Minority Report or Moneyball

I have often heard comparisons on the automation of System Status Management to the 2002 Spielberg movie starring Tom Cruise called “Minority Report” loosely based on the 1956 short story by Philip K. Dick. This science fiction action thriller is set in the year 2054 when police utilize a psychic technology to arrest and convict murderers before they commit their crime. The obvious comparison there is to the forecast of future call demand and the eerie accuracy of the reports that allow the right resources to get there in time to make a difference in the outcome. Sometimes in the movie, as in real life, there is a considerable cost to achieve that goal as well. It is easy to get wrapped up in the technology, particularly the virtual reality user interface that Detective Anderton (Cruise) uses to make sense of the premonitions and quickly locate the scene. I like to end the analogy there before we learn the darker side of the way the technology works and can even be manipulated to put a stop to the whole project. Perhaps some EMS providers think they see a similar inherent darkness and hope for an eventual collapse of the whole dynamic deployment paradigm as well. This may be where the art of a story and our reality diverge, especially considering the current economic dynamics even given the admittedly sporadic successes. This may also be why we need a different analogy.

What is CAEMS and Why Should I Care?

Two weeks ago, we started a Community of Practice to discuss EMS Deployment. The larger issue of deploying resources is all about efficiency and effectiveness in care, those are also the aims of any High Performance EMS group. However, that message is too often confused with meaning simply “better, faster, cheaper”, when in practice it must be rooted in “doing what is best for the patient” in order to be anything of lasting value.

In the following episode of ‘Word on the Street’, an EMSWorld podcast hosted by Rob Lawrence, representatives of the Coalition of Advanced Emergency Medical Systems (CAEMS) chat about the professional association and exactly what makes EMS systems “high-performance.” Give it a listen (or even download it) here: http://www.emsworld.com/podcast/11327832/word-on-the-street-coalition-of-advanced-emergency-medical-systems.

We Need Some New Stories

We always hear that EMS is still a relatively new discipline. And in the scheme of medicine, or even public safety, that is certainly true. But we shouldn’t let the fact of its youth keep us from acknowledging that it has already been around long enough to accumulate some of its very own antiquated dogma. If you have any doubt, consider the reaction to changes in protocol – even those with good evidence to support some new practice. Working cardiac arrests on scene, for instance, was not met, at least in my experience, with enthusiasm at the prospect of improving patient outcomes. What I heard were excuses for why something different wouldn’t work. I thought about that exchange this week as I was listening to a recent Medicast podcast on an entirely different topic. Near the end of that recording, Rob Lawrence remarked that we really need to do away with the old stories that start out with “back in my day…”

The stories of some grizzled professionals include not just memories of MAST pants or nitrous oxide, but the idea that tourniquets take limbs, not save lives. More recently stories have been spun about the movement away from the long-held reliance on the long spine board as an immobilization splint during transport or even the value of therapeutic hypothermia for cardiac arrests.

While there is no denying, or even stopping, a rapid state of change in EMS, we must be sure that it is not just change simply for the sake of change or even resistance for the same reason. Change must be meaningful change that is guided by reasoned thought and scientific evidence, not personal anecdote. And new practices should be carefully modified to address current issues or new understandings of the problem.

Another sacred, yet unjustified, belief among too many providers is that the dynamic deployment of resources (commonly referred to as “SSM”, or System Status Management) is an unmitigated failure of cost-consciousness that actually leads to increased expenses and provider dissatisfaction. The evidence, however, from many of the services who now employ some facet of dynamic deployment has proven that while it can be tricky to implement well; the savings in time, money, and lives are definitely real. And those savings need not come at the cost of provider safety or comfort either. Whether you have had bad experiences in the past, or just heard about it from others, it is time to set aside the old stories and take a new look at the current technology and practice in every aspect of EMS that leads to improved performance.

To advance our profession, we must completely ban the expression,  “but that’s how we’ve always done it” and look toward “how we can do it now!”

 

A Bibliography on EMS in a State of Change

Most scientists agree that earthquakes are difficult to predict, but last Thursday should have been a “gimme” regardless of how the Supreme Court would have ruled. �Independent of your perspective on the ruling, we now know how health care reform will play out – at least until the next major shift changes the landscape again. �There are some fine articles that have looked specifically into the basics of U.S. healthcare, reform and the high court, or�How Health Reform Could Hurt First Responders, even�What the�Supreme Court�s health care decision does�and does not�mean. �Also, hospitals are seeing the�healthcare ruling as a new challenge and suggest that�Federal Proposals Would Limit Aggressive Hospital Collections Practices. �So I have no intention to try to argue any of those contributing factors. �There are still many other factors affecting the future of emergency health care delivery that aren’t getting as much press attention even though their impact is at least as important. �Make no mistake, reform is coming to EMS!

Steve Whitehead at The EMT Spot blogged on the 7 Myths About Fixing Our EMS Systems. �It is a well-thought out article focusing on how to improve the system, but doesn’t approach the underlying causes. �From my perspective, one of the most important influences I see making an impact is politics. �In the article�Ambulance debate rough road: Government could grow, it is clear that local politics specifically regarding government is driving too many decisions. �The Mayor of�Columbus appears to be favoring a significant initial investment along with an annual subsidy to expand the local fire department rather than award a contract to one of the service providers claiming no subsidy would be required. �This also brings to mind the case in Utica, New York where the city sees an opportunity to actually generate municipal revenues through an ambulance service even though they could not certify a need as the�Revised bill on ambulance plan still a bad policy�opinion article suggests. �Which brings me to my second primary factor of money. �There are too many differences in how EMS is funded. �Unlike the fire and police department, which are so-called “free” services paid completely through your taxes, most EMS agenices charge for their services, going through your health insurance where they can. �Some operating costs are also covered by various combinations of property taxes, usage fees, or subscription fees without any consistency between jurisdictions. �There are many ongoing debates including this one by Letter: Emergency Medical Services In Great Neck. �But as long as there are such diverging funding schemes,

HP-EMS Profile: Cetronia

Growth in both the industrial and residential populations has dramatically changed the Lehigh Valley of Pennsylvania since 1955 when the non-profit ambulance service,�Cetronia Ambulance Corps, first began its all-volunteer BLS services.� In response to the communities need for an increase in public health and safety services, Cetronia has grown to include ALS service, 24-hour dispatch, and non-emergency medical transportation.� Additionally, Cetronia provides billing services, community outreach, education, special events coverage and special operations teams.� The diversity of their fleet�allows the most appropriate level of service for the customer�s need from a doctor�s office visit to a critical care transport.� Cetronia continually strives to understand the medical needs of its communities and remains �Always Ready� to accommodate any pre-hospital emergency care and medical transportation needs.� This attitude of adaptation is not new to Cetronia, rather a continuing legacy of a truly innovative EMS system and a commitment to providing �Health on Wheels�� for its residents.

In recent years, Cetronia recognized the enormous challenges facing the EMS industry including severely diminished reimbursement rates.� Since EMS billing specialists must be ready to meet these ever-changing reimbursement and additional compliance issues with competency and expertise, Cetronia has maintained their own team of nationally certified ambulance coders who offer an exceptional blend of ambulance billing experience, knowledge, and customer service to ensure fiscal stability and the organization�s continued success.

The increasing demand for healthcare services which threatened their ability to maintain response times is another example of what motivates their mindset of continual improvement.� Choosing to be a�

The Role of Response Time in EMS Performance

Several months ago, Rob Lawrence of the Richmond Ambulance Authority started a thread on the High Performance EMS Group of LinkedIn by asking “So what does the phrase ‘High Performance EMS’ mean to you?�? This innocent sounding question sparked immediate debate even within the small group at that time. Benjamin Podsiadlo of AMR quickly tied the quality of EMS performance to “experience�? and “outcomes�? stating further that “response time is not an evidence based factor in ALS performance.�? He later backed up his assertion by writing that “the catch 22 of pushing the workforce to be responsible and accountable drivers while simultaneously achieving narrow response time goals to the vast majority incidents that have no medical need for such high speed driving is also a bizarre and irresponsible contradiction.�? This is a point that even Lawrence admits could foster the “mentality of ‘arrive on time and the patient dies – good outcome, arrive late and the patient lives – bad outcome’�? that has already been affecting common sense both in the UK and increasingly in the US since NFPA 1710 set response time standards several years ago.

While there were other good comments, I would like to focus on the specific assertion that measuring response time (a well established practice today such as at Huron Valley Ambulance’s public web Performance Dashboard) is not an “evidence-based�? practice. There are many specific accounts of individual lives saved that I have heard mentioned by different agencies, but I will concede that the plural of “anecdote�? is not “data�?. However, one of the best stories of response time saving lives was made on February 9 when Richard Sposa of Jersey City Medical Center EMS discussed an interesting finding in a recent webcast. The chart reproduced here shows a correlation between

response time and the Return of Spontaneous Circulation (ROSC). This unexpected finding clearly traced an upward trend of ROSC with the decline in Average Response Time for Priority 1 Calls graphed quarterly from the beginning of 2005 to the end of 2007. This is a verified statistical trend (Mount Sinai Hospital reviewed these findings) and I suggest you click to view the graph in full detail. This shows not just living anecdotes, but a statistical increase patients with restored heartbeats.

Many things about our business can and should be questioned, but this is exactly the sort of evidence I would like to see investigated at other services. Can what Jersey City Medical Center is experiencing be reproduced elsewhere? And probably more importantly, does fast response necessarily mean “high speed driving�??

The point of System Status Management (SSM) is that ambulances can be effectively pre-positioned through scientific statistical forecasting in order to reduce the time of a response even without driving faster to the call.  Zoll Software Solutions, as an example, considers the elimination of inefficiencies to be a core component for closing the loop on your dispatch process and is even offering free medical equipment to customers who use this technology to improve their system. One customer who has done this already with Zoll technology is Grand Rapids who was also featured in the following FOX News video on Predicting Where your Next Emergency will Happen.

If you believe that knowing where your next calls are likely to come from in time to allow you to safely prepare for that response, the science is available today. You just need to be able to integrate that knowledge into your process.

Index of Suspicion Includes Me

It doesn’t take long in an EMT career before the excitement of “rushing to an emergency” turns in to “just another transport call.”  The philosophy of “you call, we haul” in nearly every service can break the community servant’s spirit by turning a skilled paramedic into just an ambulance driver.  But our system “just is what it is,” right?

Well, far from being a service based strictly on tradition, EMS is constantly challenging previous assumptions and struggling to reinvent itself.  How we administer CPR has changed (again), we question the effectiveness of C-spine immobilization that we do standard on nearly every trauma patient, or argue the very validity of the “Golden Hour” around which many services have been designed.  Almost all assumptions are open to be questioned.  I say “almost” because I have found that there still are some boundaries to the willingness of many EMS practitioners to consider change.  Some limitations are easily admitted, like the aversion to legal liability that means we transport anyone who asks us to do so regardless of their suspected need or ability to pay, but there are also less easily acknowledged sacred beliefs.

One of those that comes quickly to my mind is response time.  To many, a quick response indicates excessively fast driving and is contraindicated by safety concerns.  Besides that, we can justify ourselves since very few of our daily calls actually “require” a code response.  While that point may be strictly valid medically, I would argue that our performance is often measured by the public in the agonizing minutes between the 9-1-1 call and the ambulance arriving at the curb.  A patient does not need to be in some form of arrest in order for them, or their family members, to be distressed.  Part of our job is being a calming and supportive influence.  At the same time, I admit that it does not justify putting the driving public or ourselves at risk with an ambulance speeding to every call. But is it really a given that one means the other?

System Status Management – oops, another term laden with strong negative feelings in the field – is actually all about improving performance (both time and economic efficiency) without sacrificing safety.  As advocates for patients, medics see themselves sometimes fighting the system in order to provide the best possible care.  Talk of economic efficiency is seen as just making their job harder.  But again is it really a given that one necessitates the other?

Imagine a system where patient needs are accurately forecast in advance. Where the posting of ambulances is not just another place to sit and wait, but in a practical sense it is the staging for a call that has yet to be received.  Response is thereby improved not by excessive haste, but by the strategic pre-positioning of resources.  The cost savings is not simply an amount  taken from others in a “zero-sum game”, but effectively rescues budgets for proactive wellness programs or, in the current economy, may mean simply saving jobs that allows us in turn to save lives.  This process really works and these systems do exist.  They are called “High Performance EMS” systems and many are profiled here each month while others receive recognition through accreditation agencies like CAAS.  What sets them apart is often observed in technology, but the reality is that it is a culture of seeking constant improvement by the entire staff that makes a difference.

While we consider improvements to the many technical aspects of our profession, let us not neglect the philosophical perspectives that motivate us as individuals.  We operate as a team, not just the pair on the truck, but the whole EMS system is one team with a singular goal.  A goal to do even better each day. So, as we continue to assess our profession should the index of suspicion not include our attitudes toward improving the overall system?

The Cost of Saving Money

There are two fundamental ways to save money: either cut your budget and make do with less resources or invest in process efficiency to cut future expenses while continuing to provide at least the same level of service.  These are important considerations as the costs of doing business clearly continue to increase, whether we consider the expenditures on goods used in providing a service or the price of fuel used to deliver that service.  At the same time, the ability to effectively raise the price of the delivered service in order to recoup those additional expenditures is not typically possible.  This paradox leaves many ambulance services in a quandry.  If your decision is to continue operating at a diminshed capacity to reduce spending, there is probably little advice I can offer.  But if cutting service is not a prudent long-term option, then we can look at how an agency looks to improve performance.

A good case study may be the Lexington County (SC) EMS, a service directed by Brian Hood responding to roughly 30,000 calls per year.  As a growing county outside one of the largest cities in South Carolina, Lexington has seen their call volume grow at an annual rate of about 7.5%.  To keep pace with this growth in demand, they would likely have needed to add one new vehicle per year at a cost exceeding $3M for an ambulance, crew, station, equipment, etc.

Additionally, one of the ongoing, and rapidly growing expenses, for any service delivery organization is the rising cost of fuel.  Controlling mileage can often be a great option for managing expenses.  Of particular interest to some services is also the incurring of fines for exceeding response times.  This is a particularly good area to control costs for affected services since this type of expenditure does not lead to any revenue nor does the payment itself provide any service.  But to achieve these goals, performance must improve.

High Performance EMS is about doing things better – specifically providing advanced pre-hospital care with a focus on higher economic efficiency.  The result of better performance is patient satisfaction with cost savings.

For Lexington County, the more efficient posting of ambulances based on predicted demand and time-based routing using MARVLIS has allowed the service to actually improve response in the face of rising demands while foregoing the acquisition of additional resources and the commitment to ongoing costs associated with them.  Over the 4 year period since implementing MARVLIS, the projected cost savings of $3M per year is compounded by the avoidance of recurring staff costs and therefore totals closer to$16M for that period.  The initial investment required to make that savings was less than $400K in hardware and software systems.  As a result, satisfaction has improved for both the patients (who experience quicker service), and also staff (who endure fewer post moves while being closer to incoming calls.)  This is not just a promise or hope of what might happen, but a real world experience of leveraging county GIS services and an experienced High Performance EMS consultant, Bradshaw Consulting Services.  Watch for a more detailed article soon from Esri Press.

The Future of Prediction

I have read the positions stating that calls for emergency services are completely random (justifying the reason they are often called “accidents”) and therefore not able to be predicted.  But both academic literature and practical experience show that demand prediction can be an effective tool in helping to balance scarce resources (ambulances and their trained crews) with public demand (requests for emergency responses even without taking into account the abuses to the system as discussed in a previous posting on the problem of “frequent flyers”) while still improving response times and controlling costs.

For anyone who thinks all of this sounds too good to be true, there are examples of where expensive technology is not having the desired affect.  One such location is Lee County EMS in Florida where not only have response times not been improved, but ambulances are burning more fuel than ever and the critics include the very paramedics it is supposed to help.  While predicting where the next 911 call will come from may be similiar to “picking the winning card at a casino” as the Florida investigative news reporter suggests, that isn’t really the objective.  We don’t need to know which phone will make the next call, it is enough just knowing the probability of a call coming from any given location within the service area.  This may be a subtle distinction, but one that makes a huge difference at MedStar in Fort Worth or Life EMS in Grand Rapids where response times were dramatically improved by taking the next step beyond simple demand prediction and placing ambulances at positions where they can be the most effective.

Academic studies show that demand pattern analysis can be used without hourly, daily, or seasonal calibration to achieve potentially acceptable tolerances of demand prediction, but when adjusted with these appropriate corrections, software applications like MARVLIS (the Mobile Area Routing and Vehicle Location Information System) can effectively predict demand in practical situations.  According to Tony Bradshaw of BCS, the makers of MARVLIS, it routinely calculates where about 80% of demand will occur and when paired with realistic drive-time response zones it demonstrates valuable support for a dynamic System Status Management plan to pre-position, or “post” ambulances closer to their next call saving valuable time and increasingly expensive fuel costs.

What matters most, though, is what agencies experience in the field.  At SunStar they say ” the most significant result was improving our emergency response time from 90.2% to now over 93% in lieu of an increase in patient call volumes.  This equates to ambulances arriving on scene more than 1 minute quicker.  We additionally saw a savings of $400,000 in penalties by exceeding our contractual goal of 92% and performing above 93% compliance.”  Similarly, Steven Cotter, Director of Sedgewick EMS added that “the technology has opened our eyes to be able to understand how we are performing, where we are deficient in our performance and how we can make changes quickly and adapt to a changing environment.”  And beyond simple response times, “it’s what technology should do,” says Joe Penner, Executive Director at the Mecklenburg EMS Agency, ” take the complex and present useful, straightforward information.  It has helped us improve response times, resource utilization AND simultaneously reduce unnecessary post moves — your patients and employees will appreciate it!”

My conclusion is that proper demand prediction paired with realistic response creates significant opportunity to improve performance and cut costs even in growing communities.  When used properly, the future looks bright for High Performance EMS!