A recent JEMS survey found that only 20% of EMS systems collect data on a notebook computer at the patient’s side.1 This fact seems astounding, considering the volume of portable computers and software applications available and customized for public safety. As professionals, we must realize that any delay in collecting patient information may mean losing accurate data, especially in a busy service where back-to-back calls can keep us on the road for hours before we start writing our reports.
But 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.
The Basic Needs
The success or failure of any ePCR system is almost always decided by the end users. So, like the responders themselves, these tools must not only function in all environments—hot or cold, day or night, wet or dry—but be highly dependable. Your ePCR system must be user friendly, extremely reliable and well engineered for the real EMS world. It must be convenient, easy to use and efficient at collecting data at the patient’s side in the mobile environment.
The hardware (e.g., laptops and handheld devices) that runs the software must be tough and rugged. If it meets military specifications, it’s perfect for the prehospital environment, where Murphy’s Law reigns supreme. 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 on a scene. Your software should have a feature to convert drop-down menus to large buttons that are easy to press with a "fat finger" on the touch screen.
Wi-Fi and broadband cards can be imbedded 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, which is a benefit for busy services that may run multiple calls back to back all day long.
Any computer and ePCR system can have hardware or software glitches from time to time that will frustrate and anger end users once they’ve become reliant on computer technology. In the event of an acute failure during a call, such as a "lock up" or "crash," the backup plan is always a paper report, but getting the system back on line quickly is the key to reducing user aggravation. To minimize hardware downtime, extra laptops, batteries and charging cords should be available and be immediately swapped out from the problem unit. The defective equipment can be repaired at someone’s leisure while first responders continue to answer calls and complete reports. Software trouble, more frequently seen after a system upgrade, can cause unpredicted problems on a stable system. Waiting a few months after an upgrade release before installing it allows other users to discover problems and gives manufacturers time to develop a "patch" or fix for the unexpected glitch.
Success—Roadside or Bedside
Without an ePCR system, a typical run goes like this: The crew arrives at the patient’s side and quickly performs a scene survey and initial assessment, determines the chief complaint and gathers SAMPLE history, executes needed interventions, transports, scribbles handwritten notes on gloves or cot sheets then finally on a report form (often hard-to-read). The patient is transferred to the destination facility with mostly completed documentation then the unit returns to service to tidy up the report later at the station.
With a mobile ePCR system in use, an ideal run goes like this: Crew arrival, documentation, scene survey, documentation, initial assessment, documentation, chief complaint, documentation, SAMPLE, documentation, interventions, documentation. You get the picture—documentation goes on continuously during the call, producing perfectly completed reports by the time you return to service with no paperwork to do back at the station.
Ideal? There’s so many steps! Not really. Let’s take a closer look.
First, understand that documentation is critical to the overall success of an EMS system. Without complete and accurate documentation, we can’t correctly transfer patient care, bill for services or defend our actions in court (should the need arise). Also, this quality of documentation allows us to benchmark skills and procedures after arriving by the patient’s side, which is an authentic measure of system effectiveness and performance. Truly understanding how and when we deliver care in the field will reveal areas for improvement and ensure we’re performing to accepted standards.
Now, let’s consider what’s really involved in all those extra steps of documentation. With an ePCR system, you can type in the patient’s social security number or date of birth in the patient 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 computer-aided dispatch (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. With some systems, the narrative author simply selects the appropriate template from a list (such as "stroke," "heart problems," "sick case," "auto collision," etc.), then answers predetermined questions suited to the medical case. Afterward, the "auto-narrative" feature generates an accurate narrative from the author’s chosen answers. Whenever a template is applied, the user should be encouraged to add to the narrative so that each patient report is unique and accurately represents the patient involved.
Using a template ensures important points are always covered in each narrative while avoiding the use of abbreviations and indecipherable shorthand. The software should include a spell-checker with both standard and medical dictionaries. The system should also automatically correct sentences written in all lower case or all upper case letters. Also, such fields as phone numbers and social security numbers will be automatically formatted to ensure consistency.
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. Some systems allow users to drag-and-drop pictures, videos and audio files directly into the incident report. And with Internet access via a broadband card, users can directly access the FDA medication Web site from the ePCR system to review information on prescribed medications while on scene.
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 information and data in real time and processing it as fast as it’s happening on scene. 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 unable to communicate. And with the "fetch function," data can be transferred quickly to another laptop, reducing patient transfer times between agencies.
Beyond the Bedside
There’s no doubt that your city manager or medical director routinely asks for data on your system’s performance, run volume, patient transports, medical procedures, medications given, skills performed, patient destinations, etc. Medical reports must be accurate, comprehensive and completed in a timely fashion to be used by a variety of our customers—patients, attorneys, coroners, organ recovery agencies, insurance companies, billing agents, etc. Patient records must be easily accessible at any time, and the power of good data should not be underestimated.
So, how much time does it take you without an electronic system? More than it needs to, that’s for sure.
First things first. 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 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.
With a central data repository, an EMS administrator can validate that customer service doesn’t end when patients are dropped off at the hospital. Although responders may feel that completing patient care reports is the least favorite part of their job, administrators know how important the paperwork really is. Besides the canned reports that you should expect with any ePCR system, administrators may have the ability to create customized reports without having to wait for the IT department to write a special program. The possibilities are infinite and instantaneous. 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 for further analysis. (Just be sure that the data you query is actually meaningful!)
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. Some systems can be customized to lock out authors who haven’t corrected previous reporting errors. A complete history of any modifications made to a report should be maintained by the system and can be retrieved for review.
With an electronic system, you should be able to establish a link to a third-party billing company as well. This link would allow 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 looks very clean on your state report.
Do Your Homework
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 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.
Training Coordinators! Read more from Wayne Zygowicz in "Managing Lifelong Learning" at www.jems.com/documentation.
Listen to the Experts
Register for the free webcast "Effective Documentation in the Digital Age" at www.jems.com/webcasts.
For any EMS agency to be successful, field providers must use effective documentation on every call. To deliver the best care with the lowest risk of liability, the right data has to get into the right hands in the right way. Attorneys Douglas M. Wolfberg, Esq., and Stephen R. Wirth, Esq., of Page, Wolfberg & Wirth LLC, present a dynamic webcast on how to document care the right way.
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1. Williams DM: "2008 JEMS 200-City Survey." JEMS. 34(2):36–51, 2009.