In doing so, medics now have access to specific information drawn not just from one hospital but from more than 30 different types of venues–multiple hospital systems, freestanding clinics, health departments, pharmacies, physicians groups, etc. The system is vast, cutting edge and truly one of a kind.
Ironically, Indianapolis EMS providers only recently transitioned from paper to electronic patient care records on July 1. Although late to enter the ePCR game, waiting turned out to be advantageous. All 20 agencies in the two counties made the leap at the same time to Medusa’s Siren ePCR system.
Implementing a single ePCR system at the same time across Indianapolis made tying EMS into the larger INPC system much simpler than trying to tie in various ePCR platforms. Of note, the EMS model in the 20 counties varies, but the institute succeeded in overcoming the monumental task of gaining buy-in from multiple administrations and management organizations.
The INPC backbone
The Regenstrief Institute developed the INPC network in the mid-’90s. “One of the investigators here received funding from the National Library of Medicine and the Agency for Healthcare Research and Quality to look at sharing data between hospitals,” said John Finnell, MD, an investigator with the institute, associate professor of emergency medicine at the Indiana University School of Medicine and director of the informatics division of the department of emergency medicine. “That was the first time that two hospitals that weren’t related in any way started sharing data. That’s grown over the years to include more than 30 different types of facilities. It really is a regional health information exchange.”
Patients who arrive in the emergency department who have at some point visited one of those 30-plus sites will appear in the INPC repository, enabling ED physicians to view a comprehensive file that includes such information as a problem list, medications, allergies, clinics visited, lab results, radiology reports, etc.
“The thought was, “˜Would this information be useful to paramedics in the field?'” Finnell said. To find out, the paper records had to go.
Funding
“The electronic medical record system itself was funded out of several years’ worth of Urban Areas Security Initiative dollars,” said Charlie Miramonti, MD, deputy medical director for the Wishard EMS service, an emergency medicine physician with the Indiana University School of Medicine and an assistant professor of clinical emergency medicine.
“The synchronization [with EMS] piece was funded out of the 2007 [HHS] Health Care Partnerships Grant. We were one of five sites in the country to win, and this was a $5 million, two-year grant to improve surge capacity amongst emergency departments and hospitals.”
The grant was administered through a joint project between the school of medicine, the Health and Hospital Corporation of Marion County and Wishard Hospital. It was managed through an organization called MESH, Managed Emergency Surge for Healthcare.
Going live
“We started testing earlier this year,” said Tom Arkins, a paramedic and special operations manager with Wishard EMS. “We have computer tablets in the field and a wireless network, which is how paramedics access these records. They authenticate into the system, and then they look for four pieces of information: the first name, last name, date of birth and sex of the patient. Once they have those four qualifiers, they can put it into the system and request their medical record. Within about 30 seconds to a minute, they’ll get feedback on whether a record is found and if it was in our internal medical record system or in the INPC.”
The information EMS personnel can access is limited to a single snapshot of predefined information, such as recent vital signs, medical diagnoses, medications and allergies. Patient information is protected through authentication processes and a secure audit trail.
“If there was ever a breach in security, we could go back and pinpoint to the day, the time and the user,” Arkins said. “You actually have to generate a medical record in our system to even get to the point of accessing a patient’s medical record. Everything is captured.”
The implementation has been fairly smooth, they say, but the switch from paper records to the ePCR system and the subsequent synchronization with the INPC within a relatively short timeframe is a cultural shift the crews are still adjusting to.
“We’re working on showing them the advantage of having these things,” Arkins said. “Are you going to use it on every patient? Probably not. But there are specific times that it’s going to be very beneficial.”
Arkins gave the example of arriving to assist an elderly person who can’t remember the names of their medication, only that they take a blue pill at 8, a green pill at noon and a brown pill at 5.
“If we have access to their medical record, we can look it up and know that they’re taking pills for high blood pressure, water retention and atrial fib.” Obviously, the system proves particularly useful when caring for unconscious or incoherent patients. “It gives us a bigger, broader picture of what’s going on with the patient.”
Of course, that picture is useful only if it’s available when and where the medics need it, and wireless systems do occasionally present challenges. “Their systems rely on wireless networks, so if they don’t have connectivity, they can’t access the server at all and receive things in real time,” Finnell said. “The system is smart enough that it queues those things up and then waits until there’s connectivity, but that may not be when the medics need the information. As in any city, there’s going to be dead spots where we just don’t have the connectivity we’d like.”
The golden question
It’s too early to tell how useful the system will prove to be over the long run. The golden question is, “Now that you’ve pushed this data out to the medics, does it make a difference?” Finnell said. “It’s a very complicated question, because there’s a lot of things that influence care. It’s very difficult to do research in the prehospital field because of the ethical issues and consents and waivers and whatnot. But the goal would be to say “˜Yes, now that the medics have access to this information, we’ve improved care.’ We just don’t know the answer yet.
“We assume that it’s helpful, because we know it is in the emergency department,” Finnell added. “There’s been studies that show there’s a cost savings to having access to the regionalized health information repository. We can reduce our tests; we don’t have to keep repeating things on patients. The question is, does that translate to the prehospital field?” Finnell said the anecdotal stories are encouraging, but they look forward to using the repository to study exactly how access to the information affects care in the field, patient outcome and costs.
From a big picture perspective, synchronizing the prehospital and hospital records has improved surge capacity among EDs and hospitals in Indianapolis. “Being able to increase your surge capacity by capitalizing on the outpatient, community health center and alternate care site venues has been a real win for us,” Miramonti said.
“Instead of just relying on emergency departments or just relying on hospitals, we’re using this system to create networks of different venues of care that can work together to manage all kinds of surge capacity. To do that, you have to be able to put the information management and data structure into the hands of the people who have to do care.”
Although the necessary infrastructure is now in place, the system is still evolving. “The next steps are to develop the two-way communication so that EMS records are integrated with the hospital record system in such a way that any care provider working in the ED or in-patient setting can access the EMS run when and where they need to, so that we have two-way communication,” Miramonti said.
Lastly, he reiterated the goal of using “those communication pathways to do outcomes data so that we can see if the interventions we’re implementing in the field are making a difference into who gets admitted, who goes home or how those patients do overall. Being able to see what effect our care has on the overall picture plays greatly into our ability to do better quality assurance, better training, better education.”
Vision
EMS is moving toward a preventive model, Arkins said. “So if I’ve come to your house and you’ve cut your hand and you say, “˜I really don’t want to go to the hospital,’ I can pull up your medical record and see that you haven’t had a tetanus shot in the last 10 years. Why don’t we make sure you get one? Or, if it’s flu season and we’re at your house, why don’t we give you a flu shot?”
He’s optimistic that the integrated system could eventually lead to these types of health-care efficiencies.
The system’s success is drawing the attention of federal agencies and other regions around the country that would like to implement a similar integrated health registry.
“Information management is a huge part of where health care is going,” Miramonti said. “Being able to extrapolate a lot of the successes on the hospital inpatient side out to the EMS side, I think it’s inevitable, it’s intuitive and it makes good patient care and sense.”
