A $15 million project funded by the Obama administration is one of the first of its kind to affect EMS in a big way. Phase I of the San Diego Beacon Project went live in December 2011 and integrated EMS within its Health Information Exchange (HIE) design. It broke “new ground” to innovate EMS data reporting and the sharing of patient data in near real-time with healthcare providers and organizations. The project is on track to accomplish its vision of achieving its three proposed clinical targets:
- 1. Improving quality of care for cardiovascular and cerebrovascular diseases through prevention measures aimed at high-risk patients, better acute care through ECG transmission from EMS to ST-elevated myocardial infarction (STEMI)-receiving centers and more efficient chronic care management;
- 2. Improving the health of San Diego county’s population through better immunization rates and syndromic surveillance; and
- 3. Identifying and implementing cost efficiencies through reduced emergency department (ED) visits, hospital admissions and less-repeated imaging tests.
The forward-looking vision of San Diego’s HIE design integrates EMS in San Diego county community healthcare delivery. It has the potential to influence the role of EMS within other HIE communities, the solution offerings of EMS products and services vendors, and most importantly, the delivery of healthcare by EMS professionals.
Let’s briefly introduce the Beacon Community program and how San Diego became involved. The program is part of the $30 billion American Recovery and Reinvestment Act of 2009. This legislation set aside $250 million under the HiTech Act to provide funding over three years to selected communities to pilot health information technology (IT) and exchange with a goal of making marked and sustainable improvements in healthcare quality, safety and efficiency.
Nationally, there are 17 Beacon community awardees. By extending advanced health IT and exchange infrastructure with the leveraging of data to inform specific delivery system and payment strategies, these Beacon communities are charged with demonstrating a vision of the future where hospitals, clinicians and patients are meaningful users of health IT; these communities also seek to achieve measurable and sustainable improvements in healthcare quality, safety, efficiency and population health.
The national vision of each Beacon HIE is connectivity and interoperability with the National Health Information Exchange (NHIN) (see Figure 1, p. 43).
The San Diego EMS community owes its involvement in the Beacon project to the proposal submitted by the University of California Medical Center (UCSD) at La Jolla, headed by Ted Chan, MD, and James Killeen, MD. San Diego’s award totaled more than $15 million. Chan and Killeen defined the San Diego Beacon Community objectives:
1. Integrate health IT into care delivery:
> Coordinate clinical improvement efforts ;
> Improve care coordination among providers; and
> Engage patients and families.
2. Measure and evaluate clinical targets.
3. Build a regional health information exchange infrastructure.
4. Improve the ability to integrate data across electronic health record (EHR) platforms:
> Grant access to and sharing patient data to improve healthcare quality;
> Have the ability to view clinical information from other health systems; and
> Alter clinical decision making to change healthcare outcomes.
5. Achieve cost-efficient care by reducing redundant imaging, ED visits and re-admissions.
6. Aggregate information across the San Diego region for patients who obtain healthcare at multiple institutions or population-based interventions:
> Department of Defense, Veterans Administration and Centers for Medicare and Medicaid Services patients ; and
> Vaccinations and other public-health initiatives.
7. Assist providers, medical groups and medical centers with the following tasks:
> Achieve meaningful use and other federal incentive/requirement programs; and
> Position it for other future healthcare reforms.
The project got underway in 2010 and is now implementing many of its objectives. This article should provide local and national EMS communities with a level of detail and insights that hopefully will inform and inspire EMS professionals.
Let’s begin by describing the project’s EMS infrastructure. Doing so will lay the groundwork to emphasize and highlight the significant role EMS plays in San Diego’s delivery of community-based healthcare.
San Diego Beacon HIE’s design is unique in that EMS was defined as a specific architectural layer within the HIE application. Other Beacon Community HIE applications didn’t incorporate EMS interoperability and communications within their initial system design. This presents an opportunity for the San Diego Beacon Community project to have a profound effect on advancing the state-of-the-art in the delivery of near real-time EMS in community-based healthcare not previously possible.
The potential advances in understanding how to best use and “tune” real-time prehospital patient data, including the use of patient outcomes data within a time-critical operational framework, should have the following significant implications for EMS nationally: technology innovation, realization of long-standing goals in time-critical information delivery of prehospital patient information and care coordination, new business opportunities for vendors and advancement of EMS policy development.
The EMS Project
Let’s now examine the EMS portion of the project and its forward-thinking system design in detail. Within the overall San Diego Beacon HIE architecture, the EMS project is defined by a network topology that incorporates a bi-directional interface from San Diego responding agencies serviced by vendor-supplied electronic EMS documentation systems capable of interfacing with the HIE EMS hub server.
The vendor electronic patient care record (ePCR) Web server submits a near real-time EMS run report and ECG data elements to the EMS hub. Real-time 9-1-1 computer-aided dispatch data is exported to the EMS hub. The EMS hub then feeds this patient data to the HIE clinical vault (i.e., database server) based on business rules. This clinical vault stores all imported EMS hub patient data and provides an interface to a participating hospital’s administration, discharge and transfer (ADT) system.
This process allows for the combination of the following data: demographic, billing data and clinical outcomes (e.g., laboratory, immunizations, diagnosis and discharge).
The EMS hub pulls this patient data payload from the clinical vault, based on business rules, and exports it to the vendor ePCR Web server.
This bi-directional patient data capability means a patient’s discharge and ED diagnosis outcome data, including demographic and billing information, can now be made available by the external ePCR vendor for distribution to the relevant responding agency.
The implications are considerable. Now, in addition to the real-time aggregation of 9-1-1 dispatch information and EMS run reports for sharing with receiving hospitals, the patient’s clinical outcomes will be made available for “distribution” back to agencies.
There were several key challenges to overcome in the HIE technical and non-technical design, clinical integration and EMS project areas. Each challenge area may serve to define a design definition and requirements to assist other Beacon Community and/or community-based healthcare projects wishing to incorporate EMS. Table 1 (below) briefly summarizes these challenges.
By and large, the challenges have been overcome and addressed through the HIE system design and architecture developed in 2011. All required system interfaces and integrations have been defined and are in various stages of completion and implementation.
Within the EMS project, the design was broken into two distinct integration phases to achieve connectivity. The Phase I integration specification described the export of specific National EMS Information System (NEMSIS)/California EMS Information System (CEMSIS)/local agency data elements by ePCR vendor to the EMS hub.
Phase II specifies the data export from the EMS hub to the vendor ePCR. Completion of phase I occurred in the fourth quarter of 2011. Phase II is scheduled for completion by the end of the first quarter in 2012, pending completion of final San Diego County specifications describing data reporting requirements.
The San Diego Beacon Project posed not only HIE design challenges but also technology and innovation challenges to the EMS vendor community. Here’s why: the ability for EMS vendors in the San Diego region to provide ePCR solutions capable of achieving connectivity with the HIE. Interfacing with the EMS hub requires a specific level of technological advancement.
In other words, ePCR solutions must be Web-based and supported by a range of next-generation and available hardware options. For example, as trends favor smaller and more powerful form factors, EMS systems are beginning to favor the use of mobile devices (e.g., smartphones and tablet devices) for faster patient data collection.
This would imply that vendors currently offering Web-based solutions may also need to expand their systems to include native smartphone or tablet operating systems (e.g., Android and iPad). Any system must be supported by available hardware. For example, there are abundant smartphone and tablet device options for Android and iPhone operating systems, but few for Windows mobile-based operating systems.
To keep in line with emerging trends in the EMS industry and compatibility with HIE environments, EMS technology must support secure Internet environments, incorporate back-end database structures, operate on next-generation smartphone and tablet devices and provide the capability for potential user interface customizations. Each community-based EMS system will need to adhere to NEMSIS, regional and local data reporting requirements, supply management and protocols affecting user interface data capture capability.
Currently, the vendor ePCR data systems listed in Table 2 (at left), provide Phase 1 connectivity between San Diego County responding agencies, area hospitals and the San Diego Beacon HIE EMS hub.
The last key remaining EMS project challenge is the development, consensus and deployment of the combined NEMSIS/CEMSIS/San Diego local agency data set strategy. A combined data set specification is expected by the first quarter of 2012.
The Ultimate Goal
As is obvious from the discussion thus far, the project is ground-breaking and represents an example of the nation’s initial HIE designs for creating a new national health cyber-infrastructure. San Diego, representing a 21st century city, is in the forefront as a live test bed of health cyber-infrastructure innovation to include the role(s) EMS is capable of providing in emerging community health systems.
The implication for EMS, as a key role in the delivery of healthcare, is powerful, even on a national level. In San Diego, the project plays the central role of providing the basis for advancing new EMS technology, operational processes and insights for better patient care.
Technology implications may be thought of as both “incentivizing” and “pressuring” EMS vendors to advance EMS product development cycles. Vendors who respond by supporting dominant operating software systems will be able to offer their customers a wider range of advanced hardware mobile device options and data plans.
Advanced devices and operating systems will enable better interface connectivity with the HIE, increasing the level and speed of data interoperability. Patients and paramedics will benefit from more efficient data collection and more effective sharing and routing of the data.
The operational implications to EMS and San Diego county patients are even more potentially enriching. The project provides the basis to evolve the sustainability of new, evolving interoperability processes for EMS as part of the emerging community-based healthcare delivery framework. The project will benefit patient care and EMS in San Diego in many ways:
STEMI: ECGs will be sent from the EMS monitors to the “EMS hub,” and ED staff, and cardiologists will be able to see them before the patients arrive. The benefit is that EMS providers can achieve faster door-to-balloon times and better outcomes for cardiac patients. This will also lead to greater integration of EMS into emergency care and set the stage for stroke alerts or other time-sensitive medical conditions.
Patient information: PCR information will be sent in real-time bursts to the receiving hospitals. The benefit is better resource management and preparation of the hospital ED for when the patient arrives.
EMS crews: Critical patient information will be available to the crews in the field. The benefit is that patient hospital histories, medications, allergies and medical information will be available at the scene.
Faster ambulance turnaround times: Crews will have a majority of their reports auto populated from the Beacon EMS hub, so they’ll spend less time in the hospital ED charting. The hospital ED will also have the ability to receive prehospital patient information more efficiently (i.e., some ePCR solutions, such as the FieldSaver Android, include a fax/print from device capability to exploit the connectivity options to the hub). The benefit is faster and higher quality documentation.
The Beacon project will also improve EMS crews’ documentation. Crews will have access to a consolidated database of all patient billing and demographic information across all participating hospitals for auto-insertion into their reports. This means faster access to patient billing and outcomes data, less time taken for EMS crews to enter billing information, more accurate data, better reimbursement and faster return to zone time.
Another huge benefit will be the ability to “close the loop” or complete the “360° data,” and have ED diagnosis and patient outcome information available to EMS providers. The benefit is improved quality assurance (QA) and training to the crews.
Yet another benefit will be improvement realized in the EMS crew and department perspectives. When EMS providers drop off a patient with an altered level of consciousness, they’ll now be able to get important feedback about the chief medical complaint, which should enhance QA and assist agencies in improving the clinical skills of their personnel.
From the department’s perspective, it gains improved QA and an improved ability to determine which individual crew members need additional training and will allow each department to focus clinical training in a truly systematic manner.
Some other presumed benefits to EMS include further integration into the healthcare system. EMS providers’ early reports and assessment will become vital to patient care. EMS care will become more of a continuum or extension of the ED instead of a “drop off.” Patient care now will now truly begin in the field, and EMS will be a part of the total healthcare delivery system
The project also holds some future implications for EMS. One of those implications is more responsibility. EMS will be held to a higher standard as it becomes more integrated with the evolving continuum of emergency care and response. EMS will also have integrated technology.
Future data and communication systems will be faster, simpler, truly mobile and will integrate with other databases and medical devices. This creates more pressure on monitor companies and other EMS data systems to embrace connectivity and co-operability.
Finally, this introduces a concept of data-driven care. How EMS provides care in the field will evolve as data from the San Diego Beacon and other projects guide us on giving better care.
This project is clearly on the cutting-edge of innovations for healthcare information systems technology within time-critical environments and its deployment. The potential for improving EMS is significant. We also believe it will change the way prehospital and hospital staff view their involvement and responsibilities with each other and the involved patients. JEMS
This article originally appeared in January 2012 JEMS as “We Meet Again: Now you can know what happened to your patient after you dropped them off.