I recently had two articles published by EMS1 as a couple of “mythbusting primers” on the topic of dynamic deployment. The articles were Dynamic deployment: 5 persistent myths busted and Dynamic deployment: 5 more persistent myths busted. My intention was not to convince anyone of a position that opposes their current EMS world view pertaining to deployment models, but I had hoped to extend the work Dave Konig began in The EMS Leader defining the terms of EMS resource deployment in 2013 and to have an open discussion about it. My hopes of engaging in dialog fell somewhat short of my expectations. But after watching the presidential debate last night, I understand that the idea of a robust “give and take” may be more difficult to achieve in public interaction than simply setting a stage with opposing actors.
One comment I received the first week after publication of my articles was a posting that basically just left a link for an article by Dr Bryan Bledsoe from 2003 entitled “EMS Myth #7: System Status Management Lowers Response Times and Enhances Patient Care.” The assumption being that the topic was settled long ago. While I have great respect for the man who calls himself “The EMS Contrarian” and his robust body of writings (including by first EMS textbook), I respectfully disagree with the finality of some of his assertions. A great deal has changed in the past 13 years. Some readers may actually recall that MySpace debuted the same year that his opinion was written. For those who do not recall that social media phenomenon, MySpace was a precursor to Facebook that was once the largest social networking site in the world – even surpassing Google as the most visited website in the US. This was also a time when almost every patient was administered high-flow O2 because it was considered safe, even if not always effective. Fortunately, the evidence-based movement in EMS has caused many practices to be re-evaluated both for inclusion as well as exclusion. And computer technology has also made great developmental strides from the 2003 introduction of the first wristwatch cellphone named the Wristomo. At that time, engineers were still thinking of wearable technology as a cross between the 2-way wrist radio device that became iconic for Dick Tracy in the 1940’s comic strip and the modern flip phone of the day. Naturally, the device was designed to be easily unclipped in order to hold it to the ear like a traditional cell phone. It even offered an optional cable allowing it to exchange data with a computer. The development of Bluetooth freed designers to reconsider how a smartwatch could interact in an entirely different way with a user’s smartphone. The evolution of dynamic deployment has followed a similar trajectory.
The Gartner Hype Cycle is a graphical and conceptual presentation that describes the maturity of emerging technologies through five common phases. Each year, the organization follows several technologies through this consistent cyclical journey. While EMS deployment was not one of these tracked technologies, I would submit that the initial technology trigger in the case of dynamic deployment would have certainly been the work of Jack Stout on System Status Management in the 1980s. His publications in the Journal of Emergency Medical Services (JEMS) throughout the decade inflated the expectations for performance returns. Implementation issues however, contributed to it sliding down into the trough where many disillusioned system providers left it for dead around Y2K. But the story doesn’t end there. The combination of his economic theory with Geographic Information Systems (GIS) provided a new operational view of both demand as well as current positions of available vehicles reported in near real-time with growing bandwidth. The advancement of computer processing has allowed some of these same Stoutian concepts to now be performed in real-time. With practice in modifying the parameters, the concept of Dynamic Deployment has become, as one comment to the article stated, effectively SSM 2.0. The benefits are no longer theoretical or even limited to Public Utility Model services, but are being realized by both public and private EMS providers climbing the slope of enlightenment or who are content with the productivity gains they have already reached.
One of Stout’s assumptions that has changed since the Bledsoe article is the “20 week” rolling window for analysis. This is too broad of a query that effectively combines different seasonal impacts throwing off focused projections not improving them. Experience shows that just a few weeks backward or forward from the current date for only a few previous years gives the best demand forecast. Tests conducted at BCS show that MARVLIS correctly forecasts 80-85% of calls in the next hour by identifying hotspots that are limited to approximately 10% of the overall geography. Going back too many years, as Bledsoe was led by a consulting statistician, can actually unfairly weight more established neighborhoods while undervaluing newer communities. The clinical significance of shorter response times is not always in the “37 seconds” that are saved or even in meeting an arbitrary response goal, but in reducing response to a meaningful 4-minute mark. Achieving this milestone has had a proven impact on ROSC in New Jersey for instance. And beyond clinical significance is contractual obligation. Like it or not, EMS is often judged (and even purchased) similar to fire protection – by compliance to a time standard. Software makes a difference in meeting those goals. Running a system so that it performs well in most cases means it is more likely to perform well in the cases where it really does matter to the long term health of the patient.
The increase in maintenance costs of 46% as claimed by Bledsoe has also been disproven with services showing a reduction in the number of unloaded (non-reimbursed) miles driven and even a reduction in the number of post-to-post moves in favor of post-to-call dispatches. By reducing fines for late calls, some services have found significant cost savings compared to previous operations.
In trading station lounges for the cramped cab of an ambulance, there has been a genuine cost to the paramedics and EMTs. However, the argument they make is not about fixing the plan, but rather it becomes an attempt discredit the foundation of that plan completely. Consider the fact that most field providers in a closest vehicle dispatch operation describe a “vortex” that traps them in an endless cycle of calls if they do not escape it in time. They find ways to try to beat the system rather than suggest that recommendations account for the unit hour utilization by vehicle and allow busier units to leave the high call volume area and move to less call prone posts to complete paperwork and recuperate. It is not that the strategy is inherently evil or wrong, but is designed to support a business philosophy that is not properly balanced, so the outcome becomes skewed. It is time to stop challenging the core notion and focus on specific concerns of the implementation that will make the system work better for all participants. As long as we demonize the idea, we will not be able to impact how it works.
Much like the polarization of the presidential debates, I have learned from experience that when we perceive only bits and pieces of the world around us, our minds fill in the blanks to create the illusion of a complete, seamless experience, or knowledge of a system in this case. Sometimes that interpolated information is no longer correct and it can keep us from participating in the crafting of a solution that truly works for everyone.