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Hawaii, Missiles and what healthcare can teach us about emergencies

Hawaii, Missiles and what healthcare can teach us about emergencies

The funny thing about something truly terrifying is that it doesn't create the kind of panic we see in movies. People tend to get quiet.

I was on a flight once into Pittsburg in the middle of summer. A squall line of thunderstorms popped up as we were on our approach. While I can't be 100% certain, as a pilot it felt to me like we missed our approach 3 times. Regardless, there was certainly some dramatic maneuvering, bouncing, dropping and climbing. At one point the passenger next to me leaned over and asked: do you think we're going down. No one screamed. Some people were obviously praying. And my palms sweated through the page in the book I'd been pretending to read for 15 minutes. I looked up at the fight attended who was buckled into her seat and saw a look I don't care to see on someone's face again. We made it to ground and I sat in the boarding area to see the pilots when they came off the plane. They looked like they had been run through the rinse cycle of a dishwasher.

That was, up until last week, the most scared I've ever been.

Last week we were on the Big Island of Hawaii. Around 8:15 in the morning, we were walking towards a beach trail to meet some colleagues at a nearby resort. I heard my phone make the disarming tone it makes for an amber alert and thought: that's strange to have a missing child in paradise. I looked at my phone and saw the message that's already made its way around the internet and through news cycles:


We could see people around us going through a similar range of reactions. Reach for phone, do a double take, pause for a minute, then walk quickly and quietly somewhere. Anywhere.

We headed towards the ground floor of our hotel. We quickly ruled out going to the room. Getting in an elevator didn't feel safe and the room itself was on a top floor and had an sea-facing wall of glass. We tried to get as close to the interior core of the hotel as we could.

A woman looked at us and said: This has to be a joke or hack, right? I told her I thought it looked like an official message and those would be hard to hack. I don't even know where I am, she said. I was out on a run and my family is at another hotel.

All around us people continued to walk quietly and purposefully. Many were headed to their rooms or to rendezvous with loved ones elsewhere. There was no screaming, no running, no outward panic.

The hotel's PA pierced the silence. We have received an inbound missile threat. Everything will be ok. Please take shelter in your rooms.

Having already ruled that out, we made our own plan. This resort, like many in Hawaii, is largely open-air. There were virtually no solid walls on the ground floor. By the elevators there was an emergency fire exit with one of those alarm will sound signs. That felt like the safest place to be and, besides, we'd already gotten the alarm to beat all alarms.

Cori suggested we check to make sure we could get out. Smart! She went in and tried to open the door from the other side. No dice. How could that be? We turned the handle and the latch retracted. She closed the door and tried again, this time it opened. In we went.

We sat on the stairs, a few up from the ground floor landing but not all the way to the next level. I was looking around to see if there was a better spot. What happens if this door blows inward? ... and then my mind drifted to the scariest though I'd had all day: what if we don't die. What if we survive a nuclear blast? We'll be burned and injured. I'm wearing flip flops, so that will make traveling by foot hard. We won't have cell service or wifi.

I messaged my parents:

We’re at the hotel in Hawaii. Just got a ballistic missile alert. I’m sure it’s noting. But we’re all headed inside. Will keep you posted.

Decided it wasn't worth correcting the typo.

We both refreshed twitter. Refreshed again. Kept refreshing. We started to see mentions of an error. Then a tweet from Hawaii Emergency Management Agency said it was an error. I could feel my heart rate slow and my hands stopped shaking. A few minutes later it was official - it had been an error.

We exited our make shift bunker and joined the other guests starting to come back to life. Conversations restarted, people went back out into the sun and there was a general air of shell-shock.

The hotel's PA confirmed the false alarm. A few minutes later, our phones buzzed again. Same tone, same disarming feeling. This time it was the official all clear.

We're still processing. In the hours and days after, there were some small attempts at humor and some news reports were quick to point out humor is a natural reaction to trauma. But mostly, it was the event that we all acknowledged and didn't talk too much about.


Over the rest of the week Hawaii Public Radio ran many stories about reactions. They played audio recordings of people describing what they did. Some called loved-ones, some sat with their families and prayed, some sought any form of shelter they could find. HPR also ran stories featuring childhood psychologists with tips about helping children process what had happened.

I'm a designer with a rather myopic focus on healthcare. I've spent my entire career working in or around hospitals. And while our healthcare system is far from perfect, there are some lessons our emergency response system might borrow.

Over the last 20 years, simulation has become an integral part of training physicians, nurses, and first responders. Fortunately, true disasters are fairly rare. So emergency room teams regularly conduct simulations to drill things like a mass shooting, plane crash or natural disaster. It was pretty clear to us that neither our hotel or local agencies had done any kind of simulation. The accidental alert was unfortunate but it could be a prime opportunity for everyone to think through what should happen. Does going to rooms make sense, or should there be a central gathering point? Is the messaging helpful or confusing? What do people need, how do they behave and what systems do they need to put in place to account for those reactions?

Healthcare has also had the tragic opportunity to learn from some sad errors. For a long time, it was too easy to mix up an oxygen line with a vacuum line. We still worry about and put systems in place to try and prevent drug-drug interactions. Things like bar codes, 'break the glass' firewalls in electronic systems and color coding have helped a lot.

Here's the screen the Hawaii emergency team was using the day of the accidental alert.

Setting aside that it looks like a webpage from 1993, there's very little to distinguish a drill from the real thing. Any user interface designer would have a field day reimagining this screen. And that's an opportunity. Hawaii should hold a series of challenges; call it Design for Hawaii or Code for Hawaii, or whatever they like. But get smart, skilled people in the room to work on these challenges.

We're also in the midst of an awesome trend of co-designing new approaches to healthcare with patients and families. The idea is to bring the people with the most lived experience to the forefront of reimagining processess, services, and treatments. What would it look like if state and federal agencies engaged the people of Hawaii? What actions did they take? Where did they feel equipped and where did the feel unprepaired? What ideas do they have for future alerts?

Lastly, we're just starting to talk about truly integrated healthcare delivery. We're starting to understand that physical pain and trauma is often accompanied by mental anguish. Both require attention, treatment and acknowledgment. Hawaiians and visitors will be on heightened alert for some time —not just because of the false alarm, but because of the world we find ourselves in today. An integrated approach would acknowledge the caustic effect of heightened stress. Perhaps we might even come to think of our current state of diplomacy as what healthcare calls a never event.

Invisible Building Blocks of Digital Innovation: the Internet of Things in a Hospital

Invisible Building Blocks of Digital Innovation: the Internet of Things in a Hospital

Innovating —the act of doing anything new in a creative way — is inherently disruptive. This is doubly true inside complex systems and regulated industries. And organizations are built to avoid disruption. Often, what we see as an example of a simple innovation is actually the result of small, invisible — but nonetheless crucial — enablers. I love these enablers and how they allow us to innovate with much less discomfort. They are the unsung heros of change and rapid cycle development. Lately, we've been on the bleeding edge of inexpensive Internet of Things technology in the hospital. And none of it would be possible without these enablers having laid some invisible bricks of digital innovation.

A few years ago, our team got very interested in voice-first interfaces; or, for the less nerdy, Amazon Echos. We were working on a project to give patients more control over their hospital rooms. It felt like voice control was a prototype worth pursuing. We were early enough to express interest to Amazon and cleared their waiting list quickly. We unboxed our magic cylinder, plugged it in, and then realized the next big hurdle: wi-fi!


our digital pal

this Echo sits in our team's space and spits out jams all day long!

Hospitals, even among regulated industries, take data privacy and security even more seriously than most. We also have lawyers with keen eyes on protecting patient data and mitigating the organization's risk. So, like any sophisticated large organization, our Wi-Fi networks are rather locked down. Unlike the set-up most of us have at home, joining wi-fi at the hospital requires a corporate username and password. While that authentication mechanism is easy enough on a laptop or smartphone, it's outright impossible for most consumer-oriented devices. Simply put, there's no way to put a corporate username and password into an Amazon echo.

Around the same time, we met someone (who would quickly join our team) who knew how to move quickly in the digital world. Matt strolled into our innovation studio one day and immediately belted out: "I know what this place is!" We often say we know our kind of weirdo when we meet them and Matt was clearly our kind of weirdo. In joining our team, he helped us create our Digital Services model. We cribbed notes from our friends a few miles across town in the federal government — the U.S. Digital Service. That team was formed to bring modern, Silicon Valley-style tech skills to existing U.S. government teams.

For us, and our friends in the U.S. Digital Service, digital services is different from IT. Where IT is responsible for designing and maintaining our networks, electronic medical records, and business systems, digital services is all about building and testing new things quickly to address the needs of end-users and innovators.

Matt's presence on the team expanded our horizons about what could be possible. We realized we needed a safe sandbox —a place to safely test our ideas before going public. We implemented our own entirely separate, airgapped network. We installed a commercial-grade business line for Internet from a different Internet service provider than the one used by the hospital. We set up our own wi-fi network to be completely separate from any of the hospital's corporate infrastructure. We also set up a second network dedicated to Internet of Things devices like the Amazon echo.

Having our own separate infrastructure provided a platform on which to rapidly experiment with emerging technology without putting the organization or patients' data at risk. And having a platform in our team's control means we can get devices up and running without burdening another team in the hospital.

Today, we have expanded our network to cover large portions of the hospital. It enables us to test new devices and concepts in patient rooms, waiting areas, and clinic spaces. Our innovation network has also given us the ability to help others in the organization in ways never before possible.

A few months ago, The head of our case management department approached our innovation team's lean engineers with a challenge: she needed a new way to capture data on the types of services and programs that patients needed. She wanted something like the famous Staples easy button. Matt had been waiting for a use case like this, and knew exactly what he wanted to deploy.


a stack of Amazon Dash buttons awaiting deployment



Around the time Amazon introduced its echo device, it also came out with something called IoT buttons. Originally offered as a convenient way to reorder frequently consumed products, the unbranded versions are amazingly flexible. Imagine something the size of your thumb with adhesive on the back and a button on the front. You attach them to your wi-fi network and can easily program them to do internet-y things. Well, someone like Matt can easily program them.

Matt set up five of the $20 IoT buttons for case management. Each one corresponded to a type of patient need. When pressed, they automatically create a row in a Google Sheet spreadsheet; instant data capture. When our radiology department needed to capture data on patient flow, the IoT buttons let them log things like arrival time, navigational issues and reasons for being late to an appointment. Matt and the lean engineers deployed them in hours at nearly zero cost.

We've also been using the IoT buttons in a patient-facing prototype. For another project, we want to capture real-time feedback from people about their experiences. Matt and team mounted some of the buttons in a cardboard box, covered it with a slickly-designed label, and we had an instant, wireless feedback device. We were able to iterate on how we asked questions about patient experiences quickly and deploy the experience boxes into patient areas without any obstacles. And, since they are easily programmed, we can get the data in really convenient ways. When a button is pressed, not only is it logged into a Google Sheet, but a robot pops a notice into our team's Slack board telling us what the feedback is and from where in the hospital it originated.

There is so much neat tech in the world and we're in a time when the release cycle is speeding up exponentially. Taking advantage of these things for testing, inspiration and innovation is a game-changer. But, it requires some building blocks like a sandboxed network and digital services leads like Matt. Investments in those enablers pay dividends in efficiency and expediency and they do it in ways we haven't traditionally embraced in healthcare.

version 1, 2 and 3

IoT button-powered patient feedback boxes 

Cutting through traditional organizational silos or finding outside contracted partners takes time, burns momentum and all too often stifles innovation entirely. Teams that want to move quickly need the resources and people who make speed and agility possible and inexpensive. It also reduces the cost of failure. Find a Matt for your team, get a mobile hotspot or your own network and you start changing healthcare with $20 buttons.

IoT enabled in-room signage (version 1.0)

IoT enabled in-room signage (version 1.0)

The journey is the Innovation

The journey is the Innovation

Sometimes it's not the impact of the project, it's the experience that makes all difference to patients, staff and innovators.