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TIME-CRITICAL INFORMATION SERVICES: A REVIEW OF CONCEPTS, CASES AND IMPLICATIONS Thomas A. Horan and Benjamin Schooley Claremont Graduate University

PREFACE This white paper provides an overview of Time-Critical Information Services (TCIS) for the purpose of promoting response and feedback from workshop attendees. The paper begins with a general introduction to the concept of TCIS, including the focus on Emergency Medical Services (EMS). Then it reviews briefly the past two years of related research by the CGU research team (Part II). Next, a preliminary conceptual model is presented as well as the general research approaches for assessing TCIS (Part III). The paper concludes by outlining research objectives and workshop agenda (Part IV). The workshop agenda will feature a roundtable discussion of approximately 15 experienced academics, researchers, and practitioners, focusing on three areas: 1) examining the concept of time-critical information services (with a focus on mobile EMS), 2) addressing the means for assessing improvements in such services (with a focus on technological and related organizational innovations), and 3) exploring regional and local applications of these concepts. As noted in Part IV of the paper, the workshop will address the following questions: 1) How clear, valid and useful are the Time-Critical Information Services (TCIS) concepts? 2) What are the best methods for measuring the quantitative and qualitative dimensions and impacts of TCIS? 3) What (inter) organizational and policy challenges exist to achieving system/service improvements to TCIS? 4) What insights do ongoing deployments and operational tests have for the TCIS concepts? 5) How do the concepts of TCIS relate to current and emerging EMS and e-government policy trends? 6) How can TCIS advance our understanding of e-governmental services and contribute to the well being of citizens? This paper is a “work in progress”! An important outcome of the Time-Critical Information Services Workshop will be the expansion and refinement of the concepts and research methodologies put forth in this draft. Written comments are also appreciated and should be directed to [email protected]. Acknowledgments This Workshop is sponsored by the Digital Government Program, National Science Foundation (Award no. 0508938). The workshop is being conducted in cooperation with the National Center for Digital Government, Harvard University. Additional co-sponsorship is provided by the State and Local Policy Program, Humphrey Institute, University of Minnesota in collaboration with the ITS Institute, University of Minnesota.

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PART I: Introduction to TCIS A.

Taking Just-in-Time to e-Government

From an e-government perspective, contemporary Emergency Medical Services (EMS) systems such as 9-1-1 are emblematic of what could be considered a “time-critical information service”. The time-critical element refers to the medical necessity to deliver emergency services in as rapid a time period as possible, executed through a chain of dispatchers and responders. The information-critical element refers to the fact that this service has become highly dependent upon information—from the nature and location of the incident, to the medical needs of the patient that should be attended to at the awaiting hospital (Arens and Rosenbloom, 2002; Hale, 1997; Turoff et.al., 2004). Moreover, both time and information service elements are fundamentally organizational issues: effective and timely service depends upon all participating organizations working cooperatively and utilizing information technology effectively (Mayer-Schonberger, 2003). In particular, wireless carriers, emergency dispatch center administrators (e.g., PSAP’s), law enforcement, fire and EMS officials, and state and local political leaders need to cooperate to deliver an integrated set of 9-1-1 services (Jackson, 2002; Lambert, 2000; Potts, 2000). Of course, time efficiency and effectiveness are not new concepts to business, computer and information professionals. Concepts such as Just-in-Time (JIT) and Business Process Reengineering (BPR) have become central to private sector business operations and information technology planning. These concepts, and others like them, coincide with the notion of improving the integrated delivery of business related processes and services using information technology. Real-time, information rich, computer aided processes to reduce costs and increase efficiencies in the value chain are driven by the private sector axiom that “time is money”. While private sector oriented information systems have focused on the critical role of information technology in achieving JIT delivery and improved value chain management, our thesis is that similar attention is needed to those public sector services that are also highly time and information dependent. EMS represents an illustrative application domain of JIT in public services, where in this case “time is lives”. Transportation research, specifically Intelligent Transportation Systems (ITS) research, has looked at how IT can create efficiencies (i.e. time and cost savings) in transportation related public services (for example see NHWA, 2003). However, to date, limited research has been done to understand how IT can enhance time-critical functions for public services (such as EMS) that are information intensive. Further, we have found a paucity of research that investigates time-critical dimensions to those public services that depend on multiple cooperating organizations. In a related sense, there is a need to understand the best methodological approaches for examining this phenomenon. This exploratory research and workshop on timecritical information services is motivated by the potential impact that timely information can have on governmental service performance and on the general public welfare. It is aimed at improving the influence that information technology (IT) has on governmental processes, especially as they affect the well being of injured travelers 1. The conceptual emphasis is on the interplay between information and the organizational network charged with delivering EMS. It is structured as an inter-disciplinary investigation at the interface between information science and organizational 1

Other time-information critical services include police, fire, public health, child safety, and homeland security.

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science, focusing on the information and organizational processes involved in time-critical information services. This research builds on an initial investigation of EMS conducted under sponsorship from the Minnesota Department of Transportation and extends the analysis to additional regions so as to inform national e-government, highway safety, health care and emergency management policies. B.

The Need for a Socio-Technical Approach

Important dimensions related to time-criticality are the overarching organizational, institutional, and technical systems that interact with each other. Improving timeliness, and overall performance, means looking at not only technology, but how technologies interact with the people and organizations using them and the policies governing organizations and their usage of IT. In her private sector (business) research, Markus (2004) explains the need for more integration between IT development and organizational change management; a need which she has termed “technochange.” Markus states, “Technochange situations call for big improvements in organizational performance. These improvements cannot happen unless tasks, jobs, and organizational processes all change along with IT (p. 7).” Similarly, but from a public sector research perspective, Fountain (2001) explains the need for coordination between interorganizational networks of people, organizations, and policies to gain a better understanding about how they interact with information technology. Fountain’s Technology Enactment Framework provides a set of guiding propositions that explain the interactions between objective information technologies, organizational forms, and institutional arrangements. These interactions influence the design, perceptions, and uses of information technologies. The socio-technical approach must be holistic, addressing the entire system. Addressing the application of e-government to public health systems, Fountain (2004) explains that the accumulation of more sophisticated technology and specialists is insufficient. In order for public health agencies to develop new, integrated e-government programs, they must first examine the entire existing system to assess their organizations’ readiness to integrate digital government from technical, managerial, and political perspectives. Time-critical public service systems are large, complex, and often dynamic, and thus need to be investigated from such a perspective. Sussman (2002) and colleagues speak of “Complex, LargeScale, Integrated, Open Systems” (CLIOS). A significant aspect of their analysis is examining the nesting of technological systems within institutional processes and linkages. As Dodder and Sussman (2002) note: We therefore have “nested complexity” when the physical system is being “managed” by a complex organizational and policymaking system. However, while we make a distinction between the physical system and policy system – which captures the primary stakeholders as well as the policymaking and other decision-making institutions – we also need to explicitly represent the connections between the physical and policy systems. Indeed, an important step in the CLIOS representation process is to identify and characterize these policy-physical system links. Understanding nested complexity is a necessary step in moving towards better integrating institutional and policy design with physical system design (p. 4).

To restate in the domain of e-government, an infrastructure system (such as EMS) includes a technical system that is nested in a social and institutional system. The degree and nature of these linkages are complex, and in this sense complex includes dynamic, emerging, and not fully predictable elements. Moreover, their (CLIOS) approach suggests the utility of portraying a

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complex system as an important conceptual step toward understanding how the system operates and evolves. Included in this portrayal is the need to examine links across the various institutions, including their various socio-technical permutations. Within the field of Information Science (IS), the focus is on inter-organizational systems. C.

Introduction to Emergency Medical Services as a Time-critical Information Service

Emergency responses have become inextricably linked to the nation’s telecommunications systems operationally and to the public sector organizationally. Indeed, in the three and a half decades since the first 911 phone call in Haleyville, Alabama, the nation’s emergency response system has evolved into a sophisticated network of dispatchers and responders and the communications system has evolved to include an array of mobile and computer-aided systems. This evolution has occurred within the context of public demands for better and faster emergency medical services (EMS) that will minimize the consequences of accidents and other health emergencies. From the moment a 911 phone call is placed to a local public safety answering point (PSAP), time is of the essence – every moment of delay can significantly reduce an accident victim’s chances of survival. In this regard there are concerning statistics, for example, of the disparity in timely services for rural versus urban incidents. In rural areas the average time that lapses between a rural crash and the victim’s arrival at a hospital is 52 minutes, compared to 34 minutes for an urban crash victim (NCSA, 2002). The result is that fatalities on rural roadways account for approximately 60 percent of all vehicle fatalities in the United States, with even higher figures in predominately rural states (e.g. Maine, 90%; Minnesota, 73%; Montana, 92%). But the service is not just time-dependent, it is information dependent as well – this information can include locational data on the callers address, accident data on the nature of the injury, or health data on biological constitution (e.g. blood type) of the injured party. It can also include information kept by various agencies about service operation and performance. It is for these reasons that EMS provides an emblematic case of time-critical information services and serves as the foundation of both our early work and our subsequent development of a broader TCIS concept.

PART II: Team Research and Related Cases A.

Review of Preliminary Work

Over the last two years, our research team has investigated rural mobile EMS performance; indeed, these two years of research activities have led to a grounded (if preliminary) understanding of the importance of the constructs noted above. This initial work was conducted in Minnesota, funded by the Minnesota Department of Transportation (Mn/DOT). Our research focused on the implications of wireless 911, within the rural Minnesota context, at three levels: organizational, policy, and technical. Field visits, interviews, and roundtable discussions were conducted in two stages in rural Minnesota, including visiting two of nine new Mn/DOT funded rural public safety answering points (PSAP’s). The following discussion expands upon key findings from this research, and in doing so, raises conceptual and methodological issues related to EMS specifically and e-governmental services more generally.

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i) Preliminary Descriptive Research The first phase of our research was descriptive in nature and our methodology consisted of a series of semi-structured interviews, supplemented by analysis of local EMS systems. These interviews helped us develop an EMS architecture that portrays the organizations, technical systems, and policy aspects of the entire end-to-end system, as well as critical inter-organizational linkages in the system (summarized in Horan, Schooley, and Dadabayeva (2003)). We sought to understand the mobile EMS process tracing the occurrences of rural EMS service requests and dispatches across public and private organizations. From a technological perspective, we documented the service process for rural EMS systems (see figure 1) and the extant technological systems for delivering this service. In terms of policy dimensions, this research identified both local (e.g. funding) and national (e.g., FCC regulatory) policies that influence rural EMS systems. In short, this stage of research provided us with a general understanding and framework to further explore end-to-end EMS systems, including the need to address technical and organizational dimensions of performance.

Figure 1. Rural EMS System Process ii) Research on End-to-End Performance Our second phase of research built on this descriptive base. We captured and analyzed performance data related to rural EMS activities. The general methodology of this phase was a case study involving field visits, interviews, and data analysis and simulation (Horan, Kaplancali, Schooley, 2003). This field visit (which evolved into a full case study) uncovered how disparate information systems are used to monitor individual (vis a vis end-to-end) performance.

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Nonetheless, through follow-on interviews and data collection, our research team was able to construct a performance profile that explained the performance both in quantitative terms (through development of a knowledgebase and related simulation); the team also analyzed qualitative responses that addressed organizational perceptions and challenges. First, in terms of the knowledgebase, we obtained data for end-to-end performance for 2002. The ontology knowledgebase provided a means to aggregate performance data and document performance attributes, as well as construct a factual ontology based on case study data2 (see Table 1). This knowledgebase design provided a framework for categorizing and measuring system performance. Figure 2 provides a summary graphic of some of this data from the second case study, compiled from three databases and several supplemental interviews; the factual ontology contains more detailed information about breakdown of incident reports by type, location and time of rural emergency response, and distribution of rural fatalities. Further analysis revealed that a significant proportion of the accidents and fatalities occurring during a few select weekends (e.g. July 4). (see Horan, McCabe, Burkhard, and Schooley, 2005). Moreover, we obtained and analyzed the fatality data for the case region, compared to general rural response averages and urban response challenged. As noted in Table 2, the average time in the case area to lapse between notification and hospital arrival was approximately 60 minutes, twice the average time as in urban areas and higher than the average time in rural areas of Minnesota (Horan, McCabe, Burkhard, and Schooley, 2005). This analysis confirms the importance of improving the timeliness of response systems, particularly in rural regions.

2

The conceptual model was constructed using a software based knowledgebase structure (using Protégé), which provided an overarching framework and vocabulary for describing system components and relationships and represented a means to devise, analyze and compare performance metrics with others (Holsapple and Joshi, 2002).

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Wireless EMS Process

Mayday Call

Call Routing

EMS Dispatch

Response & Hospitalization

Related System Information

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Conceptual Wireless EMS Ontology Mayday Call o Cellular phone call o Automatic crash notification o Radio communication Call Routing to EMS Dispatcher o Routing delay o Third party routing (GM OnStar) Response to Mayday Call o Response delay Dispatch Data Management Response to Incident o Response delay Response Coordination Hospitalization Fatalities E-911 Technology o Network based o Satellite based Wireless Coverage E-911 Deployment

Factual Ontology Brainerd, 2002

Around 9000 wireless calls in 2002 at Baxter TOCC

Two of seven PSAPs in MSP-D2800 accept all local wireless 911 calls

Crow Wing County PSAP made 36,488 dispatches

71 Fatalities in MSP District 2800.

Phase I – 100% complete Phase II – 33% complete

Subclass – 1st level. o Subclass – 2nd level. Table 1. EMS Conceptual and Factual Knowledgebase

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22,000

7,215 3,325

Incident Reports Resulting from Wireless Calls

Total Wireless 911 Calls*

71 Deaths Resulting from Crashes

Rural Automobile Crashes

Sources: Minnesota State Patrol District 2800, Brainerd PSAP, FARS Database

Figure 2a. Overall End-to-End Statistics

Incidents

180 160 140 120 100 80 60 40 20 0

F

in ish

gO

ICRs Crashes Fatalities

r ne pe M

ia or m e

ay lD h 4t

ly Ju f o

R BI

ce Ra

s La

bo

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ay S

m um

er

h Ot

er

Weekends

Figure 2b. Distribution of Events

Interval (in minutes) Accident/EMS Notification Accident/EMS Arrival at Scene Accident/EMS Arrival at Hospital

MN Urban Areas Mean Range 2.1 0-28 10.3 1-73 5-86 33.0

MN Rural Areas Mean Range 5.8 0-275 21.3 1-285 12-197 51.8

MN Case Study Area Mean Range 4.9 0-61 20.8 2-94 17-197 60.5

Source: Analysis based on data from FARS & Minnesota FARS, 2003. Table 2. EMS Notification and Response Intervals in Minnesota, 2002

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As noted in Figure 2b, the distribution of accidents was not uniform across the year. This phenomenon led us to be interested in modeling performance of the system under differencing stress conditions. Consequently, we used the performance data as inputs to construct a preliminary simulation using ARENA Simulation Software. The simulation provided a visually oriented demonstration to understand system performance in normal vs. peak conditions. Figure 3 provides a visual screenshot of ARENA performing a 14day simulation of rural Minnesota EMS based on performance data obtained during the second case study. The figure conveys a graphic summary of the rural EMS model researchers developed for assessing EMS performance and a display of how ARENA is able to model this system. The preliminary findings from this research phase were summarized in Horan, Kaplancali, and Schooley (2003), and revealed major differences between normal versus crisis responses (namely, up to a 700-percent increase in queues).3 These preliminary findings demonstrate that ARENA simulation can be used as an important methodology in future stages of research.

Figure 3: ARENA Model Simulating Rural EMS Performance

3

For this simulation, which has just been completed, a judgmental sample of case study responses was used. This sample yielded a range of eight to thirty-four incidents per day, with a mean of approximately 14 incidents per day. A crises case was constructed elevating the incidents by one per hour (a 50-700% increase) for a 48-hour period. The model successfully ran under normal versus crises conditions for a 14 day simulation period, with significant differences between normal versus crises queues, such as increases from .1 hour to 1.9 hour in mean dispatch receiving time and from 0.15 hour to 6.18 hour in mean incident clearing time.

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In terms of qualitative responses, several themes emerged from our interviews that are worth mentioning here; these included the management information needs, inter-organizational cooperation dynamics and policy constraints (see also Horan, et al, 2005).  Management Information Needs. It quickly became apparent that the availability of performance data varied considerably and its use was quite ad hoc. The interviews revealed that local field managers need a more dynamic information system that can monitor and guide EMS response. For instance, several interviewees noted that it would be helpful for rural PSAP management to know the number of calls that the PSAP received over a given time period that were managed there or transferred elsewhere. Also, there was little feedback from the FARS data to local managers that would give, for example, the spatial distribution of accidents and fatalities over time. In this sense, there appeared to be a disconnect between information systems coordination and service coordination whereby the former is lagging behind the latter.  Inter-organizational Cooperation Dynamics. The rural PSAP systems are the result of a recent cooperative effort between the Minnesota Department of Transportation and the Minnesota State Patrol for the purposes of sharing resources (buildings, dispatch systems) and creating inter-organizational efficiencies. However, there were interesting cultural and organizational differences between the two collaborating entities. The state patrol tended to be responsible and focus on the time-critical response, while the transportation department took responsibility for non-critical items. However, both noted the absence of a forum for sharing EMS performance information across the full range of organizations involved—that is, not only involving transportation and state patrol, but also emergency response and health care providers.  Policy Issues. Funding and financial constraints are significant prohibitors of enhancing EMS systems. Interview responses highlighted the budgetary constraints confronting the local EMS system and these concerns were also reflected in the recent 2002 Annual Report of the Department of Administration (2003). This report found three financial threats to the Minnesota Statewide 911 program: 1) if the call volume is greater than projected, program funding will be inadequate; 2) the costs of implementing E-911 services are great; and 3) maintaining and improving 911 services is prohibitive due to increasing costs. All interviewees stressed that strategy and vision for financing rural PSAP operations in the long run are needed, especially considering the rate at which technology is changing.

In sum, these quantitative and qualitative data assisted us in better understanding the timeinformation dimensions and organizational and policy contexts inherent in EMS response. Moreover, during the course of conducting this research (including presenting the findings in several national forums), it became clear to us that the topic, and preliminary model, could have national implications and should be expanded accordingly (We have begun to review other applications and these will be discussed in the workshop—see also appendix A). It also became clear that there was a need for greater conceptualization related to time-critical information services, both for EMS specifically and for e-government generally. And, the interplay of technical information flows and more qualitative organizational flows called for a more detailed query into appropriate methodological approaches for investigating this phenomenon.

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PART III: Overall TCIS Framework A. Conceptual Model Our analysis has led us to identify several features that we think are important for understanding end-to-end performance in Time-Critical Information Services. We provide a preliminary conceptual illustration in figure 4. Based on this preliminary analysis there are several components that would enter into a conceptual model for time-critical information services, both in regard to EMS specifically and other public services generally. These components include: 1) the time and information critical elements of the service, 2) inter-organizational linkages that include both qualitative organizational elements as well as “hard” information flow elements, 3) end-to-end elements that consider performance metrics within and across the process flow, and 4) context variation elements such as normal versus peak conditions (in terms of service demand). Such a conceptual model could then inform the empirical examination and these finding would have both scientific and applied implications.

Timecritical service

Incident Report (911 Call)

Incident Information Acquisition

Information Critical Exchange

Information Critical Exchange

Interorganizational System

Organization A

Interorganizational linkages

Dispatch/Call Routing

Organization B

Interorganizational linkages

Response/ Coordination

Information Critical Exchange

Organization C

Interorganizational linkages

Organization D

End-to-end Performance Performance Metric 1

Performance Metric 2

Performance Metric 3

Performance Metric 4

Normal vs. peak conditions END: Incident Resolution/ Reporting

Figure 4. Illustration of TCIS Concepts

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i.

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Time-Criticality

The first concept focuses on the time-criticality of the e-governmental services and improvements therein. In the case of EMS, time is measured in minutes and seconds and these differences can have pronounced impact on the heath condition and survivability. For other services, time matters in terms of weeks and years. For example, in the case of determining disability or eligibility benefits, the time to determination can substantially affect the quality of life for disabled veterans. In short, time matters, even for government services. As illustrated by the top row of figure 3, a point of departure for examining EMS is the linear sequence of events. The “end-to-end” EMS service typically begins with a consumer action (placing the call), involves the private sector (the cellular service provider) delivering the call, the public sector (PSAP or state police) receiving and dispatching the call, the private and/or public sector (an ambulance service or fire/police) providing first response, transport and health care services, and finally, either a public or private sector hospital delivering additional health care services. It is this process that needs to be made efficient. As noted in the introduction, the importance of ‘Just-in-Time’ systems is widely understood across multiple business functions. However, the issue of time is less well understood in the egovernment domain, even though it can be a critical feature of public service. Looking at the private sector, the literature has discussed means for improving the efficiency of processes. One of the most widely used is Business Process Reengineering (BPR) (Davenport, 1993; Lowenthal, 1994; Johansson et. al., 1993). BPR emphasizes redesigning business processes using an IT-enabled approach to organizational and process improvement. This means “…achieving improvements in critical measures of performance, such as cost, quality, service and cycle-time reduction (Hammer and Champy, 1993, p. 32).” Businesses have extended the BPR concept to include a network of organizations, across value chains, to improve business processes with partners, vendors, suppliers, distributors and sales channels. Through these actions, notions such as “just-in-time” (JIT) have become common concepts and frequently practiced approaches in the private sector. ). Perlow’s (1999) research negates much of the “time management” popular press in that it points out how focusing on improving an individual employees use of time can actually decrease effectiveness of the larger group. What is needed, she states, is a new type of “collective time management...that takes into account individuals’ interdependent work patterns, the macro context in which they work, and the interconnections between this context and their work patterns (p. 80). For TCIS, it is ‘end-to-end’ time efficiency that matters. On a more theoretical level, Monge and Contractor (2003) discuss multiple theories that work to shape (improve) organizational structure over time. For example, they discuss the emergence (time-social processes) of networked organizations from the perspective of evolutionary and adaptive behavior. Similarly, Pierson (2001) describes cause and outcome dimensions of time, in a long-term sense, in relation to macro-social processes. Researchers have examined how time influences and shapes individual and group/team development (Gersick, 1988), and how time effects decision processes within organizations (Eisenhardt, 1988). This leads to the notion of how organizations create processes and cultures that recognize and embrace time-criticality

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and improvements therein. That is, it is plausible that organizations can to a greater or lesser extent embrace to concept of ‘time-criticality’ in their processes, procedures and preferences. ii.

Information Exchange

Even in the early days of the 911 system, information was important. Conveying voice information on location and the nature of an emergency proved valuable to response agencies to help prepare for the unique circumstances of each individual emergency incident. As this information becomes digitized, more information can be available to responders. The second concept focuses on dynamics surrounding the exchange and sharing of information throughout the time-critical process. An example from the recent 9/11 Commission Report provides a dramatic lesson on the information critical dimension that is inherent in emergency services. The NYFD had ordered both World Trade Center towers fully evacuated by 8:57 a.m., but these orders were not communicated to 911 operators and dispatchers. For the following hour, these operators and dispatchers continued to advise civilians not to self-evacuate, regardless of whether they were above or below the impact zones. Local 911 operators and dispatchers were also not advised that rooftop rescues had been ruled out. “This failure may have been harmful to civilians on the upper floors of the South Tower who called 911 and were not told that their only evacuation hope was to attempt to descend, not to ascend.” The report continues, “In planning for future disasters, it is important to integrate those taking 911 calls into the emergency response team and to involve them in providing up-to-date information (italics added) assistance to the public (National Commission on Terrorist Attacks, p. 318).” Alas, it is not just time that matters, but effective exchange of information as well. One of the key problems of governmental services is that information travels serially and sequentially, from one processing unit to the next, often with time-consuming feedback loops when incomplete or inaccurate information is detected. In the case of EMS, information mistakes can be tragic, as when an ambulance is unable to find the victim due to inaccurate location information about the scene of the accident. Further, new technologies, such as computer-aided dispatch, can establish technical inter-organizational linkages, but do not ensure a comprehensive linkage between organizations to accommodate the dynamic human response elements inherent in responding to unexpected events (Turoff, 2002). In our research, we found that while the service hand-offs were incrementally improving the time and information flows, what was missing was an integrated “organizational awareness” between organizations on how they were to inter-operate (Horan and Schooley, 2005). The software can only go so far without the “org-ware”—that is, integrating organizational policies across the service (see figure 1, second row from the top). iii.

Inter-organizational Systems (IOS) Performance

Lipman-Blumen (1996) notes that we are in fact heading into a “Connective Era” where organizations thrive to the extent to which they can successfully harness their linkages to crossorganizational resources and talents. These cross-organizational linkages, or inter-organizational networks, have been defined as “any collection of actors that pursue repeated, enduring exchange relations with one another, and at the same time, lack a legitimate organizational authority to arbitrate and resolve disputes that may arise during the exchange (Podolny and Page, 1998, p. 59).” Within this definition, inter-organizational systems (IOS) help to foster relationships

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between independent organizations using information technology (Cash and Konsynski, 1985; Bakos, 1991). A time-critical information service is typically inter-organizational in nature – there is a hand off from one agency to another, or if within an agency, across the functions of an agency. The design of an information system for a service delivery system is as much of an interorganizational phenomenon as it is a technical undertaking. Businesses have extended the aforementioned Business Process Reengineering (BPR) concept to include a network of organizations, across value chains, to improve business processes with partners, vendors, suppliers, distributors and sales channels. Key lessons from two decades of BPR experience however, is that BPR necessitates organizational understanding and change (Hammer, 1997). This private sector concept of the need for organizational change, induced by information technology implementation, has recently been expanded into public sector e-government research (Scholl, 2004). This third concept focuses in on the formal and informal organizational relationships and how the affect and are affected by information exchange strategies. New technologies can be developed and implemented to enhance organizational performance, but raises the question about how well these technologies and system affect the inter-organizational linkages and relationships. For time-critical information services, the total performance is the sine qua non of the operation (see figure 1, third row from the top). For example, it makes little difference for an operator to dispatch quickly if the ambulance takes a very long time to arrive and/or goes to the wrong location. The critical descriptor here is “end-to-end”. Measuring effectiveness across organizations (end-to-end performance) is essential to understanding how public services are delivered to the public, the level of service (timeliness, quality) that they are delivered, and how the network can be improved to deliver better services in an information-critical and time-critical manner. The challenge is how to implement this “end-to-end” concept within and across emergency provider organizations. Our work in this area has made clear that a challenge exists for public agencies to first agree on how to measure performance across agencies and then build performance tracking across new or existing public agency information systems. While information systems are often implemented to address separate silos of a governmental process; the end-to-end nature of time-critical information services facilitates or at least allows for information systems that can report on overall system performance. The real challenge then becomes working across very different organizational cultures—for example, departments of transportation, law enforcement and fire/ambulance response—to achieve a holistic understanding of the total service performance. The concept of “end to end” highlights this aspect of e-government service delivery. iv.

Normal and Extreme Events

It is said that crises define character; in EMS, crises define performance. End-to-end performance is not only a function of system processes but also a function of exogenous occurrences such as storms, natural disasters, or terrorist attacks. Public security and safety (homeland security) under large-scale, catastrophic, extreme events has become a major policy concern. One critical aspect of this enterprise is the ability of first responders (e.g. EMS) to ramp-up rapidly and effectively. Research focused solely on a system’s normal behavior cannot fully characterize the full range of possible system dynamics. Fedorowicz, Gogan, and Ray (2003) explain that an inter-

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organizational “ecology”, or dynamic inter-organizational information sharing system, must examine “punctuating events, processes of co-evolution, and other dynamics that are not often captured in research studies (p. 2782).” Thus, from a research perspective, extreme events provide unique opportunities to examine the systems, including the functioning of cooperative organizations under “extreme accident” conditions, such as system overload or collapse. From a systems performance perspective, dealing with crises or extreme events can be a pivotal test of the overall system management capability (Horan and Sparrow, 2004). As Perrow (2000) proclaimed “…it is no overstatement to suggest that humanity’s future will be shaped by its capacity to anticipate, prepare for, respond to, and, when possible, even prevent extreme events (p. 2).” For this reason, the National Critical Infrastructure Report devotes considerable attention to the use of modeling and simulation of crises events to learn about system performance and response. This final concept calls attention to the need to consider e-governmental services both under normal circumstances and under stressed—or crisis-- circumstances.

B.

Methods of Assessment (Note: Under Development)

Our preliminary research has explored these concepts using several quantitative and qualitative methods. One major aspect of the workshop will be to obtain insight as to how these and related approaches can be used to examine time-critical information services. The TCIS concepts presented above will have value in so far as they can be subjected to empirical examination. Provan and Milward (2001) explain that most of the past inter-organizational network research has been “lacking an examination of the relationship between inter-organizational network structures and activities and measures of effectiveness (p. 414).” The methods to accomplish measuring this goal have traditionally been to assess aggregate outcomes for the population being served, and to examine the costs of the service within a given community (Provan and Milward, 2001). Through the workshop and related research, the research team will explore various methods for examining TCIS, some of which build on preliminary work in Minnesota. The following is a very preliminary listing of promising avenues. i.

Quantitative Measures of End-to-End

There is undeniable value in ascertaining the actual “time-criticality” impact in quantitative terms. For example, we gathered some quantitative data from local case studies to understand the response time of each “leg” of a 9-1-1 response, starting with a 9-1-1 phone call and ending with arrival to a hospital. The Fatality Analysis Reporting System (FARS) is an online source for such data at state and national levels. It is unclear how this data has been utilized to gain a more indepth understanding about the timeliness of emergency services to accident victims. A query into the usefulness of this existing (or related) data would be an important discussion point. Central to this discussion would be insights into how to best account and test for technologies’ contribution to efficiency gains and the consequent impact on public heath. We found simulation to be a promising technique for understanding system performance dynamics (Sterman, 2000). Traditionally, modeling has been used as a technical systems and operations research tool, but it has recently been used to understand more dynamic interorganizational interactions, such as levels of trust, knowledge sharing, and collaboration (Black et. al., 2003). In addition, simulation has been previously used as a methodology for studying EMS systems’ efficiency (Su and Shih, 2003). The ARENA simulation package we have used is

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a robust, visually oriented software system that is well suited to processes such as call centers and emergency medical response (see Kelton, Sadowski, and Sturrock, 2004; Saltzman and Mehrotra, 2001). One challenge with simulation modeling, however, is that the models are highly dependent on assumptions. Moreover, the model doesn’t distinguish between time savings of those accidents that may be life threatening and time-savings of those that may be serious but perhaps not life threatening.

ii.

Qualitative Measures of TCIS

Qualitative measures help to uncover organizational, cultural and human interactions and processes that are otherwise difficult to obtain. Several of the case studies (noted earlier) revealed organizational and policy dimensions to rural EMS. It is worth noting that a current NSF funded research project is taking a multi-disciplinary and multi-method approach to understanding how to integrate and share information in complex multi-organizational government settings. Researchers are collecting data in multiple phases through individual and event observations, interviews, group decision conferences, and document analysis (Dawes, et. al., 2004). One phase includes six field visits to observe ongoing organizational and technology integration initiatives and to interview key actors. These findings could have application to the study of time-critical information services. Agranoff (2003) investigated multiple networks of rural public organizations that worked together to solve common problems. His grounded theory/field study approach included observation and limited participation, guided discussions with public managers, and document analysis. The qualitative methods employed allowed researchers to gain more in-depth understanding from subjects (public managers), including cultural and human interaction dimensions between organizational network actors. For example, researchers were able to understand which “actors really ‘carry’ the network by their knowledge and efforts, and if unequal power is a relevant factor within the network (p.43).” Additional but valuable information was often added, including political and administrative tactics that could not be offered otherwise in a closed-ended questionnaire response. Such qualitative analysis allows researchers to gain a richer understanding about system processes and organizational (e.g. cultural) dimensions to inter-organizational information sharing. In the context of TCIS, this would include organizational norms concerning the use of information systems, inter-organizational tensions or collaboration practices, and macro-level influences from public policy and related budgetary pressures. The research and evaluation methods briefly described above are intended to spark discussion among workshop participants as to the most appropriate (not to mention innovative!) combination of methods that could be used to examine both the technical and organization dimensions of such systems, with an eye toward a achieving a robust understanding of how technology can best be applied to improve service quality and delivery.

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PART IV: Workshop Structure and Questions The TCIS workshop is structured to provide an opportunity for expert (academic and practitioner) input and feedback on the TCIS dimensions outlined above and the best means for understanding their occurrence in on-the-ground services in the EMS area. The first level of discussion will be at the overall conceptual level, for as Shanks, Tansley and Weber (2003), note: “Perhaps the best way IS [Information Systems] professionals can facilitate the validation of conceptual models is to generate high-quality conceptual models at the outset” (p.89). Moreover attributes outlined by these authors, in particular the extent to which it is accurate and complete, in addition to high-level conceptual development with both stakeholder and empirical validation, will be followed in this exploratory examination and workshop.

A.

Conceptual Validity and Refinement (see Agenda (Appendix B))

i.

AM Conceptual Overview and Discussion

The first portion of the workshop will systematically present and discuss the concepts of timecritical information services. A key objective for all participants in the morning will be their reaction to the overall notion of “time-critical information services” and each of the models’ components. Moreover, an important goal of the workshop is to assess the usefulness of alternative methodologies in measuring time-critical information services, such as impacts on time savings. Representatives from case locations will be invited as well to provide a “realitycheck” as to the conceptual and methodological approach(es) devised. Specific questions to be addressed by workshop presenters and attendees during the morning session include:  How clear, valid and useful are the Time-Critical Information Services (TCIS) concepts?  What are the best methods for measuring the quantitative and qualitative dimensions and impacts of TCIS?  What (inter) organizational and policy challenges exist to achieve system/service improvements?

ii.

PM Cases and Their Implications

This section of the workshop will turn to the state of practice for a “grounded” perspective on how time-critical information services are being realized within the context of EMS. Presenters will address both rural and urban perspectives, including the role that technological improvements have played in enhancing performance and related organizational and policy challenges to achieving service improvements. The workshop will provide an opportunity to obtain feedback about on the ground challenges to innovative technology use. Questions to be addressed during this session are:  What insights do ongoing deployments and operational tests have for the concept of timecritical information services?

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Building on the earlier session, these questions will be considered within the context of operational tests and deployments:  What methods have or could be used in conjunction with ongoing or planned deployments to ascertain the impact of IT on the nature, efficiency and effectiveness of services deployed?  What (inter) organizational and policy challenges exist to achieve system/service improvements within the context of regional deployments? iii.

Policy

The final section of the workshop will address TCIS within the policy context, both locally as well as nationally. The moderated discussion is aimed at better understanding the context in which TCIS services operate. Both EMS policy and e-government policy contexts are relevant to this discussion. This session of the workshop will address the question:  How does the concept of TCIS relate to current and emerging EMS and e-government policy trends? Policy plays a critical role in the development and implementation of e-government generally, and EMS specifically. A preliminary review of related e-governmental (and EMS) policy research is underway (see Appendix C) and will be discussed by participants. From this review and discussion of government evaluations and policy reports, we aim to understand the role policy plays in shaping and influencing the design and deployment of TCIS. This analysis will inform the analytical framework to be devised for time-critical e-government services in consideration of the conceptual, methodological, and practical dimensions.

iv.

Conclusion: Focus on Good Science and Societal Impact

In the concluding session final and summative remarks will be made about TCIS attending to two critical dimensions  How can TCIS advance our understanding of e-governmental services and contribute to the well being of citizens? On the first item, the overall intent of the research is to develop a framework that can be used to understand and improve a broad range of time-critical information services. As such, the research aims to better understand the benefits and possible limitations of IT on time-critical governmental processes. The findings are intended to serve a broad range of policy makers and increase general understanding of IT and organizational dynamics associated with time-critical information services. TCIS will be valuable to the extent that it can help explain the processes of EMS from both a technical perspective as well as from an organizational and policy perspective. Moreover, does it fill a gap in our understanding about governmental processes in the digital age? On the second item, contributing to the welfare of citizens is a matter of minimizing the effects of an emergency incident for a citizen. There is no doubt IT is being used to improve collaboration between government agencies, but does the service work at a moment’s notice when an accident victim’s life depends upon it? Indeed, the immediate focus of the research is to help EMS responders and agencies improve their services in order to reduce emergency response time, reduce disability consequences, and save lives. TCIS will be valuable to the extent that it can be

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applied to make a difference. What information or information systems can demonstrably impact public safety and societal welfare in general?

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National Emergency Number Association (NENA). (2001). Report card to the Nation: The effectiveness, accessibility and future of America's 9-1-1 service. Columbus, Ohio: The RCN Commission and National Emergency Number Association. National Highway Traffic Safety Administration (NHTSA) and Department of Health and Human Services. (2001). National EMS Research Agenda. December 31. Retrieved from http://www.nhtsa.gov/people/injury/ems/ems-agenda/EMSResearchAgenda.pdf National Highway Traffic Safety Administration (NHTSA) and National Association of EMS Physicians. (2004). National Research Agenda: Emergency Medical Services. Final Publication of the Research Symposium "National EMS Research Agenda," Washington D.C., June 3-4. Retrieved on Feb. 28, 2004 at: http://www.naemsp.org/researchagenda/DownloadPDF2.asp Podolny, J.M., & Page, K.L. (1998). Network Forms of Organization. Annual Review of Sociology, 24(1), 57-77. Perlow, L. (1999). The Time Famine: Towards a Sociology of Work Time. Administrative Science Quarterly, 44, 57-81. Perrow, C. (2000). Extreme Events: A Framework for Organizing, Integrating and Ensuring thePublic Value of Research, Paper prepared for Extreme Events: Developing a Research Agenda for the 21st Century, Boulder, CO., July 7-9. Pierson, P. (2003). Big, Slow-Moving, and . . . Invisible: Macro-Social Processes in the Study of Comparative Politics. In Mahoney, J. and Rueschemeyer, D. eds., Comparative-Historical Analysis in the Social Sciences. New York and Cambridge: Cambridge University Press. Potter, J., Miller, L., Dubrueler, , E, and Dubreuler, A. (2004). Interoperability Now: Integrating Emergency Communication and Information – A Virginia Case Study. Topics in Emergency Medicine, June. Potts, J. (2000, Summer). Wireless phone calls to 911: Steps toward a more effective system. Currents. Provan, K. G., & Milward, H. B. (2001). Do Networks Really Work? A Framework for Evaluating Public-Sector Organizational Networks. Public Administration Review, 61(4), 414423. Saltzman, R., Mehrotra, V. (2001). A Call Center Uses Simulation to Drive Strategic Change. Interfaces, 31(3), 87–101. Scholl, H. (2004). Current Practices in E-Government-induced Business Process Change (BPC). Presented at the National Science Foundation Digital Government Program Annual Meeting. Retrieved from: http://dgrc.org/dgo2004/disc/presentations/egov/scholl.pdf Shanks, G., Tansley, E., Weber, R. (2003). Using Ontology to Validate Conceptual Models. Communications of the Association for Computing Machinery, 46(10), 85-

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Sussman, J. M. (2002). Representing the transportation/environmental system in Mexico City as a CLIOS. Paper presented at the 5th Annual US-Mexico Workshop on Air Quality, Ixtapan de la Sal, Mexico. Sterman, J. (2000). Business Dynamics: Systems Thinking and Modeling for a Complex World: McGraw-Hill/Irwin. Su, S., Shih, C. (2003). Modeling an Emergency Medical Services System Using Computer Simulation. International Journal of Medical Informatics, 72, 57-72. Turoff, M., Chumer, M., Van de Walle, B., Yao, X. (2004). The Design of a Dynamic Emergency Response Management Information System (DERMIS). Journal of Information Technology Theory and Application, accepted 12/25/03 and forthcoming. Turoff, M., (2002). Past and Future Emergency Response Information Systems. Communications of the ACM, 45(4), pp. 29-32. .

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Appendix A Related Case Applications (Note: Under Development) Rural Application: Shenandoah Valley, VA In addition to our own research, there are a variety of innovative projects underway or in development across the country, for example, rural EMS agencies and other emergency response organizations in five counties of the Shenandoah Valley, plus the City of Winchester, launched an information technology test project three years ago. This test project, the Virginia E-Safety Network, utilizes distributed computing technologies (web services) to connect these agencies to each other and to external sources of emergency information. It aggregates emergency incident data into a centralized repository for any and all participating EMS agency/organizations to utilize for immediate (real-time) and long-term decision-making. This time-critical information system is based on open, non-proprietary technical standards in order to facilitate technical interoperability between systems and agencies and to encourage the development of new applications by private companies competing for a national market. As such, it addresses the time-critical aspect of the service. For example, a series of notification services selectively “push” new alerts to pre-identified and pre-authorized recipients on the basis of geospatial and other message content through an Intelligent Message Broker (IMB). The IMB integrates GIS data about an incident with these message alerts and sends them to users (Public Safety Answering Points, emergency responders) and associated applications. The IMB tracks the emergency response and facilitates real-time information exchange between response agencies and organizations. A system that has for many years been completely reliant upon serially transmitting emergency information using voice now has the capability to transfer data to and from multiple organizations dynamically. In addition to enhancing the timeliness of transmitting key information, the system also supports inter-organizational collaboration and information sharing. This is organized through a shared registry of emergency response and associated agencies and organizations called the Emergency Provider Access Directory (EPAD). This is a set of linked directories containing contact information for local emergency responders, such as hospitals and law enforcement, as well as telephone carriers and telematics providers. Of course, the development and use of this EPAD directory hinges on inter-organizational participation and in this case there is active cooperation in producing and maintaining the information. Moreover, the system consists of a suite of tabulation and analysis services for the generation of historical, statistical and forensic reports to better understand how the “end-to-end” system is performing. This is of particular interest for policy and management decision-making to improve the performance of the entire system during normal and peak periods. This provides a unique opportunity to research how this leading edge, highly researched, and publicized technology will affect inter-organizational cooperation between EMS organizations and how it may change inter-organizational effectiveness (performance). Future of Rural EMS In addition to the work in Minnesota and Virginia, the have been a number of studies on the future of Rural EMS and the role of technology therein. These cases include several applications in New England, such as in Maine. A recent study of the future of rural and frontier EMS noted that the information infrastructure in these regions is aging and that there is a pressing need to

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develop more integrated systems appropriated scaled to the needs for rural and frontier areas (McGinnis, 2004). Urban Application: San Mateo County, CA A second example can be found in a recent public/private partnership formed to provide emergency medical services to the citizens of San Mateo County. The partnership was formed between American Medical Response (AMR) ambulances, the fire service agencies in San Mateo County, and the County Health Services Department’s EMS office. The new system includes a single consolidated dispatch center that performs all dispatch services for fire departments within the County as well as for the ambulances. The system dispatches the closest fire engine and ambulance to every medical incident regardless of local fire agency boundaries. The system features a single e-patient record per patient that includes data from computer-aided dispatch (CAD), first responders, ambulance services, as well as the emergency department. First responders and ambulances utilize laptops and in vehicle PC’s to transmit data through wireless connections. The partnership has standardized such functions as training, communication protocols, quality improvement, equipment, supplies, and record keeping across organizations. Since deployment, emergency response times have diminished by approximately two minutes.

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Appendix B Date: Friday, April 1, 2005 Location: National Center for Digital Government John F. Kennedy School of Government Harvard University Taubman Room 401 DRAFT AGENDA 8:15 – 8:30am: Breakfast and Coffee 8:30 – 10:00am: Conceptual Framework Similar to Just-in-Time (JIT) concepts in the private sector, timeliness can have a significant impact on governmental service performance and general public welfare. Closely linked to this timing issue is the time-availability of information. In this opening session, a framework will be presented for considering time-critical information services generally and within the context of Emergency Medical Services (EMS), followed by discussant perspectives and roundtable discussion. Presenter: Thomas Horan, Associate Professor, Claremont Graduate University, Workshop Chair Discussants: Jane Fountain, Director, National Center for Digital Governance, Harvard University Joe Sussman, Professor, Engineering Systems, Massachusetts Institute of Technology Open Discussion 10:00 – 10:15am: Break 10:15 – 11:45am: Methods and Impacts The advent of electronic means for improving time-critical information services promises gains in efficiency and effectiveness, yet it remains a major research challenge to identify appropriate metrics for detecting technical and organizational improvements. The second session will feature a presentation about expected technological gains, followed by a discussion of organizational and performance metrics for detecting service changes. Presenter: David Aylward, Director, ComCare Alliance Discussant: M. Lynne Markus, Professor, Bentley College Open Discussion 11:45 – 1:15pm: Lunch (Provided)

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1:15 – 3:00pm: Applications The third session will turn to the state of practice for a “grounded” perspective on how timecritical information services are being realized within the context of EMS. Presenters will address both rural and urban perspectives, including the role that technological improvements have played in enhancing performance and related organizational and policy challenges to achieving service improvements. Presenters: Kevin McGinnis, Rural EMS Expert, Maine Barbara Pletz, EMS Director, California Bradley Estochen, ITS Project Manager, Minnesota Open Discussion 3:00– 3:15pm: Break 3:15 – 4:10pm: Research Needs and Policy Implications This fourth session will consist of an interactive discussion among workshop participants focusing on the research and policy directions suggested by prior case and research presentations and discussions. The focus will be on critical research needs and policy implications for both improving EMS services specifically, as well as enhancing the efficiency and effectiveness of time-critical e-governmental services generally. Moderator: Lee Munnich, Director, State and Local Policy Program, University of Minnesota Open Discussion 4:10 – 4:30pm: Concluding Comments In this closing session, workshop conveners will summarize suggestions for refining the analytical and empirical dimensions of time-critical information services approach to egovernment. Moderator: Thomas Horan, Associate Professor, Claremont Graduate University Closing Comments

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Appendix C E-Government and EMS Policy Research: (Note: Under Development) At the national level there are a plethora of related reports from agencies such as the National Emergency Number Association (NENA) (2001), the NHTSA and the National Association of EMS Physicians (2004). A current example is The Leadership Forum on Performance Measures in EMS, sponsored by the Emergency Medical Services Division of the National Highway Traffic Safety Administration (NHTSA), in cooperation with the Health Resources and Services Administration (HRSA) ((NASEMSD, 2002). This forum found a need to pursue a National EMS Performance Measurement initiative to clarify and develop performance measures and to define an adequate level of EMS service and preparedness for a given community. Another example includes an NSF funded workshop titled “Responding to the Unexpected”, which made recommendations and priorities for emergency response system improvement for areas such as organizational response, support and integration, policy, jurisdiction and regulation, and information management (Arens and Rosenbloom, 2002). There are also several projects underway to create standards for data sharing across EMS agencies, such as the National Emergency Alerting and Response System (NEARS). The NEARS Project Launch is on March 30, 2005, and will highlight the projects’ effort to demonstrate and deploy interoperable emergency data messaging, using national emergency message and data standards, commercial information technologies, and a shared, electronic directory of agencies such as the Emergency Provider Access Directory (EPAD). This directory gives agencies the ability to distribute emergency messages based on geography, incident or agency type, for all types of emergency events. The Institute of Medicine has a study underway on the Future of Emergency Medicine4.The objectives of the study are to: (1) examine the emergency care system in the U.S.; (2) explore its strengths, limitations, and future challenges; (3) describe a desired vision of the emergency care system; and (4) recommend strategies required to achieve that vision. A wide range of research issues include organizational and technological needs for the evolving role of the emergency response and care system. Policy Analysis at a more general level also informs our understanding of TCIS. Atkinson (2003) describes the importance of an information technology oriented approach to restructuring bureaucracies, where performance is measured to increase agency accountability. Such an approach, explains Atkinson, will reinvent government agencies and how they deliver services to the public. He goes on to explain that we are far from such an “information driven network governance” as illustrated by Dale Hatfield’s (2002) testimony to the FCC about the challenges associated with FCC E-911 policy. He states: “…while various entities have responsibility for parts of the system, there is no entity charged with examining how the parts fit together and how they might be redesigned or reconfigured to improve end-toend performance or reduce the overall costs of meeting the requirements spelled out in the Commission’s [FCC] rules. Likewise, there is no single entity charged with carrying out the systems engineering studies necessary to develop the means to accommodate changing technology and changing requirements at minimal overall cost (p. 22).”

4

The National Academies Institute of Medicine project description on The Future of Emergency Medicine can be found at http://www.iom.edu/subpage.asp?id=17962

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As such, Hatfield’s recommendations to the FCC centered on creating policies to support crossorganizational collaboration, share information more readily between organizations, and increase agency accountability to support E-911 deployment.

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