EMS and Information Sharing: Challenges and Innovations in Getting Patient Data From the Ambulance to the Emergency Department and Back

Abstract

As more paramedics use electronic devices to document patient care, there is increasing frustration when they cannot easily share that information with the emergency departments (EDs) where patients are delivered. Emergency responders also want to find out how patients fared in the hospital afterwards but often find they cannot access the information in hospital electronic medical records. In response, emergency medical services (EMS) agencies are working on a variety of technical and logistic fixes to make the information transfer easier. And federal officials are trying to ease the way by funding innovations that allow smart use of electronic patient records for more efficient handoffs. “It’s a piece that is really critical for both everyday care and for disaster care,” said Kevin Horahan, JD, MPH, senior policy analyst for the Office of the Assistant Secretary for Preparedness and Response in the US Department of Health and Human Services, and himself a working paramedic. “The EMS community and the emergency care community recognize that the information that EMS providers generate must be included in a patient’s health record, and that EMS providers [must] have access to information that other health care providers generate.” Advocates say better sharing of patient information could help avoid duplicate effort for a patient with multiple transports to various EDs, for information such as test results, medications, and allergies. And it could support coordinated care models that would allow a less urgently ill patient to be transported to a more appropriate site, such as an ambulatory care clinic, rather than the ED. Nevertheless, significant challenges have kept electronic sharing between EMS and the ED to a minimum. These include incompatible information systems, hospital worries about security of patient data, and inconsistent maturity of health information exchange across the country. The few recent studies in the literature assessing ambulance-to-ED handoffs suggest there is room for improvement. A 2009 study at a Level I trauma center found that even when EMS providers and hospital clinicians had direct verbal contact, just 73% of key out-of-hospital data points were documented by hospital staff. Among the elements often missed were hypotension, Glasgow Coma Scale score, and other vital signs.1Carter A.J. Davis K.A. Evans L.V. et al.Information loss in emergency medical services handover of trauma patients.Prehosp Emerg Care. 2009; 13: 280-285Crossref PubMed Scopus (63) Google Scholar A small study of handoffs in 2 British EDs, published in 2007 in Emergency Medical Journal, found that just half of the information given verbally by ambulance crews was accurately retained by ED staff, who often ignored it and started their own assessment from scratch. Use of a structured verbal description of patient status, known as DeMIST, improved retention to a modest 56%.2Talbot R. Bleetman A. Retention of information by emergency department staff at ambulance handover: do standardized approaches work?.Emerg Med J. 2007; 24: 539-543Crossref PubMed Scopus (91) Google Scholar Proponents of electronic data sharing argue that handoffs would be more efficient if ED clinicians could receive electronic updates about patient status from the road and have out-of-hospital care easily updated in the ED’s electronic patient record. California EMS official Pat Frost, RN, MS, is a strong supporter of the concept but cautions that busy clinicians do not need yet another electronic workflow. “I’m a big advocate of not creating siloed and separate expensive, difficult information exchanges,” said Frost, who is director of the Contra Costa County Emergency Medical Services. “It needs to be flexible, almost invisible to the end user so they don’t perceive it as getting in the way of patient care.” Receiving the information in a timely way is also crucial in an emergency. Kirk Schmitt, MS, director of the Monterey County, CA, Emergency Medical Services Agency, noted that if emergency clinicians do not have out-of-hospital information within an hour of arrival, the information is perishable and of no value in treatment. “Doing this electronically, we are hoping to overcome that 1-hour limit,” he said. EMS providers want to submit information more easily to their state and national EMS databases, carry out required quality reporting, and study the success of various medical interventions on scene and in transit. They are also abandoning paper to improve billing and be reimbursed more quickly. In approximately half the states, EMS agencies are required to leave a patient care report behind at the receiving care provider at transfer. However, there are scant national data about how much of that reporting is on paper, by fax, or electronic. California’s EMS agency explored the issue with a 2013 survey of its 33 local EMS agencies. The survey found that most emergency providers remain in the early stages of electronic transmission of patient care reports to hospitals. Most agencies (78%) reported that at least some of the EMS providers they oversee use an electronic version of the patient care report. At the same time, most (87%) said their providers are not integrated with hospital electronic health record systems; several said they were working on it. Hospitals, particularly in California, remain wary of legal liability in making electronic patient records available to ambulance companies. California’s hospitals want to support EMS quality efforts and provide the best patient care, but see legal barriers around protecting patient privacy that need to be worked out, said B. J. Bartleson, MS, vice president of the California Hospital Association. “Conceptually we believe it’s the right thing to do,” she said. “It’s a question of how we do it safely.” Specifically, California Hospital Association legal counsel Lois Richardson points to California’s patient confidentiality law that prohibits disclosure of a patient’s medical information without the patient’s express approval. The language includes a number of exceptions, but none refer to the release of information to an ambulance company. A catch-all provision in the law could apply, Richardson said, but attorneys do not agree on its interpretation and no court has yet ruled on the question. Given the number of high-profile, potentially expensive data breaches in the news, Richardson said, it is unlikely that many hospitals want to send records if there is any question of a privacy violation. California Hospital Association officials said they have had discussions with EMS providers about information sharing but need to know more from them about what specific data points they want. Those privacy restrictions are specific to California. For hospitals in states without privacy laws more restrictive than Health Insurance Portability and Accountability Act, there could be more flexibility. According to a 2012 letter from HHS to the National Association of State EMS Officials, a hospital may share patient health outcome information with the EMS provider for quality improvement as long as both entities have or had a relationship with the patient in question. The hospital must make reasonable efforts to disclose the minimum amount of individually identifiable health information as necessary. The letter was sent at the request of National Association of State EMS Officials to help its members work out more open information sharing arrangements with hospitals.3Lurie N. Sharing patient health outcome information between hospitals and EMS agencies for quality improvement.Health and Human Services. August 13, 2012; (Available at:) (Accessed June 26, 2014)https://www.iafc.org/files/1EMS/ems_HIPAALetter-NASEMSO.pdfGoogle Scholar Meanwhile, local EMS agencies in California are working on a variety of ideas to improve the information flow:•Mapping system interfaces: Recognizing that the incompatibility of computer systems is a major roadblock to information sharing, the Monterey EMS agency hired a database developer to carry out mapping between a national ambulance company’s e-patient care report system and each hospital’s records system so information from one record can be in the correct data fields of the other. It is time consuming but doable to build them one hospital at a time, Schmitt said. “It’s not that it’s hard, but it is more complicated than somebody who doesn’t have IT [information technology] expertise might envision,” he said.•Building on Epic: Because all of the hospitals in Contra Costa County are adopting the Epic electronic medical record, the area’s EMS agency is using that platform to allow the out-of-hospital system to send information to area hospitals. Eventually, EMS hopes to use the same channels in the other direction, to receive outcome information for hospitalized patients. The agency would use the data to conduct quality analysis on its patient care protocols, particularly those for trauma, cardiac arrest, stroke, ST-segment elevation myocardial infarction, and patient safety.•Hospital ambulance dashboard: In a grant-supported project, the Contra Costa County EMS agency created an electronic dashboard for EDs to monitor the time from when an ambulance arrives to the scene of a medical response to when it leaves, and also the number of units parked at each hospital. The initial deployment had to be reworked when the agency found that ED staff did not have time to go to a separate monitor and pull up the dashboard. In the new version, the monitor will be placed in an easily viewable location and it will be visible at all times, without requiring the extra step of opening it on the computer. “You can create all sorts of tools, but if the tools aren’t part of people’s workflow they won’t be successful,” noted Frost.•Continuity of care document: Contra Costa County is also working with its local public health system on a secure continuity of care document they can send back and forth with information about transported patients. It could be similar to the secure continuity of care document that is sent to primary care physicians for patients treated by Contra Costa Regional Medical Center’s ED and could be a model for future real-time information exchange.•Using a health information exchange organization as go-between: California’s Inland Empire (San Bernardino, Inyo, and Mono Counties) is home to a robust Health Information Organization, and its EMS agency is working on integrating their databases. “Once we connect, they can pull up any patient at any time and get a complete medical history,” explained Ron Holk, RN, EMS nurse specialist for the Inland Counties Emergency Medical Agency. Hospitals that participate in the Health Information Organization can get information on what happened in the field, along with past medical transports for that patient, even if they went to a different hospital.•Sharing data in the cloud: The Los Angeles Fire Department has moved its paramedic firefighters from paper patient records to electronic devices, maintaining the information in a data cloud. With the new system, participating hospitals can access information in the department’s electronic record in nearly real time as the paramedics are typing it in during on-scene care and transit. Just as electronic patient records are changing patient care workflows in ambulances and hospitals alike so also the reimbursement system for health care is being turned on its head. Health systems are taking on longitudinal responsibility for a patient’s care, prompting coordinated care arrangements that raise questions about the traditional way EMS agencies have delivered most patients to EDs. New “community paramedicine” programs are testing out models in which the paramedics are key partners in ensuring that patients are transported to a place with the most appropriate level of care, which may not be the ED. The truly critical patients for whom the emergency medical system was first created are actually now a minority of those transported, as low as 13%, said Frost. “Everybody else is sick and needs to be evaluated,” she said, but the current model doesn’t allow much flexibility for how that happens. “There’s probably a subset of patients, maybe 40 to 50%, who could be taken care of very appropriately in the urgent care or clinic setting,” she said. “But the EMS system needs a strong medical partnership to make those decisions and build changes in policy that create flexibility in the system without compromising patient safety.” Those kinds of changes require the easy exchange of patient data across the continuum of care, and that is going to take some time, Frost said. Still, she is encouraged by the increasing recognition that paramedics and ambulance crews are an essential part of the continuum of medical care. “EMS services tend not to be considered part of the health care system; people think we are just transportation,” Frost said. “But we really are health care providers.”