Wednesday, June 13, 2012

Managed Attributes, Not Standards, Lead to Interoperability

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I.     Introduction

Managed attributes ensure essential interoperability. This is the foundation for providing the most skilled, most timely and most appropriate response to any situation, regardless of size. Emergency managers and incident commanders can make sound decisions with the additional data that comes from knowing when and where specific resources are located, what tasking assignments have been given and to whom. Not only is everyone on the scene accounted for, but tasks are given to responders with verified skills and capabilities thereby contributing to the command staff’s ability to predict the next threat and deploy resources accordingly, maintain critical situational awareness and respond to dynamic conditions quickly and effectively. Assigning responders to duty is not an issue. What’s critical is assigning the responder with the appropriate and verifiable skills to a job he/she is capable of accomplishing, ensuring a positive outcome for the situation and the responder.

II.    Setting the scene

A.                   Personal experience sets the stage for complete understanding

My first exposure to pre-hospital care was the mandatory “first responder” training required for firefighters by the State of California more than twenty years ago. The training program which was taken concurrently with a CPR class added up to more than the 120 hours of training required to be certified as Basic EMT in the Commonwealth of Massachusetts a couple of years later. In the end it was not the hours required to complete a training program that struck me as being the unusual dichotomy but the difference in skills. As a “first responder” I was trained in how to properly remove a helmet, place the electrodes from the 12-lead EKG on a patient, spike IVs, assist with medications, etc. As a “Basic EMT” in Massachusetts I was not trained in any of those skills. In fact I did not use them again until the PB waiver program was instituted. Many years later as a regional hospital preparedness coordinator I struggled with the concept that we could not send paramedics across regional boundaries within the same state, even within the same county and still allow them to work as paramedics because scope of practice and certification was regional and there was no reciprocity within the state!

Times have changed but the essential challenges in the practice of pre hospital care have not. There may be an EMS community but it is segregated even within its day-to-day practices never mind responses to what can be categorized as disasters. On February 20, 2003 the fourth deadliest   nightclub fire and the 9th deadliest place of public assembly fire in U.S. history took place at the Station Nightclub in Rhode Island. The multi-jurisdictional (on a very large scale) fire EMS response was atypical when it comes to patient care and it worked. It is conjecture but I would hypothesize that the response was modern in capability but traditional in implementation. That is, a small state with close boarder ties to services in Massachusetts and Connecticut and familiarity among the services responded as needed, there were no questions of scope of practice, patients were cared for at the level the provider was trained to without immediate regard for local or regional regulations.

In addition to the one hundred fatalities there were an estimated 230 casualties, 186 transported to hospitals by first responder agencies. Over five hundred firefighters, EMS, and Police responded with fifty-seven public and six commercial ambulance companies providing both basic and advanced life support services. (Kuntz, June 23 2000)1

I would argue the Station Nightclub fire response was a success carried out by heroic and dedicated professionals. The brethren of these same professionals also answered the call to service for hurricane Katrina in late August and early September of 2005. I would argue that that response was more typical of large multi jurisdictional, multi state responses. Some level of organization was applied to the call out and activation of resources on a national scale. The typical American answer of a call to duty resulted in a massive response. However, many police, fire and EMS organizations from outside the affected areas were reportedly hindered or otherwise slowed in their efforts to send help and assistance to the area. FEMA sent hundreds of firefighters who had volunteered to Atlanta for two days of training on topics including sexual harassment and the history of FEMA. (Bluestein, 2005)2

III.   Underlying Problems

So what is the underlying problem? We can look at it from a national service prospective as well as a level of service prospective. Take a look at the state of the service in general. An excellent summary is contained in a recent report issued by the National Academy of Sciences.

“Each year in the United States approximately 114 million visits to EDs occur, and 16 million of these patients arrive by ambulance. The transport of patients to available emergency care facilities is often fragmented and disorganized, and the quality of emergency medical services (EMS) is highly inconsistent from one town, city, or region to the next. Multiple EMS agencies some volunteer, some paid, some fire based, others hospital or privately operated frequently serve within a single population center and do not act cohesively. Very little is known about the quality of care delivered by EMS services. The reason for this lack of knowledge is that there are no nationally agreed-upon measures of EMS quality, no nationwide standards for the training and certification of EMS personnel, no accreditation of institutions that educate EMS personnel, and virtually no accountability for the performance of EMS systems. While most Americans assume that their communities are served by competent EMS services, the public has no idea whether this is true, and no way to know.

The education and training requirements for the EMTs and paramedics are substantially different from one state to the next and consequently, not all EMS personnel are equally prepared. For example, while the National Standard Curricula developed by the federal government calls for paramedics to receive 1,000 - 1,200 hours of didactic training, states vary in their requirements from as little as 270 hours to as much as 2,000 hours in the classroom. In addition, the range of responsibilities afforded to EMTs and paramedics, known as their scope of practice, varies significantly across the states. National efforts to promote greater uniformity have been progressing in recent years, but significant variation remains.” (Committee on the Future of Emergency Care in the United States Health System, 2006) 3

My initial brief example of the differences in training between states pales in comparison to the preceding quote. We have established the fact that we have dedicated trained and competent personnel working in an environment that is restrictive primarily due not to the lack of a national standard but to a lack of information. I will expound on that statement shortly. First, however, let’s take a look at the problem from a scope vs. patient care prospective. An excellent example was discussed in an article by Tori Socha published in February, 2011. The article dealing with stoke reminded me of the initial introduction of thrombolytic drug therapy through pre-hospital providers in Massachusetts and the personal struggle some metropolitan medics had being able to use this lifesaving tool in one region, with their big city services, but not have it available to them in the small local, sometimes volunteer ALS services in the communities in which they resided. Ms. Socha stated;

“Stroke, with direct and indirect costs totaling $68.9 billion, is a major primary health priority in the United States. Every 40 seconds, someone in the United States experiences a stroke, and every 3 to 4 minutes, someone dies of a stroke. Administering intravenous (IV) recombinant tissue plasminogen activator (tPA) within 3 hours of onset of symptoms is associated with a 30% greater likelihood of decreased disability compared with placebo. In selected patients, IV recombinant tPA may be safely used up to 4.5 hours after symptom onset. Despite its clinical efficacy and cost-effectiveness, only 3% to 8.5% of patients with stroke receive recombinant tPA. One limitation is timely access to care. In 2000, the Brain Attack Coalition recommended establishing primary stroke centers (PSCs). Researchers recently conducted a study to determine the proportion of the population with access to Acute Cerebrovascular Care in Emergency Stroke Systems (ACCESS). The analysis found that if ground ambulances are not permitted to cross state lines, fewer than 22.3% of Americans (1 in 4) have access to a PSC within 30 minutes of symptom onset.” (Socha, 2011)4

There is no doubt that lack of definition causes, at bare minimum, organizational angst and disparity in the EMS service. It can also be argued that this lack of definition can result in loss of life, not due to negligence but the inability of available service to provide a timely response across jurisdictional boundaries stymied by the invisible but very real wall of scope of practice limitations. This is evidenced by the research from the Socha article as well countless additional journal articles and studies. The truly disquieting issue is that this conundrum is not one unique to an incident of national consequence but can be found in day-to-day EMS operations.

IV.   Solutions

So what is the solution? I left emergency services several years ago to seek technology solutions for common operational problems faced by our nation’s first responders. Over the last ten years I have listened to a consistent theme propagated in general by well meaning federal civil servants. Regardless of the problem the solution is of course to regulate it at the federal level. The following quote from the Committee on the Future of Emergency Care starts with a rousing call to arms.
“While today’s emergency care system offers significantly more medical capability than was available in years past, it continues to suffer from severe fragmentation, an absence of system wide coordination and planning, and a lack of accountability. To overcome these challenges and chart a new direction for emergency care, the committee envisions a system in which all communities will be served by well planned and highly coordinated emergency care services that are accountable for their performance. In this new system, dispatchers, EMS personnel, medical providers, public safety officers, and public health officials will be fully interconnected and united in an effort to ensure that each patient receives the most appropriate care, at the optimal location, with the minimum delay.” (Committee on the Future of Emergency Care in the United States Health System, 2006)3
All communities should be served with highly coordinated emergency care services that are accountable for their performance and those services should be interconnected. I do, however, disagree with manner in which the coordination, accountability and connectivity should occur. A bit further in the report the foundation of the proposed solution is revealed.
“The National EMS Scope of Practice Model Task Force has created a national model to aid states in developing and refining their scope-of-practice parameters and licensure requirements for EMS personnel. The committee supports this effort and recommends that state governments adopt a common scope of practice for EMS personnel, with state licensing reciprocity. In addition, to support greater professionalism and consistency among and between the states, the committee recommends that states accept national certification as a prerequisite for state licensure and local credentialing of EMS providers. Further, to improve EMS education nationally, the committee recommends that states require national accreditation of paramedic education programs. The federal government should provide technical assistance and possibly financial support to state governments to help with this transition.” (Committee on the Future of Emergency Care in the United States Health System, 2006)3
There it is. Solution by national regulation. This could be effective if the United States were the size of Switzerland. It would also be quite effective if we did not have 50 different autonomous state governments, not including territories. The individual states do not want to give up their sovereignty, nor should they be forced to. It is not necessary. The solution is to allow the authority having jurisdiction the freedom to define the scope of practice. How can this premise, the perceived status quo, change things? The logical proposal is the delivery of this [scope] information in a trusted fashion attached to a non-reputable identity. For those familiar with the ongoing work to leverage trusted identity by the federal government for physical and logical access control you likely have an idea where I am going with this concept. Several states have taken definitive steps to leverage the work done by the federal government to institute their own identity management (IDM) programs. One or two truly visionary early adopters are using the trusted identity as a foundation and attaching attributes. For example some states have implemented, as part of its functional mandate, “authenticated qualifications and attributes” by which they mean trusted and validated by the authority having jurisdiction or accrediting organization and the ability to tie first responders' identities and attributes to authoritative sources of information (e.g. licensing, certification, and status databases for paramedics, police, licensed heath care practitioners, firefighters, etc). 

Management of these attributes allows for the rapid and effective allocation of personnel resources during an operation.  Historically, management of these resources, assisted through mutual aid compacts, both formal and informal, was hampered by a lack of information and trust.  Further there often is a lack of understanding as to the differing individual elements that defined the attribute from jurisdiction to jurisdiction.  Without any mechanism to provide a trusted and detailed definition of the attribute the only recourse has been to compare attributes between jurisdictions at the lowest common denominator.  Categorization of resources has been limited to generalized groupings like Emergency Services Functions (ESFs) and subsets of Critical Infrastructure and Key Resource sectors (CI/KR).  A frequently disputed alternative has been for the federal government to dictate the attribute definitions to state and local authorities.  This lack of information is compounded by the specter of legal accountability for the jurisdiction receiving the resources especially in those attributes which directly influence life safety.  The result is an under utilization of the available resources.

Attribute management within an identity system is similar to that in network management. In a network an “attribute” is the property of a managed object that has a value. Similarly in one example of an IDM attribute-enhanced system an attribute is the property of the person who has enrolled, and the value is “what that attribute is.” For example: Joe Smith enrolls and designates he is a paramedic. Joe is the “managed object” and paramedic is the “attribute.” The system then associates the “value” as the skill set of a paramedic.
Also similar to network management, certain mandatory initial values for attributes are specified as part of the managed object class definition. Associating the skill set of a paramedic is a mandatory initial value, but conditional values can also be added, these may be unique to the jurisdiction where a responder works on a local, regional, or state level. These paramedic conditional attributes could also be additional training or certifications that are above and/or beyond the initial mandatory value of a paramedic as defined by the federal AHJ. This allows all stakeholders to have their cake and eat it too. The federal government establishes the baseline and state and local jurisdictions are not forced into long term expensive programmatic changes.

When the attribute dataset is read by a computing device the retrieved information is reported to the user in local terminology and an instant comparison is made between the individual knowledge and task statements and requirements of the local jurisdictions certification requirements and the sending jurisdictions certification requirements and critical discrepancies are reported. For example as part of the comparison the table of pharmacology for a paramedic is compared between a sending jurisdiction and a receiving jurisdiction is compared and the receiving jurisdictions report shows that the medic is not trained in the administration of a thrombolytic, part of the scope of care of the receiving jurisdiction.

My example was originally designed to use national regulatory or volunteer compliance standards as a baseline. A methodology was developed allowing for local, regional, or county based training and skill sets to be incorporated into the system. The subsequent modifications to the system provided both a means of tracking these local training programs, optionally using the resources that are the outcome of these programs and communicating this information to disparate jurisdictions whose training has a completely different baseline but whose terminology and outcomes are similar. 

Systems of this type are designed to give command authorities trusted, verified, data on skills licenses and certifications held by respond in individuals and teams in order to allow use of these human resources at the highest common denominator thereby making the most effective use of the resources available and providing the highest level of care and services to those in need during times of disaster of any scale.
Twenty five years ago very little if any consideration was given to a need for instant reciprocity.  With a few exceptions emergency resources were drawn locally or regionally from immediately adjacent jurisdictions.  Today responses to critical events can be national, leveraging the spirit and altruism that defines America.  Twenty five years ago a piece of paper, a uniform, or a badge could serve as proof of qualification.  Today the litigiousness of our society has prevented even the federal government from using emergency services personnel to their demonstrated capabilities.   The advent of the “Google” age of instant access to information has raised both demand for service and expectations that such service will be quickly and effectively delivered.

[1] Kuntz, K. (June 23 2000). Federal Advisory Committee June 23 2000, National construction Safety Team Investigation, Station Nightclub Fire Emergency Response. Washington D.C.: U.S. Fire Administration, U.S. Department of Homeland Security .
 [2] Bluestein, G. (2005, September 7). Firefighters stuck in Ga. awaiting orders. USA Today .
[3] Committee on the Future of Emergency Care in the United States Health System, B. o. (2006). Emergency Medical Services at the Crossroads. Institute of Medicine , National Academy of Sciences. 500 Fifth Street, N.W. Washington DC: National Academies Press.
 [4] Socha, T. (2011, February 15). Timely Access to Primary Stroke Centers in the United States. (HMP Communications LLC) Retrieved April 12, 2011, from First Report Managed Care:

This concept paper was first delivered as an open letter to the National EMS Advisory Council in January of 2011.  A revised version of the paper was published by the IEEE as part of a poster presentation at the annual IEEE Conference on Technologies for Homeland Security in December of 2011.

1 comment:

  1. Tom - giving the rights and responsibilities to the authorities having jurisdiction makes all the sense in the world and is an idea that people at any level of government or role within the emergency response sector would support.


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