Columns, Commentary, Mobile Integrated Healthcare

The Opportunity & Need for a Nuanced View of Prehospital Information

On the final day of the 2018 North Carolina EMS Expo, Steven Howell, NRP, the EMS captain and coordinator at New Hanover Regional EMS, gave a talk audaciously titled “How Data Drives Success.” Having seen many such presentations over the years—many of which have fallen short of innovative or anything more than platitudes about the “need” to chart patient care for legal coverage, and a pining, fruitless, frankly overblown and never-really-explained desire to gain unfettered access to hospital-side electronic health records—I was curious.

Mr. Howell offered a sophisticated overview of the value of prehospital information (not just data!) to EMS and Fire agencies, delivered in a state that still has parts underwater in the aftermath of Hurricane Florence. He grasps the power of statistics, both to reveal unseen truths and to dig rabbit holes down which to tumble. Though not in so many words, he emphasized a vision of insight gleaned out of stochastic entropy (i.e., in non-math geek terms, increasing complexity and randomness that gets evermore confusing).

The complexity of data is a plight of prehospital providers. But the more layered the available useful information, the more it can help with resource planning, clinical performance and even hiring. Nuanced data used well elucidate your agency’s excellence—and where it needs to improve. “Let the numbers do the talking” to optimize your budget, determine how (and whether) to deploy a mobile integrated healthcare or community paramedicine (MIH-CP) program, and even discover just how much your state-provided “free” ePCR really costs in terms of time, efficiency and morale.

With the exception of Mr. Howell’s unnecessarily specific reference to two prehospital technology vendors—instead, he should have used more generic language to recognize that there are far more options in the market than those two, and that highlighting two specific vendors that everyone in the room probably already knows actually does them a disservice by failing to expand the field of vision—I only found myself thinking of one criticism that I would have suggested to the speaker. That is, he didn’t mention that if we fail to dig more deeply into data than counting things, we’re missing the overarching point of spending time, effort and money aggregating statistics, logistical details and clinical performance metrics.

Simply put: Data like to mingle, rather aggressively. They bounce off one other, and in so slamming, manifest unexpected findings and insights far beyond the menial tasks (relatively speaking) of counting things.

Data help EMS and Fire services understand how they managed to get the patient to the right treatment, at the right place, at the right time. Seen as a tool rather than an unfunded mandate, data help agencies grasp the implications of discrete data, like counts, in light of population health, interoperability and regionalization of care. Conversely, a “free” but inflexible data system—vs. one that’s paid-for but tailored and bendy—can impose a higher Total Cost of Ownership, including a reduced opportunity to dig into local priorities. (Consider the Spanish adage: “What is ‘free’ may end up being more expensive.”)

Getting Creative with Data

Far more interesting than counting the number of intubations or administrations of naloxone or STEMI transports and cath lab activations, is to analyze discrete data in light of one another.  How each clinical indication fares with respect to ZIP code, demographic slices, times of day, and historical patterns like seasonality and weather. How does a population that’s experiencing higher catheterization rates correlate with respect to nutrition?

Do you think you need an MBA to ask these kinds of questions? All you need is to think creatively about the work your crews are already doing—all of the information you need lives in NEMSIS v3.

A suspected STEMI is an emergent, “incident-specific” data value; malnutrition is generally classified as a non-clinical, longitudinal “patient-specific” value. But separating incident-specific data from patient-specific data introduces a nonsensical distinction, because so much of what becomes emergent is caused by that which built up over time until the body could take no more.  Solve the disease, eliminate the symptom.

Medically speaking, STEMI and malnutrition may have little causal linkage. However, with eyes to population health, syndromic surveillance and the regionalization of care, if a particular region or patient cohort faces both a higher rate of cardiac catheterization, as well as a higher rate of malnutrition, what sorts of physical and human resources should be deployed in the vicinity, at a specific time of day (if applicable), and with the appropriate cultural sensitivity (if applicable), etc., to offer not only adequate but optimal and targeted prehospital care? 

Asked a different way: When did you last assess a non-MIH-CP patient for access to food, transportation and even something as “fluffy” as friendship? And yet, lack of friendship may be as severe a disease contributor as tobacco, alcohol or drugs. Loneliness has been definitively shown to deteriorate health over time. Why wait for an MIH-CP program to undertake steps that address patients’ underlying needs, even if those are psychosocial? Surely it’s not a matter of funding!

I’ll confess to being a tad disappointed when Mr. Howell cited community paramedicine and the provision of care at alternate sites, but didn’t highlight the opportunity to leverage data to build care delivery models that aren’t only sustainable but that actually generate an operating profit through a reduction of actuarial risk (that is, the value that insurance companies measure) among patient populations facing high recidivism, or risk of return to the hospital. Reducing risk has the potential to more potently drive MIH-CP program success than seeking to prove elusive “health system savings,” some of which are unsupported by the literature. (For more on this point, please see my presentation, “Harmful Habits Make Financial Sense,” from the 2017 International Roundtable on Community Paramedicine.)

We talk about the emergence of prehospital care as part of the broader healthcare system, and that we need to stop being reactive. Are we actually taking steps to be proactive except in special cases like MIH-CP?

Think you lack money to proactively engage beyond life support and transport, or that laws restrict your ability to creatively serve your community and patients? Copious funding sources, from grants to hospital VC and philanthropy funds to insurance payers, will compensate you for value delivered … if you can speak the language of whoever manages the checkbook.

You do speak the language—or you could, anyway. Rich, nuanced data are your Rosetta Stone. Learn to use data as a canvas on which to paint a picture of diligent care delivered. To do so, stop thinking of data as a necessary evil. Instead, reframe data-driven insights as critical, following closely behind airway, breathing and circulation.