Administration and Leadership, Documentation & Patient Care Reporting, Equipment & Gear, Special Topics

Devices, Technology and Care Will Unite to Bring Clinical Decision Support

We’ve been fighting a long time. We’re outnumbered by machines. We can’t escape the software, devices or technology. They all arrived with a mission to improve operations and patient care. But something is missing. It seems much harder than it should be.

I know this sounds like something more out of Terminator than Star Trek. Machines becoming aware: Was that Skynet, FirstNet, or the Internet?

The reality is that there’s something missing in EMS when we try to implement software, technology and data. I would suggest to you, what we’re missing is an awareness of things important or critical to patient care that our data systems and machines could be alerting us to as we’re providing care to a patient.

We’ve hit significant technical milestones over the past ten years both from a device and software perspective. We’ve united around standards such as National EMS Information System, the Internet, and XML data exchange. Yet we consider devices and software external to our EMS service delivery and clinical care.

The goal of the Institute for Healthcare Improvement’s Triple Aim is to improve the patient care experience (quality and satisfaction); and improve the health of our community while reducing healthcare costs.1 EMS has historically been a leader in each of these areas and the vision of the EMS Agenda for the Future seems even more applicable today as we extend into mobile integrated Health and patient directed care.

The EMS Agenda for the Future states: “Emergency medical services (EMS) of the future will be community-based health management that is fully integrated with the overall health care system. It will have the ability to identify and modify illness and injury risks, provide acute illness and injury care and follow-up, and contribute to treatment of chronic conditions and community health monitoring. This new entity will be developed from redistribution of existing health care resources and will be integrated with other health care providers and public health and public safety agencies. It will improve community health and result in more appropriate use of acute health care resources. EMS will remain the public’s emergency medical safety net.”2

We have complex medical devices that monitor and resuscitate the critically ill and injured we encounter in the field. We document the services and care we provide using software that gives us unlimited analytic capability on the backend. We combine our data with data from other healthcare providers and outcome sources. In the end we define, measure, analyze and improve following key performance improvement processes.

Is this all there is to the EMS universe? I think not.

So what’s next?

Clinical Decision Support
The future of healthcare rests with clinical decision support (CDS). CDS combines the tools we use in EMS (e.g., devices, software, protocols) to create a new “member” of the healthcare team.

CDS systems, by definition, provide knowledge and guidance to the healthcare provider to enhance the care of the patient. The knowledge provided is specific to the patient and appropriate and organized for the time and presentation of the medical condition.

Imagine if key details from our treatment protocols were configured into our ePCR system. For instance, a chest pain protocol would “expect” two sets of vital signs, documentationof a past medical history and medication list, a 12-lead ECG, aspirin administration, and patient transport to the closest appropriate destination.

What if your cardiac monitor and ePCR were “following” the patient with you? As the patient is processed and evaluated, the monitor/defibrillator would communicate with the ePCR. Device data would be accepted by the ePCR software to document the patient care event, and the ePCR data would be accepted by the device to provide assistance in the care of the patient.

CDS systems can provide several types of feedback to assist the healthcare provider. Computerized alerts currently exist in most medical devices. These can be as simple as a minimum or maximum alarm based on a vital sign parameter. But they can also be much more. It could be an alert that the patient has been seen recently by EMS or another healthcare provider.

Another alert might be that the patient is allergic to a specific medication that’s a component of the clinical guideline directing that patient’s care. The idea is the alert combines information known at the time of the patient’s care with meaningful information derived from other healthcare electronic healthcare records (EHRs) or data sources.

In CDS, “reminders” are similar to alerts except they provide information that may have otherwise gone unrecognized. For example, a reminder might be provided to repeat the vital signs because greater than the protocol’s defined interval of every 15 minutes has elapsed.

Clinical guidelines can be implemented with the assistance of CDS systems. And templates and order sets can be implemented to interact with the provider to assure completion of specific bundles of care (i.e., aspirin, 12-lead ECG, etc.).

CDS isn’t intended to replace clinical judgment but through integration with clinical guidelines and other diagnostic databases connected through a variety of platforms, it can assist care teams in making timely, informed and higher quality decisions.

CDS systems will evolve to provide real-time diagnostic support. Then, CDS systems will be able to provide valuable information to care teams as patients present with a cluster of symptoms, assessment findings, and diagnostic results.

The Centers for Medicare and Medicaid Services (CMS) has included a requirement for CDS in Stage 2 of Meaningful Use Requirements for hospitals and physicians in the implementation of EHRs. CDS requirements are to be extended in Stage 3 Meaningful Use requirements.

CMS has identified five key requirements for CDS systems to be of maximal benefit in healthcare. CDS systems must provide:

  1. The right information (evidence-based guidance, response to clinical need);
  2. To the right people (the entire care team, including the patient);
  3. Through the right channels (e.g., EHR, mobile device, patient portal);
  4. In the right intervention formats (e.g., order sets, flow-sheets, dashboards, patient lists); and
  5. At the right points in workflow (for decision making or action).

Ultimately, CDS systems, when implemented appropriately, can improve quality of care, improve outcomes, decrease errors and adverse events, improve efficiency for both the provider and the patient, while controlling cost.

We’ve been fighting a long time. We’re outnumbered by machines. We can’t escape the software, devices, or technology. They all arrived with a mission to improve operations and patient care. It’s time the machines become “aware.”

References

  1. Institute for Healthcare Improvement. (2015.) The triple aim. Retrieved March 24, 2015, from www.ihi.org/Engage/Initiatives/TripleAim/pages/default.aspx.
  2. EMS Agenda for the Future. (1996.) National Registry of Emergency Medical Technicians. Retrieved March 24, 2015, from www.nremt.org/nremt/about/emsAgendaFuture.asp