Sunday, December 8, 2013
Jeff Beeson, DO
Michael Potts, CCEMT-P
W. Heath Wright, BA, LSSGB, EMT-P
EMS systems have data, mountains of data. Most, however, are unsure how to use it outside of fairly standard resource deployment and clinical benchmarking. Often, the problem is data integration. Healthcare is delivered by many different providers in different locations. These are often described as spokes on a wheel, with the patient being the center, or hub. As the patient rolls down the street, the spokes themselves are weak, but when aligned and supported by the rim, they become part of an equalized, strong machine.
While the development of electronic health records has brought new focus on the need for integration in healthcare, most EMS electronic record systems continue to be episodic. They have limited ability to query their database and pull records from previous experiences. The result is another spoke.
In fact, the data gathered by EMS systems has a much larger potential. Three key areas where EMS data should be used are integration of mobile healthcare delivery, mass-gathering events and mass-casualty incidents.
Mobile Integrated Healthcare
If you haven’t heard the term Mobile Integrated Healthcare Practice (MIHP), you’ve probably at least heard the term Community Paramedicine. The concept of utilizing EMS personnel in non-traditional roles is not new. In fact, some communities have been doing it for decades. The Affordable Care Act has simply accelerated this development. As a result, EMS systems are questioning the longevity of their current deployment styles. The days of “you call, we haul” are ending.
Although many systems want to establish a MIHP, they’re often unsure of what they hope to accomplish. The first step should always be a needs assessment: Analyze the data. Utilize the expertise of public health programs to identify gaps in the delivery of healthcare in your community. EMS data includes location and types of calls within an area. Hospitals and health providers have data on their patients and types of visits. EMS providers that do inter-facility transports have additional data of where patients are moving through the healthcare system. These systems must talk to each other and allow EMS agencies to learn the final patient outcome and be a true partner in the healthcare system.
Data collection, storage and retrieval are becoming extremely important in the dispatch discipline of EMS systems. In addition to real-time notification of critical information to responders, EMS agencies can use this information to analyze previous calls. Such analysis may lead you to identify the need speed up or slow down response to specific calls, and/or send different resources. And it can be done on individual addresses or phone numbers or general geographic areas. Identifying multiple occurrences of the same activity or type of response is a great way to reveal volume increases with geographically significant patterns.
Many MIHP programs begin with a focus on high utilizers. Every community has a population that frequently utilizes EMS or the emergency department (ED) for primary care needs, no matter how many times we direct them to appropriate care. What would happen if we spent the time to find out why these patients return? A simple needs assessment can be performed by reviewing EMS and hospital data to identify historical trends.
Community resources are the backbone of a MIHP. Most communities have a number of different types of agencies, medical providers, service systems and ancillary programs—additional spokes in the wheel. Separately, their data is utilized to provide the specific service(s) they focus on, but communication between these entities is often lacking. Imagine if the individual programs worked together and shared their data. As a community of resources, the possibilities expand.
At MedStar in Fort Worth, we hold a monthly “meeting of the minds.” Social workers from hospital systems sit at the table with community mental health workers and folks from meal-delivery programs, homeless coalitions and religious organizations. The purpose is to share data. When each individual “spoke” has knowledge of the others, the patient can be navigated to programs that meet their needs. In many communities, there is unused capacity in these programs—but often, it goes unrecognized. When all the various resources meet, the individual organizations access their own data and create an in-person data exchange with others. Although not very technical, it has become the greatest asset in our MIHP. It is simple integration.
A simple starting point is to capture the address and or phone numbers of individuals identified in the needs assessment, a service provided in the 9-1-1 infrastructures in most systems. When dealing with CAD, this is known as ANI (Automatic Number Identification) and ALI (Automatic Location Identification). The number (or residence) can then be tagged in the CAD with specific information—specialized medical equipment or needs, appropriate responses, etc.
You can also tag a specific location as a known area that may have dangerous activity, such as a drug lab or area with violent patients or history of previous domestic violence calls, which can automatically initiate a police response along with medical personnel. In the MedStar system in Fort Worth, we flag addresses where an AED is on property. In the event one is needed, the 9-1-1 call-taker can direct the caller to its location. We also flag individuals with specific healthcare needs, including patients with home ventilators, ventricular assist devices, or those with emergent medical needs. In addition, we flag hospice patient addresses so that when the family calls 9-1-1, we can notify the hospice providers.
In 2009, we began our needs assessment by reviewing CAD and electronic medical record data. We identified specific addresses and patients who utilized 9-1-1 frequently. We went into our community to locate these patients. We assessed their needs, both medical and social, and then connected them with resources in the community. Many of the patients had issues with mental health, drug addiction and basic understanding of navigating our healthcare system. Most had transportation needs.
Our MIHP started with our EMS Loyalty program. We identified a need to better respond to, manage and navigate this subset of the population within our healthcare system. We worked with community resources to create a plan of care for these individuals. We flagged their addresses in the CAD, and worked with our hospitals to create notifications in their electronic health records to identify these patients. The result has been an integrated healthcare delivery that has decreased the 9-1-1 and ED use in this population. They are getting better healthcare with better outcomes, and in a more economical setting.
Any time a few thousand people get together for an event, incidents are going to happen. Mass gatherings create a strain on any EMS organization; in fact, the strain is often felt throughout the entire healthcare system. Issues from traffic congestion to lack of resources provided by the event promoters create significant concerns for EMS systems. The ability to collect data and quickly apply it can help mitigate these issues.
Many resource deployment tools and needs assessment calculations exist for mass gathering preparation. If the event has occurred before, data on types and numbers of patients handled is available and should be used in planning. The type of event, environmental exposures and expected participants will each have an effect on how busy the EMS provider will be. A NASCAR event will have a much different crowd than a symphony concert in the park.
Planning is the key. Software applications, such as FirstWatch, can monitor current system performance, while processes, such as PULSE (Performance, Utilization, Lost unit hours, Special Events & Excellence) can help evaluate previous and future system performance. Deployment simulation software systems such as MARVLIS can model the potential impact the mass gathering could generate on system demand. These types of programs also allow a service to make changes to the system in a simulated environment, so planners can see the effects.
Working with the venue operators, promoters and local public safety and healthcare organizations allows an integrated approach for response. You should understand how traffic will be diverted and where first aid or treatment areas will be located. By utilizing the similar concepts of unified command, all responding organizations can easily communicate available resources and known events and seamlessly share data.
After-action meetings and reports are also a significant source of data. By discussing what worked well, and where future changes should be made, organizations can improve the services they provide. These reports also become data elements that can be shared with others.
The Texas Motor Speedway in Fort Worth is a NASCAR venue where all of our data comes together. With attendance in the tens of thousands, this venue becomes a city within our city. We have more than 15 years of data from previous NASCAR races and other events held at that location, and we use it to work closely with the venue, promoters, on-scene medical teams, fire responders and police to ensure the attendees and sponsors have a good event. MedStar utilizes the MARVLIS software to show the shift in geographical demand during the week of the events.
Our PULSE process allows us to review previous events and preview expected system delivery, such as unit hours scheduled, time shifts in peak call volume and resource utilization, then create a staffing plan for the event. Weather forecasts are evaluated to determine any changes needed in our plan. During the event, our unified command, on-scene supervisors and system controllers utilize FirstWatch to monitor continuous system performance and make needed changes to staffing and posting locations based on call volume. We monitor our receiving hospital’s status on Web-based data systems to ensure even distribution of patients to appropriate locations. Data allows us to not only prepare, but also shift the system rapidly if unexpected events occur.
When buses, multiple cars or mass gatherings experience problems, they are usually big ones. The simplest definition of a mass-casualty incident (MCI) is when the number of casualties overwhelms the available resources. One of the most important pieces of data at an MCI is the ability to track patients. Patient tracking applies in several different areas of EMS, including MCI evacuation/relocation, mass-gathering events and sheltering locations.
Web-based patient-tracking tools can integrate with EMS patient care reports and hospital medical records. Recent versions integrate tracking numbers or barcodes from scene triage tags. Having a Web-based tool gives the entire incident team the ability to obtain information, deploy resources, track movements and develop plans.
Once an incident is created, a series of pre-planned events occur. When a scene size-up is entered, automated alerts notify hospitals and require them to update their bed status. EMS responders then receive the bed status reports to help formulate a plan for transporting patients to appropriate receiving facilities. As patients are triaged, and transportation is assigned, the software will track movements via the unique identification number. Once a hospital has been assigned a patient, they can view the type and numbers of patients that are inbound and prepare to receive them.
Hospitals acknowledge electronically that they have received each patient, allowing the incident commander to continuously update their patient count and assign resources more appropriately. This system-wide integrated approach provides real-time data to those responsible for decision-making to allow for better tracking of resources and patient movements during the event.
Such technology maked patient tracking easier and more accurate for field providers and receiving facilities. Web-based applications are great tools for the providers working the incident, the emergency operations center monitoring the incident, and receiving hospitals determining what their demand will be. Continuous data is a key to successfully managing an MCI.
It’s What You Know
Data should drive most things in EMS. How it’s applied is limited only by the minds of those who choose to use it. As EMS transitions into more healthcare delivery, the non-traditional uses of data will become more important. As a partner in the healthcare system, our significance will only be recognized when we reveal what we know. In any setting—from MIHP to mass gatherings to MCIs—that recognition comes from our data.