Innovation in Emergency Medical Response

Here is an interesting article about innovation in 9-1-1 response. Sue Hoyt, our former Chairman for many years and former President of the Emergency Nurses Association, brought it to my attention.

Right now, when someone calls 9-1-1 and says they need emergency medical help, we often under resource (do nothing), and more often over resource (send an ambulance), when the situation calls for something in between. The English emergency medical response system began experimenting with using their 1-1-2 (their 9-1-1) system as a gateway to a range of medical services several years ago, using nurses as triage experts. Richmond EMS, led by Jerry Overton, was the first in the US to try it. Now Louisville, Ky and COMCARE member Priority Dispatch are trying it there.

With budgets tightening, and technology making it easy to pull in expert resources, we can expect more pressure for more informed response.


February 22, 2009
Lexington Herald-Leader

Louisville looks to ease emergency room backlogs


Officials in Louisville are looking at a new screening system for 911 calls as a way to reduce overcrowding in emergency rooms and limit ambulance runs.

Metro EMS recently received a $50,000 grant to look into how best to filter out lower priority calls that don't require an ambulance.

Dr. Neal Richmond, director of Metro EMS, said hundreds of ambulances are sent out each year in Louisville to respond to ailments that might not require one. Those calls are taxing the city's emergency response system.
Many of them go to 911 operators either because the patients making the calls have limited health insurance or they have no doctor or one who is unavailable.

"If there's an alternate way to handle 911 calls and get people the care they need, we're all about that," said Debbie Fox with MetroSafe Communications. "It's very innovative."

If the system is enacted, The Courier-Journal reported that 911 calls deemed low priority would be rerouted to a registered nurse, who would determine what care is needed. That could range from recommending treatment at home or making an appointment for the patient to visit a doctor or clinic.

This month, EMS officials talked about potential new software with doctors, nurses, hospital administrators, emergency dispatchers, social service agencies and others.

Greg Scott with Priority Dispatch, the company that developed the software, said only Richmond, Va., has incorporated it fully in the United States. A few other American cities have tried it, and the system is prominent in Britain.

Implementation won't happen overnight. It will take a significant network of resources, including requirements for medical providers to keep appointments open and assistance from transportation companies in providing taxi vouchers or bus rides.

"It's a vast effort," Richmond said.

Steve Heilman, a doctor with Norton Healthcare, said he expects the program could help reduce hospital crowding but warns it will take some education for the public to catch on.

"Community perception is going to be a very difficult area to address,"
he said. "People call 911 expecting to get an ambulance."

Next Generation Emergency Communications and Cloud Computing

[The following comment was written to a list serv of persons interested in 9-1-1 access and response for persons who are deaf or hard of hearing. I wrote it in response to a notice of an upcoming FCC summit on 9-1-1, and a request for questions for the panel.]

David Aylward, February 6, 2009

The clearly stated emergency communications concerns of the deaf and hard of hearing community (along with those of lots of other constituencies, use cases, etc) will get properly addressed, with a mainstream solution, when and if Next Generation Emergency Communications gets installed everywhere a person calls from, or needs help.

I think a critical question for the FCC to ask at these two safety summits, and all of us to ask and answer, is how system-wide solutions can be deployed rapidly and efficiently, rather than the current excruciatingly slow and expensive method of upgrading PSAP by PSAP, 6500 times over (and the same for every other emergency agency). How can we have the equivalent of a “software upgrade” downloaded to emergency agencies rather than the equivalent of driving out to each office, tearing out custom electronics and replacing them with new equipment on site, which is what we do now, even though it is the most expensive way to do it, whenever each agency can scrape together the money to make a big purchase.

Solving this is not a question of money or technology -- in the first instance (although those are very relevant secondarily). It is first a question of architecture (what is the best way to construct a modern emergency information and communications tech system to meet public needs?), and then of a political governance system (or new business model) to implement that architecture.

The Problem: It has taken 13 years from the date of the E9-1-1 requirement by the FCC to get to a point where at least one PSAP in counties including 90% of the population can accept and display the trivial amount of data required to do automatic location of wireless 91-1 callers: latitude/longitude and call back number. It has been almost 10 years since the time OnStar agreed to send crash data to PSAPs, and not one is getting it today. There are some large, sophisticated PSAPs and emergency response organizations. But the vast majority is small, underfunded organizations, with very limited IT expertise. There are very, very few purchasing aggregations (i.e. buy for a whole state or region all at once). This picture is repeated in the other emergency response agencies (PSAPs being 5-7.5% of the universe), which is a huge problem because NG9-1-1 rests on shared backbones and IT with them. How can we get them and the PSAPs together to get upgrades done?

Do it again is the Solution?? If the solution proposed is repeat the E9-1-1 experience, to upgrade PSAPs one at a time (or in groups of 3-10 at a time) with modern NG 9-1-1 capabilities (which will take care of concerns of this community, crash data and a whole lot more), don’t think you are going to see that any time soon. Right now there is no business or governmental alternative being proposed to the traditional way of doing business for end points (agencies).

There are very positive examples starting of shared networks (e.g. Indiana), although those are still limited only to 9-1-1. So while NENA recognizes the problem, and its NG Partner papers sometimes mention alternatives, NENA is stuck asking for more federal money to spread around to individual PSAPs or groups of them, and there won’t be anything like enough money.

No! Instead, Put your head in the Cloud: Similar problems are solved in the commercial world with software solutions offered from the network. Goes by various names: subscription-based, application service provider, managed services, network-centric solutions, cloud computing. Information technology experts can go on for hours on the differences between those four, but fundamentally they all mean the same thing to folks like us.

If you get them, in your PSAP you don’t have to worry about buying new equipment and new software, and then managing a complex information technology system. You do need to have modern windows computers, earphones and redundant, and secure connections to IP broadband networks (like Brian Rosen talked about here the other day) to plug into the software services – which are hosted remotely (at regional, state or national levels in highly secure, redundant data centers). The PSAP manager needs to worry about training staff and using the new information. S/he no longer worries about systems and upgrades to the software or equipment. R&D innovations are encouraged because now the market is clearly national, and innovations implemented rapidly and cheaply not every couple of years. Competition is enhanced.

The technology to do this is pretty straightforward and well established in the commercial fields and the US military. For it to work in safety, some work needs to be done in key areas (security, what we call “core services”). But the biggest problem in shifting gears to do it this way is the approach and decision making, the architecture/system design and procurement.

Focus on public’s experience, end to end: If we focus on the end points (upgrading the agencies themselves one by one), we will continue to upgrade very, very slowly, and very expensively, repeating the E9-1-1 Trail of Tears on a much larger scale. But we have a good chance of succeeding if either government or private sector leader(s) develop an architecture that treats safety as a “virtual enterprise” (i.e. looks at the overall picture, end to end, from the perspective of the best and least expensive service to the public), and then offers agencies the network-centric, shared services needed to get calls and data to the right places, and the option of subscribing to the best modern safety IT for handling the information delivered to them, managed in top of the line hosting centers.

I am not saying every agency should stop buying and managing its own information and communications technologies. New York City, Washington and LA can and will do whatever they want to do. I am saying that if this remains the sole or predominant approach for all of the tens of thousands of individual organizations in the safety world, we will fail both these agencies and the public.

Right now, I am pessimistic as there is no entity in government taking this broader view, much less working on such an architecture. No agency has been put in charge of the overall emergency information and communications technology issue, the “virtual safety enterprise”. Perhaps more importantly, the companies that serve these markets today are stuck in the traditional sales models, while the companies which can deliver efficient managed services/cloud computing haven’t stumbled on this market yet, probably because it is so fragmented.

But we have new FCC leadership. We have a new Administration, and the recession may push forward thinking IT companies (inside and outside the safety industries) to look for new markets. So hope springs eternal!

I will award a special 9-1-1 coffee mug to the person who does the best job at boiling this down into one or two questions for the summit!