Imagine that for every 9-1-1 call you answer, you’re able to close the patient care loop: Dispatchers know if they correctly assessed the chief complaint; EMTs and paramedics know if their assessment and treatments were appropriate; the receiving facility knows exactly what happened in the field; and finally, when the patient is discharged, all the pieces arecommunicated to all parties involved in the patient’s treatment. The patient care loop is closed and that information can now be used for quality improvement.
In this ideal state, standardized performance measures, like those created by EMS Compass, can be applied to evaluate each step in the patient’s treatment-and ultimately its effect on patient outcome.
For most EMS agencies, getting patient outcome data from hospitals has been difficult if not impossible. But that’s slowly changing, as Version 3 of the National EMS Information System (NEMSIS), combined with a national push to make healthcare data systems interoperable at all levels, has given momentum to the effort to integrate EMS data with other healthcare data. This article looks not only at the challenges of data integration, but also specific successes, where communities are using technology in innovative ways to close the patient care data loop.
The Value of Outcome Data
Without data from hospital records, EMS is limited in what it can measure. For example, a critical prehospital action is to identify when a patient has stroke symptoms and notify the hospital-this has been shown to decrease the time it takes for the patient to receive treatment, which leads to better recovery with fewer neurological deficits.
But how can we measure the accuracy of EMS stroke identification without knowing who was ultimately diagnosed with a stroke? A measure using solely EMS system data might look at whether stroke scales were performed on patients identified as having stroke-like symptoms. But by using hospital diagnosis codes, an EMS system could measure whether it’s missing any strokes and figure out ways to ensure that doesn’t happen. The agency can also see if improvements to protocols or processes actually improve important measures, such as how long it takes for the patient to receive appropriate treatment. And perhaps most important, the EMS system with access to hospital data can measure its impact on actual patient outcomes.
Other articles in this supplement describe the different types of performance measures, including process measures, which when applied to patient care are defined as specific steps-such as a medication or procedure-proven to benefit the patient. Outcome measures are what ultimately count most to patients-did my health improve after you treated me?
In the creation of performance measures through EMS Compass, the leaders of the initiative had to ask themselves if outcome measures should even be considered, because the data are largely unavailable to EMS. But at the same time, NEMSIS Version 3 added some outcome fields that align with Health Level 7 International (HL7), a standard for data used throughout the healthcare world-which will help overcome some of the hurdles that have prevented agencies from getting automated outcome data in the past. In the end, they decided they should consider outcome measures, not just for the handful of agencies that will be able to access the appropriate outcome data now, but because outcome measures are critical to achieving the initiative’s vision of improving patient care.
Barriers to Sharing Data
EMS agencies and hospitals share some outcome information, most commonly for cardiac arrest patients. This typically doesn’t happen through the seamless integration of data or using a common database that automates and simplifies the process, but rather with the manual sharing of patient care reports and hospital records.
Although there are many examples of successful collaborations between EMS and hospitals, healthcare leaders rarely viewed EMS as a partner. In their eyes, EMS agencies were considered public safety, not healthcare, and their information and data wasn’t useful. Making EMS and hospital data interoperable wasn’t a high priority, and certainly not worth the time and expense-and perhaps risk-involved. And quite frankly, the technology wasn’t there to make it a simple decision. A variety of new technological innovations are now beginning to change that attitude.
Health Information Exchanges
The U.S. Department of Health and Human Services (HHS) defines Health Information Exchange (HIE) as “electronic movement of health-related information among organizations according to nationally recognized standards.”
HIEs were envisioned as regional networks, connecting the many disparate entities that interact with a patient with data relevant to that patient’s condition. Unfortunately, EMS has been involved in only a few HIEs nationally, either because of a lack of funding, lack of technology or lack of collaboration.
A notable experiment with EMS and HIEs is now happening in California, with a grant to specifically fund EMS participation. The results won’t be known until next year, but there are high expectations. Other regions and states are also experimenting.
In the meantime, some self-contained healthcare systems with their own EMS agencies have been able to create a version of an HIE for themselves, using translator software to make it efficient to connect a variety of disparate data sources.
Jonathan Washko, the assistant vice president of operations for Northwell Health’s Center for EMS (formerly known as North Shore LIJ Health System) and a member of the EMS Compass Measurement Design Group, describes EMS in his agency as a “mashup” of many different businesses under one roof, with data sources that include computer-aided dispatch (CAD), ProQA, Emergency Communication Nurse System, electronic medical records, billing systems, and AIMS (administrative info management system), along with internally developed products for decision support. None fully talk to each other.
Making these each interoperable with healthcare systems data can be challenging. Even in his system, within one corporation, hospitals use as many as four different types of software for patient records. The good news is that they’ve been able to overcome these obstacles with a software solution that facilitates and translates the various databases, enabling their internal HIE and linking the multiple EMS data sources with the hospital data.
Very soon, Washko says, they’ll be able to connect all the dots with data, with the ability to very quickly have a patient’s information served up in a way that can be aggregated and mined for clinical decision support, quality improvement and outcome measurement-both for an individual patient and across the entire system. EMS Compass performance measures will be an important part of that process.
Encouraging Hospital Cooperation
There are many approaches EMS agencies can take when facing hospitals that are hesitant to share data. EMS provides patients and patient information to hospitals every day, and to be good partners, hospitals should also share information. If hospital officials use HIPAA as an excuse, HHS-the agency that enforces HIPAA-created a fact sheet and a letter from the assistant secretary for preparedness and response explaining when hospitals can share outcome data for quality improvement efforts. (The letter is available online at www.naemsp.org/Documents/HIPAA%20Letter-NAEMSP.pdf.)
Sometimes, the easier it is for a hospital to provide outcomes, the harder it will be for hospital officials to say no. For example, MedStar Mobile Healthcare, the EMS agency serving Fort Worth, Texas, has tapped into enterprise software already in use in many hospitals to integrate disparate data systems. According to MedStar’s Matt Zavadsky, the software acts as a Rosetta stone to translate discrete data elements. Rather than sending PDFs back and forth, they’re able to actually populate trauma, stroke and cardiac registries automatically, and then as part of the bi-directional exchange of data, MedStar receives patient outcome data and patient utilization data back from the hospitals in discrete data units.
MedStar also will use this system for its mobile healthcare programs; for example, when they see a patient who’s just been discharged from the hospital, the data from the community paramedic’s assessment will flow into the system and be available to the patient’s primary physician.
In Arizona, a statewide effort to provide outcomes to EMS agencies recently went online. In this case, the statewide EMS database vendor provided the technological solution. The system takes outcome information that’s submitted by hospitals and brings it in to a state database and links it to patient care reports that have been submitted to the state. Local agencies can then access that information for patients they transported. One drawback to this approach is that hospitals don’t submit to the state registry in real-time, so the information isn’t immediately available. But a benefit of the statewide model is that even the smallest agencies find out what happened to their patients, including hospital diagnoses, procedures and disposition information.
When the project was announced, Rogelio Martinez, the data and quality assurance section chief at Arizona’s Department of Health Services, said, “The new method reduces the strain on personnel resources and gives measurements that each agency can usefor improvement.”
Outcomes for Every Patient
The Williamson County EMS System, outside Austin, Texas, gets patient outcome data on every patient via its software vendor. While his agency is only one of a few that have been able to accomplish this, Williamson County Medical Director Jeff Jarvis, MD, thinks the benefits and possibilities are so great that it won’t be long before it becomes the national norm, rather than an exception-perhaps in as little as five years.
This is good news for those in EMS who wondered just five years ago if that day would ever come. (For an interview with Dr. Jarvis about his experience, go to “You’ve Got Outcomes!”)
This year modern EMS will be celebrating 50 years, as defined by the release of the 1966 white paper by the National Academies of Science, “Accidental Death and Disability: The Neglected Disease of Modern Society.” Imagine where EMS can go in the next 50 years, powered by data and the knowledge of how prehospital care ultimately affects patient outcomes.