Save Lives: The Application of Geographical Location-awareness Service in Iranian Pre-hospital EMS Information Management System (Preprint)
Authors: Abedian Somayeh , Abedian Somayeh 
Published: August 2021

BACKGROUND

For emergency and relief service providers such as pre-hospital emergencies, getting to the scene of an accident or any EMS mission quickly is one of the most important needs for effective service delivery. Response time (an interval as the elapsed time from the time of the call to the time of arrival on scene) is a critical factor to determine the quality of pre-hospital Emergency Medical Services(EMS) [1]. This is especially important for patients who have faced a heart attack, stroke, or accident [2]. Location-based e-services can be broadly defined as any service that provides information pertinent to the current location of an active mobile handset or precise address a place from landline phone calls at a specific window of time, regardless of the underlying delivery technology used to convey its information [3]. According to the researches, one of the effective methods to meet this goal is to determine the location of the caller with the cooperation of landline and mobile phone operators in the country. The follow-up of the Communications Regulatory Authority (CRA) organization has resulted in the receipt of two separate secured electronic web services. Thus, based on the importance of human privacy protection, design a secured technical architecture for launching the services in the pre-hospital EMS information management system was required. In addition, because of the importance of accelerating the arrival at the patient's bedside, the use of an intelligent transportation system in rescue vehicles to estimate road traffic using mobile data based on GPS navigation and independent of the internet was required. This paper seeks to illustrate the architecture of the practical national model used at the Iranian EMS organization.

OBJECTIVE

HIGHLIGHTS:
•	Response time (an interval as the elapsed time from the time of the call to the time of arrival on scene) is a critical factor to determine the quality of pre-hospital Emergency Medical Services(EMS)
•	Location-based e-services can be broadly defined as any service that provides information pertinent to the current location of an active mobile handset or precise address a place from landline phone calls at a specific window of time
•	In this paper, we applied one of main methods to determine the location of the EMS caller with the cooperation of landline and mobile phone operators in the country
•	based on the importance of human privacy protection, design a secured technical architecture for launching the services in the pre-hospital EMS information management system was required
•	Significant results were found and, response time means that interval from relief call to reach of patient bedside was reduced between 3 and 8 minutes.

METHODS

Iranian pre-hospital Information management system(EMSIS) is a decentralized system that is installed in more than 64 EMS centers in the country with separate data centers and hardware equipment (one sample of software in every university of medical science). On the other hand, consideration of a person's location privacy is led to design one secure technical architecture for GLI services launching in EMSIS. In addition, inter-organizational services in Iran are based on e-government infrastructure that is locally called Global/National Service Bus(GSB) are classified into 14 groups consist of e-health clusters. The GLISs should be present in the technical framework of the e-health cluster that is a committed platform consist of IP, servers, databases, and monitoring dashboards as an integrated API gateway [9] for Iranian health information exchange that is locally called DITAS or HIX (Health Information Exchange center).
The steps of the project implementation in the decentralized Iranian EMS Information Management System(EMSIS) are explained in the following:
2.1	Technical designing

With the purpose of access to the location of the emergency call from a mobile phone, one of the methods in LBS is Hazel positioning, which is Hazel due to the delay (Time Difference of Arrival or TDA) between receiving a signal from two masts from the same source (phone) and calculating the distance of each of them from the signal source. With three masts, the X (length) and Y (latitude) geographical coordinates of the phone, and with the fourth mast, its Z (height) coordinates are also obtained [6]. Due to numerous masts, the more accurate coordinates found will be got. Indeed, these calculations and raw information are done before tracking by mobile network operators. Finally, the caller location based on the model has between 60 and 300 meters' distance difference.
The LBS services use a Base Transceiver Station (BTS) to identify a mobile device location in aid of radio technology. For this goal, have to pass three steps: The first is to retrieve the signal strength values from the related BTS [7]. The second step involves approximating the distances from the corresponding BTS with the help of the received signal strength, and the final step is geo-coding which involves finding the actual geographic location of the mobile device.
Furthermore, the geographical location of a call from the landline phone numbers is determined by the CRA organization with the address.
These results are delivered only at the request of judicial authorities or security forces; the people and public organizations do not have access to this information. Thus, access to these top-secret data is provided for the national EMS organization after legal rules. This information is provided electronically and in the usage of Application Programming Interface (API) and Software Development Kit (SDK) which are common infrastructures to transfer data between two systems. So, as well as mobile phone location finding API, one separated API to determine the landline phone number geographical location is delivered. This e-service returns the address and geographical location of the caller by entering the landline phone number. All addresses on landline phone numbers exist in the CRA, and access to the data bank based on phone numbers was feasible. These two APIs are drive in a specific obfuscated SDK.
To ensure safety in the exchange of information, DITAS/HIX is using data encryption based on Public Key Infrastructure (PKI). The PKI uses a set of two public and private keys (X.509 certificates) for data protection. The certificate is embedded in the security tokens. In other words, a Certificate Authority (CA) issues the keys and attaches them to the identity of an agent. At first, Registration Authority (RA), which could also be the CA, verifies that the agent who is claimed. In consequence, PKI and digital signature are developed in GLI processes and are implemented in all servers that are hosted for EMSIS in each EMS center of medical science universities. The big picture of the model is illustrated in Figure1:

Figure 1. The technical infrastructure of GLISs implementation at Iranian EMSIS nodes

2.2	EMSIS nodes architecture

It was needed to provide relative security and technical requirements to operate the GLI services in every node of EMSIS in each EMS data center at the universities of medical science. In this regard, meeting some steps include the following are required:
1.	The EMS servers are in the national information network without any connection on the internet.
2.	Every edition of the software that is running in the EMS centers, has to be PKI enabled (PKIE) to make sure in supporting PKI technology.
3.	Due to the lack of internet connection, all SIM cards used in rescue vehicles such as ambulances must be connected to the EMS private APN (Access Point Name) to route the data traffic from mobile devices directly to EMS APN configured or internal private network.
4.	EMS center of the university of medical science has to introduce a responsible person to receive the username and token private key. One signed non-disclosure declaration by the representative for responsibility is obligatory.
5.	Token activation to authenticate and confirm the data exchange formed on DITAS/HIX
6.	configure a database for log management system
7.	Implementation of a monitoring dashboard to show current and reliable transactions submitted directly from EMS centers and results of GLI services from the CRA organization
8.	Develop a map server to use in the system for accurate address and routing by EMS workers
9.	Use of a local Route Planning Software (RPS) product on the EMS internal network
2.3	Use of map server

To clarify the address, an offline map with movable latitude and longitude is implemented in the system based on the local navigation map. The map is used in call centers when the caller address is registering and has not wanted work by the internet.

2.4	Monitoring dashboard development

After pilot and APIs testing in two EMS centers, EMS has developed one multi-resource monitoring dashboard. It shows current and reliable data on transactions (GLI requests and responses) submitted directly from EMS centers and the CRA organization. In addition, the dashboard has a clean and modern interface with several data visualization tools to better grasp the current status of the project.

RESULTS

In coordination with the Ministry of ICT, the use of two security APIs regarding location inquiry of calls to 115 number was requested. Project implementation has relied on the DITAS/HIX infrastructure as a national platform for information transmission between health-related systems in governmental organizations with other systems. Due to APIs information confidentiality and web-based transfer, the technical team has designed a trust model for project implementation in the EMS data centers. For more security, the APIs are embedded in one dedicated SDK.
According to government regulations, DITAS/HIX agrees on a procedure for exchanging healthcare-related information. For communication through DITAS/HIX, a dedicated ID is assigned to EMSIS as known as a System ID and for each university of medical science about communication with DITAS/HIX a unique ID called Location ID is issued. DITAS's functionality in the mentioned processes is to receive requests from different EMS centers, perform authentication and authorization (one SDK and PKI technology in the custom of X.509 certificates are employed), collecting transaction logs data, security implementation, and other local privacy instructions.
Moreover, the internal architecture of the EMSIS has been changed in a way that the caller's number is automatically taking in the electronic inquiry queue without any intervention and then suspended to receive the response from the CRA organization (Simplex mode for data transmission). This form to request does not interfere with the inquiry and use of the e-service and reduces to a minimum the possibility of abuse and intrusion.

CONCLUSIONS

Finally, after 6 months of the pilot in two large EMS centers (Tehran and Mashhad), significant results were found and, response time means that interval from relief call to reach of patient bedside [10, 11] was reduced between 3 and 8 minutes. This saving time is dependent on various variables such as traffic, weather conditions, city size, and type of EMS mission (intra-city or road). It is emphasized that all the EMS centers on a national scale are implementing this technical approach now.