I’m no Trekkie, however, like many other EMS administrators who have assumed the responsibility for review, deployment and maintenance of technology-related items, I can identify with the highly respected title of “techno geek.” The San Diego Fire-Rescue Department, San Diego Medical Services and our partners in the city of San Diego’s EMS system have had the wonderful opportunity to envision and develop many advanced tools to improve our delivery of prehospital emergency care.
San Diego’s backyard houses such wireless giants as Qualcomm Inc. and an ever-growing host of smaller medical technology companies that are working to make their mark on EMS. We have the luxury of a tight working relationship among first responders, transport medics and hospitals, and, although funding is always a consideration, we have EMS leadership that understands how investments in technology can result in better patient care and workflow. Yet again, in an environment that fosters forward progress, the elusive tricorder remains somewhere on the horizon.
We’re using the Star Trek word “tricorder” as an analogy here because it’s a useful point of comparison for what many of you might expect in an EMS technology discussion. Today, we expect our systems to collect data, turn it into useful information, move it to the right places and produce it—all in real time. Because of the nature of our work environment, we also expect our tools to be small, rugged and preferably combined into one, easy-to-carry device. Our proposed EMS tricorder is truthfully many “things” and “systems” of hardware and software, and unfortunately these things don’t always work well together.
Electronic Patient Care Records
The electronic patient care record (ePCR) has become a standard in our industry. San Diego developed its own ePCR system in 2000, basing the system on the original PalmPilot platform. Although ePCR systems for EMS were virtually nonexistent in the early 2000s, we were tapping away. Ours was a rapid entry tool that rarely crashed and had minimal delay to input. Also, because it was a homegrown product, we had the luxury of making changes to the software at will. We coined the system “TapChart” because of its stylus-driven input. The charting was straightforward, records were transferred between devices by infrared “beaming,” and printing of charts was easily performed on infrared printers.
As well as the TapChart system performed, we still had a continual need to keep up with the handheld device changes and looming wireless technologies that surrounded our homegrown effort. We watched from the sidelines as others attempted development of handheld ePCR systems. Some were successful; some were not.
Used to documenting on small handhelds our crews carried on their hips, we were puzzled at the growing trend of placing ePCR systems on ruggedized laptops, wondering what EMT would ever lug such a thing to a patient’s side for documentation. As time went on, we realized that technology was racing forward, making our venerable TapChart obsolete.
The writing was on the wall when we realized the Palm device and the Palm operating system we were using were headed for retirement. San Diego then decided to place years of homegrown software development into the hands of professionals who had entered the market well after us. Although we resolved to no longer be our own software company, we were reluctant to simply turn over what had worked so well for our EMS providers. We were looking for partners to redevelop our TapChart system, and we found that spirit in a well-established company, ImageTrend Inc.
Today, even with a decade of experience with handheld ePCRs in San Diego, we have a long way to go with this part of our tricorder. There’s an explosion of devices that will fit the bill for ePCR collection, from smartphones to tablets to slates. So what should an agency strive for in this complicated and growing selection of products? The best ePCR systems should strive toward platform independence. Our Achilles’ heel in San Diego was the reliance on software tied to companies, operating systems and specific devices. Choose a system that’s bold enough to give you a choice of devices and is built on broad standards to future-proof your investment.
The data you collect in patient care doesn’t start with tapping on a screen or keyboard. Cardiac monitors have become a central part of data collection, gathering a wide variety of vital sign parameters and saving the information for subsequent transfer to analysis software packages. The days of running a paper ECG strip and taping it to your paper medical record have transformed into saving all vital signs to a memory card and selecting what to do with all that information.
San Diego’s experience has aimed at forging a stronger link between the monitor and the ePCR system. The monitor has become as much a tool for the field practitioner as it is for our quality assurance (QA) department. San Diego was an early (and unique) adopter of voice recording through our cardiac monitors. A continuous voice recording has become a valuable part of our QA review process, providing information on cases that involve high risk.
In San Diego, a 100% audit of cardiac arrest is performed by a full-time QA analyst, and our goal is for feedback to be returned to crews within a few days. Audio aids in the confirmation that clinical expectations are met and protocols followed. Direct feedback is provided in a constructive manner as close to the incident date as possible, so it’s meaningful and educational for the crews.
San Diego’s use of voice recording data is now a matter of practice. However, this also adds a layer of complexity to data management and transmission. Although typical ECG and vital sign data are small in file sizes, the addition of voice creates a significant increase in file size. Only recently have new technologies begun to be incorporated into cardiac monitors, allowing for bulk uploads of large data files to back-end systems for archiving and later analysis. Transmission speeds over slow serial ports have been upgraded to local area network speeds, and we are now able to cut the cable in favor of wireless off-load of monitor data.
Manufacturers of EMS cardiac monitors are well aware of the potential benefits of linking the monitor data to the ePCR to the receiving hospital or medical control center. Performing this wirelessly will be an expectation and requirement rather than an interesting experiment. Today, in San Diego, the first glimpses of these capabilities are being realized.
The current version of our TapChart program runs on an HTC HD2 Windows Mobile Smartphone via the T-Mobile 3G network. Smartphones are paired with Philips HeartStart MRx cardiac monitors via Bluetooth. Resident on the smartphone is a small application that’s responsible for the integration of data into the ePCR record or passage over the 3G network to the Philips Telemedicine server for further processing and transmission (fax or e-mail). Our paramedics can now bring live computer-aided dispatch (CAD) incident data into their TapChart record, avoiding duplication of effort, input time and incident information already obtained by the dispatch center. Paramedics can quickly input data at the patient’s side via the touch screen while using the full TapChart system on their smartphone.
The touchscreen buttons are large and easy to see, and the user interface is designed to facilitate rapid entry. Monitor data can be imported directly from the Philips MRx to the TapChart ePCR on the smartphone. When it’s time to transfer the record, the engine or ladder company first responder simply releases the record to a server, where it becomes available for continuation by the ambulance crew. On completion of the ePCR, the patient chart can be automatically sent to the receiving hospital, fax machine or to a secure link that can be accessed only by staff with proper credentials. All records are housed in a secure data server, which serves the needs of all stakeholders, from billing to quality assurance.
At the end of their shift, our crews upload the entire day’s worth of cardiac monitor data, including voice data, via an Ethernet-based batch LAN data transfer to a central file server. Monitor data is matched to the ePCR and available to QA staff directly from the ePCR system.
The QA staff, however, isn’t the only end-stakeholder of ePCR and cardiac monitor data. San Diego has been at work tying in “the last mile”—the hospital system.
The Last Mile
That last mile is the need for data to follow the patient into the hospital system and allow EMS to become a part of the continuum of care and learn final discharge diagnosis for each patient. Through the University of California at San Diego (UCSD), San Diego County was the recipient of a Healthcare Information Technology (HIT) grant through the Recovery Act Beacon Community Program in 2010. Although many Beacon Community grants are in effect across the nation, San Diego is unique because it will incorporate EMS data into the overall HIT strategy.
The grant will allow for the realization of a total San Diego Health Information Exchange (HIE), which includes the ePCR and monitor data for all EMS encounters. Currently, data from our CAD system, cardiac monitors and ePCRs is entering a greater developing HIE planned to link clinics and hospitals throughout San Diego.
The efficiencies to be proved include such items as:
• Faster transfer of information for decision-making in medical control, such as 12-lead ECG transmission to cardiologists. Future interest in alternative diagnostic tools, such as ultrasound;
• Other non-traditional data transmission, such as digital images or documents that can be used to guide patient care;
• Direct sharing of the appropriate data back to the field practitioner based on records within the HIE;
• Full incorporation of the prehospital ePCR into the receiving center’s medical records system;
• Sharing of historical prehospital data across hospitals and clinics as patients move through the area;
• Provision of outcome data back to the EMS agencies to guide in QA efforts; and
• Management of high-frequency EMS system users and abusers, allowing for better use of social resources outside EMS.
As San Diego’s Beacon program fully develops and provides a well-integrated HIE, the future possibilities for EMS are astounding.
The Future Ahead:
What’s Your Tricorder?
San Diego is unique in many ways. But its technology experience probably isn’t different from your system’s—at least from the perspective of your overall needs. Our EMS professionals are demanding of our tools and equipment. The equipment must work flawlessly without failure lest it negatively affect patient care. EMS technology manufacturers, of both documentation and monitoring systems, are aware of the trends and desires from EMS, but the perfect device and system to fit everyone’s needs is difficult to obtain.
If there’s sage advice to offer based on many years of testing these types of technologies, you should consider the following four points before starting your own trek into comprehensive electronic patient care data management:
1. Demand standards: Incredible progress has been made on a national scale with the National EMS Information System (NEMSIS) data standard. A common underlying data standard is essential to any downstream processes that depend on data. Although a majority of vendors and manufacturers may abide by standards, such as NEMSIS, other innovations will benefit from standardization of national requirements. Efforts toward standardization of QA and system performance measures can have a major effect on benchmarking;
2. Demand platform flexibility and choice: Although San Diego moved in the direction of smaller handheld smartphones, this doesn’t suggest that a ruggedized, large laptop isn’t the right fit for your system. The playing field has expanded to offer devices of all sizes and prices. The suppliers should strive toward software development that can take advantage of the variety of platforms available;
3. One system doesn’t fit all, so demand connectivity: As stated earlier, many systems don’t always work well together. Moving into a new documentation system or cardiac monitor shouldn’t require you to change your billing software, CAD or QA platform. Vendors offering solutions for everything from CAD to billing may be attractive for a system starting from scratch. However, the reality is that your system can’t afford wholesale change and depends on those legacy system pieces. Look for vendors with experience making connections and a track record of working well with others; and
4. Work toward fixing the funding model: At least in San Diego, the funding model is upside down. There’s little incentive for the EMS agency to adopt new technology, especially when a return on investment is difficult to prove. Who truly benefits when a 12-lead is sent directly to the cardiologist who will open that catheterization lab at 3 a.m.? Although we can all agree that, in the name of excellent patient care, these advances will benefit the patient, it would be a stretch to say EMS should fund technology based on better patient care alone.
Truth be told, with the current billing structures, EMS has minimal incentive to invest. However, other winners exist when we improve our prehospital technologies, and those winners are the hospital systems. When prehospital care is improved and when hospitals are aware of prehospital data, hospital costs are reduced.
Although proud of the road we’ve travelled and the distance we’ve come, the trip isn’t complete. Technology is an evolving animal. It is, by definition, always new. And to remain new, it must continually change. How your system works with this change can be a positive or negative experience. Fall behind technology and you may lose market share or be considered irrelevant. Pace too close to evolving technology and you may wind up as an unintentional test, learning hard lessons for others.
Disclosure: The author has reported receiving no honoraria and/or research support, either directly or indirectly, from the sponsor of this supplement.
This article originally appeared in an editorial supplement to the September 2011 JEMS as “Where’s My Tricorder?: The San Diego technology experience.”