e-Mergency: Redesigning EMS as a Digital Service

e-Mergency

Transforming Emergency Medical Services

The Internet of Things has changed our world. Staying current and relevant in this environment requires a different way of looking at problems.[1] “Digital transformation requires seeing old problems and old processes through new eyes.”[2] A paradigm shift in thinking is especially challenging for government-based organizations, who, traditionally resist change. Jena Pahlka a leading expert in the world of digital government stated, “our government is addicted to complexity in a way that isn’t serving us well.”[3] While this may have worked with legacy systems of the past, today’s evolving and fast paced world offers no room for complexity and bureaucracy especially when technology opens the door for others to provide the same services in a much more efficient manner.

The emergency service sector, specifically, the Emergency Medical Services provides the crucial link between ill or injured people and definitive care.[4] Emergency technicians are strategically placed throughout communities to rapidly respond to any given emergency in an established time frame in order to save lives; therefore, efficiency matters!

Figure 1. Emergency Services Sector[5]

As a profession, however, EMS uses a reactionary model of response. When not in use, ambulances simply wait for the next call. This works well for a tactical approach to providing emergency medical services, but unfortunately a reactionary model is often too slow to keep up with the fast pace changes in todays world. Keeping up with these rapid changes is necessary for government services to avoid becoming antiquated and left behind by faster, more nimble models. Shifting thinking and harnessing digitization will enable the emergency service sector to stay ahead of the disruptive wave created by leaner and more efficient companies who wish to compete and offer a much-preferred customer-centric service.

Proposal

This business model proposes that the EMS is primed to create their own wave by harnessing their own digital disruption to produce a better model of response, ensuring improved end user benefits, and solidifying its place in society.[6] Transforming emergency medical services requires an understanding of how the system currently works. When someone calls 911 a cascade of events take place. From the initial phone call, dispatching the appropriate level response units, to rendering care and transporting a patient to the appropriate treatment facility, there are many gaps in the process that if narrowed using digitization could improve the overall system. This paper will narrow its focus by addressing the three steps following access to 911 in the cascade — dispatch, triage/treatment, and transport.

Figure 2. Emergency Medical Services System[7]

The benefits will be vast if digitization can accomplish a simpler, more agile, customer-centric approach to emergency services. An ambulance service, that takes a flexible and iterative approach, and works with the customer to make improvements will likely find itself holding a much stronger position in this competitive world.

Staying ahead of the digital’s transformative and disruptive shift is a worthy, albeit challenging, endeavor. As noted by Dawson, Hirt, and Scanlan, it is crucial for companies to consider a forward leaning posture, harness technology, and re-think business models to better catch and ride a disruptive wave of their own than to be taken by surprise and quickly find oneself antiquated and pushed out by competition who is able to adapt quicker and easier.[8] It is this competition, which drives companies to think ahead and take ownership of developing new and innovative ways of providing customers with the best products delivered in the most efficient and effective manner.

One of the greatest challenges the EMS service faces is call volume. With over 240 million calls to 911 each year, there is an enormous demand for ambulance services and it appears the service demands are only increasing.[9] Emergency rooms and ambulance services are in desperate need of a proactive change. As calls for services continue to increase ambulance and emergency room personnel are stretched too thin and run the risk of lower quality of care for the patients. When the supply and demand for service is in flux, people suffer. Long lines in emergency rooms and slower response times by ambulances do not provide the level of care needed for positive patient outcomes. So how is this fixed? Increasing staffing and building more hospitals is slow and expensive but does provide one solution to the problem. A better solution exists in technology and digitization as seen in many other industries-think UBER, Netflix, who offer a customer-centric approach, which is quicker and cheaper than their competitors.

The emergency services sector is primed for such a proactive change to address issues of inefficiency and improve quality of care and ultimately, customer satisfaction. In fact, many places in the United State are beginning to move in that direction with the adoption of enhanced-911 — which allows for location of caller to be transmitted to the dispatch centers, wireless phases I and II, and voice over internet protocol (VoIP) telecommunications services of wireless within dispatch centers.[10]

Digitization is a game changer. It is transforming how people communicate with the emergency services sector. In 2017, the National Emergency Number Association (NENA) also known as, 9–1–1, reported, “an estimated 240 million calls are made to 9–1–1 in the U.S. each year. In many areas, 80% or more are from wireless devices.”[11] The current trend of people moving away from landline to using wireless forms of communication is a small example of how digitization is creating change. The emergency services sector must embrace these changes and anticipate the future of digitization. The privatization of emergency medical services poses an existential threat to government based systems.

As governments embark on their digital journeys, it is important to recognize that “being digital” is about far more than technology — it’s a changed mindset.[12] Digital transformation requires seeing old problems and old processes through new eyes.[13]

With platforms such as Skype, Zoom, Facetime and other forms of real time video conferencing also known as telehealth, physicians have the ability to put eyes on their patients exponentially sooner than the time it takes a patient to arrive in an emergency department. The Houston Fire Department is utilizing telehealth and reports, “roughly 80 percent of those 911 calls can be resolved without a costly trip to the hospital.”[14] If 80 percent of call volume can be eliminated and free-up highly demanded resources, the ambulance service has the opportunity to provide a much improved service to its customers.

If triage of patients can improve there is also an opportunity to use alternative methods of transportation. On average an ambulance ride costs close to $1,000.[15] Ride share services such as Lyft or Uber may offer a non-emergent transportation service to lower level of care facilities such as urgent care or a patient’s primary care physician. Freeing up the ambulances for high acuity calls such as, heart attacks, strokes, or major traumas increases the chance of positive outcomes for critically ill or injured patients.

This approach will create its own disruption wave by harnessing new technology and connecting systems that, in and of themselves, are exponentially better than latter services. This synergistic relationship may very well revolutionize the emergency services sector. However, the opposite also holds true. If technology is not harnessed to digitize medical services, the emergency services sector may find itself on the sideline watching their own demise while faster and more agile private sector services take over. Helping to direct and or staying ahead of the digital disruptive wave should be a primary focus of all emergency services.

Hacking Hiring and Training

Technology that can enhance medical care already exists and more will be developed. Government leaders must see the potential benefit of these technologies to improve standards of care, capitalize on efficiencies, and streamlines resources. This section will outline an approach for “hacking” the hiring and training needed to implement the new digital emergency services, or “e-Mergency.”

The revolution of emergency medical services by embracing technology will require leaders to maneuver traditional management processes. This will involve manipulation, or “hacking,” normal systems to not only change the mindset about emergency medical services, but to gain political support and acquire the requisite technical expertise to manage the services program. This will require constant forethought about both limitations and opportunities of incorporating technology into the way emergency medical services are provided. To that end, leaders must adopt a deliberate engagement strategy with the public to ensure that provided services will meet the public’s needs while avoiding a “huge potential for wasted time and energy.”[16] This strategy of human-centered design will require leaders and adopters of this technology to adapt technology to meet the needs of the people-not see how the needs of the people can be met with technology. This subtle difference in approach will help avoid many pitfalls associated with implementing a new technological approach to an existing problem set.

The first step involves ‘branding’ and efforts to enhance future abilities to foster a public-private sector relationship. Adopting the name “e-Mergency” will fuse traditional emergency services with a recognized naming protocol for digital technologies. Building upon the branding, political support will be critical to adopt and implement this new innovation. As Eggers points out, this effort will require “a political sponsor to champion the initiative.”[17] This champion will need to be an individual who has influence throughout the community, including and especially with government leaders, who can help drive the transformation through the bureaucracy.

Along with the political support from individual leaders, this digital transformation needs to be part of a broader comprehensive strategy to embrace technology across multiple government services. While e-Mergency will be a critical service provided to the public, it must be complemented with other digital services provided by the government. Sir Francis Maude, who helped create Government Digital Services (DGS) in the United Kingdom, recognized the value of “a digital strategy built into policy” that would be part of an “overall civil service reform.”[18] This effort will align technological shifts across the government and enhance the relationship with the public to improve services.

With political support to shift the approach to emergency medical services, systems and processes will be needed to align technology with traditional medical services. Two complementing issues are introduced here. First, physical systems and software, or the actual information technology (IT) platforms and processes, must be acquired to meet the needs of e-Mergency. Second, knowledgeable and properly trained IT personnel must be on hand to recognize proper approaches to integrating the two. The first requires research and development while the second requires hiring and recruiting.

For the first element, or research and development, existing open source options must be considered to minimize cost and time needed for developing new systems. This will also ensure that support is available since the IT systems are being utilized, even if it is in other applications. This approach has the added benefit of mutual cooperation with other municipalities or elements that may be pursuing the same goal of interfacing digital technologies with emergency medical services. Merici Vinton, who helped build the Consumer Financial Protection Bureau (CFPB), recognized three key points to building a digital capacity in government service:

1. Never build a website that’s too big to fail; instead, start small.

2. Let’s do open-source when possible (preferably always)

3. Let’s build the capacity to do in-house strategy, design and tech.[19]

Drawing from the first of these points, a key element to consider during this process is the need to scope the problem appropriately. This effort will fail if the goal is to provide a far-reaching and instant, total transformation of emergency medical services through technology. Rather, the scope needs to start small with providing a core service such as dispatch, then building out to triage services through dispatch. As Mike Bracken, who co-founded DGS with Maude, astutely points out, “no policy or service…will ever work in practice the way we thought it would in theory. We have to start out humble and rapidly iterate in response to the messy reality of real users using real services.”[20] Integrating the vast IT platforms into traditional emergency medical services will prove to be a large hurdle by itself. Focusing on this core service, and adapting it along the way to refine the initial interface with the public, will pave the way for future adaption of digital technologies across emergency medical services.

It would be negligent to not address a key challenge with integrating digital technologies into medical services. As Bracken commented regarding the need for an agile process, it is important that “you not only accept that failure is inevitable, but that it’s desirable.”[21] This is a concept that is important for creating a process that can rapidly adapt to feedback and lessons learned, and is true for most technological transformations. It has a much different application, however, when lives are at stake. While e-Mergency adoption will require an ability to remain agile and adjust to real-time feedback, it must not disregard the fact that failure could result in a life being lost. Any new process must respect the traditional roles of emergency medical services and maintain a ‘fail-safe’ backup that will ensure proper medical services can still be provided even during technology failure or when individuals do not have access to technology. For this reason, an appropriately narrow initial scope will be critical to ensuring a gradual and deliberate approach to e-Mergency.

Drawing from the second bullet Vinton cited, open-source options should be considered to minimize cost and increase accessibility by the public. Social media platforms are good examples of existing technologies that should be incorporated into the process design. Enabling access to 911 dispatch and triage services through Skype™, Instagram™, and Twitter™, for examples, should be a central element to e-Mergency. Continuous research and outreach must also be conducted to adopt new platforms into the emergency services. Lessons have been learned by government responding to natural disasters and other crises. Hurricane Harvey, that struck Texas in August 2017, provided such lessons for Houston, particularly when access to traditional 911 services was unavailable.[22]

Finally, drawing from the third point Vinton cited, personnel must be hired and trained to support this transformation. Technologically-savvy people must be attracted to government service. According to a recent survey, 77 percent of millennials stated that “their company’s purpose was part of the reason they chose to work there.”[23] Recruiting efforts, therefore, must focus on the public service and humanitarian aspects of e-mergency-the chance to save lives.

Hiring efforts need to shift away from traditional cumbersome government processes. Matthew Burton, another individual who helped build CFPB, recognized this need when he worked with his Human Resources department to make “initial application reviews less restrictive and broadened the minimum qualifications.”[24]He worked to find the best talent by looking outside normal channels that are traditionally aligned with government jobs. Outreach via social media that are popular with young and technologically-minded individuals should be adopted. CFPB even recruited by placing advertisements for open positions inside website source codes.[25] While not all-inclusive, these non-standard approaches to hiring will be important to attracting the best talent and shifting the mindset of government service.

Human Resources approaches to training and retention need to acknowledge that people will transition out as they look to build their experience elsewhere. Some of the individuals who are brought into to implement e-Mergency may be temporarily looking for experience. This goal for professional experience should be embraced. New talent should be incorporated into the digital transformation process, their knowledge needs to be tapped quickly to help build the e-Mergency capacity, and their experience needs to drive further development and innovation.

The political leadership that helped build the initial transformation of emergency medical services must also help sustain it. The leaders that manage e-Mergency must maintain political capital and constantly strive for, and demand, direct access to government leadership. Successful outreach that is aimed at improving service and enhancing the relationship with the public will help gain community support and build this political capital. By improving emergency services to the public, government leaders will be inclined to support and expand the digital adoption strategies. In order to sustain the progressive transformation of emergency medical services in a digital age, this will be critical to aligning the technological development across all government services and will ultimately help the people it serves.

Hacking Procurement

The e-Mergency design focuses on the component of call taking and dispatching. Successful procurement for this element will be accomplished by using several techniques.

Collaboration

As we develop the various required items, we will need to ensure there is a great deal of communication between all segments of the project. There should be continuous dialogue between those developing, procuring, implementing, and the end user. Emphasis and consideration should be given to the end user and they should be integral in the decisions and development of this system.[26] The end user is not only the patients that will be served but the employees who will be operating the system as well as physicians and medical personnel who will be diagnosing calls coming in. All of these groups should be considered as end users and they need to all come together to discuss best practices.

Agile Development

The system will be developed in smaller segments to prevent mass failure. Often times private and public corporations attempt to create large complex projects that result in failures.[27] By working on smaller parts of the project and pushing it through to completion we stand a better chance of being successful. If the one small segment does not succeed we have not expended an inordinate amount of time, money, and effort and are better suited to learn from our mistakes and start over. For instance, in this project we should start by focusing only on the call taking of request for medical service. Specific details required such as software, hardware, and personnel need to be analyzed to determine the effective way to proceed. Once the details of the call taking component have been finalized to satisfaction we will then drill down on the dispatching component.

Procurement Process

In procuring the various components for this project, we need to require specific deliverables from those desiring to provide services. Our Request for Proposal (RFP) should be time sensitive allowing a quick turn-around time-possibly three weeks. We should require a short and concise concept paper-no more than eight pages along with a cost proposal. This succinct requirement will eliminate those vendors who provide inconsequential data in an effort to lead us on with volumes of innocuous documents. We should be open to receiving proposals from a wide variety of vendors not only those considered to be familiar with our subject matter. Being open minded to a variety of ideas and concepts from various vendors will allow us the ability to consider innovative models for our design.

After we review the proposals, we will request the top six contractors to submit actual working prototypes of their products. This type of vetting is effective in that it causes the vendor to show what they’re capable of rather than just explaining what they can do. We can then narrow the vendors down to the top four and offer them financial incentives to produce a working product. The vendors will be required to provide teams of personnel who will work in conjunction with members from other teams in an effort to deliver the best product. We will evaluate how well the members from each team collaborate with those of other teams as a determining factor as to which vendors continue on with the project. This form of recruitment for vendors or contractors is referred to as Flexible Agile Development Services (FADS) and has proven to cause vendors to be more competitive and excel as they attempt to impress the client in order to maintain a contract.[28] The contracts we enter into with vendors should be short in duration. This will allow us to change course if needed without being obligated to any specific vendor. The short term limits will also cause vendors to work harder to produce positive results so that they can continue to do business with us.

Security of the System

The fundamental core of our digital ambulance will be tied to the internet and cyber-related technologies. Once designed, we will need to take steps to ensure security of the system and clients we will be serving. Cybersecurity needs to be considered during the design phase of our system and throughout the lifetime of our product. Knowing that perfect cybersecurity is impossible, we need to build a system that is keen on detection, response, mitigation, and resilience.[29] Prevention of a cyber-attack to the system would be ideal; however, there is no currently known full proof preventative measure against an attack. Thus, quick detection, mitigation, and recovery should be a key focus of our design.

Understanding that it is virtually impossible to prevent an attack or breach of our system we must plan to manage the risk with appropriate safeguards. One such precaution would be that the system requires a two-factor authentication for basic access. The operator logging into the system would have to input a password and ID number. All operators need to be educated on potential threats and how they can prevent hackers by not opening unknown, untrusted sites. The system should be designed with a built in “whitelisting” application which would prohibit unauthorized and malicious programs by blocking unknown executable files and software libraries.[30] Administrators who generally have all-encompassing clearance rights need to be ever vigilant when accessing sites that may allow malware to infect the system. This type of intrusion may be described as an unintentional insider threat.[31] In order to prevent this type of breach of the system administrator’s privileges should be restrictive with stringent oversight. Our system should be designed with the concept of “cyber hygiene;” built in safeguards of automatic upgrades and patching when anomalies are detected.[32]

Collective Intelligence and Reconnaissance

The idea of collective intelligence is for various agencies and organizations to share their data and information on attempted hackers and breaches.[33] We should continuously network with a multitude of agencies-not only those affiliated with a similar business, but those who use the internet as a primary mode of doing business. Other companies may be aware of malware or hacking techniques and by collaborating with each other we can prevent breaches to our system.

In order to protect our system we need to dedicate an effort to cyber reconnaissance, the exploration of cyber-criminal activity from the viewpoint of the criminal. We accomplish this by infiltrating the dark web and observing the cyber criminals tactics so we can avoid being targeted or able to defend impending attacks.[34] Another tactic we should employ in the realm of reconnaissance is the use of decoy information. Once we determine the attractive data hackers are seeking, we can activate fake servers with false information.[35] This method will cause hackers to expend time and effort on a fraudulent system while we maintain a secure network. There are no guarantees in this format and it will be timely and costly. It is, however, another tool in our effort to function in a safe environment.

Training for Breaches

In a continuing effort to protect our network, we need to participate in cyber “war-gaming.”[36] Similar to a table top exercise, this is an application in which we simulate our system being hacked or infected with malware and test our organization for response. This exercise will keep us sharp and test our capability of readiness and resilience. This drill may also cause us to think outside the box of possible vulnerabilities which in turn will help us to prepare for and possibly thwart real life attacks.

Ultimately, the best protection of our digital ambulance system is “perpetual unpredictability.”[37] That is, we continuously anticipate a cyber-attack and we keep moving, changing, and planting fake information or servers, and transfer data to various locations.

Hacking Silos

According to Delivering on Digital, one of the greatest areas of focus in developing and advocating for the adoption of innovations such as the digital ambulance model should be in eliminating duplicative, overlapping, inefficient, and/or obsolete elements from the environment, system, or process. These redundancies and extraneous components exist primarily because individual stakeholders of complex systems and processes tend to be self-interested, non-integrated, and/or hamstrung by rules and regulations. Consequently, the process or system is filled with disconnected and inefficient components known as “silos” or “stovepipes” that make the system slow to adapt and more complex than it needs to be. There is no question that the current ambulance service model contains a number of silos upon which it is dependent: the 911 dispatch system run by the municipality; the EMT and ambulances’ physical location and operating procedures governed by the local fire department and stationed at firehouses or hospitals that may not be optimally located to reach constituents; the route or navigation system relied upon to respond to the scene as quickly as possible; the system of gathering information from the patient for initial treatment; and handoff of the patient from an ambulance to a given hospital, to name a few.

Since our goal is ultimately to improve the effectiveness and efficiency of the ambulance service for patients, taxpayers, first responders, and medical practitioners, a key element of our digital ambulance proposal aims to “hack these silos.” Every part of the process, including 911 dispatch, EMT services, ambulance transit, patient onboarding, information gathering, initial treatment, and hospital delivery could theoretically be standardized and shared across stakeholders. This not only gets needed treatment to the patient as quickly as possible, it also saves money. Eggers contends that “Whenever multiple agencies carry out common processes — payments, payroll, authentication, reservations — they can save considerable amounts of money by sharing systems.”[38]

The digital ambulance model potentially disrupts a number of silos once seen as essential to EMS and ambulance delivery:

  • The EMT: Does measuring of blood pressure and temperature, administration of oxygen or simple medications, have to be carried out on by a certified EMS technician? With simplified technology, automated instructions, or a remote dispatcher offering instructions, an ambulatory patient or a friend, family member, or Good Samaritan riding with them could accomplish this without the need for an EMT on board. This would mean that ambulances could often race to the scene without the need to wait for an EMT to get ready, still transport a patient to the nearest hospital quickly, and would be lighter and more fuel efficient in the process.
  • Fire department EMT programs: When a medical technician is needed for a particular call, does it have to be someone from the fire department? Police officers on patrol, personnel at local hospitals and clinics, and on-call emergency management specialists could be trained and certified in the services required during an ambulance transport. If so, perhaps they could all be given phone apps, RFID chips, or dongles that would allow them to be digitally pinged to determine the closest available qualified helper near each location to which an ambulance is dispatched, and report to the scene as quickly as possible (under their own power or picked up by the ambulance before or after the patient as appropriate).
  • Firehouse garages: Do all ambulances have to be stored in the physical silos of hospitals and firehouses? They could instead be strategically positioned them throughout the city to be optimally located to respond. These positions could be dynamic, changing throughout the day based on available data regarding population shifts such as work and school hours, traffic issues, and special events such as a local sports game. In this way, precious time and fuel is saved, the fire department/EMS is no longer a single point of failure, and successful response does not depend on the location, staffing, and current workload of the nearest firehouse.
  • 911 dispatch: Is a human dispatcher needed to field all calls? The digital ambulance service could be directed by an intelligent system automating the process of sending ambulances and equipment as needed for each situation. After launching the ambulance, the system could patch in a trained technician when expertise and ongoing communication are needed or requested. This saves money on manpower, mitigates operator error, and solves the problem of call volume exceeding the number of available operators.
  • GPS/mapping system: Is existing ambulance service GPS-based navigation truly the most efficient way to get an ambulance from Point A to Point B? A system integrated with crowdsourced and local DOT data could not only send the ambulance on the most efficient route through traffic at any given time, but also actively divert traffic and re-synchronize stoplights and even drawbridges in order to free up the route at the right moments all the way from the starting point to the incident and from the incident to the hospital when needed. In addition to cleaning the ambulance’s path, this could also be of benefit to the drivers in traffic who would have otherwise needed to yield to it unexpectedly. Once self-driving cars become the norm, ensuring cars do not block the ambulance’s path or fail to yield will be even easier across an integrated system.
  • Jurisdictional boundaries: Should a person in distress near the edge of one city, county, or even state line who is physically closer to an ambulance service in a neighboring jurisdiction, whether due to distance or traffic, really have to wait for the “hometown” ambulance to respond? With a standardized system and reciprocal agreements, patients could get adequate response from wherever makes the most sense geographically and chronologically, every time.
  • Proprietary technology and infrastructure: Should our company or any municipality necessarily even create proprietary solutions for each of these ideas? We could work with app developers and cellular carriers to have an Uber-like app pre-installed on phones (or at least freely available) to hail an ambulance and transmit necessary location data, patient biographical information, pertinent vitals, any special medical needs, health insurance specifics and hospital preference. Perhaps when an incident requires a live technician to talk the patient and anyone assisting him or her through first aid steps while waiting for the ambulance to arrive, and takes place in a location using network-connected CCTV, the technician could tap into the feed to have a visual on those he or she is guiding. Perhaps Tesla, Chevrolet, or another company whose self-driving technology is progressing nicely could be awarded a contract to administer driverless ambulance services rather than developing new proprietary system. Like the FCC under David Bray, we should “consider writing code only after all other avenues are exhausted.”[39]

Eggers suggests that getting “buy-in” from all pertinent entities often requires presentation of the value standardization and silo elimination would add. The value the digital ambulance model creates for citizens is obvious: if you or a loved one is hurt, the ambulance and any needed emergency responders arrive sooner and get the patient to the hospital quicker, the threat of pertinent medical information being miscommunicated or forgotten is mitigated, tedious and confusing paperwork is eliminated, and both patient and taxpayer cost is eliminated. Municipalities would save money on fuel efficiency, firehouse footprint, and reduced demand for professional manpower from drivers to dispatchers to full-time EMS technicians. Hospitals stand to save money and time on the ambulance handover and patient intake process. Insurance companies could even benefit from a likely reduction in claims re-processing and investigation that tends to result from fielding information from multiple entities that bill for individual services and collect initial patient information differently.

Furthermore, if our model could be shared with hospitals and ambulance services throughout the country, the cost of maintenance and improvement for our software could drop, anyone needing medical services more than once across multiple jurisdictions could be served instantly with minimal information gathering, and best practices could easily become standard, increasing the quality of ambulance services for all. As Van Hitch, the Department of Justice’s Chief Information Officer responsible for founding the National Information Exchange Model, “Standards like NIEM have a network effect. The more people who use them, the more data exchanges that are built off them, the better and more valuable they become.”[40] A standardized system handling digital dispatch, patient information and assistance throughout the nation would be faster to update and improve than local siloed systems since there would be no need for IT specialists in every single jurisdiction to individually learn, perform, and train users on upgrades to their unique systems.

Hacking Delivery

Delivery is defined as “the carrying and turning over of letters, goods, etc., to a designated recipient or recipients” or “a giving up or handing over; surrender.”[41] Normally when referencing or having discussions about delivery it is in the context of a verb such as an action. There are the routine visualizations of parcel services or services. Or, a discussion about the merits of an inaugural or commencement speech whereas ‘wow, he really delivered on that.’ But, in order to successfully rethink and transform the ambulance of the future we must focus more of delivery as a noun or product using the concepts of Delivering on Digital as an activation of the modern ambulance as opposed to the zenith of conventional ambulance services.

Rethinking and reimagining service delivery should always begin with the user’s requirement rather than the existing programs. This means focusing foremost on patient’s actual needs and touch points, even if they don’t fit or reflect current operating model.[42] Understanding whether a design is good or not sometimes is obvious but sometimes it isn’t. The current design around ambulances and ambulance medical services is founded around evacuating a casualty expeditiously from a battlefield. Because battlefields are largely dangerous places, casualties must be withdrawn from one location to a safer location as fast as possible to receive medical treatment. This model is important given the dynamics of combat and getting traumatic wounds addressed as soon as possible, but are the criteria exactly the same in a non-combat environment? To address the question and rethink the concept using Delivering on Digital methods requires imagining a different reality in the future and reflecting on what design actually means. A different design for design’s sake doesn’t equate to a better design. “Design is an approach to problem solving,” says Hillary Hartley, deputy executive director at 18F. “It’s how you think about something. It’s not the typefaces; it’s not the pixels. Design is what makes a product successful. It’s the thing that makes it useful, that makes it understandable.”[43] To transform everything known about ambulance services by implementing digital technologies, we break away from traditional organizations that are based on value-chain theory, which put the end user or customer at the end of the process. Our digital delivery model implementation organizes the business model into three phases to create a customer-centric experience that meets core requirements for effective service to our citizens. These stages and processes are to be built with agility as a building block, thoroughly tested and operated by evaluating end-user needs regardless how much transformation is required.

Design Strategies.

The e-Mergency digital ambulance service is nested in ‘user-centered’ design for a new and more successful medical services business model. E-Mergency will task-organize its services based on the requirement, not the capability. This strategy is based on determining best practices from real world experiences from those who have used ambulance services. Current Standard Operating Procedures (SOP) for ambulance operations are not necessarily the required norm and agility in response will be based on pre-response triage data in order to determine what level of ambulance reaction is required or best meets the call. The e-Mergency design group is basing ambulance prototype design on ‘asset to task’ determination. Basically, there will be different categories of ambulances based on the categories of risk to the patient’s survivability of the specific injury, illness or diagnosis. Current data indicates that determining the anatomic region of every wound, probability of fatal injury, and whether the wounds are potentially survivable assumes pre-hospital care within ten minutes and definitive trauma center care within 60 minutes.[44] These times to care data points are commonly referred to as the “Platinum ten minutes” and the “Golden Hour.”[45] This ‘asset to task’ ratio will be allocated on pre-assessment checklists codes that are delivered rapidly during the initial call on mobile phone software. E-Mergency designs its response capabilities in concert with the actual requirement of the patient. For example, in the case of a patient that is in imminent peril of death due to cardiac arrest the response would be specifically assigned to getting a cardio respiratory asset dispatched rapidly to the sight. Speed and immediate life-saving care would be the priorities and therefore require sending an e-Mergency asset designed for speed as opposed to a full service ambulance that is cumbersome and slow would respond. Based on the data and calculated routes for speed, the traffic lights would receive special codes, which suspended all traffic while the e-Mergency responding unit sped to the scene. This approach, based on critical data, would far exceed the results of current ambulances that are large, cumbersome, bulky, designed for stabilizing patients in ‘mini triage’ stations in the ambulance’s cargo area. These awkward behemoths rely on loud sirens to alert traffic congestion to make way, but a faster ambulance designed for speed combined with route clearance options could get the life-saving care on scene faster and transported to advanced care sooner. Speed in getting the casualty to a definitive trauma center in particular cases will diminish the need for slower full-service ambulance designs.

Delivery Strategies

‘If it isn’t broken, break it.’ In accordance with the lessons learned in Delivering on Digital the concepts of delivery will be based on practical exercises, lessons learned and agility. In short, this means that while the focus on ‘asset to task’ design is sound, its actual effectiveness will be closely monitored and assessed to continuously improve it. This is a delivery strategy based in digital ‘learn by doing.’ Changing the way things have always been done can be an uphill climb, especially in the public sector. How do you get skeptics on board? By encouraging them to try the new approach and learn as they go. Whether it’s agile sprints or design thinking, a hands-on approach can improve understanding and debunk myths and prejudices.[46] Constant appraisal of effectiveness is crucial to creating the best ambulance of the future. Determination of why a design isn’t functioning to the projected level facilitates the identifying the delta, which then allows for analysis of estimates of how to correct or replace the shortcoming. E-Mergency must create a business model whose atmosphere not only permits but encourages, rewards and welcomes concept and idea contribution from the practitioners of our products and services, the patients, end users and recipients to the top of the e-Mergency policy approval tiers.

While e-Mergency fosters a creative and effects based program, it must also manage to remain agile. Part of the failure of legacy systems is the refusal or inability to adjust to changing conditions, technology advancements, industry trends, or end user requirements. In short, a failure for an ambulance company or service to be agile in the digital age of technological improvements, healthcare breakthroughs, and service norms will be its downfall. For example, the modularity of treatment systems is rapidly changing the expectation of when or even if a patient should be admitted to a hospital. The level of care outside of treatment facilities by qualified medical professionals is meeting the needs of people that would otherwise have to travel to the hospital, receive initial consultation at the hospital, and then be admitted. Due to technological improvements in modularity, these trips to the hospital can be re-evaluated and diagnosis made in the very living rooms of the patient. Also, with increases in medical technology, there is a potential for “inverse medical transport.” The same service that e-Mergency provides getting patients to the hospital could also be used to get them back to their residence or point of origin. This is an unintended byproduct of advances in medical technology that is increasing hospital and urgent care proficiency, which in turn is producing shorter stays in hospitals. Patients that, in the past, might be spending days or weeks in recovery after surgeries in order to be observed are now being released within hours or in some cases minutes due to technological breakthroughs in short-acting anesthetics.[47] The market for receiving professional medical transport after short-term hospital stays has potential for expanding the ambulance service due to these and other technological advancements. E-Mergency must remain agile enough to identify and adapt to such opportunities.

Operation Strategies

Operational strategies include, but are not limited to, using available data from existing services and operations to modify or ‘tweak’ methods. Delivering on Digital refers to this as “feedback loops” or “data analytics.” It is the ability to adapt to delivery by fine-tuning services to enhance effectiveness or improve the customer’s experience. Part of this procedure is easily quantifiable data including statistics of survivability as a direct result of efficient processes. In other words, does the data available support the use of categorized response units based on supposed threat to the patient’s life? Have the digitized codes for patient or caller initial diagnosis demonstrated a significant increase in the likelihood of a patient’s survival? These feedback loops can also be measured by collecting information by a series of questions indicating level of satisfaction in performance as part of completing the service contracts with customers. Delivering on Digital engages the customer and thereby empowers them to shape the business model through their experiences, which allows for operational flexibility to meet these expectations.

In summary, the task of this design challenge by “re-thinking” and “transforming” everything known about an ambulance requires a complete paradigm shift. This considers not just using digital technology to make something better or more effective or efficient, but reengineering the entire concept based on a new and previously unknown criteria that is nested with the evolution of technologies as they are already interacting in everyday life in the twenty-first century. The outline for this is creating a digital delivery methodology for future ambulance services utilizing a series of key aspects including: design, delivery, and operation. While it must be customer-centric it also must fully implement the technologies available and the probability of where the next stage of technology growth will be most useful. Accumulated information and synthesizing the available data is required to rapidly analyze the most logical response and create a more successful ambulance service. Responding faster and arriving earlier doesn’t help if the needs of the patient aren’t clear and the capabilities to best serve the patient isn’t available. Likewise, arriving with an overabundance of medical, psychological, and behavioral assistance options when the patient is simply off his or her medication is a misuse of expensive resources. This approach can eventually bankrupt the ambulance service. ‘Asset to task’ assessment, therefore, is a critical component in making the e-Mergency ambulance service work effectively and compete against legacy ambulance systems. Data assessment to allocate the necessary response to the call is just as important as achieving a faster response time than what is currently the norm.

Conclusion

Transforming emergency medical services in the digital age will require a fundamental shift in attitude. As Eggers asserts, adapting to the digital age “is about far more than technology — it’s a changed mindset.”[48] He goes on to state that “Digital transformation requires seeing old problems and old processes through new eyes.”[49] This shift in perspective is essential to transforming a field such as emergency medical services that has been built from experience and learning from mistakes. The old processes of telephonic dispatchers and limited triage services prior to the arrival of medical personnel must be adapted to embrace new technology. With this approach, e-Mergency will revolutionize emergency medical services to optimize efficiency while improving patient care.

[1] William D. Eggers, Delivering on Digital: The Innovators and Technologies That Are Transforming Government (Kindle Locations 412–413), RosettaBooks, Kindle Edition.

[2] Ibid.

[3] Ibid., Location 531.

[4] DHS, “Emergency Services Sector,” Emergency Services Sector | Homeland Security, accessed September 15, 2017, https://www.dhs.gov/emergency-services-sector.

[5] DHS, “Emergency Services Sector,” Emergency Services Sector | Homeland Security, accessed September 15, 2017, https://www.dhs.gov/emergency-services-sector.

[6] Eggers, Delivering on Digital, Kindle Edition, Location 3551.

[7] EMS.gov, “What is EMS?” What is EMS? , accessed September 18, 2017, https://www.ems.gov/ whatisems.html.

[8] Angus Dawson, Martin Hirt, and Jay Scanlan, “The economic essentials of digital strategy,” McKinsey & Company, March 2016, http://www.mckinsey.com/business-functions/strategy-and-corporate-finance/our-insights/the-economic-essentials-of-digital-strategy.

[9] “National Emergency Number Association,” 9–1–1 Statistics — National Emergency Number Association, accessed September 11, 2017, https://www.nena.org/?page=911Statistics.

[10] “National Emergency Number Association,” 9–1–1 Statistics — National Emergency Number Association, accessed September 11, 2017, https://www.nena.org/?page=911Statistics.

[11] Ibid.

[12] Eggers, Delivering on Digital, Kindle Edition, Locations 411–413.

[13] Ibid.

[14] MHealthIntelligence, “Telehealth Helps Houston FD Improve 911 Efficiency,” MHealthIntelligence, April 11, 2016, , accessed September 14, 2017, https://mhealthintelligence.com/news/telehealth-helps-houston-fd-improve-911-efficiency.

[15] Lisa Zamosky, “Ambulances: Basic info about a service you may take for granted,” Los Angeles Times, January 26, 2014, accessed September 16, 2017, http://articles.latimes.com/2014/jan/26/business/la-fi-healthcare-watch-20140126.

[16] Eggers, Delivering on Digital, Kindle Edition, Location 463.

[17] Eggers, Delivering on Digital, Kindle Edition, Location 745.

[18] Eggers, Delivering on Digital, Kindle Edition, Locations 747–760.

[19] Ibid., Locations 698–711.

[20] Eggers, Delivering on Digital, Kindle Edition, Location 581.

[21] Ibid.

[22] Lauren Silverman, “Facebook, Twitter Replace 911 Calls for Stranded In Houston,” National Public Radio, http://www.npr.org/sections/alltechconsidered/2017/08/28/546831780/texas-police-and-residents-turn-to-social-media-to-communicate-amid-harvey (accessed September 1,, 2017).

[23] Deloitte, “Mind the gaps,” 2015 Deloitte Millennial Survey, Executive Summary, 3, https://www2.deloitte.com/content/dam/Deloitte/global/Documents/About-Deloitte/gx-wef-2015-millennial-survey-executivesummary.pdf.

[24] Eggers, Delivering on Digital, Kindle Edition, Location 723.

[25] Ibid.

[26] Eggers, Delivering on Digital, Kindle Edition, Location 1891.

[27] Eggers, Delivering on Digital, Kindle Edition, Location 1947.

[28] Eggers, Delivering on Digital, Kindle Edition, Location 1969.

[29] Eggers, Delivering on Digital, Kindle Edition, Location 3046

[30] Ibid., Location 3110.

[31] Ibid., Location 3088.

[32] Ibid., Location 3080.

[33] Eggers, Delivering on Digital, Kindle Edition, Location 3122.

[34] Ibid., Location 3145.

[35] Ibid., Location 3129.

[36] Ibid., Location 3204

[37] Eggers, Delivering on Digital, Kindle Edition, Location 3129

[38] Eggers, Delivering on Digital, Kindle Edition, Locations 2297–2298.

[39] Eggers, Delivering on Digital, Kindle Edition, Locations 2373–2374.

[40] Eggers, Delivering on Digital, Kindle Edition, Locations 2454–2455.

[41] Dictionary.com, http://www.dictionary.com/browse/delivery?s=t

[42] Eggers, Delivering on Digital, Kindle Edition, Locations 1251–1254.

[43] Ibid (location 1249)

[44] The Profile of Wounding in Civilian Public Mass Shooting Fatalities, 2016 Wolters Kluwater Health, Inc., p 8.

[45] National Association of EMTs and the American College of Surgeons Committee on Trauma. Prehospital Trauma Life Support. 8 ed: Jones and Bartlett Learning; 2013.

[46] Eggers, Delivering on Digital, Kindle Edition, Locations 1624–1626.

[47] “BBC News | Health | Short Recovery Times Cut Hospital Stays.” Home — BBC News. Accessed September 23, 2017. http://news.bbc.co.uk/2/hi/health/196633.stm.

[48] Eggers, Delivering on Digital, Kindle Edition, Location 411.

[49] Ibid.

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