Healthcare information exchanges
The concept is not new: Integrate electronic patient care records with healthcare information to provide for the mobilization of patient information across organizations and within a community. The result would mean faster, safer and more efficient care. Healthcare information exchanges (HIEs) are particularly helpful to EMS providers caring for patients who are unable to provide their own healthcare information.
Of course, the implementation has proved problematic. There are issues of access, security and retrieval of data. Then there is the money needed to launch such an endeavor.
Despite the daunting challenges, the Oklahoma EMS Authority (EMSA) decided follow similar HIEs in Oklahoma, Florida and Indiana and work with local healthcare providers to establish an information exchange.
EMSA is the largest provider of prehospital emergency medical care in the state, serving more than 1.1 million residents in central and northeast Oklahoma, including Tulsa and Oklahoma City.
Led by Chief Information Officer Frank Gresh, the Oklahoma EMS Authority (EMSA) began its foray into the brave new world of HIEs with a study commissioned by Myhealth Access. The results indicated a cost savings of $50 million annually, primarily in the reduction of duplicate procedures. If successful, the HIE would also push improved healthcare to rural areas of the state.
Prior to the exchange, there was no centralized link between labs, pharmacies, clinics, hospitals, physicians and payors. Field EMS records were only partially integrated into the hospital system. The plan was to establish a healthcare information exchange to use as a hub for patient information. It would be called Oklahoma SMRTNET.
Today, EMSA paramedics have access to SMRTNET through a Web interface. Eventually, Gresh says, it will be integrated into the electronic patient care reports (ePCRs).
By simply inputting the patient’s driver’s license number, first and last name and date of birth, the paramedic can locate a patient’s medical history, known allergies, current medications and previous hospital visits.
Gresh describes one recent encounter as a prime example of how well the system works. Paramedics were called for a man down. The patient was found, face down and unconscious. According to the HIE, he had recently been treated at a local hospital for a seizure. Armed with this information, they were able to quickly determine that he had experienced another seizure and transport him to the hospital where he had previously been treated.
Gresh says that of the four to eight patient contacts per day, there is useful patient information in the HIE approximately 50% of the time. Aside from the system’s usefulness to the paramedic, he sees EMS becoming a fully integrated component of the overall healthcare system–an important step as healthcare reform looms.
Some HIE systems simply put the information into a PDF format rather than attempt to integrate it into the ePCR, but that doesn’t get to where Gresh wants to be. He had concerns that the paramedics would become data entry technicians. To avoid that situation, he is working to integrate hospital data into the ePCR in order to automatically populate fields for last known address, allergies and long lists of medications.
“What I’m attempting to do is take away some of that data entry information. Why not make the system work for them?” he says. He is hopeful this portion of the system will be completed by the fourth quarter of this year.
Gresh notes that many Health Insurance Portability and Accountability Act (HIPAA) issues have already been ironed out with the lawyers. At hospitals in his area, each patient is assigned an Electronic Mater Patient Index (EMPI) number. The EMPI is used by hospitals to help maintain patient privacy. However, hospitals often have the luxury of time when filling out patient records. In order to work for EMS, the process had to be upgraded to address some of the specific challenges faced by field providers.
The first is to build into the system a way to identify a single patient whose name has been entered in multiple ways (e.g., with or without a middle name, with an incorrectly spelled first name or nickname). To avoid giving each new entry a separate EMPI number, the system analyzes 17 points of information to identify the patient as the same person.
Then there is the issue of addresses. Often addresses are not immediately accessible or available to EMS providers. A hospital analyst was astonished to note that dozens of patients were listed at the same address. It turned out to be a homeless shelter that EMS workers often listed for the homeless patients they transported.
HIE improves EMS
EMSA providers send preliminary patient care information to the hospital while en route with the patient. The electronic medical record in the emergency department is already started and partially completed by the time they arrive. If nothing else, Gresh says, the system saves EMS providers time searching for a printer.
Outcome information is generated by the hospital on each patient. This information is accessible to EMSA, allowing for field EMS research and quality assurance. Gresh says that as accountable care organizations (ACOs) are established and bundling begins to occur, this type of technology will go a long way to assisting EMS in the clinical integration that is expected in the future.
By 2014, healthcare providers, including EMS, will need to show meaningful efficiencies or lose money. “It’s not here yet, but the train is coming down the tracks,” he says. “We’re not going to have a choice.”
It’s been two years since Gresh approached the first hospital about HIE. Overall, however, he is pleased with the direction EMSA is heading. “We’re onto something,” he says.
Integration of data has been a major hurdle to overcome. Surprisingly, he found that there is a corollary to the familiar EMS adage, “If you’ve seen one hospital medical records system, you’ve seen one hospital medical records system,” he says.
An important step in the process is to develop a requirements document. Because the HIE simply stores whatever it gets, the detailed document will help integrate the various data formats and unstructured data into useful information.
It’s especially important to include standards for coding medications, for example. Although hospitals are similar, each uses a slightly different coding system that can pose challenges when attempting to access such things as medications. According to Gresh there are 7,400 medications. Each needs to be mapped to ensure that they correspond correctly.
When planning the HIE, Gresh looked at other agencies that had implemented similar systems. He also found resources at the federal government. The Health Care Information Technology Standards Panel has developed several useful case scenarios for field EMS integration. The 140-page document is available at www.hitsp.org.
Gresh encourages EMS agencies to talk to healthcare partners to see if an HIE is already in existence or in the process of being implemented–then get involved. With the new healthcare legislation, hospitals have become increasingly interested in working with EMS.
When developing the program, don’t forget the patient. Although patients have the right to view their HIE, the front end is not consumer friendly, says Gresh. There must be some way to allow patients access to their information. Patients also have the right to opt out of the system.
Gresh admits that he still faces challenges. “IT costs never end,” he says. EMSA uses grant money to cover those costs. He notes that with no formal IT department some agencies will struggle to provide the resources needed. Gresh says that community involvement, especially through the state health department, can be an effective resource. He also suggests approaching community-based agencies that have a vested interest in improving healthcare, such as the Salvation Army and Planned Parenthood.
If agencies don’t have the resources to implement an HIE program, he recommends staying informed and, at the very least, starting talks with the hospitals. Often, EMS has not been considered in the plans for such hospital-based systems. The key is to get to the table early.
Other issues that need to be addressed include how the data is used; who owns the data and what the security is for the data. There is some shared risk if an improper user accesses the information. “Until it’s absolutely clear it’s not your responsibility, assume it is your responsibility,” Gresh says.
The bottom line is that HIEs are coming. “It’s not a matter of if, it’s a matter of when,” Gresh says. “There will be a short window of time to jump on board.”
Canada and the United Kingdom have had HIEs for 15 years. Gresh says that he is working on sharing information across borders. “It involves a whole other level of layers.”