Tag Archives: MARVLIS

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.

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Improving Operations in Crisis

Our practice of EMS is facing significant challenges right now. Although many traditional aspects must still continue, we have a few more obstacles to overcome in a crisis. This “pilot podcast” highlights some practical modifications to consider for operational improvements, especially for MARVLIS users.

Notes:

HPEMSpodcastDemand for EMS services is disproportionate across America and outside of normal patterns, but some changes to our practice are helpful across any service right now. If you haven’t begun seeing longer times yet, you can expect it to be coming as we face longer dispatch delays for extended EMD, longer on-scene times for re-triaging patients using a “1-in and 1-out” scouting method, longer decontamination times for ambulances possibly infected with COVID-19, and fewer professional human resources collectively making operational efficiency and crew management even more important than ever. At the same that time we are still dealing with our regular calls, mass quarantines and stay-at-home orders are likely to increase calls for domestic violence, drug abuse, acute mental illnesses, and even suicide as people socially distance.

  1. Consider modifying queries in Demand Monitor to include longer general timeframes when forecasting dynamic demand:
  • Extend the period of weeks, e.g. 56-60 days both Before and After the current date.
  • Extend the period of minutes, e.g. 90-120 minutes both Before and After now.
  • Enable hotspot accuracy reports to quantify the value of different queries.

2. Create new posting plans with Deployment Planner that balance the weight of geography and demand to limit post move recommendations.

3. Implement a Leapfrog in Deployment Monitor value to penalize moving stationary ambulances by preferring to move units already in transit.

4. Call BCS Support for any help you need to configuring MARVLIS to your operational challenges beyond simple mindless efficiency.

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How is COVID-19 Affecting MARVLIS Users?

The current situation around the new coronavirus is developing rapidly. As we begin to map more cases in new areas along with tracking the shortages of PPE supplies we are also hearing the CDC update guidance for healthcare providers with constantly changing advice. Even the stock market is falling as investors try to make sense of the extent of the impact of cancelled public gatherings and increased social distancing.

While there are significant new challenges around exacerbated staffing shortages created by potential quarantines of first responders, it is still, at least to some degree, business as usual for EMS. Panic over the declared pandemic is not eliminating the “normal” calls to which we must respond. Medical emergencies including cardiac arrests, cerebrovascular events like strokes, diabetic emergencies, and acute respiratory attacks (including COPD, bronchitis, emphysema, and asthma) in addition to common influenza and pneumonia occurrences in this season are all still happening just as before. Similarly, traumatic events are also continuing to happen as a result of motor vehicle collisions or by trip hazards in the homes of the elderly. It is these “routine” calls that are the very reason the most high-performing EMS agencies across Amercia began using MARVLIS in the first place. Now, the added pressures of concern over COVID-19 are requiring additional precautions that can delay care and increase the costs of delivering service to our communities, it may even cause an increase in call volume soon.

The need for efficiency in operations is never greater than during a time of emergency or crisis.

 

While the vast majority of EMS calls have not changed significantly in response the crisis so far, it is likely to have an impact as the pandemic grows in extent across time and jurisdictional borders. As that happens, the query used in MARVLIS Demand Monitor can be modified to highlight past respiratory emergencies to help prioritize nursing homes or the residences of the most vulnerable elderly populations. On the other hand, if the concern is that this population cannot be so easily identified, MARVLIS Deployment Planner can be used to create a geographically balanced plan that position ambulances throughout the service area based on the best ability to respond anywhere given any potential service level. MARVLIS Deployment Monitor has settings to provide automated recommendations for unit movements to match the plan according rules you can control to either minimize the time to reach that optimal configuration or limit the number post moves that crews experience. The most recent releases of MARVLIS include a “hotspot accuracy report” that allows MARVLIS Demand Monitor to grade the ability of competing queries in making the most appropriate forecasts and MARVLIS PSAP Monitor can allow neighboring mutual aid resources to be seen live on a map.

As the current crisis evolves, it is good to know that experienced advisers are available at Bradshaw Consulting Services to help MARVLIS users modify their application configuration to assist agencies in meeting their changing business objectives. As resources become more constrained, the flexibility of MARVLIS becomes more apparent.

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See What Others Can't

Ever since I was a kid, I wanted a superpower of some kind. Little did I know that one day my wish would actually come true. 

For anyone who is a serious user of Geographic Information Systems (GIS), it is not news that this week is the 2019 Esri User Conference. If you are not one of those people, the “UC” is an annual gathering of around 20,000 people who share an interest in applying geospatial technology to solve real-world problems from optimizing business to saving the environment. I was particularly inspired by the theme this year, “See What Others Can’t.”

At its core, GIS is a spatial database for the analysis and visualization of information. When it is used in EMS, it can take a deep dive through your call history and come up with an estimation of the likelihood of the location of calls for service within the next hour. Because it can be an automated process, this forecast can be repeated every few minutes to give you a constantly updated view of the near future regarding where you are most likely to be needed. Some users of MARVLIS Demand Monitor compare it to a weather map that shows the changing conditions in your service area. But knowing where you need to be is only a part of the problem of optimizing the delivery of emergency medical services.

To really be efficient, you also need to know where you are and where you can be within your response time allocation. To answer this question, you need a model of the street network and an understanding of both the daily patterns of travel as well as the unique driving conditions right now. Many counties across the US have dedicated GIS staff to maintain these navigation and addressing models, but commercial vendors can also provide a good base layer of data. TheAddresser is another product from BCS and it can be used to measure or even improve the quality of your geographic data to improve its ability to turn an address into a proper coordinate where a crew can physically respond. The digital road network that is used to calculate a route can be improved by modeling how fast vehicles in your fleet have traveled along each road segment in the past, divided by direction, and lumped into various traffic time periods. The MARVLIS Impedance Monitor automates the mining of your Automated Vehicle Location (AVL) history to generate these unique travel times to understand exactly what area can be covered even as an ambulance is moving. For the immediate hazards along the way, MARVLIS can leverage the events logged by Waze users in real-time to enhance your own road network data through MARVLIS Central. Together, this gives you the best understanding of the reach your crews have at any given moment.

The real trick is in how you choose to post ambulances to meet your specific objectives. If a fast, safe response is most valued, ambulances can be directed to uncovered hot spots which will minimize the distance they must travel to the next call. If cutting response times across the board, or minimizing post moves is preferred, a weighting can be applied in the MARVLIS Deployment Planner to optimize the geographic coverage area. Regardless of how the criteria are balanced, an hourly, prioritized posting plan can be generated based on your service objectives. That plan can then be automated through the live connection in MARVLIS Deployment Monitor that can not only see where ambulances are located by their status, but also directly viewing where calls are currently active from the Computer Aided Dispatch (CAD) software. It can then even make specific recommendations on reassigning units to automatically optimize your coverage criteria.

Together, these intrinsically GIS-based tools can provide an unparalleled insight into the operational world of EMS with timely automated recommendations on how to improve service according to your community’s values. The suite of MARVLIS applications give any EMS manager a view to “see what others can’t.”  To see clarity in the everyday chaos of EMS operations, GIS can give you genuine superpowers. 

-Dale Loberger

 

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What 'Level Zero' Really Means in EMS

Rampart, Medic 13 with anincoming patient report.”

Go ahead, 13.”

I have a patient with a pulse of 120. ETA less than 10 minutes. Over.”

Well, this sort of report certainly leaves something to be desired. What is the age of the patient? For an infant, this may be a normal rate, but in a geriatric personit could be a bigger concern. Has the patient been involved in any physical activity? If the subject just completed a marathon it may not be a concern, but if the patient had been sitting on the couch watching TV and the pulse suddenly spiked, it could be a legitimate emergency. In any of these cases, we still need more information. The patient’s blood pressure would be another good measure along with age. Some OPQRST orSAMPLE would be enlightening too. A treatment, let alone a diagnosis, cannot be advised from this single piece of data.

In a very similar vein to our pulse example, there have been several articles written lately bemoaning the dangers of any particularEMS system having hit a ‘Level Zero’ situation some number of times in the last however many months. For instance, there is an article whereSan Bernardino firefighters attack AMR. Don’t misunderstand my point, not having any ambulances available can definitely be a serious situation, but how long does the situation last in each occurence? In any significant service area, its bound to happen at some point even with proper planning and normally adequate staff.My concern is the media attention overthis single measure of an emergency health system.It may be that reporters finally got the message thatresponse time was not a good defining metric by itself. But just like our bodies, an EMS organization is a complex system of interoperating systems. Performance is not defined by any single measure. Although individual metrics, however,can cause us to want tolook deeperto understand the likelihood of potentialserious problems.

A case in point is a story last year on Paramedics Plus in Sioux Falls,that revolvedaround two specific cases where an ambulance was not available for patients in distress. While this is not ever a desirable position, the compliance of the ambulance provider in question was 95% and even the investigative news reporter found that EMS arrived before the fire department’s own”first responders” in 25% of cases. Perfection is simply not easy to maintain. While not making light of any potentiallyserious situation,my intention isto placethis measurewithin some context, just as a sole pulse readingis only a singular measure of performance and one that is not meant to be interpreted by itself.

The MARVLIS application, in use by almost every member of the AIMHI (Academy of International Mobile Healthcare Integration) organization (formerly known as the Coalition of Advanced Emergency Medical Services or CAEMS) is often viewed as a tool for improving response times. While it has proven to be beneficial in achieving that goal, that is not the only reason these “high value” systems use it. Improving individual response times alsoimproves compliance.Consistently short response compliancecan also have clinical value if the times are low enough in the right situations. Jersey City has correlated a response time near 4 minutes to improved ROSC. But other benefits are improved value in post moves. Not moving ambulances for the sake ofchanging posts, but in positioning units closer to theirnext call with fewer moves. This also means fewer miles driven with lights and sirens to improve crew safety. Mobile Medical Response (MMR) credits MARVLIS in their annual report with reducing their costs associated with unloaded miles driven. As a collection, these improvementsmean more than any single measure.

The reality is thatour professionis fundamentally changing. We arecoming from an EMS world where measurements of specific vitalperformance areevolving intoa diagnosisof value. Just as good vitals indicate good health, positive measures of performance will be interpreted as higher value. In the same way that a general impression should guide a clinician in measuring vital statistics, the evaluation of an EMS should also be guided by a broader vision of value rather than a microscope trained only on specific measures.

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HP-EMS Profile: Jersey City Medical Center EMS

The High Performance EMS we examine this month is Jersey City Medical Center EMS  located just across the Hudson River from Lower Manhattan.  It is a triply accredited service, receiving the CAAS, NAED’s ACE, and CoAEMSP accreditations all in the same year.  As a part of the LibertyHealth System, it serves the residents, workers, and visitors of Hudson County, NJ by responding to nearly 90,000 calls a year.  JCMC EMS provides both Basic and Advanced Life Support as well as services for special operations, neonatal transfers, critical care inter-facility transports, regional EMS communications, and more.

Few modern ambulance services can claim over 100 years of history, but this organization has been providing prompt, professional pre-hospital care since the days of taking patients to the Medical Center in horse-drawn ambulances.  Today, however, JCMC EMS is one of the most technically advanced EMS agencies in the country with an impressive response time averaging 6:02 – well below the 7:59 city standard.

Richard Sposa, EMS Communications Coordinator at JCMC EMS, describes how they continually improve their service saying “positive patient outcomes are the goal for any EMS agency, and at Jersey City Medical Center, it is our guiding light.  The Jersey City Medical Center’s EMS Department has taken a leadership role in positive patient outcomes by examining real life scenarios.” More specifically Sposa says, “we made a self-realization in 2005 that the system as a whole was in need of improvement in a multitude of areas, and the most notable were our response time and asset deployment.  With the help of Bradshaw Consulting Services and the MARVLIS system we were able, in less than a years time, to reduce our response by over two minutes.”

The MARVLIS application forecasts demand dynamically and displays the probability of incoming calls as a colored surface.  As paramedic David Pernell describes it, they “chase the blob” likening the constantly updating application to an animated weather forecast showing upcoming need allowing resources to be better deployed when called upon.

As one of the largest and busiest EMS systems in the state, they are proud to play a vital role in domestic preparedness education, homeland security response and educating the public and healthcare providers in CPR and advanced adult and pediatric life support.

“With an in-house study we have undertaken,” said Sposa, “we have seen that the drop in response time has improved patient survivability.  With the data collected so far we hypothesize that by reducing our response time by two minutes we will have the ability to return pulses to as many as thirty more patients a year.”  What more could be said about high performance in EMS!

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HP-EMS Profile: Sedgwick County EMS

It has been much more than a month, but we will return to featuring a monthly profile of High Performance EMS sites in order to inspire others to reach beyond just compliant services to provide advanced out-of-hospital care while focusing on improved efficiency.  This time, our spotlight is on Sedgwick County Emergency Medical Service of Kansas.

Sedgwick County EMS

Sedgwick County EMS

The public EMS agency in Sedgwick County is responsible for ALS out-of-hospital care and transportation for both acutely ill and injured patients as well as providing scheduled ambulance transportation services within an area of 1,008 square miles serving a population of approximately 498,000 residents.  In 2010, Sedgwick County EMS responded to 52,815 calls for service.  They are also proud to be part of an elite group of CAAS accredited agencies across the nation signifying that they have voluntarily met the “gold standard” determined by the ambulance industry to be essential in a modern EMS provider.  The CAAS standards, which often exceed those established by state or local regulation, also define High Performance EMS as they are designed to increase operational efficiency and clinical quality while decreasing risk and liability to the organization.

In addition to efficient performance, another hallmark of a High Performance EMS provider is community involvement.  Sedgwick County EMS is a regional BLS Training Center for the American Heart Association teaching CPR classes and frequently participates in local school programs by visiting classrooms to educate children on accessing the emergency system and demonstrating their equipment to make students more familiar with EMS should they ever need to access it.

This past summer, Sedgwick County EMS was selected as a 2011 “Health Care Hero” by the Wichita Business Journal.  The award was given in the health care innovations category which honors a person or organization for breakthroughs in medical technology ranging from research to a new procedure, device or service.  In addition, Sedgwick County EMS received the 2011 advanced life support (ALS) Ambulance Service of the Year award from the Kansas Emergency Medical Service Association (KEMSA) in recognition for promoting EMS in Kansas.  These honors recognize Sedgwick County EMS for the implementation a number of software upgrades that improved automated scheduling, patient care reporting, and deployment practices, among others.

Sedgwick County EMS Director Scott Hadley said in an EMSWorld article this week, “We needed a communications platform and software solution that would support our latest enhancements and upgrades to dispatch and deployment practices, automated scheduling, and patient care reporting for the entire health care system. In Motion Technology and Bradshaw Consulting Services are providing us with the tools we needed to support our mobile healthcare technology to benefit the citizens of Sedgwick County.”

Showing that properly implemented System Status Management can ensure the right response at the right time, Hadley says, “EMS crews have been hitting their goal of getting to destinations in less than nine minutes more than 90 percent of the time for 24 straight months.  That means technology is doing what it’s supposed to do and furthering the mission of the agency.”  Demonstrating the final component of a successful High Performance EMS, Hadley says “it’s our responsibility to continually improve our patient care.”

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Dynamic System Status Management

System Status Management (SSM) is the fluid deployment of ambulances based on the hour-of-the-day and day-of-the-week in order to match supply, defined as Unit Hours of Utilization (UHU), with expected demand, expressed as calls for service, in the attempt to provide faster response by locating ambulances at “posts” nearer their next calls.  While the practice is still not unanimously embraced by all services, it has a sound foundation both in the research literature dating back to the 1980’s as well as in practice today.  Experience has shown that ambulance response times can be dramatically decreased using this type of dynamic deployment, but it is also recognized that it is possible to reduce performance when these techniques are not applied properly.  The direction of the results of a system implementation are typically influenced by the system design, competence of the managers creating the plan, and commitment of the workforce in implementing it.  Therefore the best practice is a simple and straightforward implementation that will show positive results quickly.  This methodology ensures a positive return on investment along with garnering the necessary buy-in from staff to make the project a success.

In his article, “System Status Management – The Fact is, It’s Everywhere“,  published in the Journal of EMS (JEMS) magazine back in 1989, Jack Stout explained the concept of SSM and tried to dispel certain myths.  Based on foreseen Geographic Information System (GIS) technology and even general computing capabilities of that time, it was quite logical to assume in his Myth #2 that “no matter how thoroughly the response zone concept is fine-tuned in practice, it cannot be made to cope effectively with the dynamic realties of the EMS environment.”  But systems implemented today around the US are capable of calculating dynamic response zones in a small fraction of a second while even being based on time-aware historic driving patterns making a truly dynamic system status management process a reality.  A practical and proven example of a dynamically functioning system status management application is the Mobile Area Vehicle Routing and Location Information System, or simply MARVLIS.

The following Slideshare presentation does an excellent job of telling the story of why and how the system works:

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HP-EMS Profile: MEDIC

Each month we will feature a profile of another High Performance EMS to show the variation in these services and inspire others to reach beyond just the basic services to provide advanced pre-hospital care with a focus on high economic efficiency.

In 1996, the Mecklenburg EMS agency was one of the slowest in the US with an average call response time of about 16 minutes.  Today, calls average around 7 minutes.  That incredible transformation began when two competing hospital services joined together to create MEDIC which now contracts to serve the county of 540 square miles with a fixed population of 850,000 that swells to a routine daytime total of around 1 million people.

MEDIC Emergency Dispatch Center

Barry Bagwell, Deputy Director of Operations, is proud to state that MEDIC has been compliant regarding performance every month since 1998.  “While there is no ‘silver bullet’, all of the pieces must work together,” says Barry, “it requires technology plus the people to run it.”  But a truly High Performance EMS must not be tempted to over-utilize response times as the only measure of success. The original focus for system improvement was on routing, but the partnership with Bradshaw Consulting Services has led to many operational enhancements including successful demand prediction and dynamic System Status Management planning.  “Dispatch posting is a ‘chess game’,” Barry admits and real efficiency comes by balancing moves between the 60-65 posts to meet service demand with reducing fuel costs and minimizing disruption of ambulance crews.  With a holistic view of clinical outcomes, MEDIC has achieved a 33-minute turn-around time from hospital to availability and 82 minutes from a call to having a Code Stemi patient on an operating table with the artery open.  MEDIC also provides bicycle paramedics, ATV, and buses for special events to meet the needs of their community.

The dispatch center has used ProQA Dispatch Software protocols in both EMS and Fire since 1993 to assist dispatchers in quickly determining the appropriate determinant code.  Voice communication with vehicles is maintained with a Motorola 800 MHz shared backbone radio system with priority.  Non-emergency numbers are provided only to hospitals with the public being triaged through the 911 system.

While recognized as a High-Performance EMS already, MEDIC does not intend to rest where they are now but constantly looks toward additional improvements.

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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!

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