“How do we know we’re doing well? What should we be improving?” Anyone involved in the delivery of EMS asks these questions. They lead to more detailed questions like: “What’s our time to STEMI alert? Stroke alert? Taking a 12-lead? What indicators should guide us to transport to a Level 1 (or Level 2, 3, 4) trauma center?”
We also continually ask, “And are we in need of improvement in any area?”
Answering these questions requires data—on your own performance and on what other agencies are doing. It’s that comparative data that sheds light on areas of improvement.
Since about 2003, 52 U.S. states and territories have contributed to the National EMS Information System (NEMSIS) organized by the National Highway Traffic Safety Administration’s (NHTSA) Office of EMS.
The roots of the effort trace back into the 20th century, and extend from dedicated professionals attempting to produce the standardized data needed to answer these life and death questions.
The EMS community of professionals, administrators and software vendors have come a long way in implementing this system that collects records and assembles a database of standard data. The important thing is that we can all draw on that data for research, benchmarking and creating the initiatives to improve processes and outcomes.
The NEMSIS standard itself has improved over time and one key operational aspect of that evolution is the need to transition from one version of the standard to the next. Conference call requests and working papers are currently circulating around the preparation of the 3.5 version of NEMSIS.
Since we know that different states, regions and agencies use different iterations of the standard (some states are still using 2.2.1 versions), it’s worth reviewing some of the collective learnings we have seen assisting transitions around the nation and the realities that produced those insights.
NHTSA Vision & EMS Community Support
The NEMSIS standard grew out of early efforts to compare EMS data across states. Those projects quickly discovered that data types and terminology weren’t consistent, making comparisons that could drive improvement actions difficult to develop and scale.
In 1994, NHTSA stepped forward to develop the first standard data set with 81 entries.
Two years later, in 1996, after broad national input on that dataset, NHTSA published the EMS Agenda for the Future: A Vision for the Nation’s EMS system. With NHTSA providing both strategic direction and a coordinating body, other organizations such as the Health Resources Services Administration and the Centers for Disease Control added funding and momentum to the effort.
In 2003, a memorandum of understanding was signed by the National Association of State EMS Officials (NASEMSO) aimed at establishing the national standard for EMS data collection.
Over the next few years. the first Data Dictionary was created to provide the common language of data collection along with the base programming for the databases (called “schema”).
By 2006, the first public release of EMS data for research. including more than 300,000 records, was available.
Based on 2016 data (the latest data publicly available from NEMSIS), the national database now houses more than 30 million records from more than 10,000 agencies across the nation.
As of May 2016, 56 peer-reviewed articles using EMS data had published.
The selection of XML as the common data format for extracting and transmitting records from the local to state and national levels finished much of the technical work. XML is a widely used standard format.
Once a record is entered into a local EMS system, its standardized NEMSIS fields are extracted and configured into an XML file that’s then transmitted to the state level. A similar process occurs between the state and national level.
As we look toward developing the 3.5 version of the standard we should recognize that we have states operating on version 3.4, version 3.3.4 and even version 2.2.1.
No two transitions are completely the same, but experience teaches that they face common issues that can be addressed with proper planning and attention to detail in the rollout from the state to local level.
State-Specific Customizations: Keep It Simple
Data is a powerful enabler. Once you collect a little of it and see the value it brings, the temptation to collect more is hard to resist. NEMSIS and its associated software can make it look easy to collect even more data than called for in the national standard.
Over the years, states have added data fields or elements that are a superset of NEMSIS. These efforts are rooted in legitimate desires to measure one phenomenon or other in a given state that might see a trend they want to understand better. For instance, public health officials might want to know if a patient travelled outside the area in the past 30 days to spot contagions on the march. Having EMS collect data concerning different aspects of these occurrences can be a step toward improving public health.
But, this customized data collection must be treated with care for technical and operational reasons. Technically, any adjustments to the NEMSIS data collection tools cannot break conformance with the national standard. Agencies must still collect the data called for by the national data dictionary.
The coding of new data elements or fields also can’t disrupt the extraction of national data into the XML format. Seemingly minor glitches—if not caught in testing—can result in empty records transmitted to the national database.
Operationally, it’s important to recognize that any additional data collection mandates have cascading effects.
It will take more time to code while a transition in the national standard is under way. Likewise, it will require additional training in the midst of the larger rollout.
Recommendation: Keep it simple at first. Implement only the national standard data fields and elements at the time of transition. Train EMS agencies on using those elements only. You might foreshadow some customization at those meetings, but position them comfortably in the future.
Make sure usage of the updated standard is uniform across your state before implementing customizations. Simply updating the database, the tools and the training manual is not sufficient.
You need to know that the right data is actively flowing into your systems and correctly extracting and transmitting to the national repository before you start tinkering with further data granularity.
Training: Why, Why, Why?
The goals of the NEMSIS community include developing and deploying universal data standards to promote uniform national data collection. Training EMS personnel is key to those goals, and transitions are important opportunities to emphasize the goals as well as the reasoning behind changes in data collection.
Any change can have a direct impact on what EMS personnel do at a scene. In preparing a training program, it’s important to recognize that EMS are devoted first and foremost to helping the sick and injured.
Anything that appears to distract from that mission is suspect. As discussed earlier, there are perfectly good reasons that a state might want to know where a patient recently travelled, especially if that patient is presenting symptoms of contagion. But, filling in that field in a tablet can’t be a barrier to helping the patient at the scene.
Training regimes, therefore, have to be more than preparing protocols and materials. Training is an opportunity to build the collective knowledge of the EMS community and plant the seeds of new thinking and innovation.
Recommendation: Don’t deploy anything—whether it’s the mandated national standard or customizations—that doesn’t come with a “why.” Why was that change made? Why do we want this data?
If your goal in gathering customized data is to understand some trend better so you can help more people in the future, make that everyone’s mission.
Where appropriate, create metrics or incentives for compliance with changes such as making certain goals part of grant requests. But, the training protocol should aim at understanding as well as compliance.
Transition Planning: Communicate Early & Often!
NEMSIS changes impact everyone involved and no one likes to be blindsided. Data elements change from one version to the next. NEMSIS version 3.4 encompasses well over 500 data elements. Version 3.5 will as well.
Contrast that with the 80+ elements in the first standardization efforts and you quickly see that the trend has been toward increasing the total number. However, it’s inaccurate to conclude that this is merely a linear addition of more elements in each succeeding iteration. Some elements are eliminated while others are modified alongside the growth in new elements.
Any change will, at least temporarily, add time to entering a record. This has real operational impact across your states. Time is a precious EMS commodity affecting availability for the next call.
Most states encompass many agencies with a range of staff and capabilities. Rural areas sometimes rely on volunteer forces. The difference in sheer numbers of staff as well as technical talent to troubleshoot implementation issues varies greatly between rural and urban areas of a state. Transition plans need to take this diversity into account.
Recommendation: Communicate early and often as soon as you know anything. Engage all agencies in the transition plan and canvas them to understand their needs. As technical details become available for any database changes, assess the coding and even hardware needs they might entail.
Thoroughly understand the changes in data elements and any particular needs across the state before you touch anything; as I noted earlier, even small glitches can impact the data extraction and transmission process.
It helps to make contact with the people, like myself, who are involved in the national planning and rollout effort if only to have a resource who can help shed light on the “why” of one change or another.
Vendor Selection: Getting Help When & Where You Need It
NEMSIS transitions are software-driven projects. Selecting vendors for components ranging
from the field applications to the databases and the IT services entails some risk. No one wants to lose data in these transitions, and vendor capabilities can determine how smoothly the project goes. Are there offline capabilities that can assist with data backup? What are the validation processes to confirm NEMSIS compliance and complete functionality?
Similarly, upgrading the field applications that feed the state database requires attention to detail. Operationally, it’s not enough just to deploy the updated fields. Is there usability testing? How do the screens flow to help a busy EMS team through the data collection process? Are there validation steps built into that flow? These are all concerns that impact the integrity of data collection.
Recommendation: Selecting vendors who can help you at each step, from planning to deployment, involves more than just a single transition. Ideally, you’re establishing a partnership with someone who will be there at each transition, with a future orientation to the next one.
These partners can share best practices learned from numerous transitions around the nation. If there are niche needs for a given implementation or a local agency’s deployment, this partner can help evaluate the resources to fill that need in the context of the larger program. Partners can also help smoothly implement customization efforts.
Data to Save Lives
NEMSIS provides a means to collect the data we all need to save lives. It’s a platform for improving public safety and public health as thousands of EMS agencies around the nation draw on this data to create new insights and innovations.
Transitions between versions of the standard are part of this constant improvement process. Various states are on different versions of the standard and the 3.5 iteration is on the horizon. Start planning now.
As an industry, we now have a history of making these transitions so we can refine our approaches and move forward together.