Techno-Management Innovation in Indian Emergency Medical Services
Sreekanth V K is pursuing his PhD at Rajendra Mishra School of Engineering Entrepreneurship, Indian Institute of Technology Kharagpur, India. He is working on decision modeling in emergency medical services as a part of his doctoral thesis. He is an active member of a research group working in healthcare operations and analytics under the supervision of Dr. Ram Babu Roy.
Author shares his views on how techno-management innovation could help in dealing with the challenges in Emergency Medical Services in India
Emergency Medical Services (EMS), across the globe, play a crucial role in saving lives of the patients who require urgent medical assistance[1,2]. The concept of Star of Life conceptualized by National Highway Traffic Safety Administration, United States of America (1995) drives the operations of EMS which include the out-of-hospital care to the emergency patients and transport the patients to the definitive care at hospitals within predefined time standards. The Star of Life was adapted from the personal Medical Identification Symbol of the American Medical Association.
Each bar on the “Star of Life” represents one of six EMS functions. The functions include:
4. On-Scene Care5. Care in Transit
6. Transfer to Definitive Care
The story of Indian EMS started with the inception of Emergency Management and Research Institute in April 2005 that provided services across the state of Andhra Pradesh (currently Andhra Pradesh and Telangana). Earlier, people were mostly dependent on the ad-hoc emergency provider networks in which hospitals and taxis provided the services to meet the emergency needs. Later in 2005, the concept was conceived by National Health Mission (NHM) (then National Rural Health Mission) and initiated Emergency Response Services (ERS), popularly known as “108 Ambulance Service Project” to ensure emergency care for rural India along with urban India. The number ‘108’ corresponds to the toll free number which allows the patients to report the emergency cases to emergency response Centres in each state. ERS is a part of National Ambulance Service (NAS) in which NHM guides and supports the states of India to operate various ambulance services directly or in Public Private Partnership (PPP). In most of the states of India, the 108 Ambulance Services are being run in PPP mode with various private service providers such as GVK EMRI, Ziqitza Health Care Limited (ZHL) and BVG India Ltd. Apart from the 108 ambulance services, there are various other services such as 102, 1298, 1033, Centralized Accident and Trauma Service (CATS) and different localized ambulance services run by private bodies. Figure 2 shows the distribution of various types of emergency ambulance services such as 108, 102, 1033, 1298 and CATS in India.
102 Service, a government supported service, essentially consists of basic patient transport and primarily focuses on maternal and neonatal care. It provides free transfer from home to facility, inter facility transfer in case of referral and drop back for mothers and babies. 1298 and 1033 services are privately owned services which cater to various states of India. The Centralized Accident and Trauma Service (CATS) is one of the early ambulance services in India which was conceptualized and initiated well before EMRI. It focuses on accident and trauma and extends its services only in Delhi. There are various ambulance services run by private bodies which are controlled locally and serve the local people. For example, Accident Care and Transport Services in central Kerala which uses toll free number 1099. As the Figure 2 shows some of the state yet to have an EMS while other states have more than one type of EMS services which follow different implementation models [7,8,9,10].
Challenges in EMS in India
Although the implementation of NAS guidelines is mandatory for all the ambulances which are financially supported under NHM, the guidelines for training and operation of EMS are not well defined. Due to the state level PPP and private ownership models, the national level perception is lacking and people of some states do not have access to the services. The recommendation for a single number at national level for all emergency cases is yet to be implemented and there is a high variability in the emergency numbers which create confusion among the people. The lack of standardization in EMS education creates problematic situation as EMS requires highly skilled labor.
Even though the 108 ambulances are conceptualized to cater only emergency patients, in some states these ambulances play the role of 102 ambulances to provide maternal and neonatal care including the transfer from facility to home. The dual role play makes the situations complicated as the emergency resources are allocated for elective cases which would require the basic transportation facility only. Furthermore, the challenges become harder as there are budgetary constraints and the cost of operations are ever increasing along with the high capital investments. It is important to notice that the increase in the number of strikes by the emergency health care professionals in various states in the recent past. In addition to that, there are requirements for replacing existing ambulances with new ambulances as most of the ambulances have attained the mandatory cut-off retirement age of five years and covered more than 0.5 million kilometers. There is a call for more ambulances as the existing number of ambulances is not enough to serve the high density population of India.
The services are dependent on technology like Global Positioning Satellites (GPS) / Geo-spatial Information Systems (GIS) and other information and communication technologies (ICT) including internet of things (IoT). The technology development in India needs to go a long way to reduce the preventable manual error in the system. Presently, the data entries in most of the states heavily depend up on the manual effort and there is a possibility of human error in entries which makes the collected data highly unreliable. Moreover, the GPS technology fails miserably in some rural part of India which forces the system to have manual intervention in locating the incidents.
The awareness among the general community regarding the emergency service is crucial for success of the service. The people who call to the emergency response centre for non-emergency cases are not only misusing the resources, but they also prevent the real emergency users from using it. As the service is free, the chances of misuse are very high due to the ignorance about the significance of these services.
Techno-management innovation as solution
As the services are constrained with budget, resources and skilled laborers, the innovation in the way it is managed is necessary. Technological innovation could help in reducing the cost and improve the management of system.
Technology innovation is necessary to identify and forecast the requirements so that we could plan well and reduce the waste. It would help us to design and develop the ambulances with necessary equipment and remove unnecessary equipment so that cost of ambulances will be reduced, and we could place different types of ambulances depending up on the demand. The big data analytics could help us in processing the data and forecast the need so that we could be in a better position to act. Long term forecast may help us to decide up on the budget and strategic decisions. The reduction of manual intervention in data management and the streamlining of information flow in the system will help us to improve the quality of service and make action quicker. There is a need to develop an ambulance tracking system using indigenous GPS system developed by ISRO which will cover entire country and provide information more accurately.
In a nutshell, we need innovation in technology to capture and disseminate the information accurately and in a well-defined fashion, and the information captured should be processed to have better insights.
Management innovation is inevitable as the cost of operations is ever increasing and 70% of the cost is attributed to the labor cost. Developing a national standard for operations and training may improve the services, and it will improve the transparency in the system. The innovation in operations management techniques is necessary as most of the existing techniques use assumptions from other countries which are not applicable to Indian context. The high population density and low level of health literacy makes Indian EMS context a difficult nut to crack. With the help of appropriate technology interventions, we need to develop new management methods to minimize the labor cost and to improve the service quality. The regionalization of EMS, standard training process, appropriate budgetary provisions, and improving awareness among the general community might improve the performance of EMS.
 Aboueljinane, L., Sahin, E., &Jemai, Z. (2013). A review on simulation models applied to emergency medical service operations. Computers & Industrial Engineering, 66(4), 734–750. http://doi.org/10.1016/j.cie.2013.09.017
 Al-Shaqsi, S. Z. K. (2010). Response time as a sole performance indicator in EMS: Pitfalls and solutions. Open Access Emergency Medicine, 2, 1–6.
 National Highway Traffic Safety Administration. (1995). “Star of Life”, Emergency Medical Care Symbol: Background, Specifications, and Criteria. U.S. Department of Transportation, National Highway Traffic Safety Administration, Office of Enforcement and Emergency Services. Retrieved from http://www.ems.gov/vgn-ext-templating/ems/sol/index.htm
 Rajagopalan, H. K., Saydam, C., Setzler, H., & Sharer, E. (2011). Ambulance Deployment and Shift Scheduling: An Integrated Approach. Journal of Service Science and Management, 4(1), 66–78. http://doi.org/10.4236/jssm.2011.41010
 Sharma, M., &Brandler, E. S. (2014). Emergency Medical Services in India: The Present and Future. Prehospital and Disaster Medicine, 29(3), 307–zs310. http://doi.org/10.1017/S1049023X14000296
 Emergency Response Services /Patient Transport Service, National Ambulance Service(NAS), http://nrhm.gov.in/nrhm-components/health-systems-strengthening/emri-patient-transport-service.html
 Emergency Management and Research Institute (EMRI), http://www.emri.in Ziqitza Health Care Limited (ZHL), http://zhl.org.in/
 Bharat Vikas Group (BVG) India Ltd, http://bvgindia.com/emergency-medical-service Chandigarh Metro, Chandigarh now has 2 Ambulance Services (102 and 108), http://chandigarhmetro.com/chandigarh-emergency-ambulance-services-102-and-108
 The Hindu, 108 services in critical stage, http://www.thehindu.com/news/cities/Hyderabad/108-services-in-critical-stage/article7279007.ece