The Ambulance of the Future
How can advances in technology change an age-old service delivery model?
Compiled by Brian Bean, Justin Bristow, Eric Greening, Jason Readron & JW
Ambo Redesign: HISTORY, NEED & OPPORTUNITY
When you think of an ambulance what do you picture? Firefighters, Emergency Medical Technicians and Paramedics rushing to a scene to save a life? Or do you simply picture the modified ambulance “Ecto 1” from Ghostbusters? Regardless of the image, you understand the role of ambulances in our society. Getting the critically injured to the hospital for definitive care. Or so you think…
The term Ambulance stems from the Latin word ambulare which refers to walking or moving around.[i] Ambulance services have been recorded as far back as 1487 when the Spanish used them to transport medical patients.[ii] Despite consistent evolution, training and constant iteration, the modern ambulance service closely resembles historic practices. Granted, technology has advanced in vehicles, medical supplies and interventions the baseline practice of transporting patients to a hospital remains the same. For the most part…
On to the 20th century ambulance. For-profit ambulance companies, and there are a lot of them, struggle today to make ends meet in the modern economic structures of healthcare. A typical loss estimate is roughly 35% of billed expenses. This accounts for Medicare reductions, insurance settlements and simple non-payment. When you factor this in with operating costs (personnel, vehicles, maintenance, supplies, billing, etc.) the profit margin associated with this model decreases significantly. With drastically decreased revenue, ambulance companies are constantly looking to streamline practices, decrease costs and increase marketability.
What many people do not know is that modern ambulances serve myriad purposes and come in a variety of formats. “911 cars” are your typically expected emergency response vehicles that conduct emergency transport to hospitals. “Inter-facility cars” are another model of ambulance. Inter-facility cars transport patients from one medical facility to another. Typically this is from a care facility to a hospital and back. These services range from severe patients requiring advanced medical monitoring during transport to ambulatory patients who simply can’t drive themselves. Additionally, “wheelchair cars” provide a similar service as inter-facility cars but focus more on patients not requiring medical monitoring during transport. Also, they will typically transport an individual from their residence to a medical facility in a non-emergent situation. Although there are a many different models, systems and crossover, those are the prevalent examples. Many ambulance services are now cross-utilizing their resources to handle both inter-facility and 911. Again, changes have been made but nothing that revolutionizes the ambulance service.
So what opportunities exist for the 21st century ambulance service? Or even the 21.5 version? The answer…many.
Picture this…you call “x11” to request a non-emergency medical transport (prior wheelchair model). Instead of the typical ambulance arriving with one or two attendants an autonomous vehicle arrives. Through the app you have pre-designated your medical facility destination or, the receiving facility has scheduled the transport as part of your appointment. Even better, the autonomous ambulance has predetermined the routes to maximize transfer time and routes, allowing for multiple pick-ups and drop-offs all in time for everyone to make their appointments in a timely fashion. No driver, no direct payment, no tips all coordinated through the medical facilities office and provided by the newest iteration of ambulance service providers.
Taking it up to the next level, a healthcare facility schedules an inter-facility transport requiring medical monitoring (prior inter-facility model). Again, the autonomous ambulance arrives. Except this time something’s different. But what is it? How about the ability to monitor patient vital signs and condition through the vehicle itself? Again, no attendants. Instead, the transferring facility loads the patient in the vehicle and “plugs” them into a vehicle-borne multiport that provide vital signs, video monitoring and estimated time of arrival. This information is then transmitted to the receiving facility and a centralized monitoring center where medical professionals can monitor multiple patients at a time. The majority of these patients require no interventions other than monitoring. Mission accomplished.
But what if the patient condition deteriorates rapidly during the inter-facility transport? The vehicle recognizes the decline, based on patient vital signs, or the centralized monitoring personnel recognize patient deterioration based on video transmission. Once identified, the vehicle’s on-board algorithms make an immediate determination, based on average emergency response times to the given area, distance to destination, receiving facility capabilities and patient decline characteristics, whether to automatically request an emergency response or continue the transport. Regardless of the determination, the receiving facility is advised of the situation.
So what happens if the vehicle decides to stop and activate emergency response? Automatically, emergency crews are dispatched. While en-route the vehicle is giving the crews real-time updates on patient condition providing them a distinct treatment advantage. Upon arrival, first responders enter the vehicle, re-engage transport (as applicable) with same or updated destination information and treat the patient while en-route.
The same model exists for 911 cars as well. Emergency response crews simply respond to incidents with an autonomous ambulance. Once together, crews load the patient; enter destination information and the ambulance transports while crews treat.
By providing autonomous vehicles under a linked system, service efficiency drastically increases. One vehicle can be utilized for myriad types of responses. No need for customized vehicles from one assignment to another, which increases buying power for procuring resources. Based on system information, vehicles can self-assign new locations to maintain area coverage. Once the patient is delivered to the receiving facility, and crews have cleaned the ambulance, it automatically reinserts itself into the system finding the most opportune route, staging location and/or takes a pick-up.
As part of the linked system, first responders, monitors, healthcare facilities all have access to the same real-time data, which increases the continuity of care. All providers are now on the same page versus doing their own thing, or starting the interview process over every time a patient is received.
Public Acceptance: IF YOU BUILD IT, WILL THEY COME?
Based on recent studies, many Americans may be hesitant to taking advantage of autonomous ambulances. Presented at the recent International Symposium on Human Factors and Ergonomics in Healthcare conference, researchers presented findings that when surveyed, half of the participants were “significantly less willing to be transported” by a “driverless ambulance.” [iii] Researchers acknowledged the relative shortcomings of their study, as they were only able to provide hypothetical scenarios for the survey. [iv]
Given the advances in medical technology specific to emergency medical services, it is a natural progression that autonomous, or driverless ambulances become the norm. Currently, advances in telemedicine have provided opportunities for frontline personnel to connect patients through a digital medium to Doctors and specialists in hospitals. These opportunities give the deciding professional the ability to get a visual impression of the patient, which is significant in medical treatment.
Additionally, many ambulance companies have begun implementing road safety tracking devices on their current ambulances. [v] The devices provide real-time feedback to drivers to attempt to provide a safer, more comfortable patient experience. [vi] This platform provides the ability to expand and advance into full automation once committed to. The technology also shows a willingness on the part of ambulance companies to provide a better, more efficient, and more user-friendly patient experience.
As with any new technology, there is always a societal-acceptance curve. Autonomous/driverless vehicles are just now becoming a regular mainstay on city streets. As they become more familiar, and get taken out of test/prep mode, into full functionality, they will not doubt dramatically grow in acceptance, as have almost all past major technological advancements.
One area where ambulance companies can promote the implementation of such technology is to provide significant public awareness campaigns to push the familiarity. Additionally, as with many things, it comes down to money. If a cost savings can be demonstrated to the customer, acceptance will be exponential. Cost savings has to be to the end user however if it is going to affect acceptance. Cost savings, shown as increased profit margins for ambulance and insurance companies, does nothing to promote the efficiency and cost-savings of autonomous ambulances. If there is not a subsequent cost benefit, by way of lower insurance premiums or overall individual costs, the efficiency will be lost on the general populace. If I were paying the same amount for service, why would I not want someone to provide a personal, humanistic approach to my care and treatment??
Hiring & Training: ENOUGH AUTONOMY! CAN’T WE JUST HIRE SOME PEOPLE TO DO IT?
Although we are far from the day, if it’s ever seen, where patients are treated autonomously, the decrease in the human-factor of ambulance transportation dramatically increases its efficiency. Autonomous vehicles do not need uniforms, training, meals, and grocery shopping time or bathroom breaks. And they don’t have disciplinary issues. All which result in a more efficient system thus increasing revenue potential.
To achieve success as an efficient and financially successful autonomous ambulance service of the future, the company must be highly selective in staffing its organizational structure. From the top of the organization down to the line level Emergency Medical Technicians (EMT’s), the company must strive to recruit, hire, and train the most qualified forward leaning individuals to make the company succeed in it’s delivery of autonomous ambulance services. Who do we need to make this company thrive with a primarily autonomous format minimizing the need for line level EMT’s? We would need to hire high performing subject matter expects to launch and manage the company. These employees would fall into the following organizational divisions:
· Legal/ Intergovernmental Relations: The office of intergovernmental relations would be responsible for navigating the local regulatory environment which would include government officials comprised of lawmakers, police, fire, and public health. Since autonomous vehicles are relatively new, this office would be integral in lobbying local governments to permit autonomous vehicle operations. Without government permission to operate autonomous vehicles on public roads, this business model would fail.
· Information Technology: The Chief Technology Officer would be responsible for the management of all software and hardware acquisition and operations.
· Medical Services: The Chief Medical Officer, preferably a licensed medical doctor, would be responsible for overseeing the delivery of medical treatment by company EMTs.
· Human Resources: The Human Resources Director would be responsible for the recruitment, hiring, training, and retention of company staff.
· Field Operations: This division head would be responsible for the daily deployment of the autonomous and staffed ambulance fleet.
· Dispatch/Command Center: This division head would be responsible for staffing and operating a “state of the art” central command center responsible for dispatching units to calls for service 24 hours a day.
· Business Operations: The Chief Financial Officer would be responsible for accounting, procurement, finances, marketing, and strategic planning.
· Data Analytics: This division would be responsible for collecting data in order for management to ascertain if performance goals are being attained. This data would include temporal metrics, types of transports, and demographic/medical information regarding patients. This information is critical to strategic planning, innovation, and ensuring the efficient use of resources.
In order to “hack” the recruiting and hiring process, we would conduct all of our recruiting and hiring activities via our online website thereby reducing associated costs with a brick and mortar operation. We would also proactively data mine all available online and social media platforms to locate top talent that would match all of the above listed categories. Some the online platforms would include LinkedIn and similar websites. We could accept applications online and conduct interviews via Facetime or Skype to save time.
In order to attract specific talent skilled in the information technology and emergency medical services, we would employ external vendors to use geofencing to target medical service and tech hotspots. Geofencing entails pushing ads, or notifications, to mobile devices within a certain geographic radius. We would target geographic neighborhoods or cities known to be populated with tech talent such as Silicon Valley. Many major cities have neighborhoods with a clustering of hospitals and other medical providers. These areas would be ripe for targeting and attracting the type of talent to make our company competitive.
Our training costs would be greatly reduced by recruiting employees who are already credentialed, licensed, and certified to perform their duties from EMT all the way up to executive management. Once hired and deployed, the company could also save training time by creating and mandating a number of online interactive training courses employees would be required to take before deployment and in-service over the course of their employment. This would avoid taking employees away from workstations and decreasing service by delivering the newest training during employee downtime.
Procurement: YEAH, YEAH, YEAH, BUT WHAT WILL IT COST?
The future of procurement is an exciting one but currently looks variable due to lack of strategic planning, clarity, leadership and clear direction. There is an urgent requirement for procurement practitioners to look ahead and work towards effective, transparent and strategic procurement. Procurement is like many areas of government or business. Procurement has to be able to assist an organization, move away from saying ‘no/ to saying ‘yes’ and being more helpful that can meet organizational requirements.
In the years ahead, AMBO should set the procurement direction to follow and be more proactive. Procurement should have a specific and measurable procurement strategy. For procurement to help AMBO have a positive future we have to use technology to become more efficient so practitioners can benefit.
We have to look at how we operate. We can consider how we add value through value creation. We certainly need transformation. In this way we can reform procurement and create or increase the value of procurement in the way we move forward. As we move forward, we procurement practitioners who can think strategically and undertake procurement that is specific to each procurement requirement. The ‘same way’ is not the best way and thinking ‘outside the box’ is essential.
Contract flexibility provides for options and clarity of purpose that can allow you to get ‘past the norm’ and be creative in how the relationship works. Of course this is best for buyer/supplier relationships that have been in place for some time and where performance has been positive.
Procurement sustainability
Bureaucracy and lack of attention by procurement practitioners loses the opportunity to look at the ‘big picture’ and make positive change to procurement and the entire supply chain. It has to align with the vision. If AMBO is going to hack the way ambulances do business, procurement needs to be included.
We require a clear vision and the ability to implement it. We have to be flexible and our contract needs to document both the technical requirements but also an effective change mechanism of technology.
Procurement has to move from the traditional buyer/supplier relationship, which can be a confrontational one and look ahead with technology so components work effectively. Procurement can provide effective solutions to our organizations.
Looking at procurement rules — Debate should occur to establish the viability of rules, especially in respect of how long the procurement process takes and how technology can expedite it. This can be frustrating to all parties involved and cause frustration. .We cannot continue to operate in the same way -we must look at the best way of operating sustainably and innovatively. Equally, it is going to take the whole procurement and supply chain to achieve this.
A start needs to be made. New ideas are required for different results. Having a clear direction will allow you to procure strategically.
Skills and competencies
Procurement requires procurement skills as well as complimentary skills such as financial, communication, advocacy, presentation and persuasion skills including management and other ‘soft’ skills. Some competencies are:
1. Procurement basics
2. Communication skill
3. Strategic skill
4. Vision and direction
We are in dire need of procurement qualifications that reflect procurement overall but also reflect our different state specific laws and procurement rules.
2017 Procurement: Better Technology
The Future of E-Procurement
The forecast for procurement in 2017 shows better technology and falling behind for those that do not adapt. In the past, ambulance companies progressed from manual Excel solutions to procurement software. Now everyone is looking to progress from standard procurement solutions to accessible, intuitive online solutions.
— We will need to think more like a data scientist, analyzing new and expanding sources of information to determine the projects and transactions that matter, and that require human interaction.
— “ Some don’t think that most large companies will have a back office in 10 years. I think that the idea you have a procurement department, you have all of these cost centers that are not contributing to the top line is just going to be gone. We are digitizing and automating our way out of most activities. Procurement has to become a strategic revenue driver, and if procurement resists, other people in the business will do it for them” *How organizations will transition from current delivery models to accessing procurement talent on-demand, using talent marketplaces
Vroozi’s recent partnership with AvidXchange perfectly illustrates combined efforts to improve technology in both e-procurement and invoice-to-pay. Through this new partnership, users gain full procure-to-pay with the best-in-class technology solutions. Because each partner focuses on sharpening his or her own piece of the procurement puzzle, the end result is a full-spectrum of technology that is specialized to fulfill each need.
Spend Matters, procurement experts, recently released in a new report the three themes of new procurement best practices as follows:
*Shopping/Buying Enablement
*P2P Process Management
*Supplier Connectivity
There are companies like AvidXchange(tm), a leading provider of accounts payable and payment automation solutions, that can work in partnership with Vroozi, a leading cloud-based business purchasing platform. AvidXchange(tm) and Vroozi have formed a strategic partnership to deliver clients a best-in-class experience from procurement through invoice payment. For many organizations, purchasing and payables are done across multiple locations using many different suppliers, which can cause inefficiencies and inaccuracies. The companies are excited to begin development, and create an integrated offering that will empower companies to have an automated experience that creates efficiency, and ensures accuracy, from the procurement process all the way through payment of the invoice using a combination of best-in-class solutions from Vroozi and AvidXchange.
This partnership extends Vroozi’s value proposition to new and existing customers by offering end-to-end procurement capabilities with AvidXchange’s robust invoicing and payables technology. The combination of our the respective SaaS platforms provide companies with increased automation, lower processing costs, and enhanced productivity, ultimately breaking down silos and bringing tremendous operational efficiencies for companies.
The Great Industry Silos: FIGURATIVELY OF COURSE
One of the biggest challenges to the healthcare system is the goal of moving away from a fragmented or “siloed” system, which causes inefficiency of service delivery and, as a byproduct, increased cost, and toward an integrated model that provides services more efficiently and at less cost to the company and to the end user of the system. While this goal would seem to be obvious, the nature of the healthcare system causes these silos — different branches of the healthcare system working toward specific goals, with minimal concern given to how each branch’s actions may detract from the quality and cost goals of the other interconnected branches. With the AMBO project, we aim to eliminate these silos to provide better healthcare to the end user at a cost savings to all involved, by incorporating coordinated services designed to focus on key operational defects in the current ambulance model.
The first task in eliminating the threats to success that a silo system causes is to change the mindset typically associated with the ambulance model. The AMBO project aims to bring a hacker’s mindset to the way ambulance services are provided. Instead of attempting to affect healthcare by improving delivery within each of the silos associated with the current ambulance system, the AMBO project goes upstream of each of the silos and creates an integration point, which affects all of the associated branches downstream.
The AMBO project will have an impact on the manner in which fire departments, ambulance companies, law enforcement and hospitals interact in the best interests of the patients that they serve. A realistic example of a scenario faced by all of these entities, detailed below, will identify where the current ambulance model falls short of optimal patient care and cost effectiveness:
Today, in Anytown U.S.A., two vehicles collided into one another, and two people are injured and in need of medical care. After a passerby dials 911, law enforcement officers are dispatched to the scene. Depending on whether or not the reporting party was aware of any injuries involved, a fire engine from the local fire department, and an ambulance from a private company contracted to handle emergency medical transportation in Anytown may also be dispatched. They might not be.
A police officer arrives to the scene of the accident first and begins to assess, at a very basic level, the injuries suffered by the two drivers. Depending of the severity of the injuries, the police officer calls for emergency medical response and tends to the victims in a very basic life saving manner. The police officer has no idea who the patients are, what pre-existing medical conditions each person may have, and has very basic first aid / CPR training to address the victim’s medical issues. At the same time, the police officer is concerned with preservation of evidence at the scene of the collision, obtaining statements from any witnesses that may be present, directing traffic at the scene of the collision so that there aren’t any more accidents, and any criminal activity that may have caused the collision (DUI?) or is occurring at the time. In short, unless there is very obviously the need for life saving actions like CPR or massive bleeding abatement, the police officer has other things that he is primarily concerned with.
Next to arrive is the fire engine, staffed with four individuals who are trained at a higher level than a police officer, but who cannot perform advanced life support on any potential victims. While their primary concern is patient care, they too are not aware of any preexisting medical conditions the drivers may have, and they begin an assessment of the injuries of the drivers. They begin to treat immediate medical concerns and prepare the victims for eventual transition to an ambulance for a trip to the emergency room.
Finally, the traditional 911 ambulance arrives with a driver and a paramedic who are briefed on the situation by the firemen. Depending on the severity of the injuries involved, they may either begin treatment on scene in order to stabilize the patients or, in the case of a critical injury, may “scoop and go” as quickly as possible to the emergency room. In the case of the more critical patients, the driver of the ambulance is now removed from the patient’s care, and the paramedic is left to deal with the critical patient alone. The paramedic in the back of the ambulance is no longer attempting to get a background on the patient, is unaware of the patient’s preexisting medical conditions, and is simply trying to keep the patient alive long enough for the emergency room doctors to treat the critically injured party. The driver is trying to navigate his way to the hospital while not crashing the ambulance, trying to figure out which hospital would be best to go to for the particular medical situation, and is trying to do his best to update the hospital on the condition of the patient in advance of the ambulance’s arrival.
Upon arrival at the hospital emergency room, the paramedic assists in bringing the patient inside and briefs the emergency room staff on the situation. He tells them what he has discovered about the patient’s condition, what he has done to stabilize the patient, what drugs he may have used, and may assist in the initial treatment in the emergency room. The nurses and doctors in the emergency room develop a plan to treat the patient the best they can, and run tests, introduce more drugs, perform procedures, and hopefully save the patient’s life. Eventually, the hospital’s administration becomes involved and attempts to determine what kind of health insurance the patient has in order to make sure the appropriate party gets billed for the services of all of the aforementioned professionals.
At a very basic level, this is the way it is done across the country. Each entity, or branch of the system, doing the best that they can given the situation. But each entity’s services, rules, regulations, goals, and procedures are all siloed — they are all best practices for the individual field they work in. AMBO changes this, makes response to this type of scenario — and many others — more efficient, more cost effective, and adds to the effectiveness of emergency medical services with the ultimate goal of saving lives.
As an example, AMBO system is in place and responds to the same scenario:
Upon arrival at the scene of the accident, the police officer identifies who is involved in the collision and relays that information to the AMBO system coordinated dispatch center. Because the patient has subscribed to the AMBO system through their health insurance carrier, the patient’s identity, pre-existing medical conditions, medications, and medical history are automatically sent to the fire truck that is responding, the AMBO automated 911 ambulance, and the emergency room that will be used based on the patient’s and hospital’s locations and in the patient’s best interests. All of the medical professionals that will come in contact with the patient will have as much information as possible beforehand so that patient care planning can begin as soon as possible.
Upon arrival, the firemen begin to work on the patient with all of the critical information mentioned above already accounted for. As the AMBO automated 911 ambulance is en route to the scene, both paramedics riding in the back of the ambulance can focus on preparing for the patient they will receive. A real time video / audio feed from the firefighter on scene lets the paramedics see and hear what is occurring with the patient. The same feed is available to the staff in the emergency room. The AMBO 911 ambulance arrives as fast as possible because the driverless features of the ambulance factor in the fastest route to the scene.
When the paramedics arrive in the AMBO automated 911 ambulance, the firemen have already achieved a level of treatment, which is farther along than before thanks to the information about the patient being available to them prior to their arrival. The paramedics take the patient and continue their work. The real time audio / video feed in the back of the ambulance is seen by the emergency room staff, and they are aware of the procedures taking place in the ambulance. They plan their care accordingly and are ready for the AMBO automated 911 ambulance when it arrives because they have been tracking its progress as it navigates to the hospital.
Finally, the hospital administration’s piece in this patient care scenario allows them to get started on the patient’s insurance company needs, and the patient is seamlessly checked in to the hospital. Because of the automated records system associated with the AMBO system, the patient’s primary care physician and even the pharmacy can see what was done for the patient from the archived event, which was captured and stored by the AMBO system.
Does all of this seem far-fetched? What if we were to tell you that all of the technologies that are relied upon in the above scenario already exist? They do. All of the technologies referenced above — from the automated records capabilities, to the autonomous vehicle piece, to the live audio / video feed capabilities — already exist and have been proven valuable in separate aspects of society. AMBO brings all these technologies together and hacks the ambulance / emergency medical care paradigm.
The above scenario describes only one way that the AMBO system can change the way ambulance services are provided. By creating a system wherein patients, insurance companies, law enforcement, fire departments, ambulance companies, and hospitals and other medical care providers can all contribute information and draw from the system in times of patient emergencies — combined with the new automated AMBO ambulances, AMBO ambulance services can not only revolutionize the way ambulances deliver patients to hospitals, but can revolutionize the way patients are cared for across multiple disciplines in the healthcare industry.
The Future Of Tech: NOT JUST BUILDING BUT PROTECTING WHAT YOU BUILT
Protecting a new ambulance model that is heavily dependent upon using big data and mobile technologies for both bill paying and call out is a significant task. So significant that failing to prevent “hacking” of this data can completely destroy the system’s viability and credibility. Structuring the “call out” of the ambulance into a system similar to Uber or Lyft brings forth many troubling vulnerabilities that must be addressed for our future ambulance service to be credible. Central to any security precautions is protection of HIPAA data. Without measures to all but guarantee secure transactions, the future ambulance will immediately become unfeasible to operate.
First, let’s start off with a brief discussion of what HIPAA is. HIPAA stands for the Health Insurance Portability and Accountability Act and was passed by Congress in 1996. [vii] HIPAA, like most government legislation, contains multiple parts and addresses a wide range of health care issues. For the sake of this conversation, however, we are most focused on the parts of HIPAA that protect personal information. These are the same parts that a nefarious hacker could obtain and result in serious invasion of privacy as well as a wealth of other personally identifiable information that could be used against an individual. HIPAA, at its core, restricts access by third parties of an individual’s private medical records without their consent to release the information. [viii]
There is part of this legislation called the HIPAA Privacy Rule, also known as the Standards for Privacy of Individually Identifiable Health Information. This rule provides a national level set of regulations governing the use and disclosure of an individual’s health information. The HIPAA Privacy Rule makes it so that individuals control the use and disclosure of their health information to third parties. [ix] One could argue the HIPAA Privacy Rule is central to today’s patient care system and an inability to protect an individual’s health information can lead to lawsuits and a breach of trust so serious that it could completely destroy a health care business model. The ambulance service of the future included.
Today’s Uber and Lyft services are excellent precursors to the technology and operating model behind the ambulance service of the future. Simply put, Uber is a technology platform that uses a mobile phone app to connect riders and drivers.[x] By utilizing the location services on a mobile phone, Uber is able to provide estimated times of arrival and efficiently link up drivers closest to a prospective rider. Payment is automatic via the stored payment method from the riders Uber profile. [xi]
Within the confines of this simple model are vast amounts of user data. Some of it is readily apparent on the surface (such as credit card numbers), while some of the data lies in the habits and preferences of an Uber user over the course of time. This data is only protected to the level in which Uber determines is important. With some creativity applied, a hacker that steals this data could purchase items with your credit card, sell the data to a stalker who wants to know where you will be at certain times of the day, or mine the data for “blackmailable” details of an individual’s daily life patterns (such as a cheating spouse’s routine).
All of these vulnerabilities exist within the ambulance service of the future as well. Some of the vulnerable information will remain the same such as credit card information for processing payments and privacy information regarding daily routines and patterns. Added into the mix is now your full and complete digital medical record that must not only be protected as a matter of good business practice, but also to maintain compliance with the HIPAA Privacy Rule and avoid patient lawsuits.
With a driverless ambulance service, we have to assume a level of internet connectivity is required via the “internet of things” concept. The interconnectivity of these “things” would be required to drive the ambulance, operate the medical sensors, upload medical information to the hospital, take payments, and of course, to triage and respond to an emergency call. All of these sensors and transactions also represent multiple data transfers and communication between devices. Any one of these sensors and the transactions between them present opportunities to be hacked and could ruin the integrity of the service.
The problem is the multiple components and sensors are not created by a single vendor to be a “closed” system when operating together. Even if we completely secured the data transfers and communications between the patient and the medical system, we could still be vulnerable to a hack from one of our third party vendors. Perhaps it’s a hack into the driverless ambulance sensors that could then be used to attack or compromise patient information during a medical assessment or upload of medical data to the hospital. Or, even worse, a hack of the driverless ambulance sensors that overrides the ambulance’s ability to drive itself to the hospital. Motivations could range from simple criminal mischief to extortion (pay a ransom and in order to let the ambulance drive to the hospital) to attempted murder. As unlikely as some of this might seem, it only takes one well publicized instance to completely destroy any trust in the new ambulance system and render it obsolete. Putting a driver back in the vehicle and fully staffing a 911-style dispatch and triage service will result in higher costs and patient care will likely suffer as efficiency lowers.
A great present day example for comparison is that of the Target breach in 2013. In this case, hackers were able to steal Target credit/debit card holder data through a compromised third party. The third party, an HVAC contractor with access to Target’s network, was compromised by hackers that used the contractor’s stolen login credentials to access the system and steal cardholder data. [xii] In our ambulance service of the future, this is a very simple scenario to play out again. We would have a multitude of third party contractors needing access to our ambulance systems. For example, auto mechanics for diagnostics work, health insurance companies for co-pay collection and medical claims, medical equipment maintenance contractors, and the ambulance manufacturer might need to access the driverless vehicle software for updates and troubleshooting. All of these systems and users come together to form the network infrastructure needed to operate our ambulance service, but also represent a new point of vulnerability in the system and opportunities for compromise via these third parties. Not to mention the third parties that our third party vendors use to keep their own networks and sensors operating. The end result is a maze of vendors, sensors, and service “enablers” all representing points of vulnerability in our network.
In order to protect our digital system, we should consider a cooperative agreement with other companies similar to the Vendor Security Alliance (VSA). The VSA is sponsored by nine tech companies to include Uber, Dropbox, Palantir, and Airbnb. These companies then set cybersecurity standards that other businesses can use to assess how good their third party vendors are at securing their data. [xiii] By paying a fee and joining the VSA, our ambulance service can guarantee that all of its third party vendors practice best in industry security procedures. Essentially, a company that contracts work out to one of these third party vendors requires each vendor to answer a questionnaire that will determine their compliance with the best industry standards for cybersecurity as determined by the VSA. By participating in the VSA (or similar program), our ambulance service can ensure that all of the “moving parts” and networked components are operated by third party vendors utilizing some of the most stringent security standards.
The Future: SIMPLY NEW OR REVOLUTIONIZED??
A great Futurist once asked, “Can you not only digitize, but completely transform this?” The process the futurist was referencing was the standardized circular cycle of The Emergency Medical Services System.
We all know that government structures love circular modeling. Circle of life, planning, etc. etc. Additionally, it is important to recognize that this circle or wheel revolves around the patient as its hub. Again, a typical thought process. Who would ever dare to even consider that the patient is not the center of the service model?
But isn’t revolution accomplished by approaching typical problems with atypical thought processes?? Additionally, the patient centric hub and wheel is also inaccurate and unrealistic. In reality, the previous emergency service model broken out would look more like this…
The model is more or less linear, making it vulnerable to chain link breakages. It is more a matter of a patient moving through a model rather than the model rotating around the patient. Also, the model misses many key components that allow the system to function. So what if we made the delivery mechanism the hub of the service delivery wheel? (Or rather something that resembles more of a fidget spinner than a wheel).
Through automation and full system integration the autonomous ambulance service of the future can function as the centralized processing point for emergency services. Cars can detect accidents and request service automatically. The level of service can be determined based on on-board severity algorithms. Patient records can be shared, processed, analyzed for trends that feed to prevention and public education, etc. Transport, destination decisions, notification are autonomous. Etc. Etc. Etc. Again, the possibilities are only limited by the imagination. And of course the willingness to change an age-old service model.
REFERENCES
[i] “History of Ambulances,” emt-resources.com, 2016, accessed August 23, 2017, http://www.emt-resources.com/History-of-Ambulances.html.
[ii] Ibid.
[iii] Lowenstein, “New Study Shows Skepticism About Driverless Ambulances.”
[iv] Ibid.
[v] Van Wagenen, “The Next Generation of Ambulance Technology Hits the Road.”
[vi] Ibid.
[vii] “What Is HIPAA,” Whatishipaa.org, accessed September 20, 2017, www.whatishipaa.org.
[viii] Ibid.
[ix] Ibid.
[x] “How Does Uber Work?,” Uber.com, 2016, https://help.uber.com/h/738d1ff7-5fe0-4383-b34c-4a2480efd71e.
[xi] Ibid.
[xii] “Target Hackers Broke in Via HVAC Company,” Krebsonsecurity, 2017, http://krebsonsecurity.com/2014/02/target-hackers-broke-in-via-hvac-company/.
[xiii] Ken Yeung, “Uber, Square, Airbnb, and Others Form Cybersecurity Coalition for Vetting Vendors,” Venturebeat.com, September 15, 2016, https://venturebeat.com/2016/09/15/uber-square-airbnb-and-others-form-cybersecurity-coalition-for-vetting-vendors/.
