Nearly a decade ago, Acadian Ambulance Service—the nation’s largest privately owned EMS agency—developed, implemented and went "live" with its own ePCR system. With a massive service area and call volume, our organization needed to adequately transition away from paper and into the future of electronic records. Although many ePCR software packages are available on the market today, back in 2000, we decided to use our in-house expertise to develop our own program. And since then, we’ve continued to consider new methods that ensure complete field documentation, continuous quality improvement and continuing education, and efficient billing processes.
At the beginning of our movement away from paper, a pen pad system was piloted but never implemented. Then, in 2000, Acadian decided to have EMTs and paramedics call in their run reports to live operators located in a centralized dispatch area. Both operator and medic followed the ePCR software templates, navigating through nearly 11 pages of questions about the patient, their demographics, type of emergency, treatment in the field and en-route care to a medical facility.
Although the concept seemed logical, field providers faced the challenge of long "hold times," just waiting for an available operator to take their report over the phone. This was understandable given the amount of transports that Acadian responds to each day and the amount of information that was required on the ePCR. Oftentimes, a medic could be waiting between 15 and 20 minutes for an operator.
Back at the drawing board, Acadian looked at other methods and came up with a dictation option.
Greg LeBlanc, EMT-P, a preceptor for Acadian Ambulance, was one of two medics chosen to pilot the dictation system. LeBlanc went through the entire process of a scene-to-transport scenario and, once the call was completed, dictated the ePCR, which was placed in a voicemail queue. Operators then took the field reports from the queue in the order in which they were received and transcribed them. Once a report was transcribed, it was sent back to the medic’s station computer inbox for review. Providers could change or delete anything that had not been reported or understood correctly.
"The dictation process is what worked best for me," LeBlanc says, "because once I completed a call, I could just dictate the report immediately following our transport, and then I was finished with it until they sent it back for review."
Progress Over Time
Over the years, Acadian has altered, tweaked and made necessary changes to their ePCR software package. In 2001, the National Association of State EMS Directors, in conjunction with its federal partners at NHTSA and the Trauma/EMS Systems program of the Health Resources and Services Administration’s (HRSA) Maternal Child Health Bureau, developed a national EMS database known as the National EMS Information System (NEMSIS). As NEMSIS became more active and developed many useful protocols, Acadian modeled and enhanced much of its software capabilities to match some elements and recommendations set by the NEMSIS project.
Another major change was allowing providers to either use dictation or a "medic-created report." The medic-created report is prepared during shift downtime or after a shift is completed, using a secure station computer or a laptop in the units in some locations within the service area. The provider simply follows the prompts of the ePCR templates to fill out the PCR. Providers must completely fill out a screen with the appropriate answers before the software will allow them to proceed. This feature minimizes errors, misspellings and inappropriate abbreviations.
After completion, the provider e-mails the report to the call center, where reports are processed in the order received. Field providers are required to leave a record of the patient care and signature page with the emergency department, and then submit the ePCR by the end of their shift.
The ratio of medic-created document to dictation usage is three to one, meaning that approximately 70% use the computer system and about 20% use dictation. The other 10% are called in to a live person, usually by a new hire, who has a 60-day window for this coaching process.
To facilitate the ePCR process, Acadian established a Medic Support Center (MSC) that’s designated specifically to take reports from field providers. The center generates reports for emergencies, non-emergencies, facility-to-facility transports and refusals. Of the 21 call stations dedicated to MSC calls, six stations are dedicated to business office details and also handle the pre-scheduled transports. The MSC staff is made up of medically certified personnel—EMT-basics, paramedics or registered nurses.
One of the primary functions of the MSC is to begin building the patient’s invoice statement from the field report. Acadian uses the AR2000+ and EMS billing and receivable software. This system was specifically designed by an Acadian team composed of members with different knowledge sets and an external software consultant versed in EMS receivables. The system streamlines the EMS billing and collection process and offers invoice development, system audits, general ledger export properties, membership management and CAD integration.
All reports and billing are created using the ICD-9-CM Procedure Codes, which determine what, if anything, an insurer or federally funded program will pay. "Real time" data is collected, and parameters have been set up so that a more compliant record and invoice statement for Medicare, Medicaid and other insurance carriers can be created. This ensures proper billing and minimizes any appeal process that might develop over a reimbursement issue.
The MSC personnel can quickly go from the field report on screen to the AR2000 software and extract the information it needs for fast, compliant and efficient billing. Almost immediately after the field provider receives and approves the final run report, the invoice can be posted. Previously, it could take up to 90 days from the time a provider went out on a call to the time an invoice was sent out on a patient, and now that time has dropped to approximately 17 days. In today’s current economic climate, the "quick bill" is a huge advantage.
By using these two systems, AR2000 and ePCR, Acadian has improved the collection process and maximized revenue for the company, which is employee-owned. "The Acadian software package was built to fit the Acadian business model and seems to work well for the company," says Bob Richardson, business application software manager with Acadian. The connection that Acadian has made with their software programs makes it an almost seamless transition from patient care record to invoice statement.
Acadian also puts a lot of emphasis on its quality improvement initiatives, and the ePCR system allows us to look at multiple protocols and audit provider compliance. Using various ePCR reports, the quality improvement manager and medical director can evaluate how well a provider is doing in the field, review patient outcomes and can ensure a high-level of patient care with a true dashboard of the care being delivered.
The information from Acadian’s ePCR report can trigger various audits. The audits serve as a follow-up to determine if a particular provider has followed appropriate protocols, to review what type of calls Acadian is typically dispatched to, and to look at various medical issues encountered in the field to see if more education should be geared toward these areas.
Ross Judice, MD, medical director for Acadian Ambulance, believes in the ePCR as an educational tool for continuing education and for "real-time" feedback on calls. "Behaviorial models show that when a person gets immediate feedback, learns something right after a call or incident, their performance improves," he says. "When we can call up a report for audit, look it over the same day as the call and can then give that medic instant feedback, the medic will have a memorable reference for the next time a same event or call should occur. For us, as an emergency provider that’s important, as it helps us improve our quality of care in the field."
Most providers understand that the audits are for educational purposes and welcome the feedback to ensure that they’re delivering the best possible patient care. Acadian’s program can also facilitate research efforts for the EMS systems that Acadian is part of in three states and in the Gulf of Mexico. By following many of the 81 elements listed by NEMSIS for a good EMS information system and looking at the five basic NEMSIS recommendations for the success of an EMS operation, Acadian adds their own mix to the package, creating a well-rounded, diverse emergency delivery system with appropriate reporting mechanisms and documentation.
"Acadian has always been recognized in the industry as a leader in communications ... which is the heart of any effective EMS system," explains John Zuschlag, executive vice president and chief administrative officer at Acadian Ambulance. "Our ePCR program is just one more spoke in the wheel that keeps those lines open and available to facilitate continuing patient care improvement."
UNIQUE SERVICE MODEL
Acadian receives nearly 1,000 calls a day for medical or trauma emergencies and also responds to daily pre-scheduled transports. Headquartered in Lafayette, La., Acadian serves 38 parishes or counties in Texas, Mississippi, Louisiana and the Gulf of Mexico. Approximately 2,300 full-time and part-time EMTs and paramedics work on a fleet of 255 ground ambulances, 30 van/bus transport vehicles or serve on one of the company’s eight aeromedical helicopters or fixed-wing aircraft.
Established in 1993, the employee stock ownership plan (ESOP) enables Acadian’s working family to share in the wealth they help to create. According to Acadian’s leadership team, the ESOP program maximizes human potential by enhancing the self-worth, dignity and well-being of their employees. Employees are motivated to seek ways to save the company money and to work with all the best efficiency models put into place. Clearly, for the providers, the creation of their own ePCR project maintains that objective.
Disclosure: The author has reported no conflicts of interest with the sponsors of this supplement.