It’s time. Patient data needs to be shared more efficiently, officially and consistently with all services involved in the continuum of patient care, including prehospital programs. When a patient is admitted to the emergency department (ED), the admitting clerk gathers important information, which routinely is shared with other services the patient contacts once they’re in the hospital. That means the physician group, laboratory company, anesthesia department, physical therapy and other departments all have electronic access to the first record initiated in the ED.
EMS—public or private, BLS or ALS—needs to be connected to receiving facilities’ electronic patient databases. With the advent of electronic patient records, appropriate safeguards can be put in place to ensure privacy isn’t compromised. Many receiving facilities already provide patient information to prehospital crews before they leave the hospital, but this paper data isn’t efficient because most crews are busy and may not be able to obtain the patient’s admission data before they leave the facility. An electronic patient care data connection, just like other services within the hospital, would allow for an appropriate transfer of patient information in a more efficient and secure manner.
Medical insurance companies and hospitals benefit from the care prehospital crews provide and their initial role in the patient care continuum. Most of the technology on board ambulance units is purchased by the prehospital agency. For example, prehospital continuous positive airway pressure (CPAP) devices have improved care pro-vided in the field and saved money for insurance companies and hospitals. Agencies, paramedics and EMTs who provide CPAP, perform 12-lead ECGs and transport patients to their hospitals of choice instead of the closest one enact myriad additional customer service enhancements, usually with no reimbursement.
Currently, our agency’s patient care records and information are manually entered, sometimes redundantly, and are then manually moved from one location to another. The ambulance crew keys patient assessment information into their handheld device, summarizes first responder patient care information that took place prior to their arrival or during a combined team approach, and then prints a hard copy for the receiving facility and/or base hospital.
Then, the hospital admission sheet (commonly referred to as a “face sheet”) is obtained in hard copy and manually entered into the ambulance crew’s prehospital record.
Once the ambulance crew’s report is complete with the prehopsital first responder’s information, the transport crew’s information, family information and receiving facility data, it’s manually uploaded into a central network and/or printed for a currier pickup. However, every step included in the aforementioned process can be done wirelessly and more accurately.
Types of Data
In this article, I discuss four types of data that routinely change hands between the prehospital crew and receiving facilities:
Prehospital patient care record (PCR): This is a comprehensive report from the time of dispatch until the patient is turned over to the receiving facility;
Patient contact and billing information: Essentially the same data points collected by the facility’s admission clerk;
Specialized patient data: Information about the patient that needs to be produced during the call to optimize patient care (i.e., 12-lead ECG); and
Outcome data: An important goal of any quality assurance (QA) program is improving the care provided by the EMTs, paramedics and system as a whole. Currently, crucial information that’s either unavailable or difficult to obtain are the answers to the questions: “What happened to the patient after they arrived at the hospital?” And “what was the diagnosis, course of treatment and disposition of the patient?”
Prehospital agencies and hospital systems need to work together to share patient data in a more timely and consistent manner. For example, ambulance crews are typically required to leave a copy of their patient care record with the hospital, ideally before they go back in service. This initial documentation may be just that, initial, and it may be incomplete. How can the prehospital record (left at the receiving facility) be updated by the transport crew if the patient has already been admitted or discharged? This example leaves the door open to having two records for one patient—initial and final. In a small system, this may not be much of an issue when the ambulances transport to the same hospital every time or to a small number of facilities. But for a large system, transporting to a larger pool of facilities, the problem is magnified.
Essentially the same issues surround the patient’s personal information, and the patient often gets questioned twice for that information—once by the ambulance crew and once by the hospital admissions staff.
The solution to these issues already exists in virtually every hospital—they share information. Prehospital teams are recognized by HIPAA as having a right to access information about patients they encountered in the scope of their service. Opening up the electronic pathway from the prehospital agencies to the receiving facilities benefits everyone, while respecting patient confidentiality. The following is an example of what lies around the corner:
An ambulance crew is dispatched to an elderly male with difficulty breathing. The dispatch center’s CAD sends the response information to the ambulance crew’s handheld electronic PCR device, which the crew takes when they make patient contact. The patient’s identifying information is entered into the handheld device, which wirelessly connects to the prehospital/hospital inte-grated network, and the information pipeline is established. The patient’s prior contacts are made available to the ambulance crew, and the live patient assessment data is transmitted to the receiving hospital while the patient is still in bed. Vital signs and key assessments are updated, including series 12-lead ECGs, which are sent to the ambulance’s assigned base hospital and the cardiologist at the catherization lab.
Once the patient is transported, the hospital’s admission record is sent to the ambulance’s electronic patient care record, and the ambulance crew’s initial prehospital record is updated and finalized in the hospital’s patient record system. The following day, updated insurance information is provided to the hospital by the family—and this too is updated automatically back to the ambulance agency. The last piece of information to be automatically updated in the hospital and prehospital PCR systems is the outcome data.
Bridging the Gap
How is the gap between prehospital and in-hospital information bridged?
Although many EMS providers today have successfully navigated the transition from paper to electronic PCRs (ePCRs), the question of how to securely transfer data to the stakeholders within the hospital walls is still a formidable task.
At the national level, grants have been awarded to task challenged health-care systems and providers to look beyond their own silos and develop innovative solutions to sharing data in an appropriate, secure manner. The future will hold promise for systems that are truly integrated and benefit all users up and down the chain.
Imagine an integrated approach that links public safety/dispatch to electronic monitoring devices to ePCR databases to hospital systems and clinics nationally. Imagine a future in which an EMS provider could successfully determine the right place to take their patients, based on their health-care plan, while in the field assessing the patient. Imagine a system that performs surveillance and determines cost-prohibitive trends that could benefit both EMS and the hospital systems. Imagine a future in which physicians are aware of how their patients interface with the EMS system. These possibilities become reality when systems are properly linked and integrated.
The current explosion in the wireless device market and the constantly improving wireless broadband transmission field are the vehicles to this connected future. If you take a look in your local phone store, you’ll see the variety of tablets, slates and “pads” being sold as EMS applications for smartphones. With the advent of LTE and 4G networks, high-definition video over wireless is entirely possible.
Manufacturers of electronic devices and software operating systems are developing at breakneck speeds. Device chip manufacturers are producing processors for tablets and smartphones that rival the speeds you’d expect from a laptop or desktop computer. Such industry giants such as Apple have pushed the integration of video calling into the handheld market, and it won’t be long before tablet manufacturers join.
Do these technological breakthroughs have a place in EMS? Absolutely. The genesis of prehospital emergency medicine has roots in the concept of seeing the provider as an extension of the physician. We’re the eyes, ears and hands of the hospitals. By providing those physician extenders tools that allow a crew to look at the patient in clear, high-resolution video without dropped frames, that vision would become clearer. By conferencing and recording voice on scene at an emergency, the team could hear what’s happening without needing a radio translation.
The argument could be made that we won’t be using technology to change how we do business in EMS, but rather that technology may change us. Look at how society has changed in the past few years to become more connected. Because of these advancements, we’ll soon be expected have medical devices and charts capable of communicating across broad networks available to our customers. The expectation will be that we already know the patient’s medical record beforehand.
Agencies will need to build on their already existing networks and expand to a secure wireless infrastructure. Technology to make ambulances into rolling hotspots, called mobile gateways, can allow for secure wireless data transfer. The speeds supported by 4G networks could allow for larger capabilities, such as voice and video, over broadband. Mobile data gateways will provide data connections that could potentially save costs in the long run, because CAD information, PCRs and monitoring systems could all potentially share the same pipeline. In addition, many gateways provide a level of redundancy needed and expected in our infrastructure. Multiple wireless providers and modes (such as satellite) could also be included in these devices to ensure connectivity.
Probably the most important factor will be for EMS-related vendors to develop products that will allow for the transfer of data with ever-evolving speeds and technologies. The products will need to be easily upgradable for software and hardware. A prehospital agency won’t want to be locked into products that fail to keep up with technology. Agencies will come to expect products that are more “self-aware” and connected, allowing for auto-updating of software and reporting of defects or failures. Device tracking is an open area in which manufacturers should be capitalizing on such technologies as radio frequency ID. Missing equipment could be a thing of the past, and checking your rig will be as simple as looking at a status board.
Hospital and prehospital agencies need to commence discussions on connectivity and standards. Standards for communications between the hospital information
technology world and the prehospital data standards world will need to be shared.
How data is shared securely while protecting the rights of the patient, hospital and agency is currently being resolved in a few pilot projects. One thing is for sure—the day of integrated data is near. JEM
This article originally appeared in March 2011 JEMS as “Secure Data Transfers: Sharing patient information in the electronic age.”