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

Modern Approaches to Health Information Exchange Will Improve Patient Outcomes and Decrease Cost

Imagine this current-state scenario from the EMS perspective: Medic 26 responds to a patient who has been shot six blocks from the local Level 1 Trauma Center. On arrival, the crew finds an adult male, shot once in the chest and once in the groin, respiration rate 32 with a sucking chest wound, Glasgow Coma Score of 4, negative radial pulses and positive carotid pulses. They do a short head’s up radio report from the scene to the ED, knowing this will be a quick scene time and transport.

Police on scene has the victim’s driver’s license in hand and begins to rattle off the patient’s name, date of birth (DOB), address, etc. The crew, knowing this is a time-critical incident, asks police if they can bring the driver’s license with them, but for very appropriate reasons they decline. With a sevenminute scene time, the crew transports the patient to the trauma center, the patient is brought to the trauma room and care is transitioned to the trauma team. After clean-up, the crew leaves the hospital wondering how the patient will do, and wishing they didn’t have to enter everything into their PCR as a “John Doe214,” knowing the business office staff will have the task of finding all the patient information—if only the police had allowed us to take the patient’s driver’s license. Three weeks later, the crew recalls the patient interaction and sighs with frustration that they still do not know what happened with the patient.

Hospital Perspective
Now if you would, reconsider the same current-state scenario from the hospital perspective: The ED is notified of the trauma alert with an estimated time of arrival of 10 minutes. The trauma team is alerted to report to the ED and an OR suite is prepped.

The hospital team receives the patient in the ED trauma room and begins assessments, labs and radiology. Everyone asks the crew for the patient’s name, so they can do a quick registration and test results can be properly assigned. Unfortunately, all the crew knows is he’s “Tom” and he’s about 25, but explains that police have the patient’s ID and will be along “shortly.”

The patient is put into the hospital’s electronic health record (EHR) as “John Doe2761” without the benefit of any cross reference to see if he has been a patient at the hospital before.

They find numerous internal injuries and whisk him off to the OR. After 12 hours of surgery, the patient stabilizes and the trauma surgeon comments to his team that the quick actions of the EMS team saved this guy’s life—how do they recognize them and let them know what the injuries were and who this patient is? The police haven’t arrived with the ID.

Three days later, the trauma registry coordinator is slugging through mounds of faxed paper reports gleaning off the information from the PCRs that they are required to manually enter into the state’s trauma registry. All the while, wondering, “There has to be a better way.”

Give & Take
This scenario plays out multiple times a day across the country. The concept of sharing healthcare information has been the elusive holy grail of our healthcare system since the days of Marcus Welby. On the transactional side of our industry, EMS providers lament about the general lack of feedback on patients brought to the hospitals. Hospitals lament about the lack of quick registration and accurate patient IDs to help speed treatments and look up past patient records.

On the transformational side, the one that is more and more desirous of achieving the Triple Aim as articulated by the Institute for Healthcare Improvement (IHI)—improved patient experience of care, improved heath of populations and reduced costs—payers and accountable care organizations want access to information across the continuum of care. This information can be as granular as an individual patient’s course through the healthcare system for one episode of care, or as high level as the total number of pediatric asthma patients seen for acute symptoms in the past 12 months. The concept of “big data” in the healthcare system is drawing EMS into the significant discussion about effectively sharing data with hospitals, other healthcare providers and payers.

Desired-State Scenario
Let’s imagine a desired-state for the scenario we described above.

A device attached to the EMS electronic patient care record (ePCR) system scans the patient’s driver’s license QR or bar code and auto-populates the crew’s ePCR. The police officer can keep the license. If the EMS agency has encountered the patient in the past, information regarding the date of encounter, chief complaint, clinical impression, vital signs and hospital destination also populates into the ePCR. This assists with care coordination and potentially determining the most appropriate hospital destination.

Then, once the destination hospital is selected, that information is automatically e-transmitted to the destination hospital and auto-populates the hospital’s quick registration program, even before the EMS crew arrives at the hospital. With the name, DOB and address verified, the past medical records feed into the new medical record for the patient, ready for the ED team to access. In this scenario, they can even access it prior to the patient’s arrival, note the patient has A-positive blood type, is allergic to penicillin and the last time the patient was there three months ago, they were treated for hypoglycemia. This information is crucial to effective care management transition.

Feedback & Quality Improvement
Because the EMS ePCR and the hospital’s records are integrated, the EMS crew can be easily identified and cross-referenced with the EMS agency’s contact list to facilitate a secure transfer of information regarding the patient’s status. The EMS agency’s quality improvement officer is also copied on the notifications for evaluation and follow-up.

Registry Data & System Improvement
With a true information exchange, instead of manually entering the required fields for registry information at the hospital, the pertinent fields from the EMS ePCR can be identified, reviewed for accuracy and simply uploaded to the registry. This data set can also be used to identify run chart trends on EMS system and hospital performance that should be enhanced or corrected. Trauma scene times, clinical bundles for STEMI, stroke, asthma, hypoglycemia and other clinical metrics can be measured over time to identify opportunities for system clinical improvements.

Does this all sound too good to be true? Well, maybe not so much. Some systems are moving down this path already, with enhancements to come in the near future.

Several manufacturers have developed hardware and software that facilitate the scanning of driver’s license info into the ePCR. Several states have passed laws that allow EMS agencies to access this information as well. The Intermedix EMTrack system is one example of using a barcode scanner during disaster management. The ZOLL ePCR solution has the capability to capture, interpret a driver’s license and populate a PCR using an iOS device camera.

To properly integrate with a health information exchange, EMS needs to move from an incident-based record keeping system to a patient-based electronic medical record system.

Integrating with Health Information Exchanges
In the general sense, a Healthcare Information Exchange (HIE) facilitates with sharing of health information between healthcare providers. In its simplest of terms, for an HIE to be effective for EMS and the patients we encounter, it must be able to provide three key elements:

  1. The ability to search and find the medical record, across the local healthcare system, of a patient at the time of their EMS care. This is typically a secure, Web-based interface where the EMS professional can login and search for a specific patient by name, social security number, DOB, etc.
  2. The ability for the EMS EHR to follow the patient through their current episode of care, in its entirety. This is the electronic transmission of the EMS EHR using health level 7 (HL7) international standard, or some other IHE standard, into the receiving healthcare facilities EHR system using HL7, or some other standards based approach. This needs to be discrete and specific data elements must be able to be populated directly into an EHR in the healthcare system. It’s much more than simply a faxed report that gets attached to the EHR, which is of little value to the nurse or physician at the patient’s side in the hospital.
  3. The ability to query for an EMS patient and download discrete data about the patient and the care they were provided. This includes billing and outcome data for operations and clinical performance enhancement.

Hospitals, physicians and payers have predominately utilized HIEs to help improve patient outcomes and reduce cost. Over the past few years, these entities have recognized the value of including more providers, such as EMS, into their HIEs.

In 2010, at the American Medical Informatics Association (AMIA) annual symposium, John T. Finnell, MD, MSc, and J. Marc Overhage, MD, PhD, presented a research project in Indiana linking EMS with the Indiana Network for Patient Care (INPC).1 They were the first regional HIE in the country to connect preexisting health information to EMS providers. The system currently includes data from 30 hospitals in five health systems, the Marion County Health Department and various physician practices. These hospitals account for over 95% of all beds and ED visits in Indianapolis, which has a population of 1.6 million.

The primary goal of the integration was to allow Marion and Hamilton County EMS providers to exchange data with the INPC, not only to share their information with the hospitals, but also to have real-time access to patients’ past medical history while in the field.

Their research illustrated the quantitative and perceived benefits of access to medical records in the prehospital setting. The medical information provided in the INPC EMS abstract allows prehospital personnel to collect a more detailed medical history and allows for more informed treatment decisions.

Integration Trend Setters
Here are some other examples of the systems available for integrating EMS systems into HIE’s across the country:

  • ZOLL Medical Corporation implemented an exchange of clinical and administrative data for Poudre Valley Hospital EMS and the hospital’s electronic medical record systems using HL7.2 ZOLL’s new HL7 for EMS solution operates as a component of RescueNet ePCR. Poudre Valley EMS was the first service to facilitate this automated data exchange when it transmitted patient health record data from Poudre Valley’s ZOLL ePCR to a University of Colorado Health’s electronic medical records system (EPIC) in March 2014. The Emergency Medical Services Authority (EMSA) in Tulsa and Oklahoma City, Okla., began submitting HL7 PCR files from the ZOLL ePCR system to the MyHealth Access HIE and the SMRTNET HIE in Oklahoma. Field crews have the ability to log in to the HIE from the field and perform lookups of patients in both HIEs.
  • ImageTrend has rolled out their EMS Service Bridge that integrates EMS ePCRs into systems such as the integration between New Orleans EMS and the Greater New Orleans Health Information Exchange (GNOHIE),3 implementing integration platforms for EMS to be able to tap into HIEs.
  • ESO Solutions has developed a Healthcare Data Exchange (HDE) that’s currently in use by Montgomery County Hospital District (MCHD) EMS and HCA.4 With this program, hospitals will be able to view critical prehospital patient information directly from within their electronic medical record (EMR) system. They also have access to the raw EMS data they need to report to registries, trend patient populations and develop metrics. MCHD, in turn, will have views into the data they need to institute comprehensive quality management programs based on clinical outcomes.
  • The Cloverleaf Integration and Information Exchange Suite, developed by Infor, has been in use by several health systems and essentially serves like a Rosetta Stone, connecting different data exchanges, and has recently been courting EMS agencies to become part of the healthcare information integration.5 Infor also released their EMS Integrated Healthcare Suite in February 2013.6 This system helps transmit and receive patient information, allowing hospitals and providers to exchange historical patient data in real-time to present a full picture of a patient’s healthcare record. MedStar Mobile Healthcare in Fort Worth, Texas, is currently working with Infor to implement the Cloverleaf and EMS Integrated Healthcare Suite to exchange ePCR data, as well as the health information utilized in MedStar’s mobile integrated healthcare programs.

While these efforts are a great start, they don’t yet address all three of the key elements articulated earlier for effective HIE integration with EMS. The major need that has yet to be effectively addressed is this ability for EMS to see the discrete patient level clinical details in order to more effectively manage the patient’s medical condition during the EMS encounter.

It’s vitally important that the entire EMS community continue to express—or better yet, push—our ePCR vendors toward developing the two key things we need to enhance our ability to manage our patients in the field:

  1. The ability to access patient medical information—real time—in the field, to include notes from hospitalizations, physician and clinic visits, and even rehab notes.
  2. To move our ePCR from an incident-based record keeping system, to a patient-based EMR system.

This will not only facilitate better patient management on an episodic call, but also support mobile integrated healthcare programs that are expanding across the country.

Emergence of Carequality
In February 2014, Carequality (“care-e-quality”) was announced. Carequaility is a new initiative dedicated to accelerating progress in health data exchange among multi-platform networks, healthcare providers and EHR and HIE vendors. Carequality’s goal is to facilitate agreement on a common national-level set of requirements that will enable providers to access patient data from other groups as easily and securely as today’s bank customers connect to disparate banks and user accounts on the ATM network.

A rapidly growing community of healthcare providers, payers, consumer groups, IT companies and software vendors are signing up to join this effort and shape the future of interoperability in the U.S. Twenty-six organizations had pledged a commitment to join Carequality as founders as of the announcement date, including Epic, Kaiser, Intermountain Healthcare, CVS Pharmacy and Walgreens, as well as several HIEs. ZOLL Medical deserves special recognition for currently being the only EMS software data company to be part of this initiative. Carequality appears to be the best example of a true HIE that meets all three of the key elements of an effective HIE for EMS.

Federal Assistance
In February 2014, the Division of Health System Policy and the Emergency Care Coordination Center (ECCC) and Assistant Secretary for Preparedness and Response hosted a daylong workshop themed Health Information Exchanges and the Prehospital Environment. This workshop brought key EMS leaders and several representatives from HHS’ Office of the National Coordinator for Health Information Technology (ONC) to discuss how EMS can more effectively integrate health information with the rest of the healthcare partners. One of the products of that workshop was the launch of ASPR Collaboration Community on IdeaScale, which can be viewed at http://phegov.ideascale.com/a/index.

This platform is designed to facilitate the exchange of ideas for health IT (HIT) between users, providers and vendors in an effort to develop products and programs that will be essential in furthering the connections between EMS and healthcare systems.

Emerging methods for the exchange of health information show promise, from Regional Health Information Exchanges to Accountable Care Organizations and the future of Carequality.The EMS profession is undergoing one of the most significant transformations since the advent of ALS care and paramedics. We’re finally being understood as healthcare providers and being called upon to become part of the solution to meeting the IHI’s Triple Aim. On the micro level, the ability to access real-time clinical information on the patient we treat in the field, and to quickly transfer information about our encounter with the patient to the rest of the healthcare partners across the patient’s continuum of care, is essential to furthering this transformation. the system level, providing and accessing information about the needs of the communities we serve, and our healthcare system partners will allow us to effectively demonstrate the value we bring to those who pay for, and benefit from, the services we provide.

EMS providers need to become actively involved in the development and implementation of systems to integrate and exchange health information across the healthcare system—start today! If you don’t know if your healthcare system has an HIE, find out. If they have one, begin the discussions on why it’s important for EMS to be a part of that system and how you can plug in to your local HIE. Our patients deserve it.

References

  1. Finnell JT, Overhage JM. Emergency medical services: The frontier in Health Information Exchange. AMIA Annu Symp Proc. 2010; 2010: 222–226.
  2. ZOLL Medical Corporation. (March 11, 2014.) ZOLL Implements HL7 for data exchange between healthcare providers. Retrieved Feb. 4, 2015, from www.zoll.com/news-releases/2014/03/11hl7-data-exchange-healthcare-providers.
  3. Louisiana Public Health Institute. (n.d.) The strength of a community partnership. Greater New Orleans Health Information Exchange. Retrieved Feb. 4, 2015, from http://gnohie.org/partners.
  4. PRWeb. (July 25, 2012.) ESO Solutions announces launch of groundbreaking healthcare communication platform. Retrieved Feb. 4, 2015, from www.prweb.com/releases/2012/7/prweb9726242.html.
  5. Infor. (n.d.) Infor Cloverleaf Integration and Information Exchange Suite. Retrieved Feb. 4, 2015, fromwww.infor.com/solutions/cloverleaf.
  6. Marketwired. (Sept. 5, 2013.) Infor unveils innovative solution for emergency medical services. So-Co-IT. Retrieved Feb. 4, 2015, fromwww.so-co-it.com/post/293878/infor-unveils-innovative-solution-for-emergency-medical-services.html.