Administration and Leadership, Columns

Rethink the Way EMS Does Patient Care Reports

Issue 5 and Volume 40.

Cameron Decker, MD, is one of the “young guns” of EMS medical direction but, like many of us, has a long history in EMS before the “MD.” Decker began his career in EMS at his local volunteer fire department, then relocated to the Harris County Emergency Corps in Houston, Texas, and finally the Harris County Sheriff’s Office as a sergeant and tactical paramedic. Now an emergency physician, he serves as the Division of EMS and Disaster Medicine fellow and assistant professor at Baylor College of Medicine, as well as the medical director of Harris County Emergency Corps.

The EMS record is often disregarded as a source of important information. Do you think EMS as a medical subspecialty changes how we should think about the role and format of the “run record”?
EMS must let go of the idea prehospital care documentation is strictly about billing and creating a legally defensible record of events. Now more than ever, the purpose is continuity and quality of care. With the new EMS subspecialty, engaged medical directors are taking an unprecedented seat at the table and vaulting EMS into the greater discussion of healthcare for our community.

As we expand into community paramedicine and mobile integrated healthcare, the need for substantive documentation grows. The episodic run records many of us use won’t meet the need for progress reporting of chronic medical conditions. Unlike hospital documenting, EMS charting lacks continuity between visits to the same patient. Our records are going to have to look a lot more like those of a physician if we want them to seamlessly integrate into the patient’s medical record. Once we provide the hospital staff with a familiar-looking document, we’ll be one step closer to having it regarded as an important source of information.

The next step will be to ensure the data within the record is useful and accurate. Medical directors must use documentation to drive portions of their continuous quality improvement programs, provide immediate feedback and push targeted, systemwide education. Further, as we expect a closer adherence to evidence-based practice, additional questions will be raised that can only be answered with novel research: studies that are dependent on our prehospital providers collecting data via the electronic patient care report (ePCR). Every EMS organization has the ability to change the practice of medicine through data registries, but it all starts with the street medic documenting a reliable and accurate care record.

What critical changes do you as a medical director need to do to optimize the current generation of ePCRs?
The accuracy of data is paramount. Current ePCRs struggle with the balance between ease of input and quality of data. In no other healthcare setting should a physical exam include the words, ‘Neurological exam: Normal,’ yet so many ePCRs in EMS find this acceptable. It leaves me asking, ‘What exactly was included in your neurological exam?’ I’m going to let you in on a little secret: Hitting that ‘all normal’ button just stripped you of your credibility to the physician who’s reviewing the chart.

This lack of quality isn’t isolated to physical exams either. Those auto-generated narratives regurgitate redundant details that don’t often accurately reflect the provider’s thought process. Once ePCRs make it simple to input a precise physical exam and an organized narrative that also reflects clinical decision-making, we’ll have something worth sharing with our hospital partners.

We need software that intelligently reviews charts for both the community agreed-upon standard and system-based targets, flags those that don’t meet par, and allows for rapid human review and feedback. Providing the best quality of care involves benchmarking key quality indicators and ensuring every call meets expectations.

What role will new technology play in the future of the ePCR?
One word: Collaboration. EMS still lives in the world of the PCR and hasn’t graduated to the electronic medical record. We treat each patient encounter in a relative vacuum. Why shouldn’t the paramedic be able to compare today’s ECG with last week’s obtained in the clinic? The reverse should be true as well: Physicians should have access to historical EMS patient records even if the patient wasn’t transported. Collaboration must be the expectation of future systems.

A big part of improving prehospital care is patient outcome data. Without this two-way flow of information, we practice without knowing the effects of our care or the accuracy of our clinical judgment. Hospitals and EMS systems should develop methods of providing timely feedback (and I’m not talking about the cath report that’s finally shared a month later). Until the ePCR can auto-generate relevant hospital outcome data accessible by our prehospital providers by the end of their shift, the medical director is the best interim solution.

In my system, I can immediately obtain most records on patients my medics have transported. Rarely do crews have to wait two weeks for the EMS liaison to provide those details anymore. Although the legal relationships vary, transported patients should be considered patients of the medical director who’ve been referred to hospital-based specialists; he or she ought to receive this follow-up information. Most of my community understands the value of EMS physician/hospital collaboration; until the ePCR catches up, I challenge other EMS systems to develop similar programs to improve provider clinical judgment and care.