The long-overdue theme of the moment is convergence. Outside observers of all things innovation might think it is artificial intelligence (AI), but they would be missing the realization that AI is itself a convergence: the concept itself is not new, but sufficiently fast technology plus an information ecosystem hungering for “More content now!” needed to collide.
Yet we find that in AI, for example, as in seemingly all things, there are haves and have-nots; and there is value in helping the have-nots to have. In few professional settings is this truer than Mobile Medicine, because (a) lives are on the line, and (b) the rest of the healthcare world already assumes that data are available, at the ready, on demand and at the patient’s side. Therefore, both clinicians and patients are surprised (shocked?) to learn how little contextual information is available when Responders arrive on scene.
Sometimes software developers, insurers, regulators and other vested parties who aim to connect the healthcare ecosystem, receive a question that is at once terrifying and weirdly understandable in light of how little awareness there is about Mobile Medicine’s policies, processes and powers: “Why would EMS need more information about their patient?” This is a question that I received during the 2024 Digital Health Innovation Summit in Boston, in the context of polychronic patients who seek to maintain an even keel with the help of a ball full of pills. It’s called “Polypharmacy.”
The tone of the question I received was not meant to be demeaning or rude, so let us assume that it was sincere—that the asker really wanted to understand the role of patient information to the crew in the field when she recognized that both the patient’s clinician and the receiving hospital likely have access to relevant context. Why would the “ambulance driver” need this information? (AAAAHHHH!)
It took but thirty seconds to explain that the ambulance crew has custody of the patient while he or she is in the back of the rig. If the patient declines, isn’t such information essential to providing successful interventional care and avoiding an iatrogenic adverse outcome, i.e., one that is not due to responder error, but rather the lack of background detail like allergies or drug interactions (especially when the pills have been jumbled up in the aforementioned bag)?
Here we arrive at our next convergence: a topic at a healthcare IT summit in Massachusetts blended into an emerging area of focus on California. Assembly Bill 133 (AB133) created the first universal framework for sharing patient information in America’s most populous state. AB133 brought California closer to several other large states—including New York and Texas—with a “shadow health information exchange” (HIE) comprised of data pipes virtually linking the clinical ecosystem, with local HIEs providing services layered on top, rather than core infrastructure.
For better and worse, AB133 only referenced the fire and ambulance services implicitly, by virtue of the fact the bill centers on information sharing about patients who received Medicaid. It is well documented that low- or no- income patients are the largest block of ambulance utilizers. In other contexts, I have explicitly tried to remind the world that “Mobile Medicine is Safety Net Medicine.”
But California—where care providers of all service types and levels routinely work alongside one another—did not leave out ambulances. That needs to be clear. They are welcome to participate in the Data Exchange Framework, or DXF, even invited and incentivized to do so, and one hopes that the increased efficiency of patient handoffs (both lower “wall time” inbound to a hospital and a closer match between discharge arrival time and patient readiness on the outbound); streamlined revenue cycle management; and the liability shield generated by more informed care in both emergency and nonemergent contexts, would more than compensate for incidental costs associated with connecting to the broader healthcare ecosystem.
In the first iteration of this interoperability process, California sees Mobile Medical agencies as voluntary participants who can choose to submit data in the interest in clinical, operational, and financial efficiencies of their own volition. Grant dollars were available to connect Mobile Medical services to the DXF, but they expired in December 2023 after three funding rounds.
Fifteen agencies—planning the Mobile Medical gamut: both public and private agencies; rural and urban ones; agencies in the north, south and central of the state; and all service levels including ALS, BLS, and Community Paramedic—took advantage of this opportunity, signing the state’s Data Sharing Agreement and at last achieving, under law, parity with the rest of the healthcare community.
If all of this geeky, healthcare data-related evolution this doesn’t sound optimistic enough about increasing recognition of the role of Mobile Medical professionals in the healthcare continuum, a proposed amendment to AB133—appropriately called AB1331—lists “emergency medical services” specifically, thereby correcting the implicit inclusion by making it explicit.
This author is optimistic that the bill will pass because our profession has been pining for parity for so long, and this is “one of those moments.” Furthermore, several of the first Mobile Medical DXF signers are run calls in the district of the amendment’s lead author, and they will benefit meaningfully from streamlined interoperability to accompany their existing mutual aid operating plans.
Thus is the magic starting to spark: under California law, DXF participants are on par with facility-based caregivers. Legally on par. And equally entitled to give data and get data, as long as the methods comply with federal regulations, specifically the U.S. Core Data for Interoperability (USCDI). This leads to the final convergence worth highlighting: in 2020, in response to a publication from PWW, I wrote a write paper called Sharing Data Between Mobile Medical Agencies Hospitals: Ethical, Not Imaginary, Barriers (which you can download for free, in full, via Scribd).
It highlighted the legal barriers to information sharing that functionally stood in front of HIPAA, preventing hospitals can returning data to ambulance services despite years’ worth of federal guidance clarifying that HIPAA is not a barrier to sharing. Indeed HIPAA wasn’t—but 42 CFR Part 2 was. The laws overseen by the federal Substance Abuse and Mental Health Services Administration (SAMHSA) remain largely unfamiliar to Mobile Medical professionals—in several unscientific poll, performed both live at conferences and online, mentioning SAMHSA returned blank stares and raised eyebrows…which was so odd given the outsized impact of these laws ambulance operations and patient care. For example, do you see patients who are struggling with addiction. Do you have patients who use harmful substances, are depressed or schizophrenic, or are at risk of hurting themselves or others? If so, then you too are subject to the SAHMSA laws.
In February 2024, the persistent walls started crumbling, even though the change has not received nearly enough fanfare across our profession. Here is what you need to know: a Final Rule published by the U.S. Department of Health & Human Services said that just one consent received by care providers permits “all future uses and disclosures for treatment, payment, and health care operations” even in cases of mental health and substance use (alongside other healthcare applications). This is worth reading more about, because it will finally let information flow in more than one direction.
Editor’s Note: This commentary reflects the opinion of the author and does not necessarily reflect the opinions of JEMS.
More from Jonathon S. Feit
Is AI in Mobile Medicine Accountable Enough for Its Decisions?
The Unified Power of Thousands, Part 2: The Promise (and Problem) of Convergence in Mobile Medicine
The Unified Power of Thousands, Part 1: Constantly Being Undermined (And How to Stop It)
Mike Touchstone’s Joie de Vivre: Obituary to Everyone’s Friend, Mentor and Muse
