The three-day conference included a Tuesday golf tournament and all-day classes in PSAP administration and management, and two days of educational sessions and presentations by a diverse group of dispatchers, agencies and government departments. The conference also included a trade show by 35 companies who market public safety products for emergency communications. The weather was slightly cloudy for the event, but temperatures were very friendly--in the lower 70s, even as the northeast portion of the nation was swept by a snowstorm.
The conference also served as a formal "Good-bye" to Leah Senitte, the long-time director of California's 911 program--she has served 16 years as 911 director and 32 in government service. There was a last-night banquet that brought all the attendees together and honored Senitte for her role in pushing 911 along the rocky road from implementation to today's wireless era.
The conference highlights included:
The Wednesday session kicked off with a
buffet of fruit, sausage-egg biscuits and juice in Ballroom A of the convention
center--which is a very bright and airy place. At 8 a.m. the general session
was hosted by Jackie Nostaja, president of the California chapter. She made
several introductions, including NENA national officers who were attending,
CAL-NENA officers and several others.
Nostaja was somewhat downbeat as she described the association and chapter's activities with 911 during the past year. She said the started out well, but that wireless 911 was "put on the back burner" in 1999. She added that, "We weren't really successful" in reaching the association's goals.
Hinkle echoed Nostaja's remarks, saying there had been disappointments during the year. He said the passage of Senate Bill 800 was a positive step in moving 911 forward. "That was received and welcomed by, I think, both public safety and commercial members, and the telephone industry alike." But he quickly added that there were some legislative issues, "that we weren't quite as happy or satisfied with."
He said it became an emotional issue for him. "Because I'm a long-time member of APCO, and it was really disheartening and disappointing that on important national issues that means so much to us in public safety, that we weren't able to achieve consensus, and we really ended up going to the FCC with mixed messages." He explained that, "It really kind of, really did our industry a disservice," because it allowed companies to chose sides. "Public safety didn't end up speaking with one voice."
He told the group that he was not being "condescending" about APCO's position on wireless 911. "But I think it's important for you to understand NENA's position," Hinkle said. In 1996, APCO, NENA, the Cellular Telephone Industry Association (CTIA) and the National Association of State 911 Directors (NASNA) reached a consensus agreement on wireless 911. "We all agreed on what that language looked like. We all agreed that it was what we believed to be in the best interest of public safety. And just as importantly, or more importantly, we believed it was in the best interest of the public's safety."
However, Hinkle said, "This agreement started to unravel," first over uninitialized telephones. NENA had a vision of how unsubscribed telephones would impact PSAPs, particularly the heavily-advertised Magnavox phones that are, "strictly to provide access to public safety, and we don't even have the benefit of the opportunity to call back that party if that number is lost."
Hinkle said he hated to think of think of the problems that will arise when dispatchers try to track down unsubscribed telephones under Phase II, or even to obtain a telephone number to call the person back. "So we disagreed with APCO on that particular position, and we thought that every call should be required to have access to a subscriber database," so the caller could be identified. "We lost that issue," he said.
Waiver Requests
The next issue before the FCC was waiver requests from carriers who wanted to use a handset solution for Phase II requirements. "I think it's important to allay some misconceptions about NENA's position on that," Hinkle said. NENA never promoted a network solution, he said. "We were simply suggesting that the rules and orders shouldn't be changed to accommodate a particular kind of technology. We felt competitive interests should steer that issue," Hinkle said. "And we felt the public's interest shouldn't be compromised by delaying implementation of the rules and orders that would require the deployment of location technology."
Initially, APCO supported NENA's position on this issue, Hinkle said. Then three months later, APCO changed their position and filed in support of a waiver. Hinkle said he spoke to people within APCO, and they asked, "How many PSAPs do I really believe would have deployed location technology by 2001?" Hinkle said he doesn't know how many will be deployed, but, "But what if only one did, and what if we save only one life? Would it have been worth the investment? I think it would be. Because, you see NENA is all about saving lives. It is our mission. That is what we are all here for."
So NENA's board lobbied with the FCC on the waiver issue, "and we took the very, very strong position that when it comes to the public's safety, NENA doesn't waiver."
Hinkle then announced a rather dramatic step that NENA is taking to
reinforce it's feelings on the issue of wireless 911. "In order to
further demonstrate our decision to hold everyone that was part of this
decision to award waivers accountable for the lives that may be lost in
this country while technology interests are working out their most cost-effective
solutions, NENA has decided that we are going to create a national clearinghouse."
Hinkle explained, "We are going to document every case in this country
where a life is lost because we weren't able to do our job, because we didn't
have the tools to find people and save lives." He said NENA has every
reason to believe that more waiver requests are going to be filed, and the
industry is going to ask for more time to develop more cost-effective solutions.
"That was enough, we thought," Hinkle told the CAL-NENA meeting. But then in August, 1999 APCO filed "yet another petition," this time in support of taking all of the cost recovery language out of the FCC's regulations. "NENA, CTIA and NASNA, three of the original four signers of the consent agreement, felt that this was a bad decision, and would not support it." Because it was a hot topic, and NENA was looking to build a consensus on the issue, NENA surveyed chapter presidents, and asked for input from the chapter members. NENA also looked at all the comments filed with the FCC, and found 23 from commercial and public safety interests--none of them supported removal of the cost recovery provisions, and some even supported the provisions. "So we were stymied," Hinkle said. "We thought, whose interest is being represented here? Well, this is clearly a state interest, and not one state had asked for that language to be removed."
NENA, CTIA and NASNA went to Washington and "spent a great deal of time and a great deal of money lobbying." They met with all of the FCC commissioners and FCC chair William Kennard, all to salvage the language. However, the cost-recovery rules were taken out.
"We are trying to find new opportunities, and we are going to renew our effort to create a forum of discussion with APCO that will prevent us in the future from ever going to the FCC divided on important issues that are in all of our collective interests," Hinkle said. The association is going to begin that process, Hinkle said, "by attempting to meet with the APCO board at our Technical Development Conference in March, so we can renew our commitment to doing what's in the public's interest and reaching consensus on these important issues."
New Programs
Hinkle then turned to several new programs that NENA has kicked off. He mentioned the Web-based NENA store that sells log merchandise. He added, "We're going to be embarking on one of the most ambitious projects that NENA has ever undertaken, and that is our Report Card to the Nation." Hinkle explained that there are many challenges and issues facing the public safety issues, and impacting on the ability to provide services to the public. "We are going to look at the availability, the reliability, and the future of 911 in America." He said the association has an opportunity to make the report to the Congress, and they hope to make that report on September 11th this year, corresponding to National 911 Day. It will be an on-going process, he said, and will bring together the technology issues facing 911.
Hinkle then rattled off a long list of the issues that will be included in the Report Card:
Hinkle quipped, "Can you imagine the first defense attorney that's going to be defending a client whose airbag called the police, and he was arrested for DUI when he hit that tree?"
To address some of these issues, Hinkle said NENA will periodically hold Critical Issue Forums, including one in February in Los Angeles on PBX and EMS issues. On the latter issue, "It evokes a great deal of passion from me," Hinkle said. He said NENA sees 911 as a national asset, and that the public has certain expectations about 911 service. "I think fundamental to those expectations is every American's right to decide when they have an emergency, and not have to confer with their health insurance provider to determine whether they have a life threatening emergency." He added, "We want to make sure that NENA is involved in preserving that right."
Another new program will be adoption of California's National 911 Day program to the rest of the nation, "and make this a real national event, in recognition of the wonderful work and contributions that our telecommunicators make every day to the public safety."
NENA will introduce a Best Practices program, taking the best policies, procedures and methods from agencies around the country, and make them available to any other agency. Hinkle said the topics will include grant writing and personnel issues.
NENA will develop a lecture series, using teleconferencing and Web sites to bring instructors and students together. "We're going to provide more timely information," Hinkle said.
Lastly, he said NENA will hold their first World Congress, concurrently with the association's annual conference in Salt Lake City. "NENA has received a great many inquiries from countries from all around the world," Hinkle said, including eastern European countries. "But this is important if we want to be there to represent our commercial member interests, and their technologies that they're trying to offer these European countries as they're trying to develop their public safety communications systems."
Hinkle concluded, "We're working very hard to represent your interests...to meet the challenges of 911 in America."
Director's View
Next to the podium was NENA Executive Director W. Mark Adams. He said Y2K issues and inquiries from the press dominated much of the association's activities during 1999. "We worked very hard to tell your story to the national press, and let everyone know that we would be OK." Looking ahead, he hoped that NENA members would participate more in national issues, and foresees that NENA will have a higher profile among the national press in the years to come.
"In the future, I think our biggest challenge as NENA from a national office and as an organization will be to serve your interests on two very distinct and different trends," Adams said. "We have to customize our inputs and our products and services to you, in an every more-fractionalized way." He said there are different issues in counties, states and local agencies across the nation. "And unless we meet those customized issues head on, we won't be relevant."
At the same time, Adams said, there are more outside forces exerting influence on 911. "We have more global challenges from the 911 community than ever," he said, and so will also be trying to broaden its representation to reach the Congress and other agencies that influence 911.
Adams thanked William Hinkle for all the work that he's done during the past seven months. "I'm sure Bill would tell you it's the busiest year of his life," Adams said. He encouraged members to visit the association's Web site, and added, "We want to become your partner on a daily basis to do your job. It's a real simple mission that we have electronically." Over the next six months to two years, NENA wants to remake the Web site as a place to find resources and as a way to connect to peers across the state.
Attorney General
Past CAL-NENA president Bill McMurray then introduced California's Attorney
General, Bill Lockyer, a supporter of the 911 for Kids education program,
and the 
Local Heroes recognition program.
He thanked the audience for electing him, and said he is having "fun"
every day meeting the challenges of the job. He said one of the fun activities
was throwing out the first pitch during a National 911 Day baseball game.
Lockyer said he consulted the governor before the game, who told him not
to throw the ball in the dirt, or he'd risk embarrassment. Lockyer admits
that he practiced throwing a baseball, and luckily it reached the catcher.
Lockyer said public safety is broadly comprised of employment, education, health care and community policing. He said the public safety dispatching fits into both the health care and community policing concepts. "When the systems are universal and functioning, and people are trained...we will have much speedier responses to health crises, and much speedier to some crime in progress."
Lockyer, who spent several years in the state legislature, said he read and voted on hundreds of bills that were introduced to add or change criminal laws or penalties. But criminals, "don't think they're going to get caught." So, he said, "It's the likelihood of apprehension that makes a big difference, and that means response times that are quicker, so that we're more likely to catch burglars."
Lockyer told the crowd, "I don't know how often someone who represents 34 million Californians says, 'Thank you for your interest and efforts.' But that's my principle point in being here is to thank you and acknowledge the importance of what you're doing, and to have you keep on doing it."
Lockyer then called 7 year-old Zachary Harris on
stage to receive a Local Hero Award. Harris wore a T-shirt that read, "Zachary,
You Are Our Hero!" Lockyer than interviewed Harris about the incident
on Christmas Day, when his father fell ill. His school teachers trained
him how and when to dial 911, Harris said. "You know, we're very proud
of you," Lockyer told the boy. "You did a great job. We think
you're a hero." Harris said, "Thank you."
Lockyer then stepped to the middle of the stage to welcome Redlands Police dispatcher Anita Doitcher, Redlands Fire Department dispatcher Linda Luna, who fielded and handled Harris' call. Both dispatchers received a certificate from Lockyer, and he presented Harris with a Special Agent's badge--as he did so, Harris reached for Lockyer's own badge hanging on his suit coat pocket. The audience chuckled and Lockyer told him, "I work for the government...I have a plastic one." Lastly, Harris received a gold-colored medal from the 911 For Kids program.
Outside the ballroom after the meeting, Harris faced six or seven TV cameras and reporters, and answered their questions. As the interviews wrapped up, he snapped, "When's this going to be on TV?" The reporters laughed and told him to watch the 5, 6 and 11 p.m. newscasts.
What's the EMS Fuss?
During the conference, there were identical sessions on both days on issues surrounding EMS access management. The panel sessions were hosted by Denis Jackson of AMR, Bob Eisenman, Ph.D. of Kaiser, Carol Biancalana of California's EMS Agency, Jeff Clet of the San Jose Fire Dept., and Jeff Fehlberg, Director of Heartland Fire Communications (El Cajon).
As an introduction, it's a well-known fact that emergency rooms have become the source of routine medical care for millions of American's who don't have medical insurance. Instead of calling or seeing their personal physician for an ear ache or other non-emergency problem, people stream to hospital emergency rooms, and sometimes wait for hours to be seen. Over the years, this use of the emergency room has grown to abuse, creating longer wait times for emergency patients, and straining the equipment, staffing and other resources that hospitals can provide.
The same type of problem has affected the emergency ambulance services. Previously, an ambulance was designed and intended to provide quick transportation to a hospital for persons whose life was at risk. Today, a large percentage of responses involve non-emergencies or, in some cases, conditions that require no trip to the hospital at all. Some jurisdictions report "true" emergency transport rates of less than 20 percent.
Without oversimplifying the situation, this abuse of the transportation system has caused medical care providers to seek alternate methods of handling these non-emergency callers. Of course, money is one motivation--emergency care is more expensive to provide than non-emergency care. But even beyond that, medical providers are motivated by a need to conserve expensive or complex resources (testing and diagnostic gear) for those who really need it. For example, why not fly everyone to the hospital in a helicopter? Well, besides being expensive, you want to reserve that helicopter for the patient who really, really needs it.
The dilemma, up to this point, has been that medical care providers have no control over the entry point of their patients. That is, citizens dial 911, the ambulance shows up, and the patient arrives at the hospital. There is no method for providers to intervene in the calling process, to thoroughly assess the patient's condition (triage), and to offer alternative, non-emergency treatments or transportation (taxi, bus, friend, paratransit, etc.).
It's this particular point in the process--the 911 requesting medical help--that has generated a controversy. We'll let the participants of the EMS forum recount their own positions. In short, however, Kaiser Permanente, a non-profit organization that provides medical care to millions of people, contracted with AMR to provide a centralized dispatch point in Wisconsin for their inter-hospital, non-emergency transports. That set off a wave of speculation that Kaiser would try to interject itself into the 911 call process, knocking PSAPs off the line, and all, some critics complained, to save a few dollars.
Now, many agencies already triage their medical 911 calls, and the emergency medical dispatch (EMD) process facilitates the process by providing standardized questions for the dispatcher to ask. But there is still a great deal of room for local agencies to improve call-taking for medical incidents, to ensure that the appropriate assistance is dispatched.
California's View
The state of California's EMS agency formed a Vision 2000 program to study various aspects of emergency medicine. The program met late last year and came up with 66 objectives, which were then farmed out to one of six committees for work. One of those committees is studying access, including the broad issue of how medical incidents are initially received, triaged, dispatched and transported.
The Access committee ended up with eight objectives, which Jeff Clet, member of the Access Committee discussed during the forum. Four of the objectives are being actively investigated, and Clet shared draft statements for each objective:
The first objective is insuring that access to EMS for perceived emergencies should be via 911. Clet said this was the number one priority, and could be called "universal access," although a true definition of the term is still being created. So far, it means that it should be a free, local call for anyone who needs medical help, and there should be no language or socio-economic background barriers. "We feel that 911 should be the backbone and should be available state-wide," Clet said.
Second, 911 systems should use EMD principles as the core element of universal access.
Third, alternate or non-911 access systems should be linked with 911 universal access. The committee felt that non-911 systems should not be created, but if they already exist, they should somehow link to 911. "Whether the technology exists, we'll have to do further research on that," he said.
Fourth, 911 universal access systems should incorporate access management systems or principles into PSAPs or EMD dispatch centers that are capable of:
-- stratifying or prioritizing calls for medical needs (triage)
-- developing processes to allow appropriate medical responses (first-responder only, ambulance only, both, etc.)
-- develop alternate dispositions or destination policies (no response, non-emergency response, to hospital or clinic or ??),
Long Process
Carol Biancalana, communications coordinator of the state's EMD Authority and co-chair of the Access Committed, explained that the Vision 2000 program is designed to be a three-year process. It started in 1997 with a grant from the National Highway Transportation Safety Administration to review the state's emergency medical services. Phase I involved studying was the system was, and coming up with areas for improvement. The process is now in Phase II, Biancalana explained, during which the committees will further refine their goals and focus on implementing them.
The most interesting discussion about the issue of access came from Bob Eisenman of Kaiser Permanente. He said he was there to give a health care perspective, but his organization was largely just an example of all the medical providers out there. He said said the main issue was how to deal with non-emergencies that originate from the 911 system. Eisenman said he's been with Kaiser for 18 years and worked as an EMS administrator before that.
"The thing to establish right off the bat is that everybody in health care supports 911," Eisenman said. "To call 911 in case of an emergency...there's no question about that. That's really the emphasis and the backbone of the system and what everyone is doing, and wants to do." In fact, if you call Kaiser and reach a recording, it tells you to dial 911 if you have an emergency. As well, the companies Southern California brochures tell the caller to dial 911 for emergencies. When someone joins a Kaiser health plan, their "welcome" literature includes a notation to dial 911 for emergencies. Eisenman did admit that Southern California membership cards had an 800 number on the back that members might find confusing. Kaiser is changing the card format and sending out stickers for current card holders.
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Jeff Clet (San Jose FD), Jeff Fehlberg (Heartland Fire Comm's) |
Clearly there's been a lot of public education about 911 and how to use it. "It's what health plans advertise," he said. "I know there's been some confusion about this," he admitted. "There was some incorrect media...that Kaiser went through a couple of months ago on a national level. The allegation was is that we were either had, or were planning to establish a separate number that would go around and compete with the 911 system." Eisenman emphatically added, "That's just not true. That's not what we're doing and we have no intention to do that, that's not the plan."
He said that payment for emergency services is based on "prudent lay-person standards." So, "If a reasonable person thinks it's a medical emergency, we pay for that emergency department or ambulance bill."
He said another confusion arose from a contract Kaiser has with AMR. "That's really not about 911 at all. It's about non-911 or inter-facility transports," Eisenman said, those situations when Kaiser staff requests the movement of patients between Kaiser facilities. "It's really to have AMR on a national level manage that business for us, and through a third-party administrator, manage the payment of bills, that piece of it. But it really does not affect 911 at all."
The main question for everyone about 911 is, "How's it working? How well is it working?" Unfortunately, he said, no one in the state has a lot of "great data" on how medical emergencies are being handled. Although there is individual data from separate sources, but there is no state-wide source. Even so, Eisenman concluded that, "It's working pretty well for true medical emergencies."
A by-product of the current emergency medical system, he said, "is there are high number of cases that are not true emergencies." He said that pervades the entire system, from taking the initial call, to dispatching, to transporting and treatment at a hospital. He said many communities don't have flexibility for handling medical incidents, and the patients almost always end up at a hospital.
"The next question is, does that matter? Is that important that we have that, in essence, over response, over triage, more going into the system than necessary, or not?" He said ultimately it's a social question of whether it makes sense to continue providing EMS this way, or devise some other method. "What it does produce is a sort of inefficient use of resources, unnecessary and inefficient use of resources, all up and down the line," Eisenman said. "It ties up emergency resources," he said, that means more staffing at hospitals and leads to frustration by patients who have to wait for hours in the ER. It also wears on first-responders and their equipment.
Unnecessary Runs
"There's not really good data to show that this is producing any value in society or in the system," Eisenman said. In this case, "value" means, "Are we ending up with better outcomes because of doing this kind of high-level response?" Eisenman said there is no state-wide data. Nonetheless, "It does get people to the hospital, but it's not so clear that that's the most effective, most efficient and best way to do it." He added, "And then, obviously, it's more costly." Even for non-profit Kaiser, increased costs are passed along in the form of a higher medical plan cost. For governments, the cost could mean higher tax rates.
What's being considered, Eisenman said, are:
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this page updated 2-16-2000