Electronic Emergency Medical Services (E2MS)

As this graphic illustrates, it is impossible to talk about one facet of healthcare without considering all of it…

Section 1: Why EMS is ripe for digital disruption

In order to understand why emergency medical services (EMS) are due for digital disruption it is necessary to understand how most modern EMS systems work and which components of the system are most suitable for disruption. This section will describe what the goals of modern EMS systems are, how they are accessed, and how they work. As it describes these components, it will point out how these components can be disrupted or hacked to increase customer satisfaction and decrease total health care system costs. The section will conclude with a brief description of what exactly digital disruption is.

For the purposes of this entire paper, emergency medical services will refer to the systems of health care that are accessed through 911, that treat the patient at the physical location of the scene of an emergency, and then subsequently transport the patient to definitive care. This paper will not address the routine transportation of patients between skilled nursing facilities and hospitals, or of patients between hospitals, as these types of interfacility transports are not usually time dependent or commonly understood to be part of traditional EMS. However, many of the same disruptive forces facing traditional EMS may soon overtake the interfacility transport industry.

The Goals:

EMS systems are built with the goal of having emergency care resources (trained people, vehicles, and portable biomedical equipment) reach a critically ill patient in an almost immediate manner, medically stabilize the patient (i.e. keep the patient from deteriorating further), and then transport the patient in the most expeditious manner to the closest appropriate receiving hospital.

But is this the goal of the public at large? The type of calls, and the growth of a particular subset of calls suggests that the public at large uses 911 when they have nowhere else to turn, or at least nowhere else convenient to turn, when they are experiencing a wide range of health issues and they do not have transportation and/or access to health care when and where they want it.

The call load of the Montgomery County Fire/Rescue Service (MCFRS) is illustrative. MCFRS EMS calls for service can be divided into 5% high acuity (ALS2) (cardiac arrests, severe respiratory distress, etc.), 38% moderate acuity (ALS1) (chest pains, heart attacks, strokes), and 57% low acuity (BLS) (flu patients, check ups after motor vehicle accidents, abdominal pains etc.). As shown below, MCFRS is experiencing a call growth rate of approximately 3% a year, but the growth rate is disproportionately adding to the number of the low acuity calls, such that the low acuity calls are growing in preponderance.

This would suggest that the goals of EMS systems, are not in congruence with what the public wants. EMS system managers want to make sure that they have sufficient resources to quickly treat and transport the most serious of emergencies; however it appears that the public, or at least a large segment of the public, views EMS as the portal to on-demand primary health care.

In the McKinsey and Company article “How vulnerable are you to digital disruption,” the authors identify certain characteristics in demand as predicting disruption. Two are of interest here: “your customers have to buy the whole product or service when they only want a part”, and “your customers can’t get what they want where and when they want it.”

In the former characteristic, EMS works as a monolithic, single pathway model. Regardless of whether patients just need timely self-care advice, or simply transportation to primary care, the American EMS system provides at least two highly trained individuals, a plethora of equipment, and usually only offers transportation to the emergency department of a nearby hospital. Most EMS providers are actively discouraged by their managers, insurers, and medical leaders from leaving the patient at the scene, and regulatory barriers prevent EMS providers from transporting patients to anywhere but hospitals or emergency departments. The patient may just desire a simple ride, or someone to simply look at his wound and throw in a couple of stitches and a tetanus shot, but by calling 911 he is going to get treated the same as if he were suffering from a heart attack that requires immediate care and transportation to the ED.

In the later characteristic, EMS suffers for the sins of the healthcare system as a whole. Patients are encouraged (or required) by their insurers to enroll with a single primary care physician or practice which should in theory take care of most of their routine health care needs. However, most practices require patients to make a telephone call to schedule an appointment, which is usually not available for a day or two (or three), and require the patient to come to a doctor’s office. Primary care practices are usually only open during the business day. After hours patients, or patients who have little or no access to primary care resources, and/or little access to convenient or cheap transportation, know that they can call 911 and have a free (at least for the moment) vehicle show up at their door in ten minutes, which will take them to the hospital to receive at least some care.

It is true that urgent care centers and practices have sprung up to fulfill the need for afterhours or at least more convenient care for less critical walk-in patients. However, just about all urgent care centers require payment (or proof of insurance) up front, and in just about all states, EMS systems cannot deliver patients to these centers.

To summarize, an EMS/health care system which allowed patients access to timely, cheap and physically convenient healthcare, would better meet the expectations of the majority of EMS customers, and would no doubt lead to a dramatic decline in the amount of patients required to be immediately accessed and transported to an emergency room by trained EMS professionals.

Access to EMS:

Most EMS systems are accessed by dialing 911 and talking to a dispatcher. Some EMS systems do have the ability to receive text messages. There are no EMS systems that are accessed via apps. When a patient, or a member of the public calling for a patient call 911, they are put through a scripted set of “emergency medical dispatch” (EMD) questions that are designed to identify the location and phone number, detect the acuity of the patient and send the appropriate amount of EMS resources. This process often takes longer than 2 minutes. In the event that the call taker detects a cardiac arrest, they do have the ability to “short circuit” the process and send immediate assistance, while they continue to ask questions and/or instruct the caller in CPR. Even though EMD screening tools have been around for more than 20 years, most members of the public perceive that all that they have to do to access EMS is to pick up the phone and ask for an ambulance. After a few EMD questions, it is not unusual for callers to refuse to answer any more questions and simply demand the sending of an ambulance. Other items that frequently cause friction during the dispatch process is that there is no way for the caller to know how quickly EMS providers will arrive, Indeed there is often no way for even the dispatcher to know this information either.

Compare this process to the average Uber experience. Uber users can order a ride simply by typing in a destination address, and then confirming location and tapping the request button. They know exactly where the uber is coming from and when it will arrive. Uber uses the data gleaned from the app to predict demand, and set pricing, and to constantly improve the user experience.

Essentially, modern 911 systems are no better than the traditional means to order a taxi which was brutally disrupted by uber and lyft. In the above cited McKinsey article, it is recommended to “undistort demand” by “streamlining order processes and making them more user-friendly”. A 911 app that emulated uber and allowed 911 customers to answer EMD questions quickly by buttons or drop down menus, geo-located the user, and gave an expected ETA, could only improve the user experience. For many if not most EMS calls, it would be unneccessary for a human call taker to ever talk to a patient — and the patient would get quicker service. The app could be done by a design process and through the use of the big data collected by the app, the shortest possible path for predicting patient acuity could be identified, not to mention more precise demand for data service.

911 systems are mandated to offer text services by 2018, and “next-gen” 911 systems are supposed to offer access to video streaming and other smart-phone friendly systems. However, there are very few 911 systems across the country that will meet this mandate on time.

Personnel:

Most EMS systems use three levels of personnel to fulfill service needs. Personnel who provide direct care and transportation are either Emergency Medical Technicians (best suited to low acuity care or non-invasive techniques such as CPR) or Paramedics (best suited to high acuity care and invasive techniques such as IV medications, advanced airways etc.) and personnel who answer and dispatch 911 calls are Emergency Medical Dispatchers. Barriers to training are high with most training being offered at a community college, or directly by a EMS organization. Training programs usually have to meet standards set by a state or national regulatory agency. Training levels are high due to the many conditions which EMS personnel may encounter. EMS providers usually operate under a set of written protocols, and these are expected to be memorized. Real-time consultation with a physician or nurse is usually only available through verbal radio transmissions, and thus EMS providers are usually expected to operate fairly autonomously within their protocols, and thus are required to have strong assessment skills and the ability to quickly decide which protocol a patient falls into.

Turnover of trained personnel in EMS is endemic, and it is extremely rare to find a street-level EMT or Paramedic retiring from EMS after 25 to 30 years. The physical and mental stresses of the job create a lot of burnout. However, recruiting and training personnel is an ongoing burden on EMS organizations, and loss of trained employees creates substantial problems.

With the exception of lifting and carrying patients, the physical tasks that EMS workers carry out are not hard, and because of the need to be ready for all emergencies at all times, the vast majority of their skill set is under utilized on any single EMS incident. A 911 app which did a better job of discriminating between patients who simply need a ride, and those who truly require care and stabilization at the scene before being transported, could lead to an agency needing fewer highly trained personnel and more efficiently using the ones that it does have.

More use of streaming video could also lead to a more hands on style of medical direction, where physicians or mid-level practitioners could do the thinking from afar, and simply direct the EMT or Paramedic on what to do, or create a new class of EMS workers that has minimal knowledge of medical decision making but operates under the direction of a remotely located paramedic. Under both models, such personnel would take less time to train and would be less of a drain on EMS systems when they leave employment.

Regulatory / Economic environment:

Vehicles: Modern ambulances cost upwards of $150,000 and have an expected service life of 5 to 7 years. Most states have strict design and construction standards for ambulances, and also have some sort of a licensing and inspection scheme to ensure that the vehicles are roadworthy and stocked with all required equipment. EMS agencies are typically not allowed to transport patients in cars or other non-ambulance vehicles.

Ambulances are allowed priority through traffic by use of lights and sirens. There are existing systems which also change traffic lights to give ambulances priority through intersections. Existing systems are based on infrared emitters, and are fairly expensive, and thus have not seen penetration into all areas of the country or the world. However, 2nd generation systems based on GPS transmitters and designed to integrate into traffic control systems, are now coming onto the market.

Ambulances, so far, have not been part of the self-driving vehicle revolution. However, as this technology becomes more ubiquitous and safe, it is not hard to imagine a future where EMS personnel are free from the responsibility of driving to and from the scene and are therefore freer to communicate with patients and other medical personnel. This may lead to a future where dispatchers spend very little time talking to patients but very quickly hand them off to the responding EMS crew to begin self care and answer assessment questions. As explored further in Section 2, self driving ambulances or cars may also reduce or eliminate staffing requirements for certain categories of patients.

Self driving vehicles, drones, and robots although not presently in wide spread use, also show great promise for the rapid delivery of AEDs and other time critical devices (or medications) for the purpose of self or first aider care. Such autonomous delivery mechanisms may also be of value for delivering tourniquets and bandaging supplies to patients temporarily isolated by terrorist activities.

Organizational finance: EMS organizations usually have an exclusive, government granted, license to provide such services in a defined geographic area. In exchange for this exclusive arrangement, the EMS service has to provide enough licensed vehicles and trained staff to meet government expectations of response times and quality of care. EMS organizations typically are compensated directly by government tax dollars, and/or by billing health insurance companies. Insurers typically only pay EMS organizations when the patient is transported, and such payments usually only come in one of three tiers depending on the seriousness of the patient. Private insurers usually pay the full asking price of the EMS organization, while Medicare and Medicaid pay a smaller rate. Most EMS organizations treat and transport without regard for ability to pay, and therefore in practical terms patients are treated and transported essentially for free at time of service. Therefore it is not uncommon for frequent patients to accumulate thousands of dollars in unpaid EMS bills. Because emergency departments are also required to treat patients without regard to the ability to pay, patients are incentivized to call 911 and seek EMS transportation and ED care.

The McKinsey article identifies that a vulnerability to digital competition exists when customers are forced to cross subsidize each other, and when an organization has high fixed costs, and variable demand. This is surely the situation with EMS. Patients with private insurance and/or the taxpayer, subsidize Medicare and Medicaid patients, and all insurers subsidize those patients without any insurance. The high costs of vehicles and personnel must be paid around the clock, but demand is very variable.

The average cost to an EMS organization of an EMS call can be simply calculated by dividing the number of incidents by the organization’s budget. This cost is usually in the $500 to $1000 range per incident. Even on the high side, an uber ride costs less than $50 for a 5 mile trip.

Communications/system status: As mentioned above, communications between EMS providers and hospitals is normally accomplished by means of verbal communication via two way radio. Most EMS providers do not have any view of system demands on a particular hospital or a set of hospitals; nor do they know which hospitals have excess capacity. In a populous jurisdiction, this can sometimes result in several ambulances converging at once on an ED.

Moreover, ambulances are seldom where they need to be to be best positioned to respond to calls quickly. EMS demand patterns vary by time and by geographic location, but EMS systems often use a static deployment model in which ambulances respond from a fixed geographic location (or station). If a particular station is depleted of ambulances, then response times can stretch even longer as ambulances come from stations farther away to cover a particular call. There are some EMS systems that use a “systems status management” or dynamic positioning model; however such systems usually involve crews sitting in a small ambulance cab for hours and staging in differing parking lots. Such systems usually have high turnover of employees. Some static deployment systems solve the above issue by using first responders (such as firefighters or police officers) in non-transporting vehicles. These first responders gain quick access to the patient, and then treat the patient while waiting for the next available ambulance to show up. This dual deployment model allows such agencies to achieve quick response times while utilizing their ambulances in a very efficient manner.

Response time issues also occur in large cities as well. For instance, patients living in high-rises will never receive quick life saving services due to the time that it takes emergency crews to enter the building and travel the vertical distance. In fact, one recent study suggests that cardiac arrest patients found above the 25th floor never survive.

Crowdsourcing first aid response seems to be a promising answer to improving response times. Smartphone applications such as Pulsepoint, which activate nearby and willing first aid/CPR trained citizens, or Goodsam, which does the same thing for off duty medical professionals, have shown great promise in improving cardiac arrest outcomes.

Health care record integration:

By Executive Order, President Bush mandated that most Americans have access to a personal electronic health record (EHR) by 2014. As part of the Affordable Care Act, The HITECH Act of 2009, mandated the creation of health care information exchanges (HIEs) whereby records from all health care providers could be stored in a single place, and used to more efficiently treat patient. HIEs penetration into the different sectors of health care has been uneven, depending on the state, but a 2015 study did show improvements in quality of care amongst health care providers who participated in HIEs. Although most EMS systems are now using electronic patient care reporting systems, most of these do not share information with HIEs, nor receive information from them such that EMS providers on the scene of an emergency can readily access them. As shown in Estonia, the integration of health care records into a secure but readily accessible single source, is a critical component to health care integration writ large. Thus, as EMS and health care in general become more integrated, EMS will need access to the HIEs. As explored above in the paragraphs about the vehicle, EMS personnel would be greatly benefited by the ability to access a patient’s records on the way to a call so that they could direct self care and begin to better understand the patient’s emergency.

Digital Disruption:

The book Delivering on Digital defines digital transformation as consisting of five major components existing in modern technology:

• Real-time electronic communication (social or otherwise)
• Mobile access
• Analytics
• Cloud Computing
• Cybersecurity

Industries which go through major, and sometimes wrenching changes due to digital technologies consisting of the above components, are said to be digitally disrupted. An example used in the book is the video rental industry. Just as the economies of scale realized by Blockbuster and other large retailers outcompeted early local mom and pop video rental stores, the ease and low cost of access to on-line video services such as Netflix, killed Blockbuster. Similarly, Uber and Lyft are severely disrupting the taxi industry.

Conclusion:

The present EMS system is vulnerable to digital disruption in the near to midterm future. In particular, access to 911 and EMD, crowdsourcing first aid, communications, health care record integration, and the physical vehicle itself seem to be particularly prone to change due to digital transformation in the form of smartphone apps, 5G networks, blockchain information storage networks, and autonomous vehicles.

Section 2: Digital Redesign — E2MS Use Cases:

The following sections will discuss in detail how EMS can be turned into E2MS. This section will discuss how EMS can be retooled to provide better care and increased patient satisfaction through reimagining EMS as a digital service, This reimagining will be done in the form of the following Use Cases that take advantage of already existing or very near-term digital technologies.

Use Case 1: Cardiac Arrest

Mr. Jones is shopping at his local Best Buy. As he exits the store, he witnesses Mr. Smith collapse on the sidewalk. Mr. Jones touches the 911 button on his smartphone and then selects “EMS — Unconscious Person/Possible Cardiac Arrest” from the small menu of choices that pops up. His smart phone verbally tells him to look for signs of breathing and when he touches the button for “no”, his smart phone tells him to begin CPR and verbally instructs him how to do it.

Simultaneously with these actions, the local 911 center is notified. The camera and microphone on Mr. Jones’ smart phone is enabled and the dispatcher observes Mr. Jones doing CPR. The dispatcher tells Mr. Jones that he is doing a good job and that help is on the way. The dispatcher sends the closest ambulance, along with Mr. Gonzalez, a CPR trained lay responder that has signed up for cell phone alerts for cardiac arrests occurring within a half mile radius of him. The dispatcher also sends a drone equipped with an AED to Mr. Jones location.

As Mr. Gonzalez arrives on the scene, he touches a button on his smartphone that lets the dispatch center know he is on the scene. The dispatcher accesses Mr. Gonzalez’ phone and as the drone arrives with the AED, the dispatcher instructs Mr. Gonzalez in the application of the AED. The AED monitors the underlying heart rhythm and sends that information to the responding paramedics. The dispatcher asks Mr. Gonzalez to scan the QR code found on Mr. Smith’s smartphone and Mr. Smith’s health records are also sent to the responding paramedic. An app on the paramedic’s tablets pops up and provides the paramedics with a check list of appropriate interventions and drug dosages for this patient, and begins to auto populate the medical report with Mr. Smith’s information, and the biomedical information from the AED. Since the ambulance is driving itself to the scene, the responding paramedics are free to take over coaching Mr. Gonzalez and Mr. Jones in doing effective CPR and the 911 dispatcher is freed up to take the next call.

The paramedics arrive on the scene within 8 minutes of dispatch and continue care of Mr. Jones. As they load the patient into the ambulance, they touch a button on their tablet, and the receiving hospital is alerted of their ETA and given the patient’s information. The self driving ambulance proceeds safely to the hospital and is given priority through traffic by all of the other self driving vehicles. The crew is free to concentrate on the care of Mr. Smith. While enroute, they brief the receiving hospital via a telemedicine link.

Case 2: Integrated care in the home

Mary P. is a mother with 14 month old twins. Baby A has been fussy and irritable all day and running a fever. Suddenly Baby A starts shaking uncontrollably in an apparent seizure but then stops and seems sleepy. Mary P. pushes the 911 button on her phone, and selects “EMS” from the small menu on her phone (she doesn’t think that “EMS — Unconscious Person/Possible Cardiac Arrest” is appropriate). Another menu appears that guides her through a short series of questions about her baby, and then the app states “probable febrile seizure”. The phone then lights up with a Skype call with a pediatric nurse that works for Mary’s health insurance company. The nurse calms and reassures Mary and goes through a more detailed series of questions and views Baby A through the camera. Mary attaches the thermometer and pulse oximeter (provided by the insurance company on the birth of her children) to her smartphone, and the nurse receives the vital signs on her desktop screen. The nurse then discusses care with Mary and dispatches a drone which delivers Pedialyte and Infant Tylenol for Baby A. The case information is emailed to Mary’s pediatrician who reviews the notes and signs off on her agreement with the care provided.

In an hour, the nurse calls back and checks up on Mary and Baby A. Unfortunately, Baby A has been throwing up the Pedialyte and Tylenol and now appears to be more drowsy. Mary also states that Baby A has not had a wet diaper in several hours and the pulse oximeter reads Baby A’s pulse as more rapid. The nurse dispatches a pediatric specialty paramedic (also employed by the insurance company) to Mary’s house and also alerts the pediatrician. When the paramedic arrives, he starts an IV on Baby A, gives some fluids, and gives Baby A a Tylenol suppository. He also attaches Baby A to his biomedical monitor and quickly runs a blood test. He checks in with Mary’s pediatrician (who has received all of the biomedical information) and stays with Baby A for six hours. At the end of the six hours Baby A is noticeably improved, and the paramedic calls the pediatrician back. They jointly give Mary “discharge instructions” and the paramedic leaves for his next call.

Case 3: Emergency condition detected by primary care receptionist and shared with EMS

Mrs. M is not feeling well; she just feels really tired and nauseous. She calls her Doctor’s office and tries to make an appointment to come in to see the Doctor (she is a little old fashioned that way). The receptionist at the Doctor’s office uses the “Triage App” on her desk top. The App has already been fed Mrs. M’s health history and knows that Mrs. M is a 60 yo with high cholesterol and hypertension. The App directs the receptionist through a series of questions with Mrs. M and at the end of the conversation the receptionist says “Mrs. M, we are worried that you might be having a heart attack. Just to be on the safe side, we are sending the paramedics to your house. They will be able to figure this out a little better, and if nothing is found then we will schedule your appointment”. The receptionist then hits the “send to EMS” button on her “Triage App”, and the local 911 center is sent the call. The paramedics are dispatched and receive the information from the “Triage App” on their tablets. They contact Mrs. M on her phone and calm and reassure her that they are on their way. They instruct her to take 4 baby aspirins while she waits. When they arrive, they hook Mrs. M up to the heart monitor, and run a quick Troponin level on their portable blood lab machine. They find signs that Mrs. M is suffering from a heart attack. They touch a button on their tablet, and the local cardiac intervention center (CIC) is alerted and has access to all Mrs. M’s records and the information gathered by the paramedics. The paramedics load Mrs. M up in the ambulance and start two IVs while enroute to the hospital. While enroute, they talk to the attending interventional cardiologist via a telemedicine link. They take the patient directly to the cardiac catheterization lab, where the alerted team is waiting, and Mrs. M’s coronary arteries are successfully stented.

Case 4: Minor to Moderate Autonomous “Ambuber” -

Mrs. Banks is a 35 year old female who woke up this morning with moderate abdominal pain. She is unsure whether she needs to go to the Emergency Room but knows that this is not normal. She accesses the 911 app and answers the questions. The app tells her to lay the phone on her chest and takes her pulse and respiratory rate and because Mrs. Banks denies that she is sweating or becoming pale, determines that Mrs. Banks is stable for transportation via an “ambuber”, but does need to come into the ED for examination and possible imaging and blood tests. The city has provided a fleet of “ambubers” — self driving cars that are equipped with medical instrumentation and computers linked to the health information cloud. The “ambubers” locate themselves based on historical call load corresponding with the time of day. There is one close to her house, and it shows up in 3 minutes. Mrs. B gets in and places her arm in the blood pressure reader and her finger in the pulse oximeter reader. She chooses her hospital destination and within a couple of minutes the triage nurse at the hospital ED appears on the screen and asks her a few questions. The nurse cheerfully tells Mrs. B that when she arrives she should come in and report to room 112. When Mrs. B arrives at the hospital, the Doctor has already reviewed her history and the nurses notes, and has already ordered a urine test, a blood test, and an ultrasound of her belly. Mrs. B gets those things done and while an ectopic pregnancy is ruled out, it is determined that her appendix is getting ready to rupture.

Case 5: Public Assembly Autonomous Rover — includes highrises

Adam Z is a bright but forgetful 13 year old kid. He has joined his friends at the local mall but as usual has forgotten his Epipen (Adam is allergic to nuts and bee stings). Adam orders ice cream at the food court, and one of the workers forgot to wash the scoop after dipping out peanut butter ice cream. Adam eats the tainted ice cream and immediately begins to experience itching, hives, and lip swelling. One of his friends accesses the 911 app and scans Adams QR code. The dispatch system recognizes the high likelihood of an anaphylactic reaction and dispatches the paramedics. An autonomous roving EMS robot is also dispatched. The city has required these robots to be placed within 2 minutes of all points of public assembly buildings and high rises, and this mall has 4. The robots are equipped with AEDs, CPR supplies, Epipens, Narcan atomizers, Asthma inhalers, insta glucose (for diabetics) and other similar medications for time dependent emergencies. Within 60 seconds the robot is at the side of Adam and his friends (based on the geolocation of the friends phone and some questions answered) and a drawer slides open on the robot with an Epi pen. The robot shows on its screen how to use the Epipen and the friend presses it into Adam’s thigh. The responding paramedic is also watching by the robot’s camera and also coaches Adam’s friend on how to use the pen. By the time that EMS arrives to take Adam to the hospital for evaluation, Adam’s symptoms have resolved and he is just nursing a sore thigh.

In modern high rise buildings these robots are housed in the elevators and when a critical 911 is received the elevator goes to the appropriate floor and the robot rolls off and goes to the correct apartment.

Section 3: Hiring and Training

Hiring

The E2MS project is a revolutionary idea fusing emergency medicine and modern technology. The very nature of the project calls for the elimination of traditional government bureaucratic methods and the implementation of a flexible system. Optimal performance requires the company to adapt to the cultural norms of the modern workforce. According to William Eggers in Delivering on Digital, work method standards within the current tech world include “telecommunicating, flexible hours, casual dress codes, and a flatter org chart.”[1] Recruiting for potential new hires should take place in areas within the industry where the most modern advancements are taking place. The following information shall serve as a set of guidelines and plans to facilitate the hiring and utilization of the E2MS workforce.

Government positions are not synonymous with sexy, attractive, or hip places to be employed. To overcome the stigma of government employment and to attract industry professionals, the company should focus on making each employee a voice for recruiting. The primary goal of the enterprise should be the accomplishment of our mission while maintaining a focus on employee satisfaction. Happy employees who like to come to work will become mavens and mouthpieces, recruiting amongst their peers. According to Eggers, greater employee hiring results are achievable when recruiting extends beyond the human resources department.[2]

As a government agency, EMS agencies are generally unable to provide large salaries, bonuses, or other forms of monetary compensation. However, as a healthcare provider and government entity, there are unique opportunities available, which cannot be provided by the private sector. Job fulfillment, personal satisfaction, and benefit for the greater good should be the incentives used to gain the best employees in a competitive job market. A recent study by the National Academy of Sciences (NAS) found that people prefer day-to-day happiness above increased salaries.[3] The NAS survey of 450,000 people reported that money over a $75,000 annual salary was less important than job satisfaction.[4] Daniel H. Pink writes that employees flourish when they do what they are good at and what they like.[5] E2MS hiring should cultivate employee talent by providing an atmosphere where employees are willing to provide high output for short-term satisfaction.

The hiring should forego traditional workplace requirements such as extensive education and years of experience.[6] To gain employees with the knowledge of cutting-edge digital technology a demonstrable expertise has greater value than an old knowledge set. Minimum qualifications should be wide-ranging to attract the greatest variety of talent. According to Eggers, potential new hires’ evaluations should focus on their current skill set, along with their drive, ambition, and willingness to learn.[7] Special expertise can always be acquired; however, creative talent must be inherent in an individual. The training section will cover more on how employees will be brought up to the task.

Alternate Employee Programs

The enticement of high-caliber employees from the private sector requires the availability of short-term or temporary assignments. Employees may also be subcontracted from the industry to collaborate on joint projects. The hiring process should understand that people may work to achieve a particular mission and then move on to their next task with another employer. According to Eggers, current workers in the technological field do not necessarily seek careers with one organization.[8] Employees may trade a well-paying job in the private sector for a public service position, or may enjoy a temporary assignment, but eventually, people will require new forms of career stimulation. In 2012, the City of Seattle, Washington partnered with Gigabit Squared to bolster the City’s internet infrastructure. In the Seattle laid plans used Gigabit’s employees to build and provide ultra-high speed fiber connections to residential and commercial customers. [9]

Alternate employee plans may also include the use of grant contracts and contests to accomplish the E2MS mission. Minimum grant funding or contests are useful for soliciting minimum viable products for further development. The competition method taps the resources of an open workforce, gathering the talents of existing established professionals, as well as novice members of a profession. The aircraft company Boeing is a pioneer in innovation contests, announcing a 2 million dollar challenge on September 26, 2017, for the creation of personal flying devices.[10] To promote alternative hiring programs, E2MS can utilize companies that specialize in maintaining crowdsourcing platforms. Organizations that orchestrate crowdsourcing connect individuals and businesses with a sizeable community of industry professionals. For example, the company Mechanical Turk is a crowdsourcing marketplace for software developers, where workers select from tasks posted by businesses and complete projects on their schedule.[11]

Training

The first step in providing training for our personnel is to know what we are doing. An understanding of the mission, goals, and potential of an EMS agency is necessary to calculate the organization’s next move. Egger recommends that technology companies advance when pilot programs start small and move fast.[12] The training of e2ms should follow the same principles, allowing a balance of employee tech whiz kids and seasoned, grizzled EMS veterans to learn from each other. Initial or basic training should be extensive and comprehensive so that each new employee starts off on equal footing.[13] The education and training provided in the core program should cover the technology, along with an understanding of workplace culture as well as the company’s mission and goals. Employee training should also be organized, equally distributed, and commonly understood by all personnel. EMS training historically has been geared towards creating independent medical professionals; however with the widespread adoption of telemedicine, it may be possible to train E2MS providers to a lesser level and depend on remote medical decision-making more. This would probably be more in line with the mobility of the modern workforce as well as the already heinous attrition cycles suffered by EMS agencies.

Supervisors within the E2MS organization are in the best position to ensure the success of the company’s overall mission. While the goal of E2MS is to maintain a flat structure, the right supervision is a requirement. Supervisors and manager training will take place in their primary duties, with a focus on organizational teamwork. Managers and supervisors should see their positions as facilitators, supporters, and defenders of the employees. The leadership should make employee satisfaction and creativity its top priority along with customer satisfaction.

E2MS initial and continual training should reflect the overall workplace culture. The workplace should foster a feeling conducive to the expected output. Meaning, E2MS should get away from a stuffy, bureaucratic business system and should strive for a relaxed atmosphere of ingenuity. Technology is the answer for E2MS to work. The focus of training should bring practical applications and innovations together. However, even the most advanced programs may fail if the company operations remain in a silo. Training and education are necessary for the entire staff, regardless of position, and most importantly for the product consumers.

Ultimately the customer will drive the success of the E2MS system, not the technology or the employees. As such, training must go beyond in-house operations, and public education needs to be a key focus for all employees. Each person must be a representative of the organization and have full knowledge of operations. Employees should consider themselves brand ambassadors of the E2MS program. The gathering of public support and use requires the minimization of bureaucracy through employee empowerment.[14] First level employees should have the authority to provide customer satisfaction, assist with calls for service, and be afforded the resources to accomplish the task.

Training should be practical and applicable, driven by employee feedback. The operations function is always in the best placed to ascertain if agency policy is working correctly. Employees should be encouraged to push back against policies that are stifling creativity and hurting customer satisfaction. Employees should have equal footing to leverage change within the E2MS training program. Eggers writes that programs flourished when the technical development section had a direct voice to the executive officer.[15] The needs of technical and operational branches should be the driving force behind the E2MS training programs.

The training function of E2MS must utilize developing technologies to continually prepare employees for future endeavors. Employees should have at their disposal only the best possible tools to do the job. Platforms must be user-friendly along with the leading examples of equipment and software. Having the best equipment and using the most modern platforms will also help attract and maintain people who appreciate working at the edge of technology.

[1] William Eggers D., Delivering on Digital (New York, NY: Rosetta Books, 2016).

[2] Ibid.

[3] Phyllis Korkki, “Big Money vs. Job Satisfaction,” The New York Times, September 11, 2010, sec. Job Market, https://www.nytimes.com/2010/09/12/jobs/12search.html.

[4] Ibid.

[5] Daniel H. Pink, Drive: The Surprising Truth About What Motivates Us (Penguin Random House, 2009).

[6] Eggers, Delivering on Digital.

[7] Ibid.

[8] Ibid.

[9] Travis Pearl, “5 Examples of Public-Private Partnerships (P3) In Action,” October 23, 2013, https://www.onvia.com/company/blog/5-examples-public-private-partnerships-p3-action.

[10] Brian Wang, “Boeing Sponsors $2 Million Jetpack Competition with October 2019 Fly off,” NextBigFuture.com, September 26, 2017, https://www.nextbigfuture.com/2017/09/boeing-sponsors-2-million-jetpack-competition-with-october-2019-fly-off.html.

[11] “Amazon Mechanical Turk — Welcome,” accessed September 28, 2017, https://www.mturk.com/mturk/welcome.

[12] Eggers, Delivering on Digital.

[13] Ibid.

[14] Ibid.

[15] Ibid.

Section 4 Hacking Delivery Design and Execution in the Digital Age

Section four delves into hacking the delivery design and execution in the digital age. This section offers several road maps on how to make changes in the area of delivery for EMS services. An example used discusses how the affordable care act had an abysmal start when officially rolled out in October of 2013. One of the few shining stars was the state of Connecticut’s online exchange. One of the early recognitions from state was they needed to work from the customers point of view not the other way around.

They used a 3 stage user centered design process of:

1. Design by imaging a new future; utilize user based research

2. Delivering on the design; prototyping, agile development, extensive testing, multiple iterations

3. Operating the new service; stay close to the customer and use analytics to continuously hone product

Several reasons Connecticut was successful is they deferred over 40% of the initial startup before going live because the end user would not find it useful and it would have potentially bogged or even worse shut the system down. In the after action process the team felt the aggressive time line they were under also helped foster success. This was for two reason. One they felt they could not take on more than the user could handle and they didn’t procrastinate with bureaucratic red tape.

Such large entities as Amtrak have successfully used the user centered design as well. They sent their team across the country over a two week time period on their trains interviewing over a hundred customers. They were able to ascertain first hand while riding the train and experiencing what the customer was not only telling them but seeing it for themselves as well. This showed that something seeming to be a one dimensional problem could in fact have multiple layers. Fortunately for E2MS we have thousands of data points each year to show what the customer’s needs are but it has only been since the advent of the smart phone and the app that the industry can start to incorporate the advances into improving the system.

E2MS has several areas this formula can be utilized. In section 1 the possibility is posed that the system is designed to fit the worst case scenario, but that for over 57% of the calls in Montgomery County MD a much less robust ambulance crew is needed. Is this putting the customer first? When the public has no alternative they will of course take the path of least resistance. This places an extreme burden on services and most certainly can lead to the most acute calls going unanswered in a timely or lifesaving manner.

Using the above 3 stage process and imagining what the end user really needs, a more stream lined process could be developed. The app previously mentioned could be utilized by low acuity patients to establish a baseline level of need and even take a photo if necessary as the appropriate resources are being deployed. IF at the lowest level of acuity, an on-line EMS person could administer care over the internet by phone or schedule the appropriate level of follow up when warranted. This could include a single provider who could respond non-emergency to ascertain if any further care was needed, an uber ride to a primary care physician or an ambulance when appropriate. This alone would free up providers on over half the calls, so they would be available for the 43% of calls where there is moderate to high acuity needs.

Whether by app or phone this process would need extensive testing and regulatory compliance. The EMS process as previously described is heavily regulated for good reason. Lives are at stake and minutes matter. As artificial intelligence expands regulations will need to adapt accordingly. One way to work within the guidelines is by testing the new process in a beta mode to only a small percentage of patients and as problems arise the process can be modified as needed so as not to affect large numbers of individuals adversely.

As the process progresses analytics will dictate when adjustments need to be made and when to open the new process up to the larger group for full scale release. As in the Connecticut example on affordable health care. By deferring over 40% of the project until such a time as they could guarantee they had a workable user friendly process their model is now considered the gold standard.

Looking specifically at the examples given in Section 2 of the E2MS system, there are several areas where agile development could and should be utilized as soon as possible.

In agile development there are three distinct roles for staff which is referred to as the scrum. The first role is the “product owner”. This the link between the customer and the development team. An active member of the team engaged in iteration, planning and review. The “scrum master” is the coach or facilitator, but not the boss. Generally, a knowledgeable peer with expertise in the subject area. Lastly is the team member, who brings specialized critical skills to the team.

In examining case 1 where the witnessed collapse occurs, case 3 in which the receptionist uses the app to alert EMS, and case 5 the allergic reaction at the mall and then working backwards from design to utilization, this is a perfect scenario to introduce the integrated app because you will still keep the tried and true EMS response responding. The app will only serve to bolster the response. As stated before in EMS there are thousands of data points to examine in past cases as what is needed to best serve the individual in need.

Using the agile development approach in designing the app and procedure for these cases it will be a fairly straight forward process. One area of concern and seen firsthand by members of E2MS staff is the role of IT in this process. IT is very accustomed to the “waterfall” approach of development where the value of “as is” takes precedence and you carefully design the “to be” model. The rapid advancement of a wide variety of apps in all fields is making it harder for IT to cling to this outdated method. Once they see the value in being a team member and that developing an app which has the potential to save lives, they are more amenable to becoming part of the team and not the team leader. In the three cases the scrum master is a very important role to be filled. The person must possess tacit knowledge of the EMS system as well as be engaged in the day to day operations, so as to guide the team through bottle necks. The product owner is connected to what the customer needs are. As questions arise from the customer side of the equation they give the users stories so that other team members can gain understanding of what is ultimately needed from the new design. The positive with starting the disruption with these cases is the disruption can actually happen alongside the tried and true method of traditional EMS. By adding enhancements to the process on our own time line and at our own progression E2MS will have a much higher successes rate than if the old process was simply dismantled. More and more as the waterfall method is marginalized in all fields, rapid growth with agile development will only enhance all processes no matter what field they are used in.

Section 5: Procurement

Emergency medical services traditionally operate as a function of state and local government and, as such, are bound by cumbersome bureaucratic procurement processes that can vary across jurisdictions. These processes are often restricted by lengthy policies and contracting requirements. Interested vendors go through a competitive contracting processes comprised of Invitation for Bids (IFBs) and Requests for Proposals (RFPs), but can also be restricted by state contracts or discretionary purchases that are negotiated outside of these competitive contracting processes.[1]

The current government procurement processes are known hindrances to outsiders securing government contracts. New developers or organizations are often prevented from entering these marketplaces and transforming government and public services due to complex registration procedures and unwieldy APIs.[2] To allow for true transformation of existing government services, such as EMS, innovative developers and organizations should be relied upon, not excluded from the process.

In Delivering on Digital, author William Eggers proposes a ‘playbook’ for procurement of digital services. If E2MS wishes to succeed in digitally transforming the delivery of medical services to the general public, this playbook is a useful guide. Specifically, three of Eggers’ ‘success strategies’ should be adopted by E2MS: (1) tap into private sector expertise (2) convert contracts into competitions; (3) conceptualize, propose, and pilot.[3] Each of these, and their application to E2MS development, will be discussed in further detail below.

Tap Into Private Sector Expertise

E2MS should break away from traditional government procurement practices for medical supply and service vendors by not relying on existing central contractor registries, expanding the pool of eligible vendors, and thereby allowing experts in the private sector to compete for service contracts.[4] While many vendors with whom EMS may have contracted in the past will still be useful for providing products and services related to emergency medical care, they may not be the most adept at creating transformative technological services and may be disinclined to create products that disrupt the status quo.

Transformative change via E2MS will require the input of cutting-edge technology developers and organizations, many of which may be disqualified from even bidding on government contracts through the current procurement procedures. In order to allow for this private sector participation, state and local governments should adapt their registration requirements, create a process focused API, and share RFPs for E2MS related products across jurisdictions.[5] State and local staff in charge of procurement will also have to be properly trained and encouraged to adapt their approach to purchasing.[6]

Convert Contracts Into Competitions

In addition to expanding the vendor pool, E2MS can also create targeted competitions for portions of its services. Instead of a single contract for development of the entire E2MS system, smaller projects, such as those mentioned in the Use Cases above, could be opened up for the pool of contractors. Many companies are already utilizing technology that can be adapted for E2MS use and should be given the opportunity to participate in the E2MS marketplace in their area of expertise. Autonomous vehicles, drone delivery systems, CPR-trainee alerts, electronic vehicle requests (i.e. Uber, Lyft), and telemedicine are just a few of the existing technologies that are already developed and in use and whose developers could be given an opportunity to incorporate their technology into an E2MS interface. By breaking the E2MS procurements into smaller projects or competitions, it will allow for access to existing private sector expertise and the creation of smaller, more feasible, procurement targets.[7]

Conceptualize, Propose, and Pilot

E2MS is a perfect candidate for application of the iterative development process and piloting of these services will be crucial. The services being offered by E2MS are for the public at large, and would therefore benefit from consistent user feedback throughout the development process. Because EMS providers already have an idea of what users in their respective jurisdictions require, there is a baseline for development of E2MS operations.

However, the application of a digitally-driven healthcare service model may reveal unanticipated user needs or complications. By rolling out E2MS in stages with continuous opportunities for user feedback, the services can be tailored and adapted to actual user needs, thereby avoiding waste and increase the potential for E2MS’ overall success.[8]

[1] See e.g. Erie County Medical Center — Procurement, http://www.ecmc.edu/about-ecmc/procurement/ (last accessed September 30, 2017).

[2] Clay Johnson, How to Fix Procurement, https://dobtco.github.io/fixing-procurement-ebook/final/fixing-procurement-ebook/.

[3] Eggers, Delivering on Digital.

[4] Johnson, How to Fix Procurement.

[5] Ibid.

[6] Ibid.

[7] Eggers, Delivering on Digital.

[8] The U.S. Digital Service, TechFAR Handbook for Procuring Digital Services Using Agile Processes, https://playbook.cio.gov/assets/TechFAR%20Handbook_2014-08-07.pdf.

Hacking the Silos

For years, governments have been operating isolated information technology (IT) systems designed to keep information in one spot so it can be easily accessed, used, controlled, and protected. Some refer to this as a vertical process resembling a stovepipe or silo. Some have even drawn the comparison to a vending machine. While a closed system may provide an expectation that it is easier to secure, this is not necessarily true. However, we will discuss security in the next section. In this part, we will show you why silo or closed IT systems in EMS can affect delivery services and patient care. We will also discuss how migrating current systems to a more open concept, such as a “data lake” could be more beneficial as we take 9–1–1 services into the future. Finally, we will talk about how we manage customers’ identities, so they feel safe knowing their information is secure.

The first step in “hacking the silos” is to recognize when an IT system, governance, or even a corporate culture is trapped in a hierarchical, vertical system. Silos were invented to ensilage valuable agricultural grains such as corn and oats. Silage is “fermented, high-moisture stored fodder which can be fed to cattle, sheep and other such ruminants (cud-chewing animals).” The tall, cylindrical structure with smooth walls developed over years of trial and error to ensure the best process for harvesting the silage. In today’s age of interconnectedness, one can argue that siloed IT systems are not the best repositories for making data useful. Vertical systems that are consolidated and fragmented foster duplication and overlap, not innovation and integration.

Do silos exist in the current EMS system? Yes; and many of them. Let’s look at one of our use cases and extract all of the technological innovation out of it and examine it as if a traditional EMS service was responding to the call.

In our first use case Mr. Smith suffers a cardiac arrest and a bystander witnesses the event. In a traditional EMS system, the bystander, Mr. Jones, calls 9–1–1 on a cellular mobile or landline-based telecommunications network. When the call is answered by a dispatch center, an incident report is generated by the center. This report contains information such as the time, location, and nature of the call. Also, the EMS operator might be able to enter biographical information about the patient or mechanism of injury if time allows. Simultaneously, the audio portion of the call is being recorded onto a digital medium that will allow for playback and archiving. If calling on a cellular phone, the bystander is also generating data. His cellular network provider is recording the number dialed, time, duration, and cell tower location. If he is using a smartphone, his phone is also recording these details as well as his physical location.

The EMS dispatcher then dispatches the closest available emergency medical asset according to the response protocols of the EMS system. This may be an ambulance, fire truck, or both. When the call is received from the medical asset, patient care reports (PCR) are generated by the responding units. The PCR contains information about the response to the call, the patient’s medical information, care performed, etc. This report can be recorded in digital or paper format. At the receiving hospital, the EMS providers hand over a copy of the PCR to the nurse, PA, doctor or whoever will be assuming responsibility for the patient’s care. The hospital workers and Emergency Department staff begin their own set of documentation that duplicates and adds to the information received from the EMS responders.

We can think of each record as a pond which contains data. At this point in our scenario, we have multiple record ponds all containing aspects of the incident. Taking each pond independently, we can extract certain data from it and see that some ponds have the same data, while others contain different data.

The information in these ponds is valuable. Not only does it tell us what was done, but analyses of the data can help us understand what EMS is doing right and wrong. This is important because it can lead to innovation and breakthroughs in the delivery of emergency medicine. However, there is a problem. In our non-tech use case above, none of this data is integrated; it is duplicated. As a result, the patient has to provide the same information to different people numerous times. The information can be incorrectly recorded or omitted. All of this has a direct impact on the care of the patient.

If the reports are independent ponds, then we can visualize the data in these reports as fish. If a restaurant has a menu with five different kinds of fish, the chef does not go out to different bodies of water and try to fish out the catch of the day. The chef goes to one place (a fishmonger, seafood supplier, or a marketplace) and orders different kinds of fish. Also, it is not efficient or practical for a fisher to go from pond to pond catching different kinds of fish to sell at the market. Instead, efficient fishers use a fishing boat to fish large lakes, rivers, and oceans so they can catch multiple types of fish in a single outing. Using the analogy of ponds and fish, we begin to see what a vertical or stove-piped information technology system looks like and how inefficient it can be.

Consolidating the data into one large repository has benefits. For example, if all of the data is collocated and migrated to one large repository, it is easier to search with simple tools, and it allows for the use of sophisticated algorithms to analyze the data. In Delivering on Digital, the authors reference a study that was conducted on infant mortality rates in Indiana in which they reached a surprising conclusion. After extensive research, they found that a lack of transportation for mothers to prenatal visits was a contributing factor in the cases of infant deaths. The researchers would not have come to this conclusion if they did not work hard to examine a multitude of integrated data sets. If the data they used had been combined at the onset, it would have been much easier to find the correlation.

In our EMS use case, there is valuable information that is contained in those reports. Although different entities may find more value in some of the data than others, it makes sense that they all have access to the material to provide the best patient care possible. How can we change a siloed IT system and what would it look like? Let’s return to our fishing example and examine the concept of data lakes.

TechTarget defines a Data Lake as a storage repository that holds a vast amount of raw data in its native format until it is needed. While a hierarchical data warehouse stores data in files or folders, a data lake uses a flat architecture to store data. According to HortonWorks, a Data Lake is characterized by three key attributes:

1. Collect everything. A Data Lake contains all data, both raw sources over extended periods of time as well as any processed data.
2. Dive in anywhere. A Data Lake enables users across multiple business units to refine, explore and enrich data on their terms.
3. Flexible access. A Data Lake enables multiple data to access patterns across a shared infrastructure: batch, interactive, online, search, in-memory, and other processing engines.

If data obtained from patients during EMS calls were consolidated into large data lakes, analyses could be conducted on the raw data to find trends and commonalities. Imagine if all of the reports we compiled in our scenario were combined into a large data lake where health care providers and researchers all had access to it. Let’s examine how our second use case scenario would look in an e2ms system that would consolidate patient care information into a large data lake.

Mary is a mother of fourteen-month-old twins. All of the information from her prenatal care visits to include sonograms, neck-fold measurements, and fetal growth charts would be populated into her medical record as well as the children’s before they are even born. At birth, the twins’ birth records and all of the care that they received at the hospital would be associated with Mary’s medical records before discharge. Also before discharge, the process for obtaining the children’s social security numbers would be initiated electronically, and Mary would walk out of the hospital with her babies along with their temporary medical cards that are linked to their social security number application.

As Mary pushes the 911 button on her phone to alert EMS of Twin A’s possible febrile seizure, the nurse responding to the call would not only have the current vital signs of Twin A, but the nurse would also see the medical history and interventions that were performed by the delivery staff. The nurse would know if it was a normal delivery, breach, or c-section. Also, the nurse would know what medications Mary may be transmitting to her children through her breast milk. In our scenario, the nurse sends a drone with Pedialyte and infant Tylenol to Twin A, however, the infant does not respond well, and a follow-up consultation results in the dispatch of a pediatric paramedic. Could data have changed this outcome? Could the nurse have seen something in the existing data that would have initiated an immediate call to the paramedic? It is possible that the nurse could have access to data that showed Twin A had multiple episodes of unexplained dehydration in the nursery but were resolved before discharge after birth. Or, the nurse may have seen that Twin A spent thirty-six hours in the neonatal intensive care unit (NICU) post-birth due to low blood volume or hypervolemia. All of this information would be important to the nurse as she dictates the next course of action.

Access to large amounts of data is one thing, however, sifting through it and determining what is important and what is not is an entirely different matter. This is where algorithms come into play. Algorithms and advanced search techniques are changing the way we process and analyze data. More data is not necessarily useful without a way to sort, stack, and interpret the information. Algorithms can even help predict future behaviors or actions. In our scenario with Mary, it is plausible that a computer system could have alerted a nurse even before Twin A suffered a seizure.

The recording, gathering, and storing of data in large repositories that are available to the many different entities involved in emergency medical services is one way to hack the silos of current EMS IT systems. Flattening the architecture to allow for cross-domain sharing of information among healthcare providers, insurance companies, and patients can accelerate gains in patient care.

If vertical or stove-piped systems are so bad, why do so many still use them? Bureaucracy and resistance to change are some of the biggest barriers to implementation. The U.S. government has been notoriously bad when it comes to integrating networks and avoiding duplication. In the book Delivering on Digital, the authors demonstrate how the government has a propensity to want to consolidate power, are ignorant of IT integration, fear losing control, and are worried about data security. Uber, the antithesis of the government model, built a connected enterprise using simple, open, agile, and user-centric interfaces that was not just focused on technology, but on changing a culture as well.

Delivering on Digital claims that when developing a foundation for a digital government “It’s about culture as much as it is about technology.” Changing a culture starts with the users of the system. Getting the users to buy-in or adopt the system depends on how user-friendly it is and providing a seamless customer experience. This is where identity management comes into play.

Identity Management

With all of a patients’ information is one place, identity management is a topic that needs to be solved. Luckily, ever since Estonia gained its independence, it has made great strides in this area. Estonia’s system is based on an on-line e-Health system secured by blockchain technology that provides secure and convenient access between patients, hospitals, and government entities. Some of the critics postulate that this system could never work in the United States because Estonia is less populous and does not have the large medical care infrastructure that tis present in the United States. However, Estonia’s system of digital identities runs the entire country’s governance, from birth certificates to driver’s licenses to health records. However, if we start small and concentrate solely on how Estonia manages the citizenry’s health records, it may provide a blueprint for the future of EMS in the United States to follow. If the future of EMS is to leverage the gains made by countries like Estonia, public and private partnerships must be part of the business model.

The trust that develops between a patient and their primary care physician is a phenomenon that is difficult to duplicate across the EMS system. However, if this pre-existing trust can be leveraged early in the process and the patient’s primary physician is informed and included in the care of the patient as he or she is processed through the EMS system, then it is possible to imagine a scenario where all of the participants in the process can share in the trust. The data obtained throughout the process is what will ultimately drive patient care. This data should be shared and utilized by a “team” of patient care providers to give the patient the seamless experience valued in other settings. Often we find that not only is data confined to silos, but so is patient treatment. One doctor performs one procedure while another delivers the anesthesia. In a perfect world, they are all on the same page, acting as a team of advocates acting on the patient’s’ behalf. In an imperfect world, there is a lack of communication, and patient care suffers.

While hospital nurseries are the most logical place to start managing patient identities, we need to identify another starting point for those that have already been born. The most reasonable alternate settings are either the primary care physician or emergency pre-hospital care. For some healthy individuals, the responding EMS providers may be the first medically trained professionals they come into contact with. If we are to transform EMS, states and municipalities need to explore how to integrate the information their EMS systems generates and collects. The don’t have to “eat the whole elephant at once” but they need to start somewhere. Propelling EMS into the future depends on incorporating the mass amounts of data the system collects into a place where it is can be accessed, used, and analyzed. However, it also needs to be secure.

Section 7: How to Not Get Hacked the Wrong Way

Hacking is an uprising crime these days and is very costly. The hackers steal data from private and government agencies to obtain personal information about the public and they either sell it or use the information themselves for personal gain. According the McAfee, a security firm, the estimated global cost of hacking to companies and consumers is between $375 and $500 billion annually. Due to the nature of information that the government collects and stores within their systems, it has been one of the biggest targets when it comes to hacking. Therefore, it is crucial for the leadership at digital EMS to ensure that the patient information is protected and they have public’s trust in their ability to secure data. Otherwise, transformation of EMS as digital service will fall short.

While there are traditional ways such as firewalls and monitoring ports to protect data, the sophistication and intensity of the cyber-attacks these days is such that our processes needs to be just as robust to first detect and minimize the threat. Thus, for the digital EMS, we propose the following three fundamental capabilities.

1) Security-risk prioritization and enhanced controls to protect against threat,

2) Vigilance-detect violations and anomalies through better monitoring, and

3) Resilience-establish the ability to quickly repair and restore normal operations.1

These three capabilities are explained more fully below.

Security: E2MS and other health care IT managers should develop policies and procedures to protect the high value yet most vulnerable data just so the rest would be easy to protect against. Hire subject matter experts who can assist in communicating safeguards in place with the patients and other concerned members of public. Periodically spot check on the measures in place for compliance.

Vigilance: The health care industry as a whole should develop processes to stay up to date on the strategies used by hackers so that security threats can be hindered before it is too late. In addition, this practice will assist in mitigating threats quickly due to familiarization. Share as much information about the threat and vulnerabilities with staff as possible. This practice will assist with raising their awareness and help them identify and mitigate weaknesses quicker.

Resilience: develop training for employees that mirrors current threat stream so that they are more vigilant and resilient to the threats. Conduct drills so that the processes can be evaluated and the employee response can be evaluated to ensure compliance. Lastly, develop process to monitor performance to enhance early detection. As for external stakeholders, communicate as much information about the threats and the mitigation strategies.