The story starts off in a familiar way: A young man has been involved in a motor vehicle collision. When the ambulance arrives, EMS providers focus on the man’s erratic behavior and his inability to communicate.
That is, until they receive his electronic patient record on their tablet PCs—the young man has a medical history consistent with schizophrenia, so his behavior isn’t far removed from his baseline.
Although this seems like the far-off future of health-care reform, it’s now the norm in Indiana, says John Finnell, MD, professor of emergency medicine at the Indiana University School of Medicine and research scientist with the Regenstrief Institute, which oversees the Indiana Network for Patient Care (INPC).
The INPC started in the mid-’90s between two Level 1 trauma centers located minutes away from one another in Indianapolis. Since then, it has expanded statewide to include most physician practice groups and health-care systems. This past year, it started delivering (sharing) electronic patient records wirelessly to EMS crews.
When a patient is admitted to the emergency department (ED), the system queries all of the hospital departments and the INPC database, looking for records under the patient’s global identifier. ED health-care personnel then have 24 hours of access to the patient’s laboratory results, prescription list and other information. It works similarly for EMS crews via wireless tablet PCs.
“Within 30 seconds [of a request], we push back a PDF to [their] tablet,” Finnell says. “It’s that same sort of report that the emergency departments get.”
With health-care reform dictating electronic patient record sharing, the network serves as a case study.
“The Indiana system is one of a kind,” says Cindy Raisor, RN, data project coordinator for the EMS Performance Improvement Center (EMSPIC) at the University of North Carolina at Chapel Hill.
According to Finnell, the Indiana network is currently the only system of its kind in the U.S. and worldwide; a similar system is being implemented in Great Britain.
“What they’re doing [in Indiana] is actually leveraging data systems in the way that they should be leveraged,” says Greg Mears, MD, principal investigator at EMSPIC.
But what about patient privacy? How does INPC leverage the data without violating HIPAA?
“Basically, the agreements that Regenstrief has with each of its partners is a business agreement to provide health care,” Finnell says. “Patients have the option to not share their information if they so choose.”
Mears agrees. “It’s all permissive under the law; there are no HIPAA issues.”
Additionally, data is encrypted on a secure network, user authentication is required, and there are common sense fail-safes. If a user requests someone’s profile multiple times, the system notices, Finnell says.
“The patient’s identification and the sanctity of patient information can be protected, and it appears that these folks have done a brilliant job of being able to provide that back to EMS,” Raisor says.
Although Indiana is currently alone in its efforts, it won’t be for long.
“I wouldn’t describe this as an anomaly,” Mears says. “This really is the future of where everyone is going.” —Lorena Nava Ruggero
Double Sequential External Defibrillation in Wake County, N.C.
Many paramedics have seen it happen—a patient goes into V-fib, is shocked once, twice, perhaps a dozen times. Despite all this, the patient’s heart doesn’t respond to the repeated electrical shocks, and the worst happens—they die.
But what if EMS had one last way to normalize these patients’ heart rhythms?
Brent Myers, MD, MPH, FACEP, EMS medical director in Wake County, N.C., may have found it with double sequential external defibrillation. In hospital settings, the same method is used to save patients in V-fib. But, it hasn’t been used in prehospital settings until now.
“It may be a little unusual on the street, but it’s not unheard of in the hospital by any means,” Myers says.
Double sequential external defibrillation uses two monitors/defibrillator units. The second set of pads is placed just left of the patient’s existing pads, creating a new vector. Although buttons are pushed on both machines at the same time, there’s a slight delay between the two sets of joules (shocks)—pushing a possible maximum total of 720 joules—that are used to revive the patient. This causes a quick, double shock to the heart that, for unknown reasons, helps the patient return to a normal heart rhythm.
“We’re not sure exactly what the benefit is,” Myers says. “We do not think the benefit is related to the absolute energy level. We think the benefit is related to having a broader vector.”
Myers consulted with cardiologists at the hospitals in his system, received approval from their peer-review committee and instituted the new protocol on April 1. Although there have been fewer than a dozen cases in prehospital settings in Wake County and New Orleans, which also recently adopted the protocol, Myers says the results are promising, if a bit mixed.
“We’ve only used this five or six times,” Myers says. “It has broken defibrillation every time; we haven’t had a failure of it. We’ve had people that came back and we had to use it again, but it would terminate [the V-fib]. We unfortunately have yet to have a survivor.”
Meanwhile, New Orleans EMS has resuscitated a few patients using a maximum of 400 joules, with two survivors so far.
“That’s why this is so interesting—patients that would be dead because we would not be able to get them out of the rhythm, and yet we are (with this),” says Jullette Saussy, MD, FACEP, medical director of New Orleans EMS.
Both Myers and Saussy acknowledge that their systems’ new protocols are outside of accepted American Heart Association guidelines.
“There’s that subset of patients that you do everything in the guideline and they’re still in the dysrhythmia. Then, what do you do?” Myers says.
But, it’s this same last-ditch effort that may save lives.
“We have nothing to lose down here,” Saussy says. “We’ve tried it and we’ve just been very happy.”
So far, the method seems to cause no lasting, measurable damage to the heart muscle when taking cardiac enzymes and cardiac output into account.
“We are very respectful of the first rule of medicine, which is, ‘do no harm,’” Myers says. —LNR
Ambulance Fees Deter Calls for Help
Would finances stop you from calling an ambulance? Recent surveys and multiple data sources show that fewer people call for help in regions with imposed ambulance fees. According to a study by the Heart Foundation of Australia, whose medical system is similar to that of the U.S., almost 7% of participants said they would be “very” or “somewhat” likely to hesitate before calling an ambulance due to the costs involved.
Studies conducted in the U.S. also found that in terms of cardiac emergencies, economic considerations, such as lack of health insurance or general financial concerns, may undermine a patient’s intention to seek emergency care.
“Fifty percent of people who die from a heart attack actually never make it to the hospital,” said Australian Heart Foundation Chief Executive Lyn Roberts, MD, who agreed that ambulance costs shouldn’t be a barrier to people seeking immediate help.
Double Takes: Multiple PCRs Can Cause Trouble
A medic’s testimony in a recent Ohio murder trial highlighted the difficulties that arise when multiple versions of a patient care report (PCR) exist for a single call. Courtroom testimony revealed that there were two versions of the PCR for a call that ended up being central to a murder case. According to press accounts, the two versions differed markedly in key details, such as the number of intubation attempts. This raises important questions, such as, “How do I document additional information after the PCR is completed?” and, “Under what circumstances can PCRs be amended or replaced?”
First, it’s never acceptable to amend or replace a PCR for purposes of falsifying, misrepresenting or embellishing the documentation for any purpose (litigation, reimbursement, etc.). For instance, if a provider completes a PCR on what appears to be a “run of the mill” call, and the incident then results in litigation or criminal prosecution, it’s unacceptable to pull the chart and rewrite it for purposes of making the documentation or care seem better than they were. This could expose the provider to discipline from their service and the state and could lead to a complete destruction of the provider’s credibility on the witness stand.
You can amend a PCR to add information that was inadvertently omitted or to correct something that was inaccurate. For instance, if you did, in fact, use a cardiac monitor and neglected to document it, a PCR amendment is OK. On the other hand, if you didn’t use a monitor and then someone comes after you for it, it’s legally unacceptable to amend your PCR to say you did.
If it’s a situation in which a PCR amendment is acceptable, always document when the amendment was prepared and who prepared it. It should contain the date of the amendment and not be “back dated” to the date of the original PCR. The author of the original PCR—the primary EMS caregiver—should be the one to make any amendments to patient care information. Amendments to handwritten/typed PCRs should be made by crossing out the incorrect information and writing in the correct information. Don’t use Wite-Out! If you use electronic PCR software, some programs don’t allow amendments once a trip is “locked” on the system. In those situations, the use of an addendum is an acceptable alternative, so long as it’s accurately documented and dated. It’s not advisable to scrap a completed PCR and rewrite it merely so it “looks better.”
Pro Bono is written by attorneys Doug Wolfberg and Steve Wirth of Page, Wolfberg & Wirth LLC, a national EMS-industry law firm. Visit the firm’s Web site at www.pwwemslaw.com for more EMS law information. JEMS
This article originally appeared in July 2010 JEMS as “Instant Info: Indiana leading the way in electronic patient data sharing.”