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EBOOK Technology- Facilitated Innovation In 1969, paramedics from the Miami Fire Department used mobile EKG technology and radio communication with in-hospital physicians to become the first to successfully defibrillate a cardiac arrest patient. From that moment on, technology has been a critical partner in our efforts to quickly and effectively treat patients in the out-of-hospital setting. In this special eBook, you’ll read about how progressive EMS systems are leveraging mobile technology and communication in innovative new ways—from improved triage and navigation of low- acuity patients in Houston to Orange County, Calif., where providers can access a patient’s medical information through their ePCR software with a few taps of the fingertip. 3 High-Tech Physician Triage Redirects Low-Acuity Patients 12 Interview with Houston Medical Director David Persse, MD 15 Implementa- tion of EMS Access to Patient History 25 Considera- tions for a Well- Engineered ePCR System SPONSORED BY: Reprinted with revisions to format from JEMS. Copyright 2018 by PennWell Corporation

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Page 1: EBOOK Technology- Facilitated Innovation - jems.com · EBOOK Technology- Facilitated Innovation - jems.com

EBOOK

Technology-Facilitated InnovationIn 1969, paramedics from the Miami Fire

Department used mobile EKG technology and radio

communication with in-hospital physicians to

become the first to successfully defibrillate a cardiac

arrest patient. From that moment on, technology

has been a critical partner in our efforts to quickly

and effectively treat patients in the out-of-hospital

setting. In this special eBook, you’ll read about how

progressive EMS systems are leveraging mobile

technology and communication in innovative new

ways—from improved triage and navigation of low-

acuity patients in Houston to Orange County, Calif.,

where providers can access a patient’s medical

information through their ePCR software with a few

taps of the fingertip.

3 High-Tech Physician Triage Redirects Low-Acuity Patients

12 Interview with Houston Medical Director David Persse, MD

15 Implementa-tion of EMS Access to Patient History

25 Considera-tions for a Well-Engineered ePCR System

SPONSORED BY:

Reprinted with revisions to format from JEMS. Copyright 2018 by PennWell Corporation

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EVERY

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Originally published in the November 2015 issue of JEMS

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Directing Appropriate CareHouston’s innovative ETHAN program uses high-tech physician triage to help low-acuity patients

By MICHAEL GONZALEZ, MD; DIAA ALQUSAIRI, PHD; ADRIA JACKSON, PHD, RN-BC; TIFFANY CHAMPAGNE, PHD, MBA; JAMES LANGABEER II, PHD, EMT & DAVID E. PERSSE, MD, FACEP

EMS PROVIDERS OFTEN feel helpless when they arrive on scene and

discover the patient’s need is more primary care than emergent

in nature. In Houston, the fourth largest city in the United States,

this happens frequently. In fact, a recent study by a local university

estimated that 40% of all ED visits are primary care related.1

Since there’s an average of more than 800 9-1-1 EMS calls every day in Houston,

that results in a lot of unnecessary transports to the ED for primary care-related

complaints such as

minor headache, chronic

joint pain or insomnia.

Other than transporting

the patient to the ED,

there’s typically little

EMS providers can do to

address these kinds of

medical concerns.

Unnecessary ED

transports compound

Houston’s problem of

ED overcrowding—local

hospitals experienced

a 33% growth rate in

visits during a 10-year

period, with wait times

in the largest facilities in

A Houston Fire Department crew member facilitates a physician-patient video conference to direct a low-acuity patient to appropriate care—and hopefully away from the ED. Photos courtesy Houston Fire Department EMS

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excess of six hours or more.2 Providing primary medical care through the ED is

inefficient from a healthcare system perspective and often suboptimal from a

patient experience and medical care perspective.

To combat the growing problems, Houston Fire Department (HFD) EMS

developed an innovative mobile integrated healthcare project called ETHAN—

Emergency Telehealth and Navigation. ETHAN is a community-wide

collaboration led by the HFD that uses mobile technologies, community-based

paramedicine, and local and regional partnerships with other agencies and

organizations to triage and connect low-acuity 9-1-1 callers with primary care

resources in the community.

HFD Medical Director David Persse, MD, FACEP, points out, “The EMS Agenda for

the Future spoke of EMS as being fully integrated with the overall healthcare

system. If successful, ETHAN will be a major step in that direction.”

PROGRAM OBJECTIVES

ETHAN is fundamentally a community-based paramedicine approach that

integrates extensive use of health information technology with traditional

medical care. Spearheaded by HFD Associate Medical Director Michael Gonzalez,

MD, ETHAN is based on five key interrelated concepts:

1. Patient-centered navigation to appropriate levels of care;

2. Population-based tools and needs assessments;

3. Leveraging community resources, partnerships and collaborations;

4. Long-term financial sustainability through improved outcomes; and

5. Extensive integration of mobile health and other technologies.

The last component—technology—is extremely important, as it enables

physicians in Houston’s 9-1-1 call center to communicate directly with patients

via tablets with integrated telehealth capabilities. Other embedded information

systems include clinic scheduling systems, health information exchange (HIE)

access and transportation scheduling.

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Also critical is HFD

EMS’ partnerships

with local, regional

and national

organizations to

improve the spectrum

of care and augment

agency resources.

(See Table 1.) Without

community-based

partnerships, EMS

agencies would find

obtaining resources

for mobile integrated

healthcare programs

nearly impossible.

The program was in

planning stages during 2014, and officially kicked off in December. An evaluation

of clinical and economic outcomes from the program is being conducted

prospectively by the University of Texas Health Science Center. In the first five

months, over 700 patients have been successfully evaluated and over 80% have

resulted in outcomes not requiring the use of the ambulance. Navigation toward

more appropriate levels of care should produce a significant impact on efficiency,

appropriate utilization and a reduction in overcrowding at local EDs.

ETHAN is being funded during the initial multiyear period through the Texas

1115 Healthcare Transformation Waiver program. Through the Delivery System

Reform Incentive Payment, the 1115 Waiver seeks to incentivize hospitals and

other providers to transform their service delivery practices to improve quality,

health status, patient experience, coordination and cost-effectiveness. Eligibility

for this program requires participation in a regional healthcare partnership.

Within a partnership, participants include governmental entities providing public

funds known as intergovernmental transfers (IGT). The city of Houston provided

the necessary IGT funds.

Table 1: Local, regional and national ETHAN program partners

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The ETHAN project reached its current design after over six years of shaping and

development. This evolution began in 2009 with a nurse triage phone line that

was accessed by call takers at the 9-1-1 emergency communications center, where

they connected patients with nurses who used a computer-based algorithm to

triage patients and determine the most appropriate disposition. This project

failed because callers expecting an ambulance to be immediately dispatched

instead experienced a prolonged Q&A interrogation by a nurse and weren’t

cooperative with the program. In addition, it was recognized that the nurses were

very conservative in making dispositions, resulting in very few diversions from

dispatching of an ambulance.

The nurse triage phone line was discontinued and a similar algorithm was used

by HFD paramedics located at the paramedic-staffed base station used by the

HFD for all field-to-hospital medical communications. Field crews connected

the patients in the field with the paramedics over the phone. Paramedics could

schedule the patient a clinic appointment and a taxi ride when appropriate.

Due to the conservative design of the algorithm, however, it too often determined

the disposition to be immediate transport to the ED when it didn’t seem

medically necessary. As a result, a large percentage of patients still ended up

being transported to the ED and first responders grew frustrated with the project.

Although significantly more costly, replacing the algorithm with emergency

physicians allows for much quicker determination of the patient’s medical acuity

and dramatically improves the accuracy of triage results to ensure the most

appropriate disposition. The interactions using the nurse triage line algorithm

typically took up to 20 minutes or more, whereas physicians can assess the

patient and make a disposition decision in around seven minutes. This is a more

satisfactory experience for both the patient and the EMT or paramedic.

HOW ETHAN WORKS

After the first responding HFD apparatus arrives on scene, the crew assesses

the patient and makes an initial determination as to whether the patient needs

emergency care. If the patient does indeed require emergency care, the crew then

activates the ETHAN program. To do that, they use the tablet that’s available

on every fire/EMS vehicle—both ambulances and traditional fire apparatus

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alike—to connect the patient

with an emergency physician via

HIPAA-compliant and secure video

conferencing software.

The emergency physician is able to

access the patient’s medical record

that’s created on scene, including

the patient’s demographics, vital

signs, medical history, allergies,

medications and the chief complaint.

The physician consults with the

patient by video conference in a

way very similar to what’s normally

done at the ED. All physicians hired

for this project are board-certified

emergency physicians who practice

at local hospital EDs and have

multiple years of experience.

While the video conference takes

place, the field crew remains on

scene to assist the physician with

any additional information needed,

such as taking a new set of vital

signs or palpating the patient’s pain

site. The physician then makes the

final determination regarding the patient disposition, which could be one of six

alternatives, as shown in Table 2, and briefly described below.

Referral to a community primary care clinic and taxi ride: This is the ideal

disposition and is currently applied to about 10% of initial ETHAN patients. When

the emergency physician determines the patient could be better cared for at a

primary care setting, the physician will schedule an appointment at one of the

local partner clinics using a Web-based scheduling system that uses the patient’s

ZIP code to identify the closest clinic location and next available appointment

Table 2: ETHAN patient disposition after eligibility screening

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time. All clinic visits are scheduled for the same day or the next day at the latest.

The clinic receives an appointment confirmation with the patient’s demographics

and chief complaint. The clinic’s providers are also able to access the local HIE

to view additional information on the patient. If the patients need transportation

assistance to get from their residence to the clinic, the physician uses a Web-

based application to schedule a taxi ride. The clinic visits and taxi ride billing

is handled through a third party administrator. For uninsured patients, the

program covers the cost of the clinic visit and taxi ride. For insured patients,

clinics bill the patient’s insurance directly for the visit and the program covers

the taxi ride only.

Referral to an ED and taxi ride—patient declined referral to clinic: The

emergency physician may determine that the patient needs to go to the ED, but

ambulance transportation isn’t necessary. This disposition category accounts for

over 50% of initial ETHAN encounters. In this case, the physician instructs the

patient to go to the ED and schedules the patient a taxi ride. The physician can

also schedule a taxi ride to an ED if the patient refuses to be seen at the clinic

and insists on going to an ED for a low-acuity complaint.

Referral to an ED with ambulance transportation: In only about 19% of cases

thus far, the ETHAN physician has determined that a patient needs immediate

emergency care and instructs the field crew to transport the patient to an ED. As

explained previously, the ETHAN program is only activated after the field crew

determines a patient doesn’t need emergency care, so these instances are an

important teaching opportunity for the physician to educate the field personnel

why emergency transportation is needed.

Referral to patient’s primary care provider (PCP) or home care: When a patient

has their own PCP, the patient might choose to see their PCP instead of going to

a partner clinic—this disposition makes up approximately 7% of cases. When

possible, the ETHAN physician encourages this option as the patient’s own PCP is

often the best provider to coordinate the patient’s care and ensure continuity and

integration of care. Also, based on the ETHAN physician and patient’s discussion,

they might decide that no additional care is needed and the physician might only

provide the patient with home care instructions.

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Patient declined referral to clinic and receives ambulance transport to ED: The

patient might choose to decline the ETHAN physician’s advice and insist on going

to an ED. The ETHAN physician and responding crew communicate to the patient

that seeing a PCP at one of our clinics will provide them with better care and

convenience than going to an ED. They also explain that ambulance transport

isn’t necessary and doesn’t add any value to the care the patient will receive.

Nevertheless, some patients still insist on going to an ED via an ambulance,

although at 5% this disposition is rare. The physician is empowered to decline the

use of the ambulance, but in some situations the physician and EMS crew decide

to abide by the patient’s insistence.

Patient refusal to participate: The patient might refuse to participate in the

ETHAN program and refuse to speak with the ETHAN physician over the tablet.

Although this disposition is possible, it accounts for less than 1% of encounters.

PATIENT FOLLOW-UP & OUTCOMES EVALUATION

Following the ETHAN encounter, the patient’s information is automatically

forwarded to Care Houston Links, a city of Houston Health Department program

that provides care navigation services. Through this program, social workers and

healthcare navigators follow up with the patient to ensure the patient’s needs

were met and to identify any additional human/social services needs and identify

ways to address them. A patient satisfaction survey is also administered.

Follow-up may include things like insurance coverage, transportation, food

assistance, health literacy, counseling, etc. The goal is to deploy a holistic

approach to healthcare and connect patients with resources they can access for

their future health needs, thus reducing their reliance on the emergency system.

In addition, all program data on patient disposition, participation, volumes,

clinical outcomes, and costs are being measured and evaluated by an

independent third-party university researcher at the University of Texas Health

Science Center. This outcomes research will hopefully show significant reduction

in costs and unnecessary transports, with (at least) no reduction in care and

higher patient satisfaction survey scores. If annual evaluations confirm this

hypothesis, the ETHAN program will be financially sustainable for the long-term.

High-Tech Physician Triage Redirects Low-Acuity Patients

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CONCLUSION

ETHAN is a developing mobile integrated healthcare EMS program committed to

being an integral component to address Houston’s healthcare delivery system through

more coordinated out-of-hospital care. To survive long-term, it must be financially

sustainable, producing a return on investment of sorts, where outcome benefits are

greater than their costs. By focusing on technology-enabled patient navigation to more

appropriate levels of care and leveraging community collaborations and partnerships,

we expect this program to grow significantly in years to come.

REFERENCES1. Begley C, Courtney C, Abbass I, et al. (2013.) Houston hospitals emergency

department use study: January 1, 2011 through December 31, 2011. Health Services Research Collaborative, University of Texas School of Public Health. Retrieved Sept. 9, 2015, from https://sph.uth.edu/research/centers/chsr/hsrc/.

2. Wolf R. (June 19, 2007.) What does a health crisis look like? See Houston. USA Today. Retrieved Sept. 9, 2015, from www.usatoday.com/news/nation/2007-06-18-texas-healthcare_N.htm.

MICHAEL GONZALEZ, MD, is the associate medical director with the Houston

Fire Department, EMS Division, and leads the ETHAN program. He’s also an

assistant professor of emergency medicine at Baylor College of Medicine.

DIAA ALQUSAIRI, PHD, is a senior staff analyst for the Houston Fire Department,

EMS Division, focusing on emergency telehealth. He’s interested in building

innovative models and collaborations for efficient and effective delivery of care.

He has an MS in emergency management and a PhD in healthcare management.

ADRIA JACKSON, PHD, RN-BC, is a health information technology executive

and registered nurse board certified in nursing informatics. She has 26 years of

experience in the healthcare industry and 10 years in health IT, specializing in

the implementation of clinical information systems such as electronic health

records and case management.

TIFFANY CHAMPAGNE, PHD, MBA, is an assistant professor of biomedical

informatics at the University of Texas (UT) Health Science Center. She holds a

PhD in health management from the UT School of Public Health and was formerly

the vice president of the regional health information exchange in Houston.

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JAMES LANGABEER II, PHD, EMT, is a professor and research director in

emergency medicine and informatics at the University of Texas Health Science

Center at Houston. He’s a data scientist with expertise in outcomes research in

emergency and cardiovascular care.

DAVID E. PERSSE, MD, FACEP, started his career in medicine with 10 ten years’

experience as a field paramedic and paramedic instructor in Buffalo, N.Y., and

upstate New Jersey. After studying pre-med at Columbia University in New York,

he attended Georgetown University School of Medicine and then completed an

emergency medicine residency at Harbor-UCLA Medical Center in Torrance, Calif.

He later completed a resuscitation research fellowship at Ohio State University

and was then awarded a grant from the Society for Academic Emergency

Medicine to complete fellowship training in EMS and resuscitation at the Baylor

College of Medicine and Houston Emergency Medical Services program.

Following his EMS fellowship, Dr. Persse became the assistant medical director

for the EMS System of Houston, overseeing field operations and clinical research

trials. He then moved to California to become the medical director of the Los

Angeles County Paramedic Training Institute, and the assistant medical director

of the Los Angeles County EMS Agency. In 1996 Dr. Persse returned to Houston to

assume the role of the Director of EMS for Houston.

Dr. Persse now serves as a Board Member for the National Registry of Emergency

Medical Technicians. He is also an editorial reviewer for the Annals of Emergency

Medicine, Prehospital Emergency Care and Academic Emergency Medicine. He

regularly participates in the Texas State legislative process for EMS activities

and was a member of the Board of Directors of the Texas College of Emergency

Physicians for which he served as chairman of the colleges’ EMS committee and

was the founding president of the EMS Physicians of Texas. He is also a member of

the Board of Directors for the South East Texas Trauma Regional Advisory Council,

and the National Registry of Emergency Medical Technicians.

Dr. Persse has been a member of the College of Fellows of the National Academy

of Emergency Dispatch. In 2004 Dr. Persse was confirmed by the mayor and City

Council as the public health authority for the Houston Department of Health and

Human Services. Since that time he has been awarded the Michael K. Copass Award

by the U.S. Metropolitan EMS Medical Directors (2009), the Keith Neely Outstanding

Contribution to EMS Award by the National Association of EMS Physicians (2007) and

the EMS Medical Director of the Year by the Greater Houston EMS Council (2005).

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Originally published in the April 2015 issue of JEMS

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EMS Physicians Can Help Close the Gap Between EMS & Other Public Health Agencies

By MARK E.A. ESCOTT, MD, MPH, FACEP, NRP

IN CONSIDERING THE first person to interview for

this column, the choice was an obvious one for

me because my mentor, David Persse, MD, has

helped guide me over the past 20 years. In 1996,

he provided me with sound advice and support as we

launched the EMS service at Rice University. Persse

now serves as both the physician director for the

Houston Fire Department and as the health authority

for the city’s public health department. He’s been a

leader in the merger of EMS and public health in this

country and is innovating new pathways to enhance

the role of EMS in the healthcare industry.

Dr. Persse, with the subspecialty of EMS at its commencement, how do you see the role of

technology enhancing the interactions between patient, paramedic and physician?

“Technology is going to completely revolutionize EMS in America and around

the world. When I started as an EMT, the most complicated technology we had

was the radio. Today, in Houston, we’ve just introduced a portable CT scanner

mounted in our mobile stroke unit, and we’re using telemedicine technology

to allow field personnel to immediately connect with an emergency physician

who can then interview and visually examine the patient to decide how to

most efficiently resolve the patient’s issue. This includes the physician quickly

and electronically setting up a same- or next-day clinic appointment and non-

emergency transportation as well as social work or public health follow-up.

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Interview with Houston Medical Director David Persse, MD

In the future, I predict we’ll see mobile devices similar to our current day ECG

monitor/defibrillators that will perform multiple bioassays (a procedure for

determining the concentration, purity or biological activity of a substance) to

include diagnostic capabilities as well as high-fidelity monitoring of critical

physiologic functions such as central pressures, core temperatures, O2 tissue

extraction, central nervous system activity, etc. This information will be easily

and continuously transmittable to allow both the introduction of critical care

capabilities by the paramedic as well as to better inform the receiving facility

of what the patient will need upon arrival. I hope this will all return EMS to our

roots of a very close and mutually productive relationship between the EMS

physician and the field care providers.”

As a pioneer at navigating the intersection of public health and EMS medicine, what do

you see as the future of this relationship?

“I’ve always felt EMS is as much a form of public health as it is an emergency

response system. If you want to put your finger on the pulse of your local

community’s health status, look at your EMS records. EMS touches every disease

and injury pattern that exists in your community, in every neighborhood, for

patients of all ages, within every income level, every education level, every

culture, every lifestyle, for acute or chronic, medical or social problems;

regardless of the patients’ ability to pay or preferred hospital choice. The

Centers for Disease Control and Prevention define public health as the science

of protecting and improving the health of families and communities through

promotion of healthy lifestyles, research for disease and injury prevention, and

detection and control of infectious diseases. In most every community, EMS

is a central repository for much of the information needed by public health

practitioners to achieve their goal.

Unfortunately, EMS and public health haven’t been known to share their data

and combine their efforts. We’re now seeing significant improvement in the

collaboration between the two across the nation. As an example, we’ve recently

published data showing communities with some of the worst air pollution

problems in Houston also have the highest incidences of EMS responses for

asthma and cardiac arrest, which can be temporally related to spikes in certain

pollutants in the air. Our health department has responded to this information

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Interview with Houston Medical Director David Persse, MD

by working with the authorities to implement stronger restrictions on certain

air pollutants, and we’ve initiated widespread CPR training programs within

neighborhoods identified as being at highest risk.

Just imagine the potential for improving our local community’s health once EMS

provider agencies and local health departments join forces!”

What advice do you have for paramedics and EMS physicians in regard to better engaging

their community in population-based health initiatives?

“I think many paramedics across the nation have already begun to broaden their

vision of their scope of practice, especially with the advent of the community

paramedic. Board certification in EMS is a major step forward for EMS physicians

to become reengaged with field personnel and field operations. Because of the way

EMS developed in the United States, physicians were left out of the progress and

failed to stay as engaged as our physician mothers and fathers (Caroline, Copass,

Nagel, Grace, Criley, etc.) were. Today, much of what should’ve been a close and

cultivating relationship between EMS medical directors and field personnel has

been replaced with state-level bureaucracy and protocols. As paramedics become

more engaged in caring for their communities beyond emergencies, so must the

new breed of EMS physician see that the overall health of their community is also

part of our responsibility. To this end, physicians and field personnel alike should

make contact with their local public health department to seek ways to identify

the gaps in the health care system, and work together by combining resources to

achieve real progress in improving lives. I believe this is the future of EMS.”

MARK E.A. ESCOTT, MD, MPH, FACEP, NRP, is the medical director for Austin-

Travis County EMS System. He’s also a medical director and founder of Rice

University EMS in Houston and an assistant professor in the Department of

Emergency Medicine at Baylor College of Medicine. He’s the chair of the American

College of Emergency Physicians Section of EMS and Prehospital Medicine and

board-certified in emergency medicine and subspecialty board-certified in EMS..

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Originally published in the May 2017 issue of JEMS

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Orange County, Calif., Begins Field Implementation of EMS Access to Patient History

By DANIEL R. SMILEY & SAMUEL J. STRATTON, MD, MPH, FACEP, FAAEM

YOU AND YOUR partner respond to a 9-1-1 call for a woman with

altered mental status. After ensuring there are no immediate life

threats and completing your initial assessment, you attempt to get

information about the patient’s medical history, current medications

and allergies. She isn’t able to offer clear information on her current medications,

and when you turn to the family, the patient’s family member hands you a bag

with at least 15 different medications.

This is an all-too-familiar scenario for many EMS responders. EMTs and paramedics

typically rely only on those on scene to volunteer critical medical information prior

to treatment: the patient,

family members, friends or

others. A patient’s past medical

history is otherwise unknown,

leaving EMS providers to start

from scratch as they input

the patient’s data into their

electronic patient care report

(ePCR) system and, eventually,

transmit relevant data to the

receiving hospital via radio

or cell phone. This traditional

model is prone to errors and

inaccurate data and is simply

inefficient.

Health information exchange programs facilitate the secure sharing of a patient’s health information throughout the continuum of patient care. Photo courtesy Newport Beach Fire Department

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Implementation of EMS Access to Patient History

In Orange County, Calif., however, it’s a completely different picture following

the field implementation of +EMS and the Search, Alert, File and Reconcile

(SAFR) model for health information exchange (HIE), which provides a patient’s

medical information at providers’ fingertips within seconds. To accomplish this,

an established HIE is augmented by the alerting and bidirectional data flow

capabilities in

Here’s how it works: As the medic is evaluating and treating a patient in the field,

they use their ePCR software, ImageTrend Elite, to search for the patient by first

and last name, gender and date of birth. The field EMS data tablet connects to a

cloud-based HIE through HIH, where the patient’s cumulative hospital, medical

provider and EMS electronic medical record is identified, allowing the medic to

immediately populate the ePCR with the patient’s medications, allergies, recent

hospitalizations and past medical history.

An alert within Hospital Hub notifies the receiving hospital of the incoming

patient and receives pre-arrival field and medical record information transmitted

Figure 1: Illustrated SAFR model for health information exchange

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Implementation of EMS Access to Patient History

from EMS to the ED, including: primary impression, age, gender, arrival times,

vitals and procedures-including 12-lead ECGs-performed by the EMS crew. A

predetermined set of rules triggers the completed ePCR information to be sent

automatically in a National EMS Information System (NEMSIS) CCD (Continuity

of Care Document) file to the HIE, which is then available in near real-time to the

appropriate patient healthcare provider.

The HIH retrieves hospital discharge, insurance and clinical information from

the HIE, which then populates ImageTrend Elite for agencies to view and use for

continuous quality improvement and to achieve better patient outcomes.

Having immediate access to a patient’s healthcare information in the field

provides EMTs and paramedics with reliable information, such as recent

hospitalizations, past medical history, medications, allergies, preferred healthcare

facilities and end-of-life decisions, that can affect initial care decisions and long-

term outcomes. Giving EMS providers secure access to this additional patient data

helps to paint a more complete picture of the patient in order to facilitate more

appropriate prehospital care in addition to optimizing the transition of care in the

hospital ED.

Orange County’s ePCR solution, ImageTrend Elite, takes advantage of a bidirectional health information exchange to allow medics to populate the ePCR with the patient’s medications, allergies, recent hospitalizations and past medical history. Screenshots courtesy ImageTrend

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Going Electronic

California EMS providers are mandated by state regulations and local policy to

complete a PCR when they make contact with a patient to document incident

demographics, assessments and treatments. Historically, the PCR was completed

on a paper form and a carbon copy was hand delivered to the receiving hospital

ED. Despite including a significant amount of information relevant to emergency

care, it was often illegible and nearly impossible to extract data for prospective or

retrospective analysis of the quality of patient care.

This wasn’t a problem unique to California, and in an effort to begin to solve

these problems, the National Highway Traffic Safety Administration (NHTSA)

sponsored the creation of the NEMSIS standard in 2001. In a few years, NEMSIS

defined the technical infrastructure and dataset necessary to create ePCR

solutions.

The statewide California EMS Information System (CEMSIS) uses the NEMSIS

3.4 standard and includes additional data necessary to meet the needs of the

state. California’s Emergency Medical Services Authority (EMSA) requests each

of the 33 local EMS agencies (LEMSA) to submit EMS data from their respective

jurisdictions to the CEMSIS data repository. At least 20 agencies currently

participates and EMSA anticipates that the repository will potentially receive up

to four million records annually.

Orange County EMS (OCEMS) created a system called Orange County Medical

Emergency Data System (OC-MEDS) to assist with EMS provider agencies,

ambulance companies, and fire departments to transition from their outdated

paper based documentation methods to OC-MEDS and report their ePCRs in real-

time. OC-MEDS was the first comprehensive system of its kind in California that

included the collection of emergency patient information at the time of service

and made it available for instantaneous reporting to receiving hospitals, base

hospitals and the local EMS agency.

Standardization & Integration

In 2013, EMSA began exploring how to improve technology for EMS providers,

envisioning a future where EMS is integrated into the broader healthcare system.

More specifically, that EMS patient records would be shared with hospital

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electronic health records (EHRs), with the goal of eliminating the paper PCR that

paramedics drop off at the hospital during the transfer of care.

In 2014, the +EMS Project was developed in collaboration with the U.S. Health

and Human Services Office of the National Coordinator (ONC) for Health

Information Technology staff to support nationwide HIE and care coordination

efforts. Fundamental to the project, EMSA developed the SAFR model to describe

the minimum functional aspects of EMS HIE data exchange. The SAFR model

created a framework and defined concrete data elements and functions that

explained HIE concepts in terms applicable to the EMS community. EMSA also

developed a work group called Consumable Data and Transport to create the list

of specifications for the SAFR functionality and the specific elements.

In 2015, health information technology (HIT) standards were changing rapidly

and EMS systems would soon be mandated to adopt these new standards. On Jan.

1, 2016, new state law (CA Health and Safety Code 1797.227) mandated that EMS

providers transition to modern data systems and submit NEMSIS 3.4-compliant

data in realtime to their local EMS agencies.

California had the foresight to create a statewide data collection system that

modernizes all EMS data systems and would comply with federal HIT standards.

This allows EMS providers to exchange patient care information with other health

care providers (such as receiving hospitals) who use the same standards. The

exchange of patient

care information

is a cornerstone

of the Institute

for Healthcare

Improvement Triple

Aim Initiative and

is supported and

sponsored by the

federal ONC.

In late 2015, EMSA

was awarded a $2.75

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Implementation of EMS Access to Patient History

million federal grant funded by the Health Information Technology for Economic

and Clinical Health (HITECH) Act of 2009, to support the creation of bidirectional

HIE between EMS providers and hospitals. Although many other healthcare

providers have already implemented their exchanges, EMS systems have largely

been excluded from any funding to support their implementation. EMSA used

grant funds to support local/regional health systems to realize the goal of

HIE+EMS interoperability in California.

EMSA Director Howard Backer, MD, MPH, FACEP, emphasizes, “Providing patients’

current medical information to all medical providers is essential to provide

accurate and high quality care. EMS must often make rapid treatment decisions

on the streets or in homes and need access to critical medical history to provide

the best care.”

On July 26, 2016, EMSA awarded San Diego Health Connect $592,000, in

partnership with One California Partnership Regional Health Information

Exchange (OCPRHIO), to carry out the SAFR functionality for San Diego, Orange,

and Imperial Counties. The funding for this local assistance grant funding

opportunity supports a collaborative solution to integrate EMS as a critical

component of the health care system into the HIE landscape. Currently, the grant

is being piloted in three counties: San Diego, Orange and Imperial.

Pursuant to project objectives, each respective regional health information

organization must establish partnerships with their county LEMSA and must

identify one EMS provider and one hospital with which information will be

exchanged.

Health information organizations can work together with first responders

to improve the data shared during day-to-day patient care, emergencies and

disaster.

Data Sharing

There are many components for seamless HIE with EMS. EMSA established the

SAFR model with the intention of optimizing bidirectional data exchange (from

the HIE to the on-scene EMS provider, and from the EMS provider back to the

receiving facility and the HIE) as well as to support quality improvement and

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research. The SAFR model serves as an HIE framework for EMS by defining the

minimum functionality necessary to achieve HIE in easy-to-understand terms.

The SAFR model successfully meets all EMS data sharing goals through four

functions. (See Table 1 and Figure 1.)

1. Search: Search individuals’ health information for past medical history,

medications, allergies, and end-of-life decisions (i.e., physician orders for life

sustaining treatment or do-not-resuscitate orders) to enhance clinical decision

making in the field.

2. Alert: Alert the receiving hospital about an individual’s status directly onto an

electronic computer dashboard in the ED to provide decision support and prepare

for an individual’s arrival especially for conditions requiring time-sensitive

treatment or therapy such as trauma, heart attack or stroke.

3. File: File the EMS patient care report structured data directly into the receiving

facility’s EHR system for ease of access and better continuity of care.

4. Reconcile: Reconcile the EHR information including diagnoses, disposition,

billing, and payment back into the EMS patient care report for use in quality

improvement of the EMS system, performance measures, and population health,

making EMS a full participant in the exchange of electronic health information.

For EMS care teams, the verification of billing and payment information will serve

as a critical return on investment.

On Feb. 23, 2017, OCEMS, Newport Beach Fire Department and Hoag Memorial

Hospital Presbyterian were first in California to begin the implementation of

+EMS and the SAFR model for HIE.

Paramedic Geoffrey Cathey, from Newport Beach Fire Department, reported,

“I had more accurate information about the patient and saved time because I

was able to rapidly search her ePCR on my device to access the patient’s history,

medications and allergies.”

While still on scene, Cathey electronically transmitted the patient’s medical

information through OCPRHIO to the Hoag Hospital Newport Beach ED’s

dashboard demonstrating the first day-to-day emergency HIE in the state of

California and nationally.

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Carla E. Schneider, MSN, CEN, MICN, the ED director of Hoag Memorial Hospital

Presbyterian states, “Overcrowded EDs are often faced with challenges that

are associated with surges in patient arrivals. Specifically, related to allocating

resources, based on patient acuity, in a timely manner. The information available

through HIE, including patient history and current state, allows the healthcare

team to collaborate and prioritize care. Overall, the availability of real-time

health information supports our shared objective of providing safe, timely and

high quality care to the communities we serve.”

HIE programs help the sharing of secure access of a patient’s health information,

from dispatch of EMS to on-scene care, transporting of patients to the ED,

admitting them to the hospital, discharging the patient, and reporting of patient’s

outcome back to the EMS provider for data review for improving the quality of

emergency services provided.

It’s been recognized that the future of EMS patient care (and of all healthcare

providers) is now dependent on successful and secure HIE. To facilitate these

exchanges, non-profit regional health information organizations and private

HIE networks have been developed throughout the state and nation to connect

healthcare providers with one another.

Once connected, relevant patient care information is shared amongst providers,

which greatly aids in the continuum of patient care, lowers healthcare costs and

further supports the sustainment of healthy communities. These connections

further support “meaningful use” initiatives, which incentivize the use of modern

health technology.

Executive Director Paul Budilo of the non-profit One California Partnership

Regional Health Information Exchange states, “This effort is a tremendous win for

EMS and it demonstrates a profound change in the paradigm of patient care. Our

organization has established beneficial partnerships and increased functionality

between multiple healthcare providers and hospitals in Orange County including

the Hoag Memorial Hospital Presbyterian, Memorial Care Health System, St.

Joseph Health System, KPC Healthcare and others.”

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Implementation of EMS Access to Patient History

As first responders, EMS providers often have to make quick, lifesaving decisions

without any patient health information during emergencies. HIE in EMS gives an

edge previously not afforded to emergency medical technicians and paramedics.

Every entity within the healthcare continuum, from ambulance providers to

hospitals, and local EMS agencies, should benefit from immediate, secured,

electronic access to a patient’s health information.

Access to information leads to better care through efficient transitions of care,

improved outcomes and experiences. EMS ePCR systems of the near future should

support full functionality for HIE. Connecting EMS to the broader health care

system through HIE is necessary, and it’s inevitable.

Acknowledgment: Search, Alert, File, Reconcile (SAFR) Functionality for EMS

was developed by the California Emergency Medical Services Authority (Daniel

R. Smiley, June Iljana, Ryan Stanfield) under ONC Cooperative Agreement Grant

#90IX0006/01-00 (2015).

The authors would like to thank the following agencies for their assistance with

this article:

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Implementation of EMS Access to Patient History

Resources• The Office of the National Coordinator for Health Information Technology. (Jan. 2017.)

Emergency Medical Services (EMS) data integration to optimize patient care: The Search, Alert, File, Reconcile (SAFR) model of health information exchange. HealthIT.gov. Retrieved April 4, 2017, from www.healthit.gov/sites/default/files/emr_safer_knowledge_product_final.pdf.

• The Office of the National Coordinator for Health Information Technology. (June 21, 2016.) Health information exchange & emergency medical services. HealthIT.gov. Retrieved April 4, 2017, from www.healthit.gov/sites/default/files/HIE_Value_Prop_EMS_Memo_6_21_16_FINAL_generic.pdf.

DANIEL R. SMILEY has served as the chief deputy director for the Calfornia

Emergency Medical Services Authority (EMSA) since 1989.

SAMUEL J. STRATTON, MD, MPH, FACEP, FAAEM, is a deputy health officer and

the EMS medical director in Orange County, Calif. He’s also a professor in the

UCLA Fielding School of Public Health and David Geffen School of Medicine.

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Originally published November 14, 2012

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Functional ePCRs Should Be Convenient, Reliable & Easy to Use

By WAYNE M. ZYGOWICZ, MS, EFO, CFO, EMT-P

LET’S FACE IT—IN EMS, we’re always on the run. Using an electronic

patient care reporting (ePCR) system at the patient’s side must be quick

and easy. Your ePCR system must be user friendly, extremely reliable

and well engineered for the real EMS world. It must be convenient and

efficient at collecting data at the patient’s side in the mobile environment. The

hardware that runs the software must be tough and rugged. You’ll want a bright

touch screen, and if it’s a laptop, you’ll want to be able to convert it to a tablet PC

by simply rotating the screen 180°, which makes it easier to use while standing at

a scene. Your software should convert drop-down menus to large buttons that are

easy to press with a “fat finger.”

Wi-Fi and broadband cards can be embedded into your data-entry devices to

enhance communications with other devices. Ideally, your ePCR system should

communicate seamlessly between laptop and cardiac monitor using Bluetooth

technology. When scenes are too chaotic to allow for a free hand to capture real-

time information on the laptop, your crew can acquire event data on the cardiac

monitor, which can be accurately

time stamped and wirelessly

uploaded from the monitor to the

laptop after the call. The batteries

should last several hours on a single

charge.

With an ePCR system, you can

type in the patient’s social security

number or date of birth in the patient

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information screen and bring up past records to auto-fill patient information,

past history and billing data. A single-point entry system allows you to simply

check a box, and the home address information is pulled over from the CAD

system. You should be able to record patient vitals, procedures, drug dosages and

current medical history as fast as you can touch the screen with your finger. For

medical history and medications, most ePCR systems feature a drop-down menu

of commonly related conditions. More often than not, by the time the patient

is being loaded into an ambulance for transport, all that’s left to do is write the

patient care narrative.

Writing the narrative is often the most time-consuming part of charting an EMS

call. With ePCR narrative templates, users create effective and comprehensive

medical reports simply by answering related questions; the “auto-narrative”

feature generates an accurate narrative from the author’s chosen answers. Users

should add to the narrative so that each patient report is unique and accurate.

The system might also feature signature capture, which allows you to create

and use any number of electronic forms that require patient signatures and

attain those signatures while still on scene. If you have digital cameras on your

ambulances for documentation purposes, your ePCR system might be able to

import that data as well. And with Internet access via a broadband card, users

can directly access the FDA medication website.

Aside from this cool and efficient way to record vitals and interventions in a

consistent and error-free way, there’s another significant advantage—improved

patient care. The EMT attending to the patient can concentrate solely on patient

care, skills and interventions, knowing someone else on the crew is capturing and

processing information and data in real time. Entering the patient’s name from a

driver’s license can bring up patient history that may help guide patient care when

the patient is unconscious. And with the “fetch function,” data can be transferred

quickly to another laptop, reducing patient transfer times between agencies.

ePCRs also facilitate reporting of data on your system’s performance, run volume,

patient transports, medical procedures, medications given, skills performed,

patient destinations, etc. You’ll want to ensure that data captured in the field

easily and securely uploads to your main server. Wi-Fi “hotspots,” which can be

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installed at each station, allow for 10 times faster communication than using a

Broadband card. As your crew backs the unit into a station, one of the users can

prompt the system to upload the data to the main server for permanent storage.

Besides the canned reports that you should expect with any ePCR system,

administrators should request the ability to create customized reports. If you wanted

to know how many 12-year-olds got valium on a Tuesday in District 12, no problem.

Once you retrieve the data, you can export selected fields to Microsoft Excel.

Your system should also be reviewing all patient transports for protocol

compliance and complete billing information. After each report has been closed,

the incident report can automatically route to the quality assurance (QA) officer.

The QA officer should be able to easily flag a specific data field on the report, note

errors or questions, and return the report to the author. A complete history of any

modifications made to a report should be maintained by the system and can be

retrieved for review.

Also look for your ePCR to be able to establish a link to a third-party billing

company. This link allows your agency to electronically transfer patient records

in a secure environment and more quickly process patient transport bills.

Of course, your software should be compliant with the National Emergency

Medical Services Information System (NEMSIS) and the Health Insurance

Portability and Accountability Act (HIPAA). The NEMSIS project, supported

by most states, focuses on collecting national EMS data to add to the body of

knowledge in prehospital medicine. The database will be used in developing

nationwide training curricula, facilitating research efforts, coordinating disaster

resources and evaluating domestic preparedness needs in emergency medicine.

Although many of the data points in NEMSIS are somewhat narrow, you might be

able to expand your individual data points while mapping those choices back to

the original NEMSIS code set. The upload process should be simple, and your data

should look very clean on your state report.

As your mom always said, “Do your homework!” So, before you run out and

purchase a new ePCR system, gather stakeholders, do a needs assessment,

visit vendors, contact users and always field-test the product before you sign

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on the dotted line. Visit with field providers—the real experts. The people who

use the system every day can give you the best advice on user friendliness and

effectiveness of the product.

When you’re looking around for your new ePCR system, ask the vendors if

their product can do the things mentioned in this article. Although many of

these features seem somewhat simple, minimizing the time spent on entering

report data will make for happy end users, who then have more time to focus

on their number one objective—providing superior patient care and excellent

customer service.

WAYNE M. ZYGOWICZ, MS, EFO, CFO, EMT-P, is a 36-year veteran of the fire

service and has served as a paramedic/firefighter for over 30 years. Wayne has

served as a division chief for Littleton (Colo.) Fire Rescue for the last 20 years. He

holds a master’s degree in executive leadership, is a graduate of the National Fire

Academy’s Executive Fire Officer Program (EFO) and is a Certified Fire Officer

(CFO) through the Center for Public Safety Excellence.

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Company Description:Panasonic delivers game-changing technology mobile computing solutions that provide a customized experience to empower professionals throughout the public sector to increase efficiency, improve productivity and serve the public with 24/7 dependability. Panasonic engineers reliable products and solutions that help create, capture and deliver data of all types, where, when and how it is needed.

LINKS:

www.toughbookterritory.com/ems