Sunday, December 8, 2013
Greg Mears, MD
One of the best ways to visualize the future in EMS is to imagine what would happen if we combined all of technology in existence (or in development) today to describe the “perfect EMS event”—one that brings together all of the complex EMS operations, clinical care and service delivery required for any patient scenario. Let’s give it a try …
A motor vehicle crash (MVC) occurs. From the vehicle’s automated crash notification system, dispatch receives the following information: the mechanism of the crash (low-speed front-end collision) and scene location; probability of serious injury (low in this case); number of occupants (two); and the occupants’ baseline medical history (linked from personal medical records).
Dispatch identifies the closest EMS vehicle and electronically dispatches it to the scene with navigational directions. While EMS is en route, Emergency Medical Dispatch (EMD) is performed, identifying that the passenger is experiencing chest pain and is known to have coronary artery disease. The driver does not have any complaints. An existing 12-lead ECG is obtained from the patient’s medical record and forwarded to the EMS crew en route.
Once the crew arrives on scene, they evaluate both patients. All data from their cardiac monitor, as well as voice recordings, barcoded information on procedures documenting the time and use of supplies (using RFID), and video from on-vehicle and helmet cameras, are automatically downloaded to the patient care report (PCR).
The driver is packaged as a “green trauma.” The EMS crew obtains a 12-lead ECG from the passenger that indicates a STEMI (with left bundle branch block); they confirm that the new ECG is different than the baseline tracing from the patient’s medical record. No injuries are noted.
The PCR software system is able to recognize the chest pain component as well as the abnormal ECG and recommend that the EMS crew consider administering aspirin as well as to recheck the patient’s vital signs every five minutes. The software also identifies the closest PCI center and notifies the center of the incoming patient, while also forwarding the 12-lead ECG and activating the cath lab.
En route to the PCI center, information from the patient’s personal medical record, crash detail from the automated crash notification system, all information associated with the EMS event, and real-time vital signs are transmitted to the receiving hospital. On arrival, the patient is evaluated in the ED to ensure no significant traumatic injury was present before he’s transported to the cath lab. A 100% LAD lesion is identified and reopened with a symptom-onset-to-reperfusion time of 65 minutes.
After the hand-off of the patient, all of the information from dispatch, medical devices, voice, RFID and pertinent personal medical information, as well as the care provided to the patient, are aggregated to create the PCR. The EMS crew quickly adds and adjusts the documentation based on feedback from the software. Once the PCR is complete, it’s routed to the supervisor for review, to the hospital medical record system using the NEMSIS HL7 CDA, and to the EMS agency’s same-day billing department.
After the patient is discharged from the hospital, outcome information is relayed electronically back to the EMS agency using the secure HL7 CDA and incorporated into the PCR system.
Weekly, monthly, quarterly and yearly reports based on performance measures and outcomes are also generated for the EMS agency and the regional area for review and performance improvement initiatives. Aggregate information is posted on community websites, highlighting the performance of the integrated system of care, including EMS operational and clinical care outcomes. Individual patient data from EMS is also linked with hospital, trauma, stroke, STEMI, cardiac arrest, airway and other registry systems to more critically evaluate the care provided to specific patient populations.
Ultimately, performance improvement processes are identified, including the need to consider medical conditions even when the EMS event appears to be traumatic in nature. This information is included in the next continuing education offering for both EMS and the ED.
Why Not Today?
All of the technology associated with the perfect EMS event exists today—so why are we not all using it? There are several reasons:
• Most EMS systems only have a portion of the technology described in place.
• The technology that is in place does not often integrate with other technology.
• The technology is not ready for this complete level of implementation.
• The infrastructure (such as Internet connectivity) isn’t ready for this level of integration.
• Leadership at the IT, hospital and EMS levels are not ready for integration at this level.
• Devices and PCR software solutions across the industry in general do not use a standardized format; therefore, integrating data from multiple sources in a real-time fashion remains a challenge.
• Software is only beginning to engage in decision support to assist in the prevention of patient care errors, ensure protocol compliance and optimize EMS operations.
• Technology and its integration are expensive.
EMS agencies must look at their implementation from an IT and integration perspective. Devices and software are members of the healthcare team. Let’s go through a brief overview of the device and software needs of an EMS agency with an eye on integration and optimizing operations and patient care.
Other topics within this supplement describe how data and technology can greatly impact and enhance dispatch, scheduling, education, etc. It’s important to also consider the impact of the ambulance (or vehicle) itself. An EMS vehicle should provide a safe environment for the treatment and transport of both the crew and the patient, but should also serve as a center for patient care and the hub of our communications and technology.
Data coming into the vehicle should include dispatch and navigational information through a communications link. The vehicle also must have a connection to the Internet for data exchange. This can be accomplished through the development of a Wi-Fi hotspot within the vehicle that connects to the Internet through a cellular data modem.
Other forms of connectivity, such as Bluetooth or radio frequency identification (RFID), may also be included.
The Wi-Fi hotspot can be created using a standalone solution within the vehicle, a built-in
Wi-Fi solution within a vehicle safety product (e.g., Road Safety), or a solution built into a medical device (e.g., monitor defibrillator). Once the Wi-Fi hotspot is created, the existing software and devices that need to integrate and communicate can be connected. These include vehicle safety devices, cardiac monitors, defibrillators, central patient monitors, PCR software, supply inventory systems and other medical devices.
Externally, the Wi-Fi hotspot allows for the exchange of data between the central EMS data systems as well as hospitals, dispatch and other healthcare-related data systems and/or providers.
Medical Devices, Monitors & Defibrillators
Medical devices are becoming more compact yet more functional, capable of assisting the EMS professional in their patient assessment, treatment, decision-making and monitoring. It’s imperative that the data collected, analyzed and presented to the EMS professional in the field be closely incorporated into the PCR and, when needed, relayed to the receiving healthcare facility.
This data exchange and movement should be based on existing standards, such as the National EMS Information System (NEMSIS) and HL7. (For more information on NEMSIS and HL7, see www.nemsis.org.)
There is an increasing interest in the EMS use of diagnostic devices from a laboratory measurement and imaging perspective. Examples include ultrasound imaging, measurement of cardiac ischemia and markers of sepsis. As these technologies come into commonplace use by EMS, their data and images must also transmit through this network and be included in the PCR.
Finally, there has been a significant focus on the outcomes of sudden cardiac arrest. The use of external CPR devices has become commonplace within EMS agencies. These devices have been shown to provide CPR equal to high-quality manual CPR. Many of these devices also capture data on CPR metrics and can transmit it into PCR and code review solutions. This data should be used to identify, measure and improve the resuscitation outcomes of cardiac arrest victims.
Clinical Decision Support
In the past five years, EMS has made tremendous progress in the resuscitation of the victims of out-of-hospital cardiac arrest (OHCA). This success has not been the result of a new intervention, device or medication. Rather, it is the result of a focus on providing high-quality CPR as opposed to just providing CPR.
This has been one of the many success stories where devices and technology have integrated with the provider to improve outcomes. Medical devices, often attached to a monitor/defibrillator, can provide real-time feedback to EMS professionals, improving the quality of CPR and the outcomes of OHCA victims. The use of CPR quality software and devices are quickly becoming standard of care within the AEDs used by first responders and the lay public.
Beyond devices, PCR software is now capable (with FDA approval) to monitor the assessment, treatment and care of a patient in such a way that the software can provide patient safety recommendations as well as ensure that protocols are followed. This ability to guide or provide recommendations on the clinical care of a patient will increase as we move toward 2020. ZOLL is currently the only EMS PCR solution that has received FDA approval for this capability.
The hub of information associated with any EMS event is the PCR. The information making up the PCR is split between direct data entry by the EMS professional and electronic data from other sources.
The ultimate goal of any EMS agency is to maximize the linkage and use of electronic data sources while minimizing the amount of data that has to be directly entered by the EMS professional. The electronic movement of data into a PCR from an external source not only is more efficient for the EMS agency and the provider; it is also more timely, complete and accurate.
PCR solutions vary in their implementations based on the following features:
• Hardware and IT requirements, including whether the PCR is hosted on location of the EMS agency or a cloud-based Software as a Service (SaaS).
• Front-end user interface design, including ease of use, security and type of device (iOS, Android, Windows, etc.).
• Integration with medical devices, including monitor/defibrillator, 12-lead ECG, video cameras and others (ultrasound devices, glucose monitors).
• Integration with other software, such as dispatch/CAD, EMD and billing software.
• Data-analysis capability, including structured reports, user-configurable reports, performance improvement reports and outcome reports.
• Communication and messaging capability, including the ability to route documentation or alert EMS staff when certain events occur or when benchmarks or thresholds are hit (or missed).
• Export capability for entering information into the billing system, registries (CARES, trauma registry, etc.) and state systems (via NEMSIS).
Ultimately, each EMS agency must customize their ePCR solution based on the balance of the critical features noted above; integration with other data systems or devices; data analysis and messaging capability; ease of use and reliability; and cost.
No solution is perfect in all of these requirements, and it’s critical to find a solution that fits your system’s current needs and will evolve and grow as your EMS system embraces new concepts (e.g., community paramedicine).
Technology and data are key components of any EMS system. It is critical that EMS agencies consider medical devices and software as members of their patient care team. How data and technology is managed at the organizational, EMS professional and patient levels will determine the success and future of EMS.