EBOOK
Technology-Facilitated InnovationIn 1969, paramedics from the Miami Fire
Department used mobile EKG technology and radio
communication with in-hospital physicians to
become the first to successfully defibrillate a cardiac
arrest patient. From that moment on, technology
has been a critical partner in our efforts to quickly
and effectively treat patients in the out-of-hospital
setting. In this special eBook, you’ll read about how
progressive EMS systems are leveraging mobile
technology and communication in innovative new
ways—from improved triage and navigation of low-
acuity patients in Houston to Orange County, Calif.,
where providers can access a patient’s medical
information through their ePCR software with a few
taps of the fingertip.
3 High-Tech Physician Triage Redirects Low-Acuity Patients
12 Interview with Houston Medical Director David Persse, MD
15 Implementa-tion of EMS Access to Patient History
25 Considera-tions for a Well-Engineered ePCR System
SPONSORED BY:
Reprinted with revisions to format from JEMS. Copyright 2018 by PennWell Corporation
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Originally published in the November 2015 issue of JEMS
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Directing Appropriate CareHouston’s innovative ETHAN program uses high-tech physician triage to help low-acuity patients
By MICHAEL GONZALEZ, MD; DIAA ALQUSAIRI, PHD; ADRIA JACKSON, PHD, RN-BC; TIFFANY CHAMPAGNE, PHD, MBA; JAMES LANGABEER II, PHD, EMT & DAVID E. PERSSE, MD, FACEP
EMS PROVIDERS OFTEN feel helpless when they arrive on scene and
discover the patient’s need is more primary care than emergent
in nature. In Houston, the fourth largest city in the United States,
this happens frequently. In fact, a recent study by a local university
estimated that 40% of all ED visits are primary care related.1
Since there’s an average of more than 800 9-1-1 EMS calls every day in Houston,
that results in a lot of unnecessary transports to the ED for primary care-related
complaints such as
minor headache, chronic
joint pain or insomnia.
Other than transporting
the patient to the ED,
there’s typically little
EMS providers can do to
address these kinds of
medical concerns.
Unnecessary ED
transports compound
Houston’s problem of
ED overcrowding—local
hospitals experienced
a 33% growth rate in
visits during a 10-year
period, with wait times
in the largest facilities in
A Houston Fire Department crew member facilitates a physician-patient video conference to direct a low-acuity patient to appropriate care—and hopefully away from the ED. Photos courtesy Houston Fire Department EMS
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excess of six hours or more.2 Providing primary medical care through the ED is
inefficient from a healthcare system perspective and often suboptimal from a
patient experience and medical care perspective.
To combat the growing problems, Houston Fire Department (HFD) EMS
developed an innovative mobile integrated healthcare project called ETHAN—
Emergency Telehealth and Navigation. ETHAN is a community-wide
collaboration led by the HFD that uses mobile technologies, community-based
paramedicine, and local and regional partnerships with other agencies and
organizations to triage and connect low-acuity 9-1-1 callers with primary care
resources in the community.
HFD Medical Director David Persse, MD, FACEP, points out, “The EMS Agenda for
the Future spoke of EMS as being fully integrated with the overall healthcare
system. If successful, ETHAN will be a major step in that direction.”
PROGRAM OBJECTIVES
ETHAN is fundamentally a community-based paramedicine approach that
integrates extensive use of health information technology with traditional
medical care. Spearheaded by HFD Associate Medical Director Michael Gonzalez,
MD, ETHAN is based on five key interrelated concepts:
1. Patient-centered navigation to appropriate levels of care;
2. Population-based tools and needs assessments;
3. Leveraging community resources, partnerships and collaborations;
4. Long-term financial sustainability through improved outcomes; and
5. Extensive integration of mobile health and other technologies.
The last component—technology—is extremely important, as it enables
physicians in Houston’s 9-1-1 call center to communicate directly with patients
via tablets with integrated telehealth capabilities. Other embedded information
systems include clinic scheduling systems, health information exchange (HIE)
access and transportation scheduling.
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Also critical is HFD
EMS’ partnerships
with local, regional
and national
organizations to
improve the spectrum
of care and augment
agency resources.
(See Table 1.) Without
community-based
partnerships, EMS
agencies would find
obtaining resources
for mobile integrated
healthcare programs
nearly impossible.
The program was in
planning stages during 2014, and officially kicked off in December. An evaluation
of clinical and economic outcomes from the program is being conducted
prospectively by the University of Texas Health Science Center. In the first five
months, over 700 patients have been successfully evaluated and over 80% have
resulted in outcomes not requiring the use of the ambulance. Navigation toward
more appropriate levels of care should produce a significant impact on efficiency,
appropriate utilization and a reduction in overcrowding at local EDs.
ETHAN is being funded during the initial multiyear period through the Texas
1115 Healthcare Transformation Waiver program. Through the Delivery System
Reform Incentive Payment, the 1115 Waiver seeks to incentivize hospitals and
other providers to transform their service delivery practices to improve quality,
health status, patient experience, coordination and cost-effectiveness. Eligibility
for this program requires participation in a regional healthcare partnership.
Within a partnership, participants include governmental entities providing public
funds known as intergovernmental transfers (IGT). The city of Houston provided
the necessary IGT funds.
Table 1: Local, regional and national ETHAN program partners
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The ETHAN project reached its current design after over six years of shaping and
development. This evolution began in 2009 with a nurse triage phone line that
was accessed by call takers at the 9-1-1 emergency communications center, where
they connected patients with nurses who used a computer-based algorithm to
triage patients and determine the most appropriate disposition. This project
failed because callers expecting an ambulance to be immediately dispatched
instead experienced a prolonged Q&A interrogation by a nurse and weren’t
cooperative with the program. In addition, it was recognized that the nurses were
very conservative in making dispositions, resulting in very few diversions from
dispatching of an ambulance.
The nurse triage phone line was discontinued and a similar algorithm was used
by HFD paramedics located at the paramedic-staffed base station used by the
HFD for all field-to-hospital medical communications. Field crews connected
the patients in the field with the paramedics over the phone. Paramedics could
schedule the patient a clinic appointment and a taxi ride when appropriate.
Due to the conservative design of the algorithm, however, it too often determined
the disposition to be immediate transport to the ED when it didn’t seem
medically necessary. As a result, a large percentage of patients still ended up
being transported to the ED and first responders grew frustrated with the project.
Although significantly more costly, replacing the algorithm with emergency
physicians allows for much quicker determination of the patient’s medical acuity
and dramatically improves the accuracy of triage results to ensure the most
appropriate disposition. The interactions using the nurse triage line algorithm
typically took up to 20 minutes or more, whereas physicians can assess the
patient and make a disposition decision in around seven minutes. This is a more
satisfactory experience for both the patient and the EMT or paramedic.
HOW ETHAN WORKS
After the first responding HFD apparatus arrives on scene, the crew assesses
the patient and makes an initial determination as to whether the patient needs
emergency care. If the patient does indeed require emergency care, the crew then
activates the ETHAN program. To do that, they use the tablet that’s available
on every fire/EMS vehicle—both ambulances and traditional fire apparatus
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alike—to connect the patient
with an emergency physician via
HIPAA-compliant and secure video
conferencing software.
The emergency physician is able to
access the patient’s medical record
that’s created on scene, including
the patient’s demographics, vital
signs, medical history, allergies,
medications and the chief complaint.
The physician consults with the
patient by video conference in a
way very similar to what’s normally
done at the ED. All physicians hired
for this project are board-certified
emergency physicians who practice
at local hospital EDs and have
multiple years of experience.
While the video conference takes
place, the field crew remains on
scene to assist the physician with
any additional information needed,
such as taking a new set of vital
signs or palpating the patient’s pain
site. The physician then makes the
final determination regarding the patient disposition, which could be one of six
alternatives, as shown in Table 2, and briefly described below.
Referral to a community primary care clinic and taxi ride: This is the ideal
disposition and is currently applied to about 10% of initial ETHAN patients. When
the emergency physician determines the patient could be better cared for at a
primary care setting, the physician will schedule an appointment at one of the
local partner clinics using a Web-based scheduling system that uses the patient’s
ZIP code to identify the closest clinic location and next available appointment
Table 2: ETHAN patient disposition after eligibility screening
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time. All clinic visits are scheduled for the same day or the next day at the latest.
The clinic receives an appointment confirmation with the patient’s demographics
and chief complaint. The clinic’s providers are also able to access the local HIE
to view additional information on the patient. If the patients need transportation
assistance to get from their residence to the clinic, the physician uses a Web-
based application to schedule a taxi ride. The clinic visits and taxi ride billing
is handled through a third party administrator. For uninsured patients, the
program covers the cost of the clinic visit and taxi ride. For insured patients,
clinics bill the patient’s insurance directly for the visit and the program covers
the taxi ride only.
Referral to an ED and taxi ride—patient declined referral to clinic: The
emergency physician may determine that the patient needs to go to the ED, but
ambulance transportation isn’t necessary. This disposition category accounts for
over 50% of initial ETHAN encounters. In this case, the physician instructs the
patient to go to the ED and schedules the patient a taxi ride. The physician can
also schedule a taxi ride to an ED if the patient refuses to be seen at the clinic
and insists on going to an ED for a low-acuity complaint.
Referral to an ED with ambulance transportation: In only about 19% of cases
thus far, the ETHAN physician has determined that a patient needs immediate
emergency care and instructs the field crew to transport the patient to an ED. As
explained previously, the ETHAN program is only activated after the field crew
determines a patient doesn’t need emergency care, so these instances are an
important teaching opportunity for the physician to educate the field personnel
why emergency transportation is needed.
Referral to patient’s primary care provider (PCP) or home care: When a patient
has their own PCP, the patient might choose to see their PCP instead of going to
a partner clinic—this disposition makes up approximately 7% of cases. When
possible, the ETHAN physician encourages this option as the patient’s own PCP is
often the best provider to coordinate the patient’s care and ensure continuity and
integration of care. Also, based on the ETHAN physician and patient’s discussion,
they might decide that no additional care is needed and the physician might only
provide the patient with home care instructions.
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Patient declined referral to clinic and receives ambulance transport to ED: The
patient might choose to decline the ETHAN physician’s advice and insist on going
to an ED. The ETHAN physician and responding crew communicate to the patient
that seeing a PCP at one of our clinics will provide them with better care and
convenience than going to an ED. They also explain that ambulance transport
isn’t necessary and doesn’t add any value to the care the patient will receive.
Nevertheless, some patients still insist on going to an ED via an ambulance,
although at 5% this disposition is rare. The physician is empowered to decline the
use of the ambulance, but in some situations the physician and EMS crew decide
to abide by the patient’s insistence.
Patient refusal to participate: The patient might refuse to participate in the
ETHAN program and refuse to speak with the ETHAN physician over the tablet.
Although this disposition is possible, it accounts for less than 1% of encounters.
PATIENT FOLLOW-UP & OUTCOMES EVALUATION
Following the ETHAN encounter, the patient’s information is automatically
forwarded to Care Houston Links, a city of Houston Health Department program
that provides care navigation services. Through this program, social workers and
healthcare navigators follow up with the patient to ensure the patient’s needs
were met and to identify any additional human/social services needs and identify
ways to address them. A patient satisfaction survey is also administered.
Follow-up may include things like insurance coverage, transportation, food
assistance, health literacy, counseling, etc. The goal is to deploy a holistic
approach to healthcare and connect patients with resources they can access for
their future health needs, thus reducing their reliance on the emergency system.
In addition, all program data on patient disposition, participation, volumes,
clinical outcomes, and costs are being measured and evaluated by an
independent third-party university researcher at the University of Texas Health
Science Center. This outcomes research will hopefully show significant reduction
in costs and unnecessary transports, with (at least) no reduction in care and
higher patient satisfaction survey scores. If annual evaluations confirm this
hypothesis, the ETHAN program will be financially sustainable for the long-term.
High-Tech Physician Triage Redirects Low-Acuity Patients
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CONCLUSION
ETHAN is a developing mobile integrated healthcare EMS program committed to
being an integral component to address Houston’s healthcare delivery system through
more coordinated out-of-hospital care. To survive long-term, it must be financially
sustainable, producing a return on investment of sorts, where outcome benefits are
greater than their costs. By focusing on technology-enabled patient navigation to more
appropriate levels of care and leveraging community collaborations and partnerships,
we expect this program to grow significantly in years to come.
REFERENCES1. Begley C, Courtney C, Abbass I, et al. (2013.) Houston hospitals emergency
department use study: January 1, 2011 through December 31, 2011. Health Services Research Collaborative, University of Texas School of Public Health. Retrieved Sept. 9, 2015, from https://sph.uth.edu/research/centers/chsr/hsrc/.
2. Wolf R. (June 19, 2007.) What does a health crisis look like? See Houston. USA Today. Retrieved Sept. 9, 2015, from www.usatoday.com/news/nation/2007-06-18-texas-healthcare_N.htm.
MICHAEL GONZALEZ, MD, is the associate medical director with the Houston
Fire Department, EMS Division, and leads the ETHAN program. He’s also an
assistant professor of emergency medicine at Baylor College of Medicine.
DIAA ALQUSAIRI, PHD, is a senior staff analyst for the Houston Fire Department,
EMS Division, focusing on emergency telehealth. He’s interested in building
innovative models and collaborations for efficient and effective delivery of care.
He has an MS in emergency management and a PhD in healthcare management.
ADRIA JACKSON, PHD, RN-BC, is a health information technology executive
and registered nurse board certified in nursing informatics. She has 26 years of
experience in the healthcare industry and 10 years in health IT, specializing in
the implementation of clinical information systems such as electronic health
records and case management.
TIFFANY CHAMPAGNE, PHD, MBA, is an assistant professor of biomedical
informatics at the University of Texas (UT) Health Science Center. She holds a
PhD in health management from the UT School of Public Health and was formerly
the vice president of the regional health information exchange in Houston.
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JAMES LANGABEER II, PHD, EMT, is a professor and research director in
emergency medicine and informatics at the University of Texas Health Science
Center at Houston. He’s a data scientist with expertise in outcomes research in
emergency and cardiovascular care.
DAVID E. PERSSE, MD, FACEP, started his career in medicine with 10 ten years’
experience as a field paramedic and paramedic instructor in Buffalo, N.Y., and
upstate New Jersey. After studying pre-med at Columbia University in New York,
he attended Georgetown University School of Medicine and then completed an
emergency medicine residency at Harbor-UCLA Medical Center in Torrance, Calif.
He later completed a resuscitation research fellowship at Ohio State University
and was then awarded a grant from the Society for Academic Emergency
Medicine to complete fellowship training in EMS and resuscitation at the Baylor
College of Medicine and Houston Emergency Medical Services program.
Following his EMS fellowship, Dr. Persse became the assistant medical director
for the EMS System of Houston, overseeing field operations and clinical research
trials. He then moved to California to become the medical director of the Los
Angeles County Paramedic Training Institute, and the assistant medical director
of the Los Angeles County EMS Agency. In 1996 Dr. Persse returned to Houston to
assume the role of the Director of EMS for Houston.
Dr. Persse now serves as a Board Member for the National Registry of Emergency
Medical Technicians. He is also an editorial reviewer for the Annals of Emergency
Medicine, Prehospital Emergency Care and Academic Emergency Medicine. He
regularly participates in the Texas State legislative process for EMS activities
and was a member of the Board of Directors of the Texas College of Emergency
Physicians for which he served as chairman of the colleges’ EMS committee and
was the founding president of the EMS Physicians of Texas. He is also a member of
the Board of Directors for the South East Texas Trauma Regional Advisory Council,
and the National Registry of Emergency Medical Technicians.
Dr. Persse has been a member of the College of Fellows of the National Academy
of Emergency Dispatch. In 2004 Dr. Persse was confirmed by the mayor and City
Council as the public health authority for the Houston Department of Health and
Human Services. Since that time he has been awarded the Michael K. Copass Award
by the U.S. Metropolitan EMS Medical Directors (2009), the Keith Neely Outstanding
Contribution to EMS Award by the National Association of EMS Physicians (2007) and
the EMS Medical Director of the Year by the Greater Houston EMS Council (2005).
Originally published in the April 2015 issue of JEMS
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EMS Physicians Can Help Close the Gap Between EMS & Other Public Health Agencies
By MARK E.A. ESCOTT, MD, MPH, FACEP, NRP
IN CONSIDERING THE first person to interview for
this column, the choice was an obvious one for
me because my mentor, David Persse, MD, has
helped guide me over the past 20 years. In 1996,
he provided me with sound advice and support as we
launched the EMS service at Rice University. Persse
now serves as both the physician director for the
Houston Fire Department and as the health authority
for the city’s public health department. He’s been a
leader in the merger of EMS and public health in this
country and is innovating new pathways to enhance
the role of EMS in the healthcare industry.
Dr. Persse, with the subspecialty of EMS at its commencement, how do you see the role of
technology enhancing the interactions between patient, paramedic and physician?
“Technology is going to completely revolutionize EMS in America and around
the world. When I started as an EMT, the most complicated technology we had
was the radio. Today, in Houston, we’ve just introduced a portable CT scanner
mounted in our mobile stroke unit, and we’re using telemedicine technology
to allow field personnel to immediately connect with an emergency physician
who can then interview and visually examine the patient to decide how to
most efficiently resolve the patient’s issue. This includes the physician quickly
and electronically setting up a same- or next-day clinic appointment and non-
emergency transportation as well as social work or public health follow-up.
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Interview with Houston Medical Director David Persse, MD
In the future, I predict we’ll see mobile devices similar to our current day ECG
monitor/defibrillators that will perform multiple bioassays (a procedure for
determining the concentration, purity or biological activity of a substance) to
include diagnostic capabilities as well as high-fidelity monitoring of critical
physiologic functions such as central pressures, core temperatures, O2 tissue
extraction, central nervous system activity, etc. This information will be easily
and continuously transmittable to allow both the introduction of critical care
capabilities by the paramedic as well as to better inform the receiving facility
of what the patient will need upon arrival. I hope this will all return EMS to our
roots of a very close and mutually productive relationship between the EMS
physician and the field care providers.”
As a pioneer at navigating the intersection of public health and EMS medicine, what do
you see as the future of this relationship?
“I’ve always felt EMS is as much a form of public health as it is an emergency
response system. If you want to put your finger on the pulse of your local
community’s health status, look at your EMS records. EMS touches every disease
and injury pattern that exists in your community, in every neighborhood, for
patients of all ages, within every income level, every education level, every
culture, every lifestyle, for acute or chronic, medical or social problems;
regardless of the patients’ ability to pay or preferred hospital choice. The
Centers for Disease Control and Prevention define public health as the science
of protecting and improving the health of families and communities through
promotion of healthy lifestyles, research for disease and injury prevention, and
detection and control of infectious diseases. In most every community, EMS
is a central repository for much of the information needed by public health
practitioners to achieve their goal.
Unfortunately, EMS and public health haven’t been known to share their data
and combine their efforts. We’re now seeing significant improvement in the
collaboration between the two across the nation. As an example, we’ve recently
published data showing communities with some of the worst air pollution
problems in Houston also have the highest incidences of EMS responses for
asthma and cardiac arrest, which can be temporally related to spikes in certain
pollutants in the air. Our health department has responded to this information
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Interview with Houston Medical Director David Persse, MD
by working with the authorities to implement stronger restrictions on certain
air pollutants, and we’ve initiated widespread CPR training programs within
neighborhoods identified as being at highest risk.
Just imagine the potential for improving our local community’s health once EMS
provider agencies and local health departments join forces!”
What advice do you have for paramedics and EMS physicians in regard to better engaging
their community in population-based health initiatives?
“I think many paramedics across the nation have already begun to broaden their
vision of their scope of practice, especially with the advent of the community
paramedic. Board certification in EMS is a major step forward for EMS physicians
to become reengaged with field personnel and field operations. Because of the way
EMS developed in the United States, physicians were left out of the progress and
failed to stay as engaged as our physician mothers and fathers (Caroline, Copass,
Nagel, Grace, Criley, etc.) were. Today, much of what should’ve been a close and
cultivating relationship between EMS medical directors and field personnel has
been replaced with state-level bureaucracy and protocols. As paramedics become
more engaged in caring for their communities beyond emergencies, so must the
new breed of EMS physician see that the overall health of their community is also
part of our responsibility. To this end, physicians and field personnel alike should
make contact with their local public health department to seek ways to identify
the gaps in the health care system, and work together by combining resources to
achieve real progress in improving lives. I believe this is the future of EMS.”
MARK E.A. ESCOTT, MD, MPH, FACEP, NRP, is the medical director for Austin-
Travis County EMS System. He’s also a medical director and founder of Rice
University EMS in Houston and an assistant professor in the Department of
Emergency Medicine at Baylor College of Medicine. He’s the chair of the American
College of Emergency Physicians Section of EMS and Prehospital Medicine and
board-certified in emergency medicine and subspecialty board-certified in EMS..
Originally published in the May 2017 issue of JEMS
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Orange County, Calif., Begins Field Implementation of EMS Access to Patient History
By DANIEL R. SMILEY & SAMUEL J. STRATTON, MD, MPH, FACEP, FAAEM
YOU AND YOUR partner respond to a 9-1-1 call for a woman with
altered mental status. After ensuring there are no immediate life
threats and completing your initial assessment, you attempt to get
information about the patient’s medical history, current medications
and allergies. She isn’t able to offer clear information on her current medications,
and when you turn to the family, the patient’s family member hands you a bag
with at least 15 different medications.
This is an all-too-familiar scenario for many EMS responders. EMTs and paramedics
typically rely only on those on scene to volunteer critical medical information prior
to treatment: the patient,
family members, friends or
others. A patient’s past medical
history is otherwise unknown,
leaving EMS providers to start
from scratch as they input
the patient’s data into their
electronic patient care report
(ePCR) system and, eventually,
transmit relevant data to the
receiving hospital via radio
or cell phone. This traditional
model is prone to errors and
inaccurate data and is simply
inefficient.
Health information exchange programs facilitate the secure sharing of a patient’s health information throughout the continuum of patient care. Photo courtesy Newport Beach Fire Department
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Implementation of EMS Access to Patient History
In Orange County, Calif., however, it’s a completely different picture following
the field implementation of +EMS and the Search, Alert, File and Reconcile
(SAFR) model for health information exchange (HIE), which provides a patient’s
medical information at providers’ fingertips within seconds. To accomplish this,
an established HIE is augmented by the alerting and bidirectional data flow
capabilities in
Here’s how it works: As the medic is evaluating and treating a patient in the field,
they use their ePCR software, ImageTrend Elite, to search for the patient by first
and last name, gender and date of birth. The field EMS data tablet connects to a
cloud-based HIE through HIH, where the patient’s cumulative hospital, medical
provider and EMS electronic medical record is identified, allowing the medic to
immediately populate the ePCR with the patient’s medications, allergies, recent
hospitalizations and past medical history.
An alert within Hospital Hub notifies the receiving hospital of the incoming
patient and receives pre-arrival field and medical record information transmitted
Figure 1: Illustrated SAFR model for health information exchange
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Implementation of EMS Access to Patient History
from EMS to the ED, including: primary impression, age, gender, arrival times,
vitals and procedures-including 12-lead ECGs-performed by the EMS crew. A
predetermined set of rules triggers the completed ePCR information to be sent
automatically in a National EMS Information System (NEMSIS) CCD (Continuity
of Care Document) file to the HIE, which is then available in near real-time to the
appropriate patient healthcare provider.
The HIH retrieves hospital discharge, insurance and clinical information from
the HIE, which then populates ImageTrend Elite for agencies to view and use for
continuous quality improvement and to achieve better patient outcomes.
Having immediate access to a patient’s healthcare information in the field
provides EMTs and paramedics with reliable information, such as recent
hospitalizations, past medical history, medications, allergies, preferred healthcare
facilities and end-of-life decisions, that can affect initial care decisions and long-
term outcomes. Giving EMS providers secure access to this additional patient data
helps to paint a more complete picture of the patient in order to facilitate more
appropriate prehospital care in addition to optimizing the transition of care in the
hospital ED.
Orange County’s ePCR solution, ImageTrend Elite, takes advantage of a bidirectional health information exchange to allow medics to populate the ePCR with the patient’s medications, allergies, recent hospitalizations and past medical history. Screenshots courtesy ImageTrend
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Implementation of EMS Access to Patient History
Going Electronic
California EMS providers are mandated by state regulations and local policy to
complete a PCR when they make contact with a patient to document incident
demographics, assessments and treatments. Historically, the PCR was completed
on a paper form and a carbon copy was hand delivered to the receiving hospital
ED. Despite including a significant amount of information relevant to emergency
care, it was often illegible and nearly impossible to extract data for prospective or
retrospective analysis of the quality of patient care.
This wasn’t a problem unique to California, and in an effort to begin to solve
these problems, the National Highway Traffic Safety Administration (NHTSA)
sponsored the creation of the NEMSIS standard in 2001. In a few years, NEMSIS
defined the technical infrastructure and dataset necessary to create ePCR
solutions.
The statewide California EMS Information System (CEMSIS) uses the NEMSIS
3.4 standard and includes additional data necessary to meet the needs of the
state. California’s Emergency Medical Services Authority (EMSA) requests each
of the 33 local EMS agencies (LEMSA) to submit EMS data from their respective
jurisdictions to the CEMSIS data repository. At least 20 agencies currently
participates and EMSA anticipates that the repository will potentially receive up
to four million records annually.
Orange County EMS (OCEMS) created a system called Orange County Medical
Emergency Data System (OC-MEDS) to assist with EMS provider agencies,
ambulance companies, and fire departments to transition from their outdated
paper based documentation methods to OC-MEDS and report their ePCRs in real-
time. OC-MEDS was the first comprehensive system of its kind in California that
included the collection of emergency patient information at the time of service
and made it available for instantaneous reporting to receiving hospitals, base
hospitals and the local EMS agency.
Standardization & Integration
In 2013, EMSA began exploring how to improve technology for EMS providers,
envisioning a future where EMS is integrated into the broader healthcare system.
More specifically, that EMS patient records would be shared with hospital
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electronic health records (EHRs), with the goal of eliminating the paper PCR that
paramedics drop off at the hospital during the transfer of care.
In 2014, the +EMS Project was developed in collaboration with the U.S. Health
and Human Services Office of the National Coordinator (ONC) for Health
Information Technology staff to support nationwide HIE and care coordination
efforts. Fundamental to the project, EMSA developed the SAFR model to describe
the minimum functional aspects of EMS HIE data exchange. The SAFR model
created a framework and defined concrete data elements and functions that
explained HIE concepts in terms applicable to the EMS community. EMSA also
developed a work group called Consumable Data and Transport to create the list
of specifications for the SAFR functionality and the specific elements.
In 2015, health information technology (HIT) standards were changing rapidly
and EMS systems would soon be mandated to adopt these new standards. On Jan.
1, 2016, new state law (CA Health and Safety Code 1797.227) mandated that EMS
providers transition to modern data systems and submit NEMSIS 3.4-compliant
data in realtime to their local EMS agencies.
California had the foresight to create a statewide data collection system that
modernizes all EMS data systems and would comply with federal HIT standards.
This allows EMS providers to exchange patient care information with other health
care providers (such as receiving hospitals) who use the same standards. The
exchange of patient
care information
is a cornerstone
of the Institute
for Healthcare
Improvement Triple
Aim Initiative and
is supported and
sponsored by the
federal ONC.
In late 2015, EMSA
was awarded a $2.75
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million federal grant funded by the Health Information Technology for Economic
and Clinical Health (HITECH) Act of 2009, to support the creation of bidirectional
HIE between EMS providers and hospitals. Although many other healthcare
providers have already implemented their exchanges, EMS systems have largely
been excluded from any funding to support their implementation. EMSA used
grant funds to support local/regional health systems to realize the goal of
HIE+EMS interoperability in California.
EMSA Director Howard Backer, MD, MPH, FACEP, emphasizes, “Providing patients’
current medical information to all medical providers is essential to provide
accurate and high quality care. EMS must often make rapid treatment decisions
on the streets or in homes and need access to critical medical history to provide
the best care.”
On July 26, 2016, EMSA awarded San Diego Health Connect $592,000, in
partnership with One California Partnership Regional Health Information
Exchange (OCPRHIO), to carry out the SAFR functionality for San Diego, Orange,
and Imperial Counties. The funding for this local assistance grant funding
opportunity supports a collaborative solution to integrate EMS as a critical
component of the health care system into the HIE landscape. Currently, the grant
is being piloted in three counties: San Diego, Orange and Imperial.
Pursuant to project objectives, each respective regional health information
organization must establish partnerships with their county LEMSA and must
identify one EMS provider and one hospital with which information will be
exchanged.
Health information organizations can work together with first responders
to improve the data shared during day-to-day patient care, emergencies and
disaster.
Data Sharing
There are many components for seamless HIE with EMS. EMSA established the
SAFR model with the intention of optimizing bidirectional data exchange (from
the HIE to the on-scene EMS provider, and from the EMS provider back to the
receiving facility and the HIE) as well as to support quality improvement and
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Implementation of EMS Access to Patient History
research. The SAFR model serves as an HIE framework for EMS by defining the
minimum functionality necessary to achieve HIE in easy-to-understand terms.
The SAFR model successfully meets all EMS data sharing goals through four
functions. (See Table 1 and Figure 1.)
1. Search: Search individuals’ health information for past medical history,
medications, allergies, and end-of-life decisions (i.e., physician orders for life
sustaining treatment or do-not-resuscitate orders) to enhance clinical decision
making in the field.
2. Alert: Alert the receiving hospital about an individual’s status directly onto an
electronic computer dashboard in the ED to provide decision support and prepare
for an individual’s arrival especially for conditions requiring time-sensitive
treatment or therapy such as trauma, heart attack or stroke.
3. File: File the EMS patient care report structured data directly into the receiving
facility’s EHR system for ease of access and better continuity of care.
4. Reconcile: Reconcile the EHR information including diagnoses, disposition,
billing, and payment back into the EMS patient care report for use in quality
improvement of the EMS system, performance measures, and population health,
making EMS a full participant in the exchange of electronic health information.
For EMS care teams, the verification of billing and payment information will serve
as a critical return on investment.
On Feb. 23, 2017, OCEMS, Newport Beach Fire Department and Hoag Memorial
Hospital Presbyterian were first in California to begin the implementation of
+EMS and the SAFR model for HIE.
Paramedic Geoffrey Cathey, from Newport Beach Fire Department, reported,
“I had more accurate information about the patient and saved time because I
was able to rapidly search her ePCR on my device to access the patient’s history,
medications and allergies.”
While still on scene, Cathey electronically transmitted the patient’s medical
information through OCPRHIO to the Hoag Hospital Newport Beach ED’s
dashboard demonstrating the first day-to-day emergency HIE in the state of
California and nationally.
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Carla E. Schneider, MSN, CEN, MICN, the ED director of Hoag Memorial Hospital
Presbyterian states, “Overcrowded EDs are often faced with challenges that
are associated with surges in patient arrivals. Specifically, related to allocating
resources, based on patient acuity, in a timely manner. The information available
through HIE, including patient history and current state, allows the healthcare
team to collaborate and prioritize care. Overall, the availability of real-time
health information supports our shared objective of providing safe, timely and
high quality care to the communities we serve.”
HIE programs help the sharing of secure access of a patient’s health information,
from dispatch of EMS to on-scene care, transporting of patients to the ED,
admitting them to the hospital, discharging the patient, and reporting of patient’s
outcome back to the EMS provider for data review for improving the quality of
emergency services provided.
It’s been recognized that the future of EMS patient care (and of all healthcare
providers) is now dependent on successful and secure HIE. To facilitate these
exchanges, non-profit regional health information organizations and private
HIE networks have been developed throughout the state and nation to connect
healthcare providers with one another.
Once connected, relevant patient care information is shared amongst providers,
which greatly aids in the continuum of patient care, lowers healthcare costs and
further supports the sustainment of healthy communities. These connections
further support “meaningful use” initiatives, which incentivize the use of modern
health technology.
Executive Director Paul Budilo of the non-profit One California Partnership
Regional Health Information Exchange states, “This effort is a tremendous win for
EMS and it demonstrates a profound change in the paradigm of patient care. Our
organization has established beneficial partnerships and increased functionality
between multiple healthcare providers and hospitals in Orange County including
the Hoag Memorial Hospital Presbyterian, Memorial Care Health System, St.
Joseph Health System, KPC Healthcare and others.”
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Implementation of EMS Access to Patient History
As first responders, EMS providers often have to make quick, lifesaving decisions
without any patient health information during emergencies. HIE in EMS gives an
edge previously not afforded to emergency medical technicians and paramedics.
Every entity within the healthcare continuum, from ambulance providers to
hospitals, and local EMS agencies, should benefit from immediate, secured,
electronic access to a patient’s health information.
Access to information leads to better care through efficient transitions of care,
improved outcomes and experiences. EMS ePCR systems of the near future should
support full functionality for HIE. Connecting EMS to the broader health care
system through HIE is necessary, and it’s inevitable.
Acknowledgment: Search, Alert, File, Reconcile (SAFR) Functionality for EMS
was developed by the California Emergency Medical Services Authority (Daniel
R. Smiley, June Iljana, Ryan Stanfield) under ONC Cooperative Agreement Grant
#90IX0006/01-00 (2015).
The authors would like to thank the following agencies for their assistance with
this article:
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Resources• The Office of the National Coordinator for Health Information Technology. (Jan. 2017.)
Emergency Medical Services (EMS) data integration to optimize patient care: The Search, Alert, File, Reconcile (SAFR) model of health information exchange. HealthIT.gov. Retrieved April 4, 2017, from www.healthit.gov/sites/default/files/emr_safer_knowledge_product_final.pdf.
• The Office of the National Coordinator for Health Information Technology. (June 21, 2016.) Health information exchange & emergency medical services. HealthIT.gov. Retrieved April 4, 2017, from www.healthit.gov/sites/default/files/HIE_Value_Prop_EMS_Memo_6_21_16_FINAL_generic.pdf.
DANIEL R. SMILEY has served as the chief deputy director for the Calfornia
Emergency Medical Services Authority (EMSA) since 1989.
SAMUEL J. STRATTON, MD, MPH, FACEP, FAAEM, is a deputy health officer and
the EMS medical director in Orange County, Calif. He’s also a professor in the
UCLA Fielding School of Public Health and David Geffen School of Medicine.
Originally published November 14, 2012
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Functional ePCRs Should Be Convenient, Reliable & Easy to Use
By WAYNE M. ZYGOWICZ, MS, EFO, CFO, EMT-P
LET’S FACE IT—IN EMS, we’re always on the run. Using an electronic
patient care reporting (ePCR) system at the patient’s side must be quick
and easy. Your ePCR system must be user friendly, extremely reliable
and well engineered for the real EMS world. It must be convenient and
efficient at collecting data at the patient’s side in the mobile environment. The
hardware that runs the software must be tough and rugged. You’ll want a bright
touch screen, and if it’s a laptop, you’ll want to be able to convert it to a tablet PC
by simply rotating the screen 180°, which makes it easier to use while standing at
a scene. Your software should convert drop-down menus to large buttons that are
easy to press with a “fat finger.”
Wi-Fi and broadband cards can be embedded into your data-entry devices to
enhance communications with other devices. Ideally, your ePCR system should
communicate seamlessly between laptop and cardiac monitor using Bluetooth
technology. When scenes are too chaotic to allow for a free hand to capture real-
time information on the laptop, your crew can acquire event data on the cardiac
monitor, which can be accurately
time stamped and wirelessly
uploaded from the monitor to the
laptop after the call. The batteries
should last several hours on a single
charge.
With an ePCR system, you can
type in the patient’s social security
number or date of birth in the patient
Functional ePCRs Should Be Convenient, Reliable & Easy to Use
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information screen and bring up past records to auto-fill patient information,
past history and billing data. A single-point entry system allows you to simply
check a box, and the home address information is pulled over from the CAD
system. You should be able to record patient vitals, procedures, drug dosages and
current medical history as fast as you can touch the screen with your finger. For
medical history and medications, most ePCR systems feature a drop-down menu
of commonly related conditions. More often than not, by the time the patient
is being loaded into an ambulance for transport, all that’s left to do is write the
patient care narrative.
Writing the narrative is often the most time-consuming part of charting an EMS
call. With ePCR narrative templates, users create effective and comprehensive
medical reports simply by answering related questions; the “auto-narrative”
feature generates an accurate narrative from the author’s chosen answers. Users
should add to the narrative so that each patient report is unique and accurate.
The system might also feature signature capture, which allows you to create
and use any number of electronic forms that require patient signatures and
attain those signatures while still on scene. If you have digital cameras on your
ambulances for documentation purposes, your ePCR system might be able to
import that data as well. And with Internet access via a broadband card, users
can directly access the FDA medication website.
Aside from this cool and efficient way to record vitals and interventions in a
consistent and error-free way, there’s another significant advantage—improved
patient care. The EMT attending to the patient can concentrate solely on patient
care, skills and interventions, knowing someone else on the crew is capturing and
processing information and data in real time. Entering the patient’s name from a
driver’s license can bring up patient history that may help guide patient care when
the patient is unconscious. And with the “fetch function,” data can be transferred
quickly to another laptop, reducing patient transfer times between agencies.
ePCRs also facilitate reporting of data on your system’s performance, run volume,
patient transports, medical procedures, medications given, skills performed,
patient destinations, etc. You’ll want to ensure that data captured in the field
easily and securely uploads to your main server. Wi-Fi “hotspots,” which can be
Functional ePCRs Should Be Convenient, Reliable & Easy to Use
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installed at each station, allow for 10 times faster communication than using a
Broadband card. As your crew backs the unit into a station, one of the users can
prompt the system to upload the data to the main server for permanent storage.
Besides the canned reports that you should expect with any ePCR system,
administrators should request the ability to create customized reports. If you wanted
to know how many 12-year-olds got valium on a Tuesday in District 12, no problem.
Once you retrieve the data, you can export selected fields to Microsoft Excel.
Your system should also be reviewing all patient transports for protocol
compliance and complete billing information. After each report has been closed,
the incident report can automatically route to the quality assurance (QA) officer.
The QA officer should be able to easily flag a specific data field on the report, note
errors or questions, and return the report to the author. A complete history of any
modifications made to a report should be maintained by the system and can be
retrieved for review.
Also look for your ePCR to be able to establish a link to a third-party billing
company. This link allows your agency to electronically transfer patient records
in a secure environment and more quickly process patient transport bills.
Of course, your software should be compliant with the National Emergency
Medical Services Information System (NEMSIS) and the Health Insurance
Portability and Accountability Act (HIPAA). The NEMSIS project, supported
by most states, focuses on collecting national EMS data to add to the body of
knowledge in prehospital medicine. The database will be used in developing
nationwide training curricula, facilitating research efforts, coordinating disaster
resources and evaluating domestic preparedness needs in emergency medicine.
Although many of the data points in NEMSIS are somewhat narrow, you might be
able to expand your individual data points while mapping those choices back to
the original NEMSIS code set. The upload process should be simple, and your data
should look very clean on your state report.
As your mom always said, “Do your homework!” So, before you run out and
purchase a new ePCR system, gather stakeholders, do a needs assessment,
visit vendors, contact users and always field-test the product before you sign
Functional ePCRs Should Be Convenient, Reliable & Easy to Use
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on the dotted line. Visit with field providers—the real experts. The people who
use the system every day can give you the best advice on user friendliness and
effectiveness of the product.
When you’re looking around for your new ePCR system, ask the vendors if
their product can do the things mentioned in this article. Although many of
these features seem somewhat simple, minimizing the time spent on entering
report data will make for happy end users, who then have more time to focus
on their number one objective—providing superior patient care and excellent
customer service.
WAYNE M. ZYGOWICZ, MS, EFO, CFO, EMT-P, is a 36-year veteran of the fire
service and has served as a paramedic/firefighter for over 30 years. Wayne has
served as a division chief for Littleton (Colo.) Fire Rescue for the last 20 years. He
holds a master’s degree in executive leadership, is a graduate of the National Fire
Academy’s Executive Fire Officer Program (EFO) and is a Certified Fire Officer
(CFO) through the Center for Public Safety Excellence.
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LINKS:
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