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A Digital Mindset for Ambulatory Care

Exponential digital growth is transforming the way the world works in the 21st century. The “internet of things” (IoT) is a growing web of connected devices and objects; an anticipated 50 billion objects will connect to the internet by 2020. The IoT embodies the convergence of cloud computing, ubiquitous connectedness, big data, and complex analytics. This technology enables a vast number of applications to manage physical objects remotely by connecting them to machines and sensors. This digital mindset makes current ambulance services ripe for transformation and disruption. As the IoT disrupts and transforms old technologies, it is crucial that the Federal Interagency Committee on Emergency Medical Services (FICEMS) develops a digital strategy.

Digital transformation and the growing IoT will have profound implications in the field of healthcare. For example, this technology may one day coordinate self-driving cars, synchronize smart cities, manage energy efficiency in hospitals, and monitor patients remotely. With the advent of this innovation, sensors in the floors of smart homes could autonomously call for an ambulance if it detects that an elderly tenant fell. This same interconnectivity could also continuously monitor patient vital signs and alert physicians for early detection of illness.

The future of emergency medicine will not emerge as a linear extrapolation of present trends. Already, the accessibility and use of digital technology in ambulatory setting has increased exponentially over the past fifty years. Telemedicine, artificial intelligence, robotics, brain-computer interfaces, quantum computing, wearables, and other emerging technologies will continue to revolutionize the way emergency responders operate. Staying ahead of technological innovation allows the field of emergency response to maintain its relevance while continuing to provide high-quality patient care using person-centered design thinking.

With an aging population and increasing diversity and frequency of natural disasters, it is important to redesign pre-hospital ambulatory care. Threatening public health and safety, overcrowding in emergency departments in the United States has reached crisis proportions across the United States. Aging ambulances with outdated technology also pose a public health threat. According to National EMS Information System data, it typically takes 9 or more minutes for an ambulance to arrive on scene and an average of 36.5 minutes for a patient to see an emergency department physician. In rural areas, these numbers are even higher.

Approaching ambulatory services with a goal of digital transformation revolves around a mindset that the status quo is not acceptable. To embrace the emergent digital ecosystem, revised ambulatory care should be user-centric, simple, open, and agile in design. The non-exhaustive list below highlights how some emerging technologies could transform ambulatory services in the future:

Autonomous vehicles

In the future, computer-controlled technology may drive ambulances autonomously. Self-driving vehicles operate using sensors to understand the car’s relation to other vehicles as well as the road. Researchers anticipate that ubiquitous driverless car technology will decrease motor vehicle accidents; ultimately decreasing the number of emergency calls due to traffic incidences. Without the need for a human driver, this change would allow for increased productivity among the first responders working inside of the vehicle. In a world of self-driving vehicles, the design of an ambulance may appear vastly different from current models. Unmanned ambulances may one day report to a central facility at the end of each shift for refueling, cleaning, and restocking supplies. Pre- and post-shift ambulance inspections could become obsolete, saving significant amounts of time.

Quantum computing and artificial intelligence

Driverless technology becomes even more advanced when combined with cognitive computing and/or artificial intelligence. IBM Watson is a cognitive computer that combines artificial intelligence with complex analytical software. Using IBM Watson or similar technology, ambulance fleets may be optimized by an intelligent control center using complex algorithms. Reducing the need for human operators to handle dispatching would increase productivity.

Robotics

In the future, robots could eliminate the need for paramedics and first responders to lift stretchers. Using robotic lift assistance technology, the role of emergency medical responders could shift to more of a purely clinical role. In 2017, exoskeleton technology is already in use in such domains as welding, shipbuilding, and helping paraplegics walk. The use of robots for the purpose of lifting patients into and out of ambulances will likely lead to a decrease in rates of injury while working.

Telemedicine

Telemedicine is a developing field that is currently in use in limited settings. In the future, this technology may drastically change the pre-hospital experience in emergency response. Omnipresent telemedicine capabilities would allow first responders to collaborate with emergency department physicians in real time prior to arrival at the hospital. With earlier physician assessments, the role of paramedics could expand to allow for more advanced interventions. Increasing the range of pre-hospital care may ultimately improve patient outcomes. The emersion of telemedicine into emergency response also provides countless opportunities for enhancing ambulatory treatment in resource-constrained environments or locations.

Wearable technologies

Building on the concept of telemedicine, wearable technology could one day connect physicians to the visual point of view of first responders. In the future, stethoscopes could be operated by robotic assistants using Bluetooth technology. Virtual reality headsets could provide emergency department physicians with full-range, 3D vision of activity happening in the ambulance. Sensory feedback technology allowing physicians to palpate patients remotely could enhance collaboration between hospitals and ambulatory care.

The technologies required to transform ambulatory care are already in existence, and other groups are already working to remodel ambulances. For instance, the Future Electric Vehicles for Ambulances project created a proof of concept design to consider the use of small, compact electric ambulance vehicles. Teams of engineering students at the Massachusetts Institute of Technology compete annually to redesign a more updated ambulance. In 2014, researchers created a theoretical design for an ambulance based on the IoT. Other experts have discussed the potential for a smart ambulance comprising traffic-aware health monitoring applications. Beta testing for redesigned ambulances is also already underway. With robust government leadership, the United States could be an early creator and adopter of redesigned ambulatory care. Improved ambulance technology would improve health outcomes, enrich collaboration in emergency medicine, and facilitate greater equity between city and rural areas.

In the future, autonomous vehicles and other emerging technologies can decrease the amount of time connecting patients to emergency care. The Federal Interagency Committee on Emergency Medical Services can transform the ambulance for the future using digital technology. The convergence of newly emerging technologies will allow integrated patient care networks to evolve. To stay abreast of technological advances, it is important to have a digital strategy, allowing FICEMS to evaluate critically new technologies, while maintaining a leadership role in early adoption of change. This proposal outlines a human-centered digital redesign of the ambulance service. FICEMS can “hack” bureaucracy by revamping hiring and training, delivery, procurement, silos, and by protecting cybersecurity.

DIGITAL REDESIGN

The modern-day ambulance isn’t much different than what it was 5 decades ago. The primary purpose hasn’t changed; arrive fast, assess and begin lifesaving treatment to a person with medical need. Then attempt to get them to a facility of definitive care as quickly as possible. Although there are several technological advances in biometric devices that can assess a person’s vital signs and assist in decision making for treatment measures, very little have been incorporated into the back of these vehicles where patient care is delivered.

Emergency medical service (EMS) systems are structured as part of the nation’s critical infrastructure and key resources and provide an emergency service 24 hours a day, 7 days a week. The costs of running an EMS program include the constant staffing to meet the demand, the equipment costs, training, and administrative oversight. Because revenue is only captured when a transport occurs to the hospital emergency department (ED), most agencies have historically encouraged their personnel to transport as much as possible regardless of patient acuity. This may be a contributing factor to hospital ED overcrowding and understaffing issues. Because a simple business model of supply of resources meeting demand with cost recovery being limited to patient transports, EMS across the nation has become a scarce critical resource that does not have room to address surge in most instances.

One should ask, how can the resilience of these limited emergency resources be utilized in a fashion that can increase unit availability, still deliver a fast and high-quality care, while accomplishing the highest level of efficiency through technology? Looking out into the future to dream of technologies that don’t yet exist is not necessary. Combining two existing advances of biotelemetry and autonomous vehicles are the solution. Placing these two technologies into context within the current emergency medical services model creating the fourth tier of EMS, will be the best illustration.

According to the California Ambulance Association, out of the 2.7 million ambulance transports annually, nearly 90 percent are for continuous medical care and not for emergency services. Still, California pursues the conventional model and methodology of emergency response by sending highly trained responders to ambulance calls in the expectation that they are intervening in traumatic injuries with the ultimate aim of transporting these patients to an emergency room where definitive care can be rendered. Ambulance personnel trained at the highest level of emergency services delivery picking up a patient with non-acute illness and delivering them to the highest trained and highest paid emergency room physicians has proven to be incredibly inefficient. The results of the system being used in this fashion have caused unavailability of ambulances in communities, hospital ER overcrowding, and the wrong level of care being provided to the person requesting services.

Modifying Deployment

Most dispatch centers across the country utilizes a rapid dispatch system where they determine the caller’s location and call back information, determine the type of emergency and then deploy the closest ambulance and first responder. While the emergency responders are traveling to the location of the reported emergency, the dispatcher will begin to ask scripted questions to further classify the emergency and provide direction to assist in aiding the patient until resources arrive on-scene. Using the International Academy QA Guide version 13, the information on the medical emergency is categorized into one of 33 call types. Additional screening questions are asked and then the level of acuity is assigned based off further questioning to the caller. Levels of acuity are categorized by the lowest level to highest using letters, A, B, C, D, and E. There is also an acuity determinant, omega, that ultimately is used to categorize calls for which no medical care is necessary. Call takers and dispatcher make up the first tier of the EMS system. In the U.S., the second tier is comprised of the first responders and the receiving hospitals that take over care make up the third tier.

The Autonomous Ambulance

With the initial screening of every medical emergency being reported by 9–1–1 call, if the patient that would like to be seen at a hospital is at the lowest level of acuity, omega, alpha or bravo, and the patient is able to stand up and walk on their own, the nearest staged autonomous vehicle can be deployed.

Staged in every neighborhood across the urban and suburban area are the driverless sedans that are full of probes and sensors ready to not only whisk you away to the closest and most appropriate treating facility, the automation is also equipped with the highest level of biotelemetry beginning patient assessments and care.

As the patient enters the semi-reclined seat, they find themselves comfortably fitted into one of the highest bio-technological transporting units. Surrounding the patient are several sensors, nodes, and screens. In the view of the patient is the screen with a triage nurse already beginning a verbal assessment while the vehicle is en-route to the closest and most suitable facility to deliver care based from the patient’s conditions. The monitors surrounding the patient begin to capture the following measures:

· Facial recognition technology (FRT) for positive identification

· Health information exchange from FRT positive identity allowing for the patient’s protected health information (PHI) to be visible for the monitoring nurse overseeing the incoming patient

· Blood pressure cuff surrounding the patients arm

· Pulse oximetry at the patients’ fingertip to determine level of O2 in the blood

· Respiratory rate along with the patient body temperature

· Blood glucose level to determine sugar levels

· If needed, positive flow O2 to the patients face

· Probes on the back of the patients chair to listen to lung sounds

· A seat that will adjust the patient body position based from vital signs and readings

As the autonomous vehicle drives to the facility that is most appropriate to receive the patient, they enter the patient off-loading area and are met with hospital staff that already have the patients first set of vitals, medical history, and can facilitate the next steps of treatment.

What solution does this bring?

A large contributing factor that has had a measurable impact on the EMS services is the increased number of calls for service. In particular is the type of calls the EMS responders are now being dispatched to when a person calls 911. The request for low-acuity medical treatment has depleted resources that should be available for true medical emergencies. Between 1996 and 2006, a 36 percent increase occurred for patients who were delivered to a hospital ED for a non-emergency medical need. Any other medical care solutions offered to EMS providers could increase their surge capacity and availability for true medical emergencies.

Financial implications result concerning hospital EDs and tying up EMS services as well. A 2010 study revealed that between 13 percent and 27 percent of all hospital ED visits could have been handled at alternative sites and could have saved $4.4 billion in annual government healthcare savings. Most of these frequent users of 911 systems could have their issues addressed by access to other services, such as primary care clinics, psychiatric or behavioral health specialists, or other social services. This alternative model of accessing low acuity patients, assessing them en-route, and delivering them to the most appropriate facility could aid in health care savings, free up the emergency response ambulances, and provide for a higher level of patient care and satisfaction.

It can be anticipated that the new low acuity autonomous medical transports would free up the existing emergency medical response system by approximately 60 percent. By adding the fourth tier of response, the increase of the nations critical infrastructure and key resources, such as hospital EDs and emergency medical response vehicles will become more resilient for the communities they serve.

HIRING and TRAINING

According to technology author William Eggers, a capitalizing on a technologically savvy workforce full of the “best and the brightest” is essential today to capitalize on the power of digital technology. To implement quality medical care in the autonomous ambulance, smart hiring and training for personnel are critical. It is optimal that each key person to the design and delivery of ambulatory care, from the technological designer of the vehicle to the responding medical care provider, possess additional qualities highlighted by Eggers such as the desire to be civic-minded and to find meaning and purpose in their work. For the futuristic ambulance, it may be an ideal opportunity to put these experts to work in a hybrid role of tech savviness and the concern of a medical care provider. This professional may be a medical care professional lacking the expertise and credentials of an ER physician, but with the capability and know-how of comfortably operating in a technologically equipped ambulance of the future.

In a perfect world, ambulances would have an emergency physician on board which would significantly increase survival rates of patients experiencing critical medical incidents, particularly cardiac arrest. However, this is absolutely cost prohibitive and impossible due to doctor shortages. However, as a feasible alternative to this need, the future of ambulatory care should implement measures to save costs and revolutionize the delivery of life-saving procedures through smart hiring and training of personnel.

The ideal way to improve the low survival rates of cardiac arrest patients outside of a hospital stemming from the lack of doctors on ambulances is the option of bringing an ER doctor on board via virtual reality. With an integrated audiovisual and communication system, a paramedic or EMT can work hand in hand with an ER doctor in a centralized location or hospital. According to Josh Byers, an industrial designer and prototype specialist, this collaboration between experts enables medical personnel “to act as the hands, eyes, and ears of the emergency physician.” The onboard personnel can be coached and instructed through the virtual apparatus as sensors transmit essential information and vital signs to the hospital. While they certainly need medical qualifications and credentials to do their work, an interest and proclivity to cutting-edge technology would be an enhancement. Hiring practices should reflect this hybrid professional with a diversity of talent and credentials.

Just as Eggers discusses crowdsourcing for computer programmers, reaching out to a large digital community to access incredible talent for a project-based enterprise, one can also crowdsource medical care. While not an integral component to the ambulance of the future, crowdsourcing critical on-scene care to citizens could drastically assist emergency responders in bringing life-saving CPR to distressed patients. An increasingly popular smartphone app known as Pulsepoint connects CPR-trained citizens to those with cardiac arrest via an alert system to registered users in the immediate vicinity of a medical incident. It also provides information on the nearest AED locations nearby.

Another innovation in healthcare falls into the ever popular and booming gig economy. The gig economy is a flexible work system which connects customized workers to customers via online platforms, such as Uber or food delivery services. There are now “digital health” start-up companies which are forms of telemedicine, matching nurses and doctors of certain specialties with hospitals and centers in need of freelance workers to appease staffing shortages. Due to significant nurse and physician shortages, these services are becoming more and more popular. Regarding our futuristic ambulance, these same digital systems could deploy registered medical personnel on-scene to assist a patient out in public by utilizing the equipment provided with the arrival of the ambulance.

The flexibility and mobility provided by smartphone apps such as Pulsepoint, “gig” style medical personnel and virtual deployment are certainly ways around the economically impossible hiring and staffing of the necessary medical expertise to save lives.

DELIVERY and CYBERSECURITY

While emergency medical services serve the public, who are the customers of these services, this delivery hack strongly centers on local emergency medical service providers as the users and customers. As identified previously, the costs to the overall system and challenges to the ability to deliver quality care to those who need it are a consequence of the resource drain from low acuity emergency calls. This problem can be solved through the delivery of these services to stream line assessment, increase efficiency, and improve availability.

The hacking of emergency medical service delivery begins at dispatch, where good service starts. Calls for emergency help come through a 911 system similar to what is currently in place. Dispatch locates the caller, while a mid-level practitioner sorts and triages the calls based on the answers to the set of assessment questions. All calls deemed low acuity will be responded by one vehicle from the fleet of fully autonomous emergency transport vehicles. All other medical calls other than accidents requiring rescue will be responded by one fully autonomous vehicle staffed with one live, human paramedic. For both fleets, the triaging practitioner deploys a particular vehicle based on the acuity triage and the shortest estimated response time responding vehicle. This deployment is based on a real-time GPS based system which maps and tracks all fleet vehicles.

Before the vehicle arrives on the scene, it will know based on the mid-level practitioner’s initial assessment, whether it will be transporting the patient to an emergency room or a clinic. Telemedicine that is present in all autonomous fleets take vital signs and are equipped to update and, if necessary, alter the destination based on this biometric information.

Availability

Fleet management software uses the ever growing repository of data to understand where and what the greatest EMS needs in a given community are. For example, the software can ensure available autonomous vehicle services can serve, at any given time, a programmed number of citizens. These parameters may be something such as maintaining a ratio of 1 autonomous vehicle per 10,000 people, or 1 for every 20 square miles. A subject matter expert panel will be convened and consulted in order to determine initial parameters and meet regularly to analyze data over time as it is aggregated. Over time, the data can be used to better ensure availability and appropriate resource allocation to “hot spots” of need. Those numbers could be adjusted up or down as the service rolls out and collects data to analyze. This could additionally be levered during times of large-scale disasters and emergencies. This demand-based approach allows resource distribution to be tailored to those areas where there is a need, and not waste resources in areas with less demand. Delivery will begin with suburban and suburban-rural areas, where resources are often limited and demand is strong.

Efficiency

Thanks to the IOT, both simple and complex systems have capabilities for interconnectedness. Autonomous response vehicles (both fully autonomous and those staffed with one paramedic) communicate with each other, their environments, dispatch, clinics and emergency rooms, and patients.

For example, efficiency is maximized by smart routing. Equipped with data for locations of lowest level acuity, autonomous vehicles can plan multiple patient pick up routes with multiple destinations. Real time traffic data will be embedded into the system to maximize transport efficiency. Several companies, such as UPS, have found successful ways to hack delivery of goods and services, and lessons learned should be leveraged.

Additionally, these interactive fleets know wait times at various medical facilities and can adjust accordingly based on time and distance to ensure resources are equitably distributed and no one emergency room resources are depleted. This is important because quality of care and timeliness of emergency care may suffer if resources in emergency rooms are strained.

First responders will be active partners in the development and implementation of these systems (as well as continual improvement, enhancement and problem resolution as the fleets gain more experience). It is important first responders co-deliver and co-produce these systems and products, as again, they are the customers. Beyond this, utilizing open source systems allows and leverages a diverse group of minds to identify unknown problems and offer innovative solutions. Input from customers is paramount to agile development. Instead of building a team of policy people, subject matter experts will be collaborated with to ensure this hack succeeds.

These are simple solutions for an inefficient system. The goal is to maintain or improve effectiveness while reducing costs and making resource use and allocation more efficient. These simple solutions are by design in recognition of the inverse relationship between performance and complexity.

Cyber-security

The consequences of system failures and security breaches could be catastrophic in this arena. This redesign of ambulance services prioritizes risks and protects against known and emerging threats. Security, vigilance, and resilience are the components of this cyber-security plan.

As many learned with the roll out of Healthcare.gov, in order for these digital systems to be secure, a multi-pronged approach is necessary. Beta testing is essential. Involvement of industry professionals, tech subject matter experts, customers and patients should be leveraged to identify any weaknesses or vulnerabilities, and build those protections simultaneously as the software and network are being developed. Active techniques such as the use of honeypots, sinkholes, and deception can be used to lure potential malicious actors in and find the weaknesses in the systems which the cyber-security and multidisciplinary team can patch before the vulnerability is ever exploited.

System resilience will be built in during development and production. Crowd sourcing can help with identifying vulnerabilities to both outsiders and insiders. Collaboration with stakeholders, peers, and customers and the appropriate industry is essential. Additionally, using hackers during development and after deployment to identify holes in security and gaps in back up resiliency to system failures. They can ensure the doors are locked, and alert and remedy unknown open doors in the system. Biometrics such as facial recognition and fingerprints add a layer of security. More layers of security and versatility ensure system reliance and effectiveness.

PROCUREMENT

The procurement process can often be a convoluted and complicated one. Add in the fact the procurement of a digital ambulance service that moves away from the traditional “one call — one haul” model is nuanced by countless governmental and industry standards, and the strategic procurement process becomes an industry-wide challenge. However, the business of EMS is inefficient, expensive, and ripe for disruption. The following is a proposed procurement process for the digital mindset for autonomous ambulatory care. It should be noted that the premise of the procurement process is no different than any other strategic procurement process: the organization should set up a strategic procurement team that sets the overall direction for procurement, and that direction is intimately aligned with the organization’s overall business strategy.

As the starting point, the strategic procurement team identifies potential suppliers that can meet proposed standards and specifications of an autonomous ambulatory service. Much like other governmental procurement procedures, the contract for procurement will be a performance-based contract that is awarded to a company that is able to meet precise specifications. However, unlike contemporary government contracts, bureaucratic rigidity is the enemy. The autonomous ambulance procurement process is deeply seeded in redesigning the governmental framework, and seeing old problems and processes through an innovative lens. Therefore, the procurement process needs to involve deliverable incentives, governmental grants, new and old competing companies, and private and public sector sources. Furthermore, implementing a sourcing, or outsourcing, strategy that focuses more on patient care and desirable business results as opposed to the traditional competitive low-bidding process will result in a digitally transformed ambulatory service that improves emergency medical services. Ultimately, the core strategy of the autonomous ambulatory procurement process is identifying the critical components needed, and pinpointing various customer-centric and tech-savvy suppliers that are capable of meeting those needs.

Autonomous vehicles

As a potential supplier, Tesla claims that all of their vehicles, including the currently available Model 3, have the technology and hardware needed for full self-driving capability at a safety level substantially greater than that of a human driver. Tesla’s Chief Executive Officer, Elon Musk, predicts Tesla will provide true Level 5 autonomous driving in its vehicles by 2019. Consequently, Tesla would be a strong candidate to bid for the autonomous vehicle contract. If awarded, Tesla would provide the previously mentioned driverless ambulance strategically staged in every neighborhood across urban and suburban areas. This marks the autonomous ambulance shell.

Quantum computing and artificial intelligence

Driverless technology becomes even more advanced when combined with cognitive computing and/or artificial intelligence. IBM Watson is a cognitive computer that combines artificial intelligence with complex analytical software. Using IBM Watson or similar technology, ambulance fleets may be optimized by an intelligent control center using complex algorithms.

There are a number of large and start-up companies that provide quantum computing and artificial intelligence. Large companies, such as Google, would be a leader in quantum computing and artificial intelligence because of the immense amount of data, and subsequent algorithms, the company owns. However, as stated in the introduction to procurement, the aim is to make the bidding process viable for large and small companies so long as they possess the capabilities and product that meet required specifications. The start-up company named D-Wave has a quantum computer that could easily compete with IBM, Intel, and Microsoft.

Robotics

The autonomous ambulatory system is designed with robotic lift assistance technology, ultimately shifting the role of emergency medical responders to a purely clinical role. In 2017, exoskeleton technology is already in use in such domains as welding, shipbuilding, and helping paraplegics walk.

Scientists in Japan have already developed an experimental nursing care robot that is capable of lifting a patient into bed or assisting patients who need assistance while walking. The company that developed the robot, Sumitomo Riko Company, claims the robot moves quickly and precisely, allowing for softer, power-intensive movements without endangering the patient. A company with this type of innovative abilities and relevant product would be suited to bid for the robotics contract.

Telemedicine

The proposed autonomous ambulance is to be outfitted with biotelemetry, complete with probes and sensors that readily measure the patient’s vital signs. The patient’s information is wirelessly transmitted to the health care facility that will be accepting the patient so the attending medical professional can begin the pre-hospital assessment.

As a company that currently manufactures this technology on a limited level, BioTelemetry Inc. provides a full range of monitoring services to include mobile cardiac telemetry, ambulatory telemetry, wireless holter, and pacemaking monitoring. The company boasts to be the world’s leader on wireless medical technology that focuses on the delivery of health information for healthcare providers to monitor and diagnose patients accurately and cost-effectively. Consequently, BioTelemetry Inc., or a company with similar business accomplishments, is a strong candidate for biotelemetry components for the autonomous ambulance.

HACKING SILOS

Due to the lack of evolution in emergency medical systems, the existing component parts of the system have become very independent silos. The systems that exist are dispatch, the transporting ambulances, the receiving hospitals and the health care providers. Each of these has developed over time to come up with own performance measures, which don’t look at success beyond what their own area of responsibility is accomplishing. Because of this myopic focus of a system, you have performance measures that have competing interests and an overall system that doesn’t accomplish an overarching mission of quality service for the people it serves.

Dispatch

When a person dials 9–1–1, they expect to be able to get a professional who can take a quick description of the emergency and get help started as quickly as possible. Dispatcher centers can become accredited by having to meet specific performance criteria. One of the common accrediting agencies is the Accredited Centers of Excellence (ACE) that has a mission of providing superior, up to date public care and efficient resource utilization to achieve maximum results in emergency situations. Often times a performance measure that a dispatcher is attempting to meet is the shortest amount of time to process the information that a caller is giving and getting the appropriate resources on the road to respond. Unfortunately, due to this goal, the system fails to identify the urgency of the need and actually prioritize resources. The system has not looked at what the real patients needs are, just the fact that they need to get assistance as fast as possible which isn’t always the best utilization of resources for the system that serves an entire community.

Ambulance

The second part of the system is the responding ambulance. The model of staffing a vehicle with two trained emergency medical technicians and medical gear hasn’t changed in decades either. The system identifies where the ambulances should post as well as how many ambulances that a system should need based from historical data. By deploying resources in this fashion, the systems past is the only indicator of how many ambulances should be needed in the future but fails to predict any anomalies or sudden needs. This is the business model that ambulance systems have utilized nationwide. By placing just enough resources that are predicted to be needed available in a community, the community can be served near a threshold of system delivery that is close to being adequate. This business model fails to identify any surge or criteria that assists in triaging and sending more appropriate resources to specific call types that could be more suitable to take a person where they could receive a more appropriate level of care. The majority of pre-hospital emergency medical care providers are only set up to deliver patients to a hospital emergency room regardless of the symptoms or need of the patient. Transporting the patient to a hospital ER is the only mechanism that allows for ambulances to receive reimbursement for their care and treatment.

Hospitals

The third silo in the system is the receiving hospitals themselves. Regardless of patient acuity, the only department that an ambulance may deliver a patient to is the emergency room. The hospital ER’s are staffed with the highest trained as well as some of the highest paid physicians. The largest component of any EMS system is the capability of the receiving hospital and its ability to provide care for the incoming patient. The hospitals should also have the ability to provide for surge capacity and have plans in place to staff and care for those in the event of a disaster or even a local event. Any limitations on patients getting into a hospital’s emergency room are referred to as “access block.” Access block puts responding EMS “on diversion,” where an ambulance with an incoming patient is directed to go to the next closest ED. The diversions result because a hospital ER does not have any more bed capacity, and therefore cannot, accept any more ER patients by ambulance.

These events are also associated with physician and nurse-staffing level shortages to treat the high number of patients in the ER. The hospital medical staff to patient ratio associated can be linked to poor quality of care outcomes. A study of 187 hospitals in the state of California illustrates that ER overcrowding is a direct link to increased mortality, longer hospitals stays, and increased healthcare costs.

Beyond the diversions and difficulties for ambulances to choose a hospital to transport to, it has now become increasingly difficult for the crews to transfer care to the ED staff once inside the hospital. This situation keeps EMS crews in the hospital ED, which means they are not available for the next reported emergency. A study of the Los Angeles Fire Department’s EMS transport system captured the hospital wait times in an impacted system serving a large population. This study indicated that ambulance crews would wait 27 minutes per patient as the median time, and in one out of every eight visits to the ED, the crew was waiting for over one hour. In contrast, a study on EMS turn-around times in hospital EDs recommends that a transfer of patient care should only take a couple of minutes and rarely exceed 10 minutes.

Health Care Providers

Health care providers have not leveraged the existing technology to benefit the people that are covered. The industry has been overregulated due to privacy of protected health information, which has continually grown more restrictive over the years. Something as simple as sharing medical history, current prescriptions, or allergies to medications outside of a very narrow health network is technologically simple, but is bound by limitations of legality which can be counterproductive to providing quality care. People are more mobile than ever before, but it is not uncommon for people’s medical records to be able to be accessible wherever they are.

Even on a local level, access to personal health records could assist emergency responders make more appropriate decisions for a persons care while they are still on-scene of an incident, yet this has not become a common practice. One health network visionary stateS what is trying to be created is a true operating system. Such a system would encompass clinical decision support, machine learning and adaptive amplified intelligence that integrates pieces of the puzzle and gives inputs so that you can manage outputs. Systems are being improved but there still exists much room for progress for network communication amongst all health care networks.

Solutions

The problem of the existing silos has driven a current effort of backing out all of the current systems and focusing on what matters most, patient outcomes. Donald M. Berwick, author of Launching Accountable Care Organizations — The proposed rule for Medicare shared saving program, describes the dysfunctional healthcare system as having no single group of participants, physicians, hospitals, public or private payers, or employers, taking full responsibility for guiding the health of a patient or community, care is distributed across many sites, and integration among them may be deficient. Fragmentation leads to waste and duplication — and unnecessarily high costs. This problem has left room for reform and the application of technology to bring together a system of efficiencies that can be achieved.

The creation of Accountable Care Organizations are a step in the right direction in hacking the silos. The purpose of the ACOs are to foster change in patient care so as to accelerate progress toward a three-part aim: better care for individuals, better health for populations, and slower growth in costs through improvements in care. By having all parts of the system, from dispatch, through ambulance arrival, coordinated and accessible patient information, to sending the patient to the most appropriate care facility to accomplish a continuum of care needs to be the continued vision. By all parts of the EMS system breaking their own individualized performance measures and adapting to what is best for the end user should continue to drive the needed change.

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