the hospital for the full report. Our system enables the more rapid collection, analysis, and dissemination of data between patient, EMS providers in the field, and medical professionals in a hospital setting.
2. UAV Response for Accidents/Emergencies:
The use of geo-located mobile devices/apps and patient ID cards can also facilitate the use of another high-tech tool to provide more rapid response to emergencies (especially in remote areas), better use of data, and better patient care. When appropriate, vehicle accidents and other medical emergencies will trigger a response with a local unmanned aerial vehicle(s) (UAV) operated by the local 911 centers or ambulances themselves. These UAVs have the ability to rapidly transport lifesaving medical equipment like automatic external defibrillators, Naloxone, epipens, tourniquets, etc., while also providing a video-based communications link between a patient or assisting citizen and a dispatcher or EMS professional. Given the previous section that highlights a variety of data on traffic, protests, etc., the UAV becomes invaluable because it can be deployed immediately, travel rapidly to the scene without traffic, and provide a situational assessment (audio, video, exact location) prior to ground resources arriving. First responders will be able to view the incident, prepare for complex issues, and call for additional emergency vehicles. The video link using off-the shelf applications will also allow EMS professionals to provide better instructions and care even before they physically arrive to citizens on the scene. This hack, which is already being experimented with in some jurisdictions here and in Europe, disrupts the current system relying upon untrained or hysterical citizens that call 911 to report an accident. Their words and descriptions serve as the basis for the type of response.
There are a number of barriers to implementing this kind of unmanned aerial response, including safety concerns, regulatory restrictions, and technical limitations. The Federal Aviation Administration regulates the national airspace system (NAS) in the United States, and has regulated the use of unmanned aircraft in Part 107, Title 14 of the Code of Federal Regulations. The regulations are meant to ensure the safe integration of UAVs into the NAS and avoid conflicts between UAV and manned aircraft. Under the law now, UAV (or drones), must remain below 400’ above ground level, remain within the operator’s line of sight, fly only during hours of daylight, and are prohibited from flying directly over people.[8] Our proposed use of UAV would require changes to these regulations, or at least a waiver from the FAA. Additionally, the UAV currently available have limited battery life and flight time. They will typically only fly for 20–30 minutes with a light payload before the device’s battery is exhausted. This capability limitation means that the use of UAV for medical response will likely be restricted in the near future.
3. Public Safety Vehicle Network
Last, and equally important is a network of emergency vehicles that include ambulances, fire apparatus, and police officers. Imagine a nationwide connection between vehicles, which can help determine the closest public safety vehicle to help someone, but also serve as a safety net. For example, there are a large number of vehicle crashes that involve public safety vehicles, meaning, they crash into each other. With the available sensors and digital technology, this problem should be a thing of the past. But further, if a medical vehicle breaks down, needs fuel, etc., the surrounding vehicles should have the ability to know and understand the current status of all vehicles.
These hacks will not make all customers have a first class experience; nevertheless, they will enable digital integration that will have a positive return on investment. However, one aspect that will help with measuring customer experience is through customer feedback and data analysis. Both inputs will enable the digital hack to grow and improve over time.
Hiring and Training for the Digital Ambulance Service
From Digital Design: don’t leave recruitment to HR staff; create a unique value proposition to attract the best talent; offer autonomy, mastery, and purpose; empower people to push back against policies running counter to a digital way of thinking
Hiring Hack
“T-Rex doesn’t want to be fed, he wants to hunt”- Dr. Allan Grant from Jurassic Park (1993)
As of 2015, millennials now represent the highest percentage of the modern day workforce. However, attracting the best talent to any business model is not as simple as putting a want ad in the newspaper. The modern day challenge is attracting that talent to a profession that was once an automatic draw: public safety and emergency response services. As employers engage in an unofficial war for new employees, the most talented people are the most sought-after candidates.[9] There is no clear data to illustrate exactly what sector millennials are gravitating to so it may be more relevant to understand the type of work environment that suits them.
Public safety and emergency response services, specifically medic units or ambulances, represent the highest percentage of 911-calls for service with some fire departments seeing over 92 percent of their response in this demographic. Private ambulance companies like American Medical Response (AMR) and Falck response solely to medical based calls. The question at hand is how to attract millennials — and the soon to be employable centennials — to these business models. Providing a new, fast-paced career path for millennials — a generation that is highly adaptable to change — allows them to feel as if they are in control of their own fate.[10] Empowering millennials by setting them on a business track rather than inflexible or static positions within the company is highly desirable.[11]
Thinking outside the box is not the method needed to redesign the attraction of new talent; totally rebuilding the box and redefining what it means to hire futuristic thinkers is the new reality.[12] Innovation in the hiring process starts with redesigning what traits the company desires in a candidate. The archaic method of accepting a two-page resume that provides the basic skill set of a medic or basic emergency medical technician (EMT) will now live on the Internet 2.0 where talent is staged for hire. Taking a page from the gaming world where top-level programmers are at a premium, hiring medics and EMTs will come from a series of realistic challenges that examine a candidate’s thought process and analytical skill set rather than reading words on a piece of paper from a resume. This hiring method will not only provide a more complete assessment of the talent pool applying to the organization but also aligning the method of assessment with the desired traits in the employee: can they think/react/produce in pressure situations. Testing candidates in a model of realism will also set up employers to identify additional skill sets needed for future expansion of basic EMT and paramedic job descriptions. Traditional 911-call service delivery is built around the driver and EMT or paramedic attendant. Our ambulance hack is built around the service delivery model and diverse methods of initial patient surveys. The methods may include patient care from a remote location rather than in-home care. A candidate will need to currently possess or have the ability to possess the skills need to apply EMT or paramedic skills remotely much in the way of the Web MD format. The hiring process has the flexibility to source candidates with these thoughts in mind as the tests are administered.
If set up correctly, the testing can be directly marketed to potential hiring pools. To accomplish this, HR specialists will be trained to go where the ideal candidates are, read what ideal candidates read, and even do what ideal candidates do in order to immerse the marketing into talent pools desired for our new medical service delivery. Hidden talent pools live in areas that we do not currently explore in the public sector nor will the desired candidates be found by simply trolling the Internet with job postings. Modeling the private sector, companies like Google are changing the way HR specialists view employees. By hiring mediocre people a company can only expect to receive mediocre decision-making in important areas of service delivery. The same rigor that goes into setting up the new method of service delivery will also go into the people-based decisions for hiring new talent.
Training Hack
“The illiterate of the 21st century will not be those who cannot read or write, but those who cannot learn, unlearn, and relearn” Alvin Toffle (2009)
If marketing, testing, and hiring the proper talent pool for our new method of delivering medical services to the community is the life blood of the company, then training that group to learn a new way of operating is the heart that pumps that blood. When referring to 21st century training, sociologist Alvin Toffle states, “It is not the strongest of the species that survives, nor the most intelligent, but the one most responsive to change.”[13] Much of what is learned during EMT or paramedic school is a process of memorization and repetition. However, application of knowledge is accomplished through training delivered by the employer. Knowing that many candidates hired for our way of providing medical treatment is going to be foreign, a fundamental shift in training will need to occur. Unlearning old routines and habits will be built into a 12-month probationary period upon hire. Existing knowledge will be considered a roadblock to mastery of our business model.
Training will begin by unlearning a driver and EMT attendant service delivery model. New hires will be put on a 40-hour schedule for the first eight weeks of employment in “detoxification” process to purge their concept of what traditional service delivery should be. This time period is chosen to mirror the concept that it takes at least 66 days to unlearn bad habits.[14] In the business of delivering emergency medical services, bad habits can lead to total business failure and must be taken out of the risk pool. Training will come from organizationally selected mentors trained by the founders of the company and concept. Once this cleansing has taken place, new hires will be begin the process of relearning what EMSx service delivery really means.
The fire service and airline pilots have used driver simulation training aids for a number of years to provide real-life experiences without the risk of injury or death. Training instructors can provide a series of escalating scenarios to the student that incrementally test their ability to reason, make decisions, and experience outcomes within varying levels of stress. This same concept will be applied to new hires in EMSx once new hires have completed the first 66 days of unlearning old habits. Computer generated scenarios will be based on the following core concepts:
· Driving traditional medic units
· Operating drones for service delivery
· Talking to a patient remotely for low priority medical symptoms (per protocols given by medical control)
· Handling patients who are unfamiliar with EMSx service delivery methods
Ensuring that new hires understand the challenges facing them before the experience occurs in real world response is essential to establishing EMSx service delivery as an acceptable option for the community compared to traditional 911 response.
Collaborative and communal are words used to describe effective training methods for millennials in the 22nd century. Diminishing the individual silos that currently exist in modern emergency service delivery will open up opportunity to simultaneously learn from industry experts and create peer-to-peer training experiences. In essence, EMSx will reinvent the stale classroom training environment by creating an open source training model. Much like gamers share tactics and strategies in the virtual world, EMSx will use video conference technology to link new hires with other employees or outside trainers to expand the cloud of knowledge within the organization. Additionally, EMSx would invite neighboring communities to join in the training sessions in a collaborative effort to expand and upgrade the response capabilities of the region.
Hacking Procurement
“It is much easier to put existing resources to better use, than to develop resources where they do not exist.” — George Soros
The EMSx concept is designed to provide a more effective, more efficient and more patient-centric approach to emergency medical services by utilizing technological advances and paradigm shifts in the process of response and delivery. Once implemented, the program would conceptually reduce costs in staffing, labor hours and equipment. Unfortunately, initial implementation would require acquisition of new technologies and training to properly implement the concept, which would require an initial significant financial commitment for procurement and recruitment. In order to acquire and integrate the technology, traditional methods of procurement like grants could be utilized, but jurisdictions would be well served to examine more non-traditional methods like the development of public-private partnerships between municipal emergency medical services and regional health care providers.
Public-private partnerships (PPP) are not an entirely new concept to emergency medical service providers. Several large municipal agencies, like San Diego Fire and Rescue, utilize a PPP to facilitate the use of commercial ambulance services to supplement their call for service demand[15]. The benefit of a PPP is that it provides the opportunity to develop a platform which is a hybridization of the strengths of each of the partner components, while potentially mitigating the risks of the deficiencies of each. The PPP platform also provides the partners with the ability to combine resources, reduce redundancies and share combined revenues or to reinvest the proceeds back into the organization.
The PPP envisioned by EMSx would initially utilize a limited liability company (LLC) entity between a larger regional medical center and ideally engaging multiple municipal jurisdictions. This paradigm would provide capital, personnel and equipment from all partners for the initial investment in the acquisition of new technology. In addition, to being a financially viable framework, it also would provide the operational flexibility to address specific needs or surges by each of the participants. This arrangement would also facilitate the more rapid and effective flow of data, from patient records to deployment and call for service information to the expenditures of resources. This type of cooperative and comprehensive collection of data will allow for more efficient and customer-centric procurement practices.
The procurement process in a digitally designed ambulance service of the future would also need to become far more agile than the typical government purchasing practices. Too often, agencies are unable to rapidly buy equipment or enter into contractual agreements because of the bureaucratic labyrinth of attorneys and finance departments. The current competitive processes required for requests for proposals and the award of contracts stymies well-intentioned public safety leaders from acquiring and fielding equipment needed to serve our patients. In the new model, the local governments responsible for emergency medicine in the field will need to adopt far more rapid processes that reprioritizes patient care and mission accomplishment ahead of over-the-top protection against every possible liability.
Information Sharing (or lack thereof) Between EMS and Hospitals
As I enter the “early” stages of middle age, seeking medical care, both for routine visits and the unexpected urgent reason, has become a more familiar facet of my life. Recently these visits have run the gamut of urgent care clinics, emergency rooms, primary care physicians, and other specialists (with the appropriate referral to satisfy the insurance company). While there are always the routine questions during the check-in process at these providers, which usually starts with “I’ll need your insurance card”, there is also a request for permission to share my medical records, with other providers. This usually requires another signature, sometimes electronically, but mostly still done via pen and ink. Once the providers have my approval they have access to all my medical records, at least within the State. While this does not eliminate all of the medical history questions, during the initial visits, it does speed up the process. It also alleviates the need to provide a list or recite current medications and dosage, but again they are reviewed for accuracy. This increased level of information sharing and efficiency among medical providers has made my recurrent medical visits a bit less painful, pun intended.
I have since learned that this sharing of medical records between providers is an example of an electronic Health Information Exchange or (HIE). A HIE is defined as the transmission of healthcare-related data among facilities, health information organizations (HIO) and government agencies according to national standards.[16] To facilitate a HIE, the records must first be in an electronic format or what is more commonly referred to as an Electronic Health Record (EHR). With the enactment of the Health Information Technology for Clinical and Economic Health (HITECH) Act in 2009, hospital adoption of at least a Basic EHR system was above 60% in all but 2 states (Hawaii and West Virginia), and above 80% in 17 states by 2014, as shown in the figure below.
In addition, the Office of National Coordinator (ONC) for Health IT (HIT) Certification Programs has advanced standards based HIE’s across health care providers and through a variety of programs that include the Standards and Interoperability Framework, the State HIE Cooperative Agreement Program, the Nationwide Health Information Network Exchange, and the HIT Certification Program.[17] Lastly, Health and Human Services have sought to advance HIE with the adoption of interoperable EHR technologies.[18]
Even with the enactment of these regulations, the implementation of multiple initiatives, and the adoption of new technologies there are still a number of limitations to the use of HIE’s and EHR’s. One of the primary impediments, as is the case with most medical issues, is the regulatory and privacy concerns. For example, in New York State if the patient chooses to opt into the HIE it is all or nothing proposition. In contrast, the New York Civil Liberties Union (NYCLU) believes in order to preserve patient confidentiality patients should have granular control of their medical records, deciding what information is made available and to which provider(s). The next barrier, which is usually connected to the regulatory process, is the issue of geography. Once a patient crosses a state line the medical records usually do not follow, as I experienced during my recent spate of medical visits. While all my local records were accessible to the different doctors, to obtain the records from my previous provider in Maryland, I had to fill-in a paper request form and mail it to the provider’s office. The last and most significant obstacle is the lack of interoperability. The inability of systems to communicate with each other is nothing new in the arena of information technology, however as it relates to medical decisions this lack of connectivity becomes exponentially more costly.
These same barriers are present in the Emergency Medical Services and may even be more pronounced. Again, the most significant being the lack of interoperability, specifically between the Paramedics in the ambulances and the receiving/admitting hospitals. This is exemplified through an explanation of the hand off procedures between paramedics and emergency room staff, by the chief deputy director at California’s Emergency Medical Services. He stated that at the hand off “The paramedics will print out or photo copy their run sheets from the field.”[19] Not only is this taking place in the midst of a usually chaotic emergency room, but it provides limited options for hospitals using EHR to search, link, or track the data provided via a paper record. The lack of interoperability also serves to prevent paramedics form having real-time access to critical patient information that can include existing health conditions; allergies, and medical directives. It further limits the ability of multiple EMS agencies to share critical care data during the midst of a mass casualty situation. Considering the number of mass casualty events experienced in the U.S. in recent years, this would seem to be a priority issue that needs to be rectified.
A portion of the interoperability dilemma within EMS can be attributed to different technology platforms, however, the larger and more substantial concern lies in the EMS funding model. Though EMS data at the State level falls under HHS, at the Federal level it falls under the control of the National EMS Information System (NEMSIS), which is funded by the National Highway Transportation Safety Administration (NHSTA), a component of the Department of Transportation.[20] While it appears to be an insignificant structural or hierarchal concern, it serves to create silos of EMS data that are currently unusable by hospitals for a couple of reasons. The initial concern is that most hospital systems do not currently have access to the EMS data maintained by HHS at the state level. Then if the data could be accessed, by the hospital systems, it would be unusable for the most part. This is because the majority of the NEMSIS data is statistical in nature, which is attributed to the NHSTA funding. Additionally, EHR’s on the hospital side of the equation are the result of Health Level 7 (HL7) designed Clinical Document Architecture, which is defined and structured by Meaningful Use.[21] The Office of National Coordinator (ONC), which is funded by HHS, designed and established the Meaningful Use criteria. Ultimately two agencies with very different data collection requirements and funding sources, designed to incompatible data collections sources that currently serve to impede the quality of care and further increase the cost of health care.
The increased cost of healthcare is about more than just the redundancy of readmitting recently discharged patients; hospitals are also subject to increased penalties for readmitting these patients. In 2014, section 3025 of the Affordable Care Act added section 1886(q) to the Social Security Act, thereby creating the Hospital Readmissions Reduction Program (HRRP), requiring Centers for Medicare and Medicaid Services to reduce payments to Inpatient Prospective Payment System (IPPS) Hospitals with excess readmissions.[22] Hospitals participating in the IPPS, comprise more than three-quarters of hospitals in the United States.[23] As with most other bureaucratic efforts involving healthcare the reduction of payments (penalties) are based on two complicated formulas: Formula to Calculate the Readmission Adjustment Factor and Formula to Compute the Readmission Payment Adjustment Amount. These two formulas include but not are limited to the following factors: Excess readmission ratio, aggregate payments for excess readmissions, ratios, wage adjusted DRG operating amounts, base operating DRG payment amounts and more. All of this was done of course to simplify healthcare and make it more cost effective, however, the United States spends more on healthcare per person — $9,237 — than any other country with similar life expectancies. [24]
To truly simplify the EMS component of healthcare, while also making it more efficient and cost effective, there are a number of silos that need to be hacked. The first and most essential is the redesign of systems that would allow the exchange of data, not only between EMS and hospitals but also between EMS providers. In doing so, it would allow for improved information sharing, enhanced patient care, and reduced costs. This second concern is the sharing of patient information, via EHR’s across state lines. This is an issue of substantial concern in areas where the delivery of medical care regularly crosses geographical boundaries. This a common experience for residents of the greater national capital region which encompasses Maryland, the District of Columbia, Northern Virginia, and to a lesser extent the Eastern Panhandle of West Virginia. In this area, it is not uncommon for a patient to have a primary care provider in Maryland, have surgery at a DC hospital and be required to follow up with a specialist in Northern Virginia. This also means that the patient will be dealing with three different offices of the same insurance company since insurance providers also delineate their services along state boundaries. The last, but probably the most extensive hack, is the realignment of NEMSIS from the NHTSA to HHS. One of the reasons for making this last issue is identified in Part II. Hacking Bureaucracy of Delivering on Digital: The Innovators and Technologies That Are Transforming Government, when Merici Vinton stated: “Never build a website that’s too big to fail; instead start small.”[25] This why the hacks need to start with the technology platforms, move to the regulatory issues, and finally address the structural disconnects.
While there are a number of technology platforms that allow communication between EMS and hospitals, usually it is in one direction, with other providers still using pen and paper to provide patient data, it is piecemeal at best. There must be a single solution to the problem using a unified standard of communication to allow for the complete an accurate transfer of data in a bi-directional fashion. The format for the data should be based on the ONC Meaningful Use criteria, as this standard is a standard familiar to those who work with EHR’s and is more comprehensive than the information required by NEMSIS in accordance with the NHTSA statistical driven forms. Beyond the formatting need, there is a requirement that the data flows both ways, from EMS providers to Hospitals and vice versa, and between providers both public and private. The technology platform needs to be developed through the private sector, preferably using an open source medium, in lieu of an existing or government developed system. The reason for this can be seen in the failures of other government IT projects, which includes the disastrous launches of the ACA website and the United States Citizenship and Immigration Service (USCIS) transition from paper based to online applications. The first of these failures was not only a financial loss, but it served to foster the argument by many that the government should not be in the business of healthcare. This failure led to significantly different versions of health care across the United States solely based on a person’s states of residence, leading to the next area ripe for a hack.
The issue of state borders is not about the demarcation between two states, as the flow of information does not stop at these man made constructs, it is about the bureaucratic barriers that prevent the exchange of data. A possible solution to overcome these hurdles is allowing patients to sign informed consent waivers authorizing the sharing of the EHR’s across state lines. This could be accomplished through a couple of different options, starting with primary care providers. The waiver could be provided during routine visits to the primary care provider and signed by the patient at that time. The second, but a less desirable option, would be for the patient to sign the waiver at the time of EMS care. However, this requires a patient to be cognizant and capable of acknowledging the waiver at a time when they least likely to be so. This leads to a third option, which is for states to change their laws, allowing for the sharing of a patient’s EHR’s across state lines in emergent situations, or what has been termed the Break Glass in Case of Emergency scenario.
Beyond the regulatory and consent issues, there is also the need to adjust the search engines used by medical practitioners to pull the data from the disparate systems, that use varying data elements to search for a patient’s EHR. The lack of a universally adopted standard at a national level, in regards to the legal and technical issues of exchanging EHR’s across state lines, has led some to develop pilot programs to address these gaps. As part of one such effort, the script has been flipped from the standard data pull (a manual data query) to an automatic data push which is triggered by a qualifying event regardless of where the patient is receiving treatment. The qualifying events include admissions, discharges, and patient transfers (ADT) which automatically generate an alert to the receiving facility and also sends a notice to the patient’s primary care provider(s).[26] A patient’s participation in the pilot program is based on their ability to opt in through their primary care provider. The alerts occur within in a matter seconds and allow providers to be cognizant that a patient is currently under care in another state for an existing condition. The data flow of the ADT alert process is exemplified in the illustration below.[27]
The final piece of the puzzle is to realign NEMSIS, which currently falls under the NHTSA, to be part of HHS. While this may appear to be little more than a shuffling of the deck, there are distinct differences between the two organizations. The NHTSA’s focus is on road safety and crash reduction, as seen in their mission statement “to save lives, prevent injuries, and reduce economic costs due to road traffic, crashes, through education, research, safety standards, and enforcement.” This results in NEMSIS data collection efforts, which forms the foundation of preadmission-care records, as being heavy on statistical information and light on patient care. By realigning NEMSIS under HHS, it would serve to create a single standard for health care data collection pre and post hospital admission. It would also ensure that the data collected pre-hospital admission would be compatible with the hospital side EHR, which is currently not the case. These efforts would help to ensure enhanced patient care while reducing medical costs.
Cybersecurity for Proposed Feature for a Redesigned Ambulance as Digital Service
The heavy use data and analytics in emergency medical services create expanded opportunities for hackers to intercept data and corrupt systems rendering them useless. EMS agencies use “cyber systems for system deployment, dynamic resource management, computer-aided dispatch, and billing and revenue cycle management.”[28] Using a good firewall between systems is critical but it is the least common way systems are hacked.[29] Phishing scams can be mitigated by e-mail spam filters such as Mimecast, encryption through a virtual private network (VPN) can reduce the interception of signals between MTC’s and tablets, and good social engineering practices can eliminate physical attack on cyber systems.[30] Security audits of systems are required by HIPPA and those performing the audit should be a Certified Information Systems Security Professional (CISSP) or Certified in Risk and Information Systems Control (CRISC).[31]
Redundancy is also critical in the event an EMS system is hacked. This redundancy should start with the 911 dispatch and should support every aspect of the service provided. The use of next generation 911 services, alternative numbers, expansion of trunk lines, alternatives to Emergency Operation Centers (EOC’s), additional public safety answering point facilities, diversity in public safety answering point and communications infrastructure facilities, adopting and implementing rollover capabilities in public safety answering point and EOC facilities, and creating hot continuity of operations sites with database backups are all way of achieving this redundancy.[32]
It is also important to note that only 46% of data breaches in EMS are the result of malicious attacks.[33] The majority of data breaches are through physical theft, losing equipment, and insider theft.[34] Thus it is important that extraordinary measures are made to secure all hardware on the apparatus and that there is a strict accountability for the use of all the equipment and communications. The ambulance should have all computers and communications equipment to include both cellular phones and radios outfitted with GPS tracking where alerts are given when they exceed a predetermined proximity to the vehicle. If the computers or equipment are left behind or taken from the vicinity of the vehicle, an alarm is sent to the attendants. In addition, with modern analytics, programs are available to detect “anomalous actions by employees that deviate from peer-group practices or their own previous behavior. Such behavioral analytics allow organizations to flag suspicious emails and badge check-ins, downloads, and access to unauthorized sites and assets.”[35] These tools can significantly reduce internal threats.
Finally, the EMS Service and ambulance must have a balanced and comprehensive strategy for cyber security which includes;
· Identifying the most attractive data targets for attackers
· Use of enterprise-level privacy officers to identify weak spots
· Monitor and audit third-party providers
· Remaining current on full range of tactics attackers employ
· Identify potential external and internal threats and risk profiles
· Improve risk management through collective intelligence
· Create cyberaware employee user experiences
· Run simulations to glean insights on readiness
· Evolve defense mechanisms
· Have an identified cyberattack point person
· Use of private-sector partnerships to plug cyber skills gaps[36]
[1] “Digital Strategy,” McKinsey&Company, accessed September 3, 2017, http://www.mckinsey.com/business-functions/digital-mckinsey/our-insights/digital-strategy.
[2] William D. Eggers, Delivering on Digital: The Innovators and Technologies That Are Transforming Government (RosettaBooks, 2016).
[3] City of Santa Rosa, “Fire Incidents,” Government, City Open Data Portal, (September 23, 2017), https://data.srcity.org/Fire/Fire-Incidents/5n6g-g57f.
[4] “Replacing An Ambulance With A Station Wagon,” Kaiser Health News, September 5, 2014, https://medium.com/@KHNews/replacing-an-ambulance-with-a-station-wagon-d16a9a4f2c48.
[5] Ibid.
[6] “EMS Response Time Standards | EMS World,” accessed September 24, 2017, http://www.emsworld.com/article/10324786/ems-response-time-standards.
[7] “This Man’s 2-Mile Ambulance Ride Cost $2,700. Is That Normal?,” USA TODAY, accessed September 24, 2017, https://www.usatoday.com/story/money/personalfinance/2017/05/20/ambulance-health-care-services-costs/334338001/.
[8] “Fact Sheet — Small Unmanned Aircraft Regulations (Part 107),” template, accessed July 24, 2016, https://www.faa.gov/news/fact_sheets/news_story.cfm?newsId=20516.
[9] Kimberly Bugg, “Best Practices for Talent Acquisition in 21st-Century Academic Libraries” 29, no. 4 (August 2015): 4.
[10] Maria Wommelsdorff, “Six Ways to Attract and Re-Attract the next Generation of Employees,” Consulting, Implement, (December 30, 2016), http://implementconsultinggroup.com/inspiration/articles/6-ways-to-attract-the-next-generation-of-employees/.
[11] Ibid.
[12] “Hiring and Recruiting — Five Best Methods Used by Recruiters That Your Business Should Know,” Hiring and Recruiting, Clearfit, (2017), https://www.clearfit.com/hiring-and-recruiting-five-best-methods-used-by-recruiters-that-your-business-should-know/.
[13] RK Prasad, “The Illiterate of the 21st Century Will Not Be Those Who Cannot Read and Write, but Those Who Cannot Learn, Unlearn, and Relearn,” ComLab India, September 9, 2009, http://blog.commlabindia.com/elearning-design/how_can_you_unlearn.
[14] Emily vanSonnenberg, “This Is Your Brain on Habits,” Positive Psychology News, February 1, 2011, http://positivepsychologynews.com/news/emily-vansonnenberg/2011020116315.
[15] http://www.westerncity.com/Western-City/October-2007/San-Diego-Partnership-Thinks-Outside-quotThe-Box-quot-to-Enhance-Emergency-Medical-Services.
[16] “Health Information Exchange,” TechTarget Network, Accessed September 9, 2017. http://searchhealthit.techtarget.com/definition/Health-information-exchange-HIE
[17] 78 Fed. Reg. 14793 (Mar 7, 2013).
[18] Ibid
[19] David Raths, “The Importance of Bringing EMS Systems Into The HIE Loop,” Healthcare Informatics, May 31, 2017. https://www.healthcare-informatics.com/blogs/david-raths/hie/importance-bringing-ems-systems-hie-loop
[20] Jonathan S. Felt, “‘Different Colors of Money’: Federal Funding Silos Have Hamstrung the EMS-to-Hospital data Continuum. How to Correct the Disjoint,” Becker’s Healthcare, June 23, 2016. http://www.beckershospitalreview.com/healthcare-information-technology/different-colors-of-money-federal-funding-silos-have-hamstrung-the-ems-to-hospital-data-continuum-how-to-correct-the-disjoint.html
[21] Ibid
[22] “Readmissions Reduction Program,” Centers For Medicare and Medicaid Services, Accessed September 17, 2017. https://www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/readmissions-reduction-program.html
[23] “Inpatient PPS,” American Hospital Association, April 14, 2017. http://www.aha.org/advocacy-issues/medicare/ipps/index.shtml
[24] Susan Brink, “What Country Spends the Most (and Least) On Health Care Per Person,” NPR, April 20, 2017. http://www.npr.org/sections/goatsandsoda/2017/04/20/524774195/what-country-spends-the-most-and-least-on-health-care-per-person
[25] Delivering on Digital The Innovators and Technologies That Are Transforming Government
[26] Jennifer Bresnick, “New Approach Helps Health Information Exchanges Cross State Lines,” Health IT Analytics, May 15, 2017. https://healthitanalytics.com/news/new-approach-helps-health-information-exchanges-cross-state-lines
[27] Ibid
[28] Matt Zavadsky, “High-Performance EMS: Cybersecurity,” EMS World, June 26, 2017, Accessed September 15, 2017, http://www.emsworld.com/article/217946/high-performance-ems-cybersecurity
[29] Ibid.
[30] Ibid.
[31] Ibid.
[32] Department of Homeland Security, “Emergency Services Sector Roadmap to Secure Voice and Data Systems; Risk Mitigation Strategy and Activities in Response to the Emergency Services Sector-Cyber Risk Assessment,” Department of Homeland Security, March 2014, https://www.dhs.gov/sites/default/files/publications/Emergency-Services-Sector-Roadmap-to-Secure-Voice-and-Data%20Systems-508.pdf
[33] Glatfelter Commercial Ambulance, “Risk Communique; Cyber Security — Data Breach Precautions,” GCA, 2017, http://glatfeltercommercialambulance.com/Portals/gca/RiskControl/GCA-CyberSecurityDataBreachPrecautionsCOMM-042417.pdf
[34] Ibid.
[35] William D. Eggers, “Delivering on Digital; The Innovators and Technologies that are Transforming Government,” Deloitte University Press, (New York, 2016).
[36] Ibid.
