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Figure 5. Emergency calls for ambulances presented to ESTA on 21-22 November [26]. Potential: the ability to anticipate the severity of the asthma crisis. Despite a forecast for severe thunderstorms, there was no expectation of an impending emergency. Lack of situational awareness across the health system meant that, although clinicians suspected that the respiratory symptoms they were seeing were caused by thunderstorm asthma, there was no channel for sharing this information with DHHS. In addition, the traditional system for communicating public health concerns, whereby DHHS seeks to understand what is causing the problem in combination with its impact on the health system before issuing public information and warnings, was unsuited to a rapid-onset problem such as thunderstorm asthma. Factual: the ability to learn from successes and mistakes when responding to the thunderstorm asthma event. Following the event, the state Inspector-General for Emergency Management was tasked by the state government to review the emergency response.[26] The review resulted in 16 comprehensive recommendations, of which 10 were related to improving data integration and/or information systems. Various organisations that were part of the response, including ESTA and AV, also reviewed and updated their emergency response plans. Finally, an interagency working group was established to share knowledge and improve procedures for detecting and anticipating the severity of future events. 3. Explanation of success or failure of health IT system 3.1. Identifying and understanding variability in everyday work Using RHC principles enabled an understanding of Work-as-Done when delivering telehealth advice to new and prospective parents via video. The plan to use both CSOs and counsellors to deliver the service was abandoned, and a revised system R.Clay-WilliamsandJ.Braithwaite /ResilientHealthCare142