
This is cause for celebration! For reflection. And possibly, even a decade later, for explanation.
On December 17th, 2023, my software company celebrated the 10th anniversary of becoming the first ePCR system to achieve NEMSIS version 3 compliance. On the same day, another major health care software company celebrated becoming the first data repository to have met this exciting bar within its category.
(For any who are unfamiliar: the ePCR is the documentation system in the truck, whereas the repository is the database—usually (but not exclusively) at the state level—where ePCR data ultimately go for nationwide analytic processing.)
It may have been coincidental, but it should not be seen as incidental or irrelevant, that during the same week as this happy occasion, the federal Office of the National Coordinator of Healthcare Information Technology—which oversees electronic health records (EHRs), and interoperability among them, in the United States—announced that “the Trusted Exchange Framework and Common Agreement (TEFCA) is now operational.”
In brief, TEFCA is a set of data sharing agreements, processes, and rules that will allow EHRs and health information exchanges (HIEs) to talk with one another, even across jurisdictional lines. The idea is simple: if you’re from New York, and you’re traveling to Texas or California or Alaska, and you get sick, you should be able to have the doctor over here able to access your information from over there.
If you ask whether COVID-19 sparked a bonfire underneath our collective rear-ends to get this right at last…well, you know the answer to that question: in a two-part interview for this magazine (which you can watch here for Part 1 and here for Part 2, Joe Casciotti (then with Harris County ESD 48) described being unable to see vaccination information for a patient from Dallas who moved to Houston. This was no breakdown of cross-border data transfer—this was a lack of ability to share even basic information within one state.
If the COVID-19 use case does not provide enough reason to care about TEFCA, or about interoperability itself, then consider this: five years ago to the day (I am writing this on December 19, 2023), my colleague Art Groux and I also published, in this magazine, an article titled: “The Brutal Math of Drug-Seeking Behavior in Prehospital Care.”
Has the substance use problem gotten better in the last half-decade, or have the risks increased? Maybe it’s anecdotal, but to this author, stories about candy-colored fentanyl are a relatively new disaster waiting to happen—one that I am hearing even cool-headed physicians fret over. But we can arrest the substance use crisis in its tracks with effective health information exchange between Mobile Medical professionals and the Rest of Healthcare. Why? No one would fall off the grid or fly under the radar and be able to round-robin the ecosystem looking for a fix.
In the Fall of 2018, I published an article in the now-defunct Carolinas Fire Rescue EMS Journal called “Why Data Interoperability is Critical to EMS’s Role in Addressing the Opioid Crisis.” (You can read the article at this archival site, p 14-15.) Two years later, I recall a chat with Rich Raymond, CEO of Armstrong Ambulance in Massachusetts, about his region’s desire to implement a co-responder program targeting substance use from both public health and public safety perspectives. At the time, Rich said the challenge was how to share information, in real-time, among all the participants: ambulance and fire services, police, hospitals, social workers, mental health professionals, and more.
Fast-forward two more years. I had the pleasure of dining with Dr. Scott Weiner, then director of the Brigham Comprehensive Opioid Approach and Education Program and assistant clinical director in the department of emergency medicine at Brigham and Women’s Hospital in Boston. Scott expressed the patient’s Social Determinants of Health—say, whether they have a history of substance use or live in a place where substance use is rampant—is one of the top three pieces of data that he, as an ED clinician, wishes he could know about an inbound patient. (The other two were whether the patient has a POLST / MOLST, so that their medical wishes are known, and the mechanism of injury).
Brigham & Women’s Hospital is less than ten miles away from Medford-Arlington, where Rich was trying to understand how to share information with hospitals—and here was a top doc at a leading hospital saying he wished he could get data from ambulances.
(Lest you wonder if this was an East Coast thing: almost exactly the same was said by trauma nurses from the University of Louisville, in Kentucky, during the 2019 Society of Trauma Nurses annual conference. There, oddly, I was the only representative of Mobile Medicine in the room.)
But in late 2023, and we celebrate the “aluminum anniversary” of the first two firms achieving NEMSIS v3 compliance, change is here. It’s not even “coming.” It’s already afoot in California, Massachusetts, Michigan, Colorado, Louisiana, Virginia and Texas. Interoperability leaps forward are being advocated by the statewide health information exchanges as well as the state offices that support them.
Before all of the above, a lifetime ago in 2016, I published the only article that I ever wished had been wrong. It appeared in Becker’s Hospital Review, and was called, bluntly: “’Different Colors of Money’: Federal funding silos have hamstrung the EMS-to-hospital data continuum. How to correct the disjoint.” In it, I made the following point:
“The interoperability train among EMS, EHRs and HIEs is sliding down a mountain thanks to “different colors of money” being spent and departmental “siloes” that don’t talk to one another. U.S. taxpayers should be furious because it represents a paragon of redundancy. But it is also enormously important to we who build pre-hospital technology: Even if hospital systems could access state EMS data repositories (which they don’t today in general, though they theoretically could if they wanted to), hospitals would find the data in those repositories is incompatible with their own health record and analysis systems…ONCHIT, NEMSIS, and NHTSA’s Office of EMS must incorporate technologists’ perspectives ASAP, to avoid the roadblocks that will persist and get worse if our industry keeps relying on “separate but equal” data systems between prehospital and in-hospital care, when such systems are redundant, crazy expensive, and ultimately contradictory to the flow of patient information along a care continuum.”
At the time, the pending collision in mandates between Mobile Medical data and “the rest of healthcare” seemed like a slow-moving trainwreck that we collectively refused to avoid. The process has faced challenges, but not so many that the evolution was in vain. Quite to the contrary: like building a venture focused on more than just profit, “good things take time.” Those of us in the NEMSIS trenches certainly wish that some things had moved faster. But good things take time.
In the intervening years—which I suggest we celebrate on this momentous anniversary—the National EMS Information System Technical Assistance Center (NEMSIS TAC), the federal Office of EMS, and the Office of the National Coordinator of Health IT have done…precisely what I, for one, hoped they would do. They worked closely together. They pursued the inclusion of Mobile Medical data amid a continent-wide conversation about Social Determinants of Health, syndromic surveillance, and the avoidance of burnout coupled with reliable information capture and conveyance.
Top government officials traveled to meet with companies and provide in-the-trenches advice about how Fire, EMS, NEMT, IFT, CCT, and CP-MIH agencies—the whole family!—can participate in TEFCA—and why doing so matters. In other cases, six different federal agencies hopped on a Zoom guided a rural fire service doing under a thousand transports per year, through its aspirations to pursue a sustainable model for mobile integrated health.
In the Becker’s article, I made one point that didn’t age well. “NEMSIS, the dataset that forms the backbone of pre-hospital care records — basically, NEMSIS is the EMS version of HL7 — has been skewered by emergency departments and even EMS medical directors as being deeply concerned with statistics but light on patient care…”
This discussion is not happening anymore. Instead, the NEMSIS data set has become increasingly relevant, and has shown its pliability by tracking both medical advancements and changing social norms:
The real cause for celebration is that hospitals, HIEs, governments, medical directors, insurers—all are increasingly asking, even demanding, Mobile Medical insights. It only took ten years, but Mobile Medicine has been invited to Healthcare’s Table of the Future.
Whether agencies accept that invitation is a different question, but considering that, as of this writing, nearly a dozen Fire, EMS, NEMT and Community Paramedicine services have already signed up to participate in the California Data Exchange Framework—that state’s version of TEFCA—it seems that the health data geeks among us can begin chilling the champagne without feeling premature.
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