Is filling in fields making you less effective in the field?
San Diego Fire-Rescue Department was an early adopter of electronic patient care reports (ePCRs) when it introduced its own system, called “TapChart,” in 2000. Since then, patient information entering has matured and evolved. Electronic documentation of patient data, now hailed as a feat EMS, has been successfully accomplished, and rightfully so, but with the seemingly infinite possibilities for data analysis and the subsequent ability to make data-driven decisions, there has also been a downside. EMS providers now find themselves asking the question, “Am I a healthcare provider or a data collection technician?”
More than a decade into the TapChart project, San Diego Fire-Rescue paramedics might now reluctantly admit that they played a part in creating a problem of excessive data collection. But as health records systems inevitably expand, understanding the complexities and evolution of data systems means their experience allows them to also be part of a solution.
Experience suggests that the first step toward a solution is to open dialogue between EMS administrators and field personnel surrounding the question of how to integrate ePCR technology without compromising the quality of patient care. In other words, answering the question, “How do we give proper attention to an ailing patient and an electronic device at the same time?”
Though the integration of electronic health record documentation has been studied in the hospital and doctor-patient settings, not much has been done yet to examine its affect in the prehospital setting. The integration of technology has and will continue to revolutionize our job as EMS patient care providers.
All of us, from the old paramedic waxing nostalgic for the return of the “bubble form” to the new EMT whose smartphone is almost an appendage, will continue to negotiate the balance between patient care provider and data collector.
There are some practical steps administrators and patient care providers can take to successfully integrate these new electronic tools into their emergency response systems.
Computers and electronic medical records are more widely used today by clinicians in the prehospital setting than ever before. According to the National EMS Information System (NEMSIS), more than 75% of U.S. states have an electronic storage system that houses patient data. These systems are at various levels of sophistication, and many states are in the process of revising data elements, improving data capture and ensuring compliance with the future NEMSIS dataset.
Both the U.S. federal government and the National Health Service (NHS) in the U.K. have recently announced new initiatives to increase the use of computers as part of routine prehospital patient care data collection. For example, all 50 U.S. states, Washington D.C. and three territories have signed a memorandum of agreement documenting support for the NEMSIS project, a campaign to create a national EMS database. This will be done in collaboration with the Centers for Disease Control (CDC), National Center for Statistics and Analysis and the National Highway Transportations Safety Administration (NHTSA), which will store the data.
So we know data is important. Unfortunately, there’s little information on how EMS provider use of computers to obtain this data in the prehospital setting affects patient care and transmission of critical information (in the form of data) as the patient moves from EMS to the emergency department and perhaps to hospital admittance. This absence of knowledge is particularly concerning given that communication arguably is one of the most influential, encompassing and versatile aspects of EMS.
Studies in the hospital setting suggest that good communication can improve healthcare outcomes ranging from better treatment adherence to fewer interactions, even reducing medical malpractice lawsuits. But what about in EMS? Published protocols or evidence on how, and under what conditions, EMS use of ePCRs can or should affect the processes and dynamics of care is not as readily available.
Every day, EMS is focused on creating better healthcare. So why do we continue to inject complicated technology into the prehospital healthcare environment without considering the dangers along the way, such as creating distraction from high-quality clinically attentive care?
Well for one, we’ve got to pay the rent. And for that, we need data.
Data Collection in EMS
Private insurance and government coverage providers are making documentation requirements for reimbursement increasingly stringent. A missing data field great or small may mean the difference between whether your organization gets paid for transport. Billions of dollars in lost revenue for EMS organizations are at stake. The need for thorough patient documentation has never been greater. Undeniably, electronic documentation indeed has been beneficial in this regard.
Making data-driven decisions based on numbers rather than anecdotes can result in better patient care and fiscal policy, saving millions of dollars. This is imperative for private-sector EMS and public agencies with unpredictable municipal budgets. Data also helps us do a better job at showing our community what we do and how we are of value.
But we have to do it with accurate and relevant information. For instance, a 2008 study published in Prehospital Emergency Care showed that collecting social security numbers of 360 patients in the field resulted in an error rate of 73.9% (266).1 You might say that is an extreme example, but have you ever tried spelling a complicated last name in the emergency department at 3 a.m. and then tried to find that patient report through a query later on? Let’s be frank; patient care reports are rife with inaccuracies of all types.
With that kind of disparate data, what’s the use of collecting it unless we can do it with more reliability?
Medical data collection is only the first step in defining and designing prehospital EMS healthcare. Collected data doesn’t mean much unless it can be quantified and analyzed, and unless it takes form as sound clinical direction or quantitative business decisions. Most agencies are not doing this. Massive amounts of unused data sits stored in their “electronic garages.”
A 2006 National Public Health and Hospitals Institute survey asked hospitals that collected race and ethnicity data whether they used the data to assess and compare quality of care, use of health services, health outcomes or patient satisfaction across their different patient populations. Less than one in five hospitals that collected this data used it for any of these purposes.2
San Diego has been forward-thinking in using statistical data to improve patient care. For example, John Serra, MD, James Dunford, MD, and their team has extrapolated data collected from electronic patient care reports, using that data identify three neighborhoods with higher rates of sudden cardiac arrest and lower rates of bystander CPR. They announced this at the 2012 National Association of EMS Physicians conference. As a result, they’re starting to target community outreach efforts in these neighborhoods and take interventions to teach CPR and cardiac health. Eventually, they will be able to analyze the data to see whether these efforts affected save rates.
The point is that if you’re going to have paramedics collect data, you should use it.
Change for the Better?
You may be asking, did EMS intend to turn clinicians into something other than patient caretakers? To avoid these unintended consequences, EMS administrators should change the way their agency collects data. The following are seven recommendations that administrators and field personnel can use to more easily integrate electronic devices into their EMS system.
1. Insist on intuitive software design.
Few software solutions put the patient’s needs first, are organized with the information in the way a patient encounter happens and use intelligent intuitive principles to collect data. Instead, many provide complicated pages and layers, creating a labyrinth that inhibits user buy-in and engagement. This is because the programmer creating your software may never have even talked to a paramedic before and isn’t aware of the needs of your EMS personnel on scene.
Work with your vendors to communicate what you really need. Or better yet, if you’re lucky enough to have personnel in your organization who are savvy at programming, use them on special assignment to assist with creating software.
2. Streamline patient data.
At a regulatory level, insist the data collection process be made efficient. Increasingly stringent insurance and medical reimbursement requirements for documentation make it cumbersome for paramedics to create patient records. Keep in mind providers shouldn’t be burdened with collecting demographic or other data that isn’t critical for the emergency call.
3. Look at hardware as a short-term investment. There will be a better platform next year.
We’re conditioned to look at capital investment as getting the most use of our precious funds through a long lifespan of hardware. However, the opposite is actually best when it comes to technology. Once an item comes down from the shelf, it’s virtually obsolete. Look at the devices you purchase for electronic documentation as a more disposable item, something meant to be used for a time and replaced.
4. Keep it simple.
It’s tempting to want to add all the bells and whistles, questions and reference guides, and apps we can to our electronic device, but we must resist the urge. If your current vendor can’t or won’t make the changes you need to simplify your software, then find someone who will. Market hunger is an incredible incentive.
5. Build standardized data bridges to our healthcare devices and to the hospital systems we work with every day.
It’s time to insist on standardization and universal standards of healthcare data exchange. Currently, each medical device manufacturer has its own system, most of which are incompatible with others. Users need to insist on bridging the disparity of data silos from healthcare devices with a common, universal standard. There’s a need for better integration and sharing data sources within and across healthcare entities, such as between EMS, EDs and area hospital systems as a whole.
6. Be supportive of your EMS crews with the adoption of technology.
Some people are going to naturally adopt new technologies more easily than others, and you will always have a contingent that resists. Provide appropriate, hands-on training about electronic charting to improve their performance and quell concerns.
7. Solicit and accept feedback.
Watching a PowerPoint presentation about the 47 simple steps to complete a patient report on a new device isn’t going to help someone who just learned to program his microwave. Work closely with those providers who are hesitant, and assign people among the ranks on duty who can troubleshoot when necessary.
If you have the means, give your field providers adequate time to chart. If you don’t have the time, make it. Some systems are so busy that paramedics must respond to call after call from the hospital without time to document their calls properly. A paramedic at the end of their shift trying to document a cardiac arrest call that happened eight hours and five calls ago is going to be challenged, regardless of the features on the device they’re using.
This is probably an “easier said than done” item, but try asking trusted co-workers how you can improve ease of use of electronic devices. Or ask them to note specific times when you could have done better in this regard. And periodically self-reflect about how you did well or could have done better.
Evaluating electronic patient care information systems isn’t much different than clinical quality improvement steps your agency has instituted. How about evaluating your crews’ performance with integrating electronic devices and the effects of those devices on the crews’ ability to effectively communicate with a patient the way you test them on how to put a patient in C-spine and cardiac pace?
You probably got into EMS because you wanted to help people, not fill out boxes and collect data. But the integration of technology in EMS, as in life, is the inevitable way of the future. By keeping pace with your ePCR technology the same way you keep yourself up to date on the newest monitor or intubation gadget, you can be great both in the field and in filling out the field.
John Pringle is a firefighter paramedic and the electronic documentation coordinator for San Diego Fire-Rescue Department. He is also a California CEMSIS EMS systems Division Data committee member, a 2008 ComputerWorld Honor program laureate and an EMS 10: Innovators in EMS award winner.
Loralee Olejnik coordinates community outreach and education for Rural/Metro of San Diego, San Diego’s 9-1-1 ambulance provider.
1. Brice JH, Friend KD, Delbridge TR. Accuracy of EMS-recorded patient demographic data. Prehosp Emerg Care. 2008;12(2):187–191.
2. Regenstein M, Sickler D. (2006). Race, ethnicity, and language of patients: Hospital practices regarding collection of information to address disparities in health care. In National Public Health and Hospital Institute. Retrieved from www.naph.org/Main-Menu-Category/Our-Work/Health-Care-Disparities/raceethnicityandlanguageofpatients.aspx.