21st Century Medical Response

Code 3 -The Digital Ambulance Service

Archaic government infrastructure and a culture trapped in long established, and comfortable, approaches must face disruption. Society is in an era of cloud computing, mobile applications, and artificial intelligence to name a few; however, much of government and systems connected and supporting government continues to use analog and outdated legacy systems. Some of these long-established systems and infrastructure are at significant risk of collapse. Additionally, there is a lack of digital skills in the government workforce with little premium placed on disruptive, innovative thinking. For the Code 3 Digital Ambulance venture to succeed, we must recognize that culture is at the root of this stagnation. We must shift the culture toward a digital mindset of openness, agility, collaborative innovation, simplicity, and a focus on the customer and away from an ingrained culture of rules, policy, and obstructionist regulation.

Digital Mindset
William Eggers begins with a brief history of the opening days of the HealthCare.gov and its historical failure. While he called this, a wake-up call, in reality it was a wake-up call for the U.S. Government, for the private sector tech giants had overcome the issues the Federal government had stumbled with. Eggers argues this failure “might just be the best thing to ever happen to digital government in the United States.” Rather than thinking outside the box or even looking to the private sector for their best practices to IT projects, the government responded to this crisis in the only way it knows, by increasing the federal bureaucracy by creating a new organization, United States Digital Services!

Our current ambulance service seems ripe for a digital transformation, given the success of other digital transformations:
• Car services: Uber, Lyft, Zip Car, etc.
• Food Delivery: Peapod, which pre-dates Amazon Fresh for ordering groceries online for home delivery
• FetchApp — enables users to sell digitally deliverable goods;
• Stamp.com eliminates waiting in line at the Post Office to get stamps, mail a package, etc;
• Digital hotel keys allow you to check-in online and avoid having to wait to get your hotel key, that sometimes doesn’t work after you have ridden the elevator to the 11th floor and others.

Eggers claims a digital transformation is possible by combing five interconnecting components: Social, Mobility, Analytics, Cloud Computing, and Cybersecurity. Three of the five are not dependent on who uses an ambulance. Cloud Computing and Cybersecurity will strengthen privacy while Analytics using Artificial Intelligence may aid in where, when and how many ambulances needed by knowing the location of nursery homes, elderly citizens, a large gathering of people and the like who are more likely to need an ambulance. The other two components, Social and Mobility, will work seamlessly for younger, tech-savvy generations. Older generations may require a specialized device (Life Line or similar) should they lack the knowledge/skill/dexterity in using a smartphone.

For the digital transformation to become a reality, one needs a digital mindset. While there is no universally agreed upon attributes for a digital mindset, that said, most individuals and companies share the following five characteristics: openness, user-centricity, co-creation, simplicity, and agility. Openness is at the heart of a digital mindset and aims to connect the silos of excellence existing in a typical organization. Examples of Openness are the original internet (DARPA Net), Wikipedia, Lynx, Open Standards/architecture and the like. User-centric seems obvious. If you are not focused on the user, then whom are you developing your product for? Hand-in-hand with user-centricity is co-creation. Before co-creation, developers got specs for a project, wrote and tested the code and delivered the completed program/application to the customer. This assembly line approach, while ideal for making a car, was not the right model for software projects. Co-creation makes the client’s part of the process and not a recipient of the product. Simplicity is quite straightforward — make a complicated process simple — through the app (think Uber) or via interactive websites consisting of less text and more graphics depicting what functions/services are available to the user/customer. Finally, agility is the ability to change on the fly, recognizing you are not always going to get it right the first time, and agility ensure your process does not get in the way of fixing what’s wrong, in Eggers’ words “rapid iteration and scaling.” These five characteristics are not possible without the appropriate culture and mindset, and this means from the top, C-Suites in suits, to the coders in jeans and t-shirts.

Another challenge to consider in this transformation is who owns and operates the ambulance service in a given area: local fire department, a private company, local hospital, others? Can federal/state/local governments compel non-public sector ambulance operators to transform their service to a digital platform? Alternatively, the reverse, what effect would a digital transformation by private sector companies have on the public sector ambulances? Consider the impact Uber, Airbnb, and other digital transformers had and on their non-digital competitors and debates in city halls around the country.

Digital Redesign
As we move towards the redesign of our existing ambulance service, we will need to ensure that we focus on the end user and not look for ways to simply improve our current program. Code 3 has been delivering quality emergency medical care via the traditional ambulance service delivery method for many years. Despite this successful delivery of service, we need to begin the design process with a clean slate of options. We need to forget about how we deliver the service today and not limit our focus to only what we already know.
We have often used the phrase “taking care of our own,” which tends to cause us to look to our agency needs first. To be successful, we will need to focus on data-driven needs of our end user. We will need to ensure we keep the end user or customer involved throughout the design process. We must look far beyond our conventional emergency service delivery methods and imagine how technology can be incorporated into the delivery of service. We cannot assume our often-older customers cannot adapt to technology. Throughout the design process, we must communicate with and expose our end users to design concepts. We will need to expose our end users to our product early in the process. These early exposures may not in any way resemble our final product, but these early small exposures will help to form that solution. Data derived from customer feedback should steer our design. We should never let a stereotype or assumption be our design guide.

We will want to employ the concepts of Agile Program Management, in particular Scrum methodology. Ken Swaber founded this methodology in 1995 and was based on three principles:
1. Transparency
2. Inspection
3. Adaptation

Some of the key concepts of Scrum methodology include teams communicating at high levels contrasted by low levels of documentation. Teams will communicate daily and identify deficiencies and successes that will guide planning. Scrum utilizes the term “sprint” to identify iterative cycles where the team works to develop one functionality aspect of the larger project before moving on to the next aspect. Scrum concepts work best when teams are comprised on ten or less members. Our ambulance redesign team will be less than ten members, so we will use this methodology to guide the development.

Before we move into the ambulance program design, we will want to make sure we revisit and reinforce our higher-level goals. Our mission statement tells us we should save lives, which is quite abstract. Keeping this high level abstract goal in mind, we will also need to consider other influences like budget, political acceptance, or the capabilities of our available resources. Our policies, which are set by our elected leaders, and aspects of our program design must complement each other if we desire a successful outcome. We will need to “maximize complementary relationships while mitigating incompatibility.” Throughout the design process, we will introduce several “pilot programs” to our end users that will measure their reactions and guide our development. We will need to isolate these pilot programs from our policymakers. Introducing pilots or tests of certain functionality pieces of our design will not provide a complete picture to our policymakers that might result in political pressures to take the design in a direction based solely on incomplete perceptions. We must have data from end users drive the design and avoid opening doors where political pressure can overrule relevant data.

Our ultimate goal is to design an ambulance program that provides excellent customer service. We can only achieve this goal through continuous customer feedback throughout the design and delivery phases. Strong feedback “means collecting data on user behavior, constantly gathering feedback, and using it to continually improve products and services.” Our design will impact how we deliver services and operate in the future. Our program will need to be rigorously tested and adaptable to whatever changes our customers need in the future.

To summarize, to be successful we will need to have a small team (ten or less) of open-minded thinkers from diverse backgrounds who are focused on the needs of the end user and not focused on how we have always provided the service. We will need to engage the end user early and throughout the design process. The feedback received from these customer interactions must drive the process. The team must communicate daily and work to complete one piece of functionality before moving on to the next or use the “sprint” method. The design team must use caution when exposing design elements to policymakers, but be sure to consider how policy elements and program aspects complement or conflict with each other. When our customers call for an ambulance due to a medical emergency, the experience is memorable, but not typically a pleasant one. We need to look for ways within our design to make this unpleasant experience as tolerable as possible. Our design should not add strain to the situation but should make the uncomfortable process of needing emergency medical care as easy as possible.

Hiring and Training
Successful hiring and training for the Code 3 Digital Ambulance venture will require new approaches that will challenge existing government and bureaucratic systems and culture .Hiring and training for the digital ambulance workforce must recognize these challenges. William Eggers, in his book, Delivering on Digital: The Innovators and Technologies That Are transforming Government, stresses the importance of a cultural shift in order to meet mission objectives, “The goal: Identify how the faster, more precise and more reliable information that digital technologies enable might contribute to better achieving the mission. Recognizing these opportunities typically requires government agencies to fundamentally rethink how they do business — identifying new models for service and adopting the technology and corresponding organizational structures to support them.” Many existing ambulance systems, government and government contractors, lack team members with the right skills to take advantage of current technology: skills in coding, agile development, and research and design. Moving forward will require innovation in hiring and training attuned to the customer and focused on the digital ecosystem.

Hack Hiring
Going “digital” is about more than embracing modern technology; it is about an organizational paradigm shift. Hiring for digital transformation requires team members who view existing processes, challenges, and systems in new and innovative ways. How do we find these people? The first step is changing the way Code 3 Digital Ambulance conducts hiring. First, traditional government Human Resource Department hiring practices and guidelines need to be abandoned. The existing process is time-consuming and full of bureaucratic obstructions. To draw the best talent, we need to hunt for the specific skills and abilities we need for a lean startup development. A lean startups objective is a venture that takes a product or service, uses validated learning to analyze customer’s response, learn from it, and then pivot to improve the product and give the customer what they may not even know that they want. Exponential organizations utilize validated learning to determine how to proceed. If our objective is hiring people who understand coding, then I recommend we post recruiting outreach directly into sites and web locations frequented by knowledgeable tech-savvy coders. The same strategy should be used in finding emergency medical response mavens, and connectors who can spread the word about Code 3’s unique innovations.

Next, Code 3 needs to expedite the hiring process. The digital workforce is fast moving and in high demand. The traditional glacial government hiring pipeline is not suitable for finding the best candidates in the digital workforce. I recommend Code 3 begin with a filtering process for resumes and applications that culls the list by assessing technical expertise, innovative thinking, and teamwork ability. Candidates should also be evaluated for design thinking ability, which consists of, “…ability to be intuitive, to recognize patterns, to construct ideas that have emotional meaning as well as functionality…”

Third, Code 3 should market our value proposition goal of working to save lives and make a difference in the world. Seventy-seven percent of millennials say they consider an organization’s purpose before joining. Socially conscious millennials want to know that their work has meaning and Code 3 can embrace this as a means of recruiting quality candidates.

Code 3 should also evaluate the working environment and its influence on attracting the best candidates. Digital talent can be unconventional, Code 3 needs to be more flexible with regards to providing team members with greater autonomy over tasks: when, where, how and with whom they work. As Eggers asserts, “Telecommuting, flexible hours, casual dress codes, and a flatter org chart are all standard operating procedures in the tech world. Not so much in government.”

Hack Training
Code 3 should develop a digital academy as an initial “in-house” training. The purpose is not indoctrination but an opportunity for learning agile work. Students could spend time developing ideas, being creative while working with teammates, and gaining experience with the measure-build-learn feedback loop. The student would not only learn to use tools and techniques but will learn Code 3’s digital culture of focusing on the primary mission: the customer.

Code 3 must understand that the first academy and ongoing training is not an investment in an employee we hope to retain for the next 30 years. The digital workforce does not look at employment in the traditional long-term way. Employees come and go and will often move from project to project and change employers with greater frequency. This is all part of the “tech ecosystem” and can be used to Code 3’s innovative advantage. Embracing “freelance or open-source talent” will assist Code 3 with utilizing the significant flow of digital talent that exists outside of government and government contractors. Remember, “No matter who you are, most of the smartest people work for someone else.”

Hack Delivery
Code 3 will utilize a three-stage process to accomplish the digital delivery of comprehensive ambulance services. This includes design, delivery and operational strategies to meet the requirements of the project. The design components will be structured with the user in mind first. Utilizing a design thinking methodology, Code 3 will initially gain an appreciation for the unique needs of the customer through empathy and define the problem sets. Next, a development cycle will include prototyping and iterations of testing and feedback loops. Finally, the implementation of solutions will be continuously monitored through real-time analytics and continuously revisions or iterations to adapt to customer demands.

Based on this construct, Code 3 will employ an agile development strategy to advance the digital solutions offered by the ambulance service. Code 3 has identified roles to meet the needs of the mission, and a staffing plan includes product owners for each line of business and the necessary scrum masters and team members as well as user stories and product and sprint backlog components. The teams will follow the standard 5-step process of spring planning, stand-ups, reviews, and retrospectives as necessary, to include repetitions to accomplish the goals for each service line. Code 3 understands the need to focus on the user, utilize rapid development cycles and welcome a level of uncertainty while at the same time, maintaining an acceptable level or service delivery that is reliable and consistent.

Effectively outlined by Dam and Siang, “understanding the human needs involved, by re-framing the problem in human-centric ways, by creating many ideas in brainstorming sessions, and by adopting a hands-on approach in prototyping and testing.” Probably the most important aspect of Code 3’s hack on delivery includes the ability to collect extensive data sources based on the needs of the customer. By sensing what the impacts of the service is to the users through real-time evidence collection and analysis, Code 3 can, in turn, create actionable data based on the behavioral analysis in concert with the interactive feedback loops built into the delivery. All these aspects of user engagement are consequently recycled into the development strategy in order to ensure an adaptable framework that continuously evolves based on the demands and expectations of the customer.

Hack Procurement
Code 3 looks to digitize their ambulance service
For the most part, ambulance operations are structured through one of two types of systems. It is a two-tiered system referred to as advanced life support (ALS) or basic life support (BLS). In this two-tiered system, the ALS service is provided by paramedics. The BLS system is provided by emergency medical technicians. Because the ALS and the BLS systems provide different capabilities, the vehicles supporting those systems vary in design and construction. Code 3 is looking to purchase six new ambulance vehicles — four ALS, and two BLS ambulances.

Also, Code 3 is seeking vendors to provide equipment product/system price proposals for all systems within the ambulance. Systems of specific concern to Code 3 are medications (procurement and delivery), internal life support equipment (EKGs/Defibrillators/etc.), communications (internal communications/communications with dispatch/communications with the hospital and medical director), the ambulance truck, and navigation systems. Code 3 will be requesting this proposal from five of the leading ambulance truck providers in the nation: Braun Industries, Horton Emergency Vehicles, Global Emergency Vehicles, Lifeline Emergency Vehicles, and Frazer Ltd. New proposals should be brought forward with the Code 3 mission delineated in the design of the ambulance. Code 3 has assembled a team of highly trained IT experts to be the first point of contact for all items related to the acquisition of the new ambulances.

Code 3 Mission Statement:
To provide life-saving measures through effective and efficient life support transport for the citizens of Rockabrille City. Code 3 services will incorporate the latest in innovative technology and equipment combined with the highest trained professionals to deliver the best pre-hospital patient care available.

Code 3 Required Systems for Equipment and Services Proposal
Each system identified above will be offered as separate proposals, and must illustrate the IT component that separates it apart from a standard approach. Contractors will be afforded forty-five days to provide each system proposal. Delivery of the proposal will require a prototype in addition to a written illustration of the system. Code 3 will accommodate vendors by attending presentations on location. Contractors that do not meet the needs or expectations of any one system will not be asked to continue the proposal process. Contractors advancing in the proposal process to the fourth sequence will be provided financial incentives to offset the cost of prototype development. To bring forward the best possible product for Code 3, contractors are encouraged and will be rewarded extra consideration for working with competitor contractors to encourage best design capabilities and output.

Hacking Silos
Code 3 ambulance services are intent on providing the most efficient primary health service delivered by the highest trained healthcare technicians. We are striving to be innovative in a streamlined design of service which will eliminate systems which operate in a silo. This new horizontal process will be gradually integrated one system at a time, effectively phasing out the legacy system format currently found in all ambulance services.

Building a streamlined network of systems within the ambulance health provider model that can share data between systems will provide for faster more accurate emergency health care for the patient. Code 3 proposes a system where every citizen has a digital identifier which will provide authentication and approve access for the provider. This system will begin at the earliest part of the ambulance system process, the call for help, by grouping together all residents attached to the same point in a digital cloud. Immediately, at the point of dispatch, ambulance providers will know who the address occupants are, and once provided their identifiers they will be able to access all of their information immediately.

The richness of the system’s functionality is based on the individual identifiers provided by the public. Code 3 services acknowledge some individual’s trepidation in providing access to so much personal information. However, the information is already available; the only difference is that it is not shared in the same database. Protection of the system is a high priority for Code 3 but is not explained in this section.

Code 3 looks to integrate this system incrementally. Although we can foresee the larger benefit to a fully integrated digital system, we understand that a “rip and replace” approach is historically ineffective when phasing out departmentalized legacy systems. Our first phase will combine newly accessed digital data address points that are linked with the computer-aided dispatch system. The system will be tied to digital equipment within the trucks providing GIS coordinates and information to direct the ambulance to the address calling for assistance.

The next phase will be patient focused. Ambulance personnel will no longer have to depend on family or friends for personal health information of the victim, or have to rummage through medication cabinets to determine medical history. In the Code 3 digital system, all personal medical records will be available via the personal identifier which the owner will have multiple methods for providing to ambulance personnel. This medical history data will be linked directly to the hospital and the medical director in charge, creating a path of least resistance for treatment-related medical decisions for the patient. Hospitals will have the same information available to them at their fingertips as the ambulance personnel, and at the same time; thus, making a more sound judgment regarding the emergency care provided.

Phase three assures the system is all-encompassing. By that we mean the patient or individual also has full access to review the data. Full customer access will allow the patient to add essential medical items such as Do Not Resuscitate orders, or powers of attorney directing medical decision-making to other family members or pre-selected authorities. Also, phase three will incorporate the data systems that include all billing and insurance.

Ambulance, hospital, and patients will navigate the process from treatment to payment within the same system. Code 3 expects this process will drastically reduce time, confusion, anxiety, fraud, and costs to the consumers of Code 3 services. This new open source service will allow everyone involved in the process to move between processes such as records, billing, and patient treatment history without the boundaries of separate systems but the rigidity of approved authorities. This system will be secure and greatly increase the speed of all emergency health care components. We believe the future of integrating IT and digitizing our service is here, and we look forward to showing you what it can do for you.

How Not To Be Hacked
As Code 3 continues to design and develop our new ambulance model, we will want to ensure our data and systems are protected from hacking. Recent events like the hacking of the Ashley Madison site where 33 million records were compromised should be a warning to ensure we do all we can do to protect ourselves from hacking.

Our records, being medical information, do contain personal information that can be used for profit and is very desirable to potential hackers. As a government entity, we do not have the same leeway or ability to unlimited investment in our protection systems. By design, our ability to react quickly to technological challenges is slowed by our bureaucratic structure. Despite our handicaps, we must not undervalue protection from hackers. Estimates put the cost of hacking at $375-$500 billion annually. Eggers recommends focusing on three capabilities related to the prevention of hacking:

1. Security: Prioritize risks and enhance controls to protect against known and emerging threats
2. Vigilance: Detect violations and anomalies through better monitoring of workplace behaviors
3. Resilience: Establish the ability to quickly return to normal operations and repair damage to business

Total avoidance of cyber threat cannot be avoided, but we must do what we can to manage these constant threats. With the extreme sensitivity of our information, we may want to take some of our data offline. Offline storage is not as convenient but is much easier to protect.

One of our biggest threats is the insider threat. The data contained within our records can be sold. We should increase our vetting of our staff to ensure they are reliable and not a threat. We will need to increase our training of all employees so that they might notice behaviors or actions that could indicate insider threat. We will also want to train our staff and customers to use good practices while accessing our data. We should consider assistance to our staff and customers in setting up a password manager, how to use a VPN and other relevant smart practices like using fake answers to security questions that cannot be mined from the web. Australian’s use these three best practices to protect their data:
1. Application whitelisting — blocks unauthorized access
2. Prompt patching — automatic updates
3. Limited administrative privileges — limits who can make changes that might open doors for hackers

Not having the budget or ability to attract the rock stars of hacking, we will want to be very agile. We will want to aggressively modify our defenses so that by the time the hacker figures out how to break in, we have changed our defense. We will want to plant fake information that is accessible. This will discourage the hackers when they realize they have collected nothing of value and they may move on to an easier target.

We will need to test our defense, through war games, and see if it can be hacked. With the expectation of 25 billion devices being connected by 2020, the threat of an opportunity for hacking is on the rise. Most of these devices are used for a multitude of connections. They are not used only to connect to Code 3 for ambulance service. With the cost of connected devices declining, we might want to consider a connected device that is used exclusively for emergency medical ambulance use. This would limit the pathways for hackers to access our information when our customers use their devices for other connected activities that are not properly protected. We need to think about how we can protect the devices our customers use to communicate with us. Ultimately, we need to be agile and ever changing to help protect our customers and us.

Conclusion
Successfully attracting, hiring, and training digital talent for the Code 3 Digital Ambulance venture will require new approaches and innovation. Existing government bureaucracies lack the skills, processes, and systems need for Code 3 to lead the way forward in the technological transformation of emergency medical response. Code 3 must shift the culture toward a digital mindset of openness, agility, collaborative innovation, simplicity, and a focus on the customer. Code 3 must offer, train, and retain a sustainable environment of talent and freethinking that supports a culture of purpose and value in which our team can thrive. With the proper talent within the organization coupled with a digital delivery strategy that focuses on the customer first and innovative solutions based on design thinking, Code 3 is postured for success in this new era of digital ambulance services.