Implementing a Health Information Exchange


Editor’s Note: This is part two of a two-part series on health information exchanges. Part one ran in the June issue.


Electronic medical records (EMRs), also known as electronic patient care reports (ePCRS) in the prehospital setting, are rapidly becoming the cornerstone of today’s healthcare delivery system. They aren’t just a good idea; beginning in 2015, they will be required by law for hospitals and physicians. Although EMS wasn’t included in the requirement, it won’t be long before hospitals will be expecting EMS agencies to interface with their systems.


The motive behind these new mandates is the use of electronically captured health information to track key clinical conditions and communicate that information to better coordinate patient care. Once patient care information is in an electronic format and available to all healthcare providers, it can further be used to assess clinical quality measures and report public health information.


Healthcare providers are receiving financial assistance to make the mandated switch to electronic records through federal government health information exchange (HIE) grants. The Medicare and Medicaid Electronic Health Reports Incentive Program provide incentive payments to eligible healthcare professionals and hospitals as they adopt, implement, upgrade or demonstrate meaningful use of certified electronic health report technology. The primary beneficiaries are hospitals and certain types of doctors. EMS agencies don’t qualify for funding unless they’re part of a hospital system.


If your agency hasn’t already converted from paper to electronic PCRs, the first step is to determine which system works best for you. Even if your agency has converted, your work doesn’t end there. In order to gain the most from transferring to an electronic format, your system must be able to not only provide information to the hospital’s data system, but translate the data provided and distribute it in a format that’s understandable to the hospital end users.


All of this requires that the systems used by every EMS agency and all the hospitals somehow speak the same language. The solution is to translate the data from the individual sources into a common language that can then be distributed to the various end users in a format they can read, allowing all the healthcare providers, EMS included, access to the entire patient care record. This will eventually provide, for the first time, the Holy Grail of data exchange: HIPAA-compliant patient outcome data from the hospital for EMS providers to use in order to assess quality and enhance training and education programs that will result in improved patient outcomes.


Case Study: Wake County (N.C.) EMS


Although hospitals often have a cadre of technical experts in-house to assist in the monumental task of implementing such a system, that’s seldom the case for most EMS agencies or fire departments. Even so, there are still some who are willing to walk the bleeding edge of technological advancements. One of those agencies is Wake County. “I’m not sure we found an edge yet,” admits Assistant Chief of Technology Bennie C. Collins, BHS, EMT-P.


For nearly five years, Wake County has worked on the concept of creating interoperability with local hospitals in order to exchange patient data. On Oct.31, the system went live.


The Wake County Department of EMS consists of two 9-1-1 centers, 25 fire departments that provide first responder service, and four EMS providers–the Wake County EMS Division, and three contracted EMS provider agencies: Apex EMS, Cary Area EMS and Eastern Wake EMS. They’re responsible for the provision of EMS throughout Wake County, including the state capital of Raleigh. The Wake County EMS Division is the largest of the four agencies and the sole public-sector provider. It operates 35 ALS ambulances from 10 discrete stations and eight stations shared with local fire departments. More than two-thirds of all transports go to one of five receiving hospitals.


According to Deputy Director Joseph Zalkin, BSHS, EMT-P, Wake County EMS was willing to take on the task because they firmly believe data exchange will lead to better patient care, particularly if hospital providers have access to pre-hospital data. He gives the example of a patient transported post cardiac arrest. For the invasive cardiologist, the only documentation of the cardiac arrest and initial treatment provided is the printout from the EMS defibrillator. “To that extent, data drives decisions,” Zalkin says.


The Wake County EMS data exchange system has already paid for itself in corrected patient billing information.


Technology and data are already helping EMS in decisions regarding unit deployment, which units respond to which calls and, using GPS, how to get there. “If FedEx and UPS can tell you where your package is located, shouldn’t the person in charge of your life have that capability?” Zalkin says.


Start small


The proof of concept needed a smaller site for ease of management. The logical choice for Wake County’s first partnership was WakeMed, an 870-bed private, not-for-profit healthcare system based in Raleigh, says Collins. Once it was successfully launched, the agency conducted extensive testing before rolling it out to the rest of the sites. As of this past month, they’re live at all five sites. The results so far have been positive: Patient data flows successfully in both directions.


The biggest lesson learned? “Communicate, communicate, communicate within all departments,” Collins says.


Another significant lesson they learned is that it’s also essential that hospital staff develop habits that lead to appropriate patient information being entered into the patient’s records. The most important information is patient identification.


A key factor at any level of patient care is to match each patient with their healthcare records. Because of the nature of some prehospital calls, EMS often has a hard time tracking medical and billing records for unconscious, unidentified patients who have been transported to the emergency department. Even for patients who have been correctly identified, spelling errors, multiple spellings of a name or the prevalence of common names can confound an ePCR system, adding to difficulty in tracking patients for billing purposes. “One letter is all it takes to mess it up,” Collins says. “I would warn folks not to expand too far out to match EMS records and hospital records. There’s too much duplication of names and birth dates; make one, unique type of series.”


Wake County EMS addressed this issue early with bar-coded armbands, similar to the ones used by hospitals. Every patient who is transported by EMS gets a bright orange armband with a unique seven-digit UPC-style code, which is then entered at the hospital using scanners that Wake County provided. The EMS patient medical record number is combined with an automatically generated hospital patient visit number, linking the records.


If any component in the record is missing–if a nurse fails to scan an EMS armband, for example–the record is flagged as an “orphaned ticket” that must be manually reviewed to connect the record with the correct patient.


“There have only been a handful of omissions that have created orphaned tickets,” Collins says. Currently, he’s spending about an hour a day on this task. “We are very pleased at how the field providers have embraced this,” he says.


District chiefs will eventually be responsible for matching orphaned tickets created during their shift. They will each be assigned a hospital and given access to all matched and orphaned tickets. Although they can view the data, they can’t change it. They will identify the missing data from the EMS side and contact the hospital to correct the issue.


The work team that has been developing the data exchange system is also designing a tab on the EMS patient record that providers can select to view the patient data received from the hospital. Issues regarding how the data is packaged for the provider are still being discussed. Only the EMS crew who treated the patient will be allowed to view the records, since they will be used for quality improvement purposes in accordance with HIPAA regulations.


To ensure that the data is NEMSIS compliant, the EMS Performance Improvement Center, a University of North Carolina at Chapel Hill-based service that develops, maintains and supports several interconnected and extremely complex statewide web-based applications, reviews the data every 24 hours. They’re looking for ways to bundle specific types of care, such as STEMIs and stroke, to be viewed in aggregate.


Even though access to hospital records has opened the data exchange door, agency administrators are still trying to decide how to most effectively use the information, particularly in light of the changes brought about by health-care reform. “We aren’t really sure where we are going,” Zalkin says. “We don’t really know what we don’t know, especially in an ACO [accountable care organization] world.”


For now, however, the agency is busy resolving technical challenges, including frequent changes in software systems. “No one uses a software system forever,” Zalkin says.


In 2014, three of Wake County EMS’ receiving hospitals are moving to a new system. Fortunately, they’re all going to the same software system. “That will make our lives easier,” he says. “We only need to write one interface.”


Zalkin says the majority of the cost of the project is in personnel. The vendors negotiated a price with the EMS systems, and the funding was completed up front. He says that the Wake County EMS data exchange system has already paid for itself in corrected patient billing information. Previously, up to 30% of the patient billing information was incorrect. Now, the hospital automatically provides correct billing data on every patient.


Lessons learned


“The interface for the individual provider should be part of the process in order to get buy-in,” says J. Brent Myers, MD, MPH, FACEP, who is both the department head and the system’s first full-time medical director. Although it’s exciting to have mounds of data, it can also be overwhelming. He recommends identifying a laundry list of things to do with the data. “The last thing we need is information overload,” he says.


Myers believes that much of the effort to participate in healthcare information exchanges will be driven by the ACOs. Eventually, EMS will be required to provide data to prove its value. Zalkin agrees. “They want our data just as much as we want theirs,” he says. Even if hospitals are initially reluctant to share, competition can be a strong motivator. “In a competitive environment, you only need one to fall [into place],” he says.


Creating the team is critical. In North Carolina, work teams consist of WakeMed IT staff, EMS system representatives, a third party that WakeMed has contracted to participate in the program and representatives of Wake County EMS’ ePCR vendor, ESO Solutions.


“Make sure to have representatives two deep for every team member,” Myers advises. Creating a system like this takes time. People move, get married and take vacations, creating holes on the team. “You’ve got to have some depth to keep momentum going in a project as complicated as this–someone to be there at all the crucial times, if you want it to be done in a reasonable amount of time,” he says.




No one at Wake County EMS is saying this project was easy or that their work is done, but they’re willing to share their experience. “Now that we have a proven, finished product that is working, there is no reason other folks should have to bleed like we did,” Myers says.


It’s important in this period of rapid change that all healthcare providers, including EMS, communicate and collaborate to improve the effectiveness and safety of patient care. The ability to exchange patient medical records in a timely manner is vital to improving patient outcomes.


As EMS plays a larger role in community health delivery, aligning more closely with hospital systems within an agency’s service area to create an open forum for secure patient information exchange will allow EMS to enhance quality improvement programs, training and ultimately, patient care. “We are practicing medicine. We should know, from 9-1-1 to discharge, how our patient did,” Zalkin says.


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