Evaluating & Improving Evaluating & Improving Clinical and Administrative Clinical and Administrative

Tools and TechnologyTools and Technology

William E. Ott, MS, ParamedicWilliam E. Ott, MS, Paramedic

CPCS Technologies www.cpcstech.comCPCS Technologies www.cpcstech.com

EMS Management TodayWashington DCJune 28, 2003

What is the goal of technology in EMS?

To provide the best possible care for our patients?

To have the most flashy wiz-bang toys in which to impress rival services and attract new personnel?

To improve revenues and speed reimbursement?

Some combination of all of these?

Issues to Address• What do we do• Rate of technology change• Data systems• Bio-medical equipment• Communications equipment• Project management and control• Return on Investment (roi)• Total Cost of Ownership (tco)

‘I can do it well’

‘I can do it cheap’

‘I can do it fast’

‘Pick any two’

Red Adair

The Waterfall of Technology

AvailableTechnology

Learnable-Usable

Technology

Don’t be the management that you have alwayscomplained about

Return on Investment and Total Cost of Ownership

• Where will we find ROI and what is the TCO of these constant upgrades?

• Do we need the latest, greatest widget?

• Who drives our move to upgrade, especially medical equipment?

• Budgetary constraints

• Are you proactive or reactive?

Rate of Technology Change

• Medical equipment 3 to 5 years

• Desktop PC hardware 18 months to 3 years

• Servers 3 to 5 years

• Software 12 to 24 months

• Communications gear 5 to 8 years

Important?

“We believe that the greatest advances in medicine over the next two decades will result from the application of the tools and principles of information science to the problems of clinical medicine”.

The National Center for Emergency Medicine Informaticshttp://www.ncemi.org/

Security

Renewed Emphasis

Data Systems

Hardware

• PC based

• Notebooks

• Pen-Based

• Handheld

• PocketPC

• Palm-Based

• Voice Operated

Focus?

Most business sectors spend 12-

15% of revenues on information

technology*

Hospitals spend an estimated

2.5% of revenues on information

technology*

EMS spends _____?

* Source: Philadelphia inquirer

Much waste in IT expenditures

• By some estimates, only 30% of IT related projects in the public sector are completed and those that are usually have significant changes in the plan during the project

• EMS isn’t technically savvy like other public safety groups, especially law enforcement

• Poor technical project management skills and planning

Input

• User Assisted– Optical Mark Reader

(OMR)– Optical Character Reader

(OCR)– Keyboard– Voice recognition

• Automatic data capture – Medical devices

Transformation

Input Output

Control Mechanism

Transformation

Data is:• Aggregated• Cleaned• Validated• Analyzed

Transformation

Input Output

Control Mechanism

Output

• Reporting– Ad hoc– Exception reports– Aggregate

• Publishing– Web-based

Transformation

Input Output

Control Mechanism

Control Mechanism

• Quality improvement

• Education• Administrative

policies• Medical protocols

Transformation

Input Output

Control Mechanism

EMS Data System Success

• My research reveals that the happiest providers and most successful data projects were:– Built internally from scratch with work and

knowledge from staff

or– Contracted out and custom built to the

providers exact specifications

EMS Data System Success

• Providers using the ‘customizable’ off the shelf EMS packages are seldom happy with their system

• Frequently these projects fail or go through more than one product

• Lack of customization and lack of ‘your’ key data points are the biggest issues

• Support is frequently an issue of contention• Usually would be cheaper in the end to have

specced out and built custom system

Medical Equipment

• Who sets the standard?• Does it impact patient outcome?• How does it fit into your data system?• How do you measure the cost/benefit of new

technology patient care equipment?• Learn to read and evaluate technical

specifications• Where is the research?• Don’t be bluffed by sales reps

Communications Options

• Wired• VoIP• GSM, CDMA, TDMA, IDEN terrestrial• CDMA Satellite• Trunked Systems

– 800MHz– 700MHz becoming available

• Wireless Data– BSDN– GPRS– PacketStream

Role of Project ManagementRole of Project Management

Methodology

Sch

edul

e

Sch

edul

e

RequirementsRequirements

CostCustomer

ExpectationsBusiness

Objectives

RiskRisk

The Project

Constantly balancing customer expectations and achievement of Constantly balancing customer expectations and achievement of internal business objectives, while simultaneously internal business objectives, while simultaneously

delivering within the triple constraintdelivering within the triple constraint

Responsibilities of the Project Manager

• A number of demands are critical to the management of projects:– Acquiring adequate resources– Acquiring and motivating personnel– Dealing with obstacles– Making project goal trade offs– Dealing with failure and the risk and fear of failure– Maintaining breadth of communication– Negotiation

Issues in project management

• Users– Often not clearly identified

• Use environment– System Concept and environment are not

well understood

• Requirements– Not well-understood by either customer or

developer

Major Reasons for Project Failure

• Incomplete, ambiguous, inconsistent specifications

• Poor (No) planning and/or estimating• No clear assignment of authority and

responsibility• Not enough -- or wrong -- user involvement• Lack of adequate tools and techniques• Dependence on external sources (vendors,

subcontractors)• High staff turnover or inadequate training

Project Management

• Waterfall development– Emphasis on early closure

on specification– Planning and design are

“simplified”– Product may not meet

“real” needs– Schedule and resources

often problematic

• Rapid prototyping– Continuing user

involvement -- changing or evolving requirements

– Planning and design are complicated

– Product usually meets “real” needs

– Schedule and resources often problematic

Two Project Methods

• Resource constrained

• Problem: Finish project ASAP given max usage can be only Y in any period

• Time constrained

• Must finish project in X days/weeks, find a schedule that minimizes the resources needed

The Waterfall Model

• First formulated by Royce in the early 70’s• Further developed by Boehm (Software

Engineering Economics)• Based upon a series of discrete phases, with

clear phase termination events and limited feedback between phases

• Dependent on a clear understanding of the initial requirements for the system

Project Management Sub-goals

• On time

– On-target estimate of project schedule and effective monitoring and tracking of project activities.

• Within budget

– On-target estimate of project budget and effective monitoring and tracking of project costs.

• With a high degree of user commitment

– Effective client relations, including involving users, documenting requirements, and managing change.

All 3 PM Sub-goals are critical ...

• Ultimately, the success or failure of a project is determined by the satisfaction of the person(s) who requested the project!

On-time

Within budget

User commitment

Risk Management

• Explicitly incorporated into the project plan

• Implemented via Work Authorizing Agreements

• Permeate the project cycle

• Address technical, schedule and cost factors

• Risk identification• Probability and

seriousness assessment

• Decision process - trade-offs

• Preventive and contingent actions

Software Vendors

• Remember that every software vendor has the cure for your data problems

• When you sell hammers, everything looks like a nail

• Be cautious and ask tough questions when evaluating software

• Evaluate software on your hardware with no software reps around

Hardware Issues

• Using existing hardware?

• Obtaining new hardware?– Buy?– Lease?– Avoid bidding if possible..– Commit at last minute to get most for the

money

Hardware Issues

• Don’t lowball on hardware– 256MB to 512MB of RAM minimum– 19 inch monitors (15 inch notebooks)– DVD, and CD-RW on at least a few

• Slightly more cost up front will return an extra year or more in savings in life of equipment

• (as of July 2003)

Hardware Issues – Vendors

• Last minute purchasing of custom configured computers works well from Dell or Gateway

• Longer lead time required for IBM, HP, etc..• Order ‘no-tool’ systems, easy to work on• Order same configurations, preloaded, saves

hours of work

Types of Contracts

Fixed-price contract• Price remains fixed unless

the customer and contractor agree

• Low risk for the customer

• High risk for the contractor

• Is most appropriate for projects that are well defined and entail little risk

Cost-reimbursement contract

• High risk for the customer

• Low risk for the contractor

• Appropriate for high risk projects

• Customer usually requires that the contractor regularly compare actual expenditures with the proposed budget and reforecast cost-at-completion

Networking Issues

• Investigate xDSL, cable, wireless, point to point wireless, and BoP for connectivity to remote sites

• Satellite Communication• Networking with 10/100Mbps gear..keep an eye

on 1000Mbps gear now rolling out• Committed Information Rate (CIR) from

broadband vendors

Size of Agency

• Larger agencies have more flexibility in project planning, resources, budgeting, etc..– Failure is not as painful and more readily

accepted

• Smaller agencies require more precise project planning – Failure is painful

Reporting Project Status

• PERT Charts (Network Charts)• Critical Path Modeling• Gantt Charts• Calendars• Resource Utilization Charts• Personnel Utilization Charts

Keeping team updated routinely and regularly improves project success

Timeline for Project

• The parties to the project need to discuss and develop the timeline, especially if custom software is being developed

• Arbitrary milestone times don’t work, the people that must perform a task should establish the milestones in discussion with the other parties.

Training Issues

• It is best to have system installed and operational prior to training the workers

• Scheduling training early in project cycle isn’t a good idea

• Give workers access rights at training• ‘Big Bang’ or ‘Slow Roll’• Operate concurrent old and new systems until

new system is verifiable• Must create and maintain personnel buy-in

Issues in Project Management

• Design– Insufficient system analysis and no way to

measure adequacy

• Inadequate customer visibility into the development process

• No common vocabulary between customer and developer

• Unrealistic schedule and budget

Issues in Project Management

• Supply of project personnel with appropriate skills is insufficient to satisfy demand

• No management attention -- too much management attention

• No tools or training for project management• Too few or no appropriate tools and

resources for development team.

Techniques to Support Teamwork

• Don’t insist on your process or solution if another would work– Be flexible– Don’t sweat the small stuff– Evaluation - (1) How many things were

resolved differently than you thought that they should be (2) How many times did you offer solutions instead of asking for them

Techniques to Support Teamwork

• Facilitate communication– Provide tools (email, white boards, etc.)– Have an open door policy and mean it– Evaluate the communication process

frequently “Have you talked to…”, “What did Lou say about that”

– Watch team in meetings -- who is left out– Ask how you are doing and listen to the

answer

Consensus Decision Making

• Use it whenever you can

• Don’t fail to use it if….– You don’t believe that sufficient knowledge

resides in a single individual– You don’t have sufficient facts– You need group commitment for

implementation

Project Management Tools

• Microsoft Project• Microsoft Excel• Risk Radar• Website• Conference Calls• Video Conferencing..easy, cheap now• Meetings

– Have only as needed– Have set agenda and maximum time

Simple Project Tracking with Excel

Risk Radar Risks Display

‘I can do it well’

‘I can do it cheap’

‘I can do it fast’

‘Pick any two’

Red Adair

What is the goal of technology in EMS?

To provide the best possible care for our patients?

To have the most flashy wiz-bang toys in which to impress rival services and attract new personnel?

To improve revenues and speed reimbursement?

Some combination of all of these?