Why electronic health records will replace EMS patient care reports
Access to patient records through prehospital and hospital EHR integration will help paramedics improve patient outcomes
This feature is part of our Paramedic Chief Digital Edition, a regular supplement to EMS1.com that brings a sharpened focus to some of the most challenging topics facing paramedic chiefs and EMS leaders everywhere. To read all of the articles included in the Spring 2017 issue, click here.
By Nathan Stanaway
While working for a 911 service, I responded to a morbidly obese patient having respiratory difficulty. We arrived to find a patient in severe respiratory distress with an extremely low SpO2 reading. The patient and her family were poor historians but denied a history of CHF, asthma, COPD or any other chronic pulmonary disease.
We transported the patient emergently to the local hospital without much improvement to her condition despite CPAP, high-flow oxygen by nasal cannula and other interventions. Later in the shift I checked in on the patient, who was in less distress but still had a rather low SpO2 saturation.
I spoke with the attending physician, who was able to pull up the patient’s history and learn that she had significant atelectasis from a chronic condition. The patient normally had a low SpO2 saturation and frequently presented in severe respiratory distress but had yet to require intubation or other invasive interventions.
The respiratory therapist and the physician attending the patient were initially very concerned about the patient’s condition but were able to quickly gain perspective by referencing the patient’s electronic health record. As a paramedic, I didn't have this opportunity to understand the patient's condition or use it to inform my care.
Emerging technology to overcome information isolation
Perhaps one of the largest barriers to population health, especially care of chronic diseases, in the United States is the communication failure between health care providers in the hospital and health care providers outside the hospital. Every day EMS providers assess and treat tens of thousands of patients without the benefit of previously captured patient history and records of treatment provided.
Fortunately, emerging technology for patient care documentation is making the days of information isolation in the ambulance patient care compartment or the patient's home obsolete. Making patient health records from multiple specialties available to all health care providers should be a priority for health care managers.
The issue of information sharing hasn’t escaped the scrutiny of Centers for Medicare and Medicaid Services. Currently in the pilot phase, Bundled Payments for Care Improvement initiatives are designed to encourage a medical home and tear down the communication silos that inhibit a well-executed care plan. Instead of paying for procedures, health care organizations receive a bundled payment based on the patient’s condition. This model shifts incentives away from doing things to patients and toward keeping patients healthy.
Legacy PCR software
Currently, many services force their EMTs and paramedics to operate in an information vacuum devoid of any outside health data. Legacy single encounter-focused patient care reporting software does not allow EMS providers access to any patient information beyond what they are able to glean from their own assessment.
Traditional single encounter-focused reporting systems typically focus on the data required for reporting to the government and to billing companies. This approach does not typically allow for information sharing and clinical improvement efforts.
Electronic Health Records in EMS
In 2012 the Centers for Medicare and Medicaid Services defined an electronic health record as an electronic version of a patient’s medical history maintained over time that "has the ability to support other care-related activities directly or indirectly through various interfaces, including evidence-based decision support, quality management, and outcomes reporting ." (Electronic Health Records, 2012)
Most paramedics can recount a time when their patient had non-specific 12-lead EKG changes. Deciding if there are any new ST changes on the 12-lead is impossible if the paramedic is unable to compare the current EKG to past EKGs.
In another common scenario, EMS providers are unable to obtain any medical history from an unconscious patient. If the EMT can find identifying information and the EMS organization has access to the patient’s electronic health record, the patient’s complete medical history is obtainable in seconds. The unconscious seizure patient is suddenly less ominous with the knowledge of the patient’s history of epilepsy.
As EMS moves from an emergency response-focused mindset toward a more preventative and proactive approach, the EHR becomes more critical. For example, the community paramedicine revolution has improved patient health and reduced 911 call volumes through repeat visits with frequent EMS users. Successful programs rely on information sharing and communication between all of the patient's care providers.
Paramedics depend on current and timely data to achieve the best clinical results. Just like the AHA’s emphasis on interlocking links in a chain, patients fare best when their health care is a group effort. Several EHR vendors believe integration with hospital providers is the future of EMS documentation and these companies are constantly evolving to meet these goals.
HealthCall takes a proactive approach to care plan coordination by integrating in-hospital and out-of-hospital digital information.
"The importance of timely communication escalates for paramedics within community paramedicine programs," said HealthCall President and CEO Dan Hayes. "Analogous to a HIPAA-compliant social network, paramedics can quickly and securely create patient-specific care teams. Providers within a care team receive patient encounter reports, for example, in real time without extra effort from the paramedic."
An informal social media poll found widespread support for ESO. The software facilitates bi-directional information sharing so that paramedics have access to not only the health records from previous EMS encounters, but also the health records from in-hospital patient encounters.
Hurschell Mathews, director of emergency transport services for Greenville Health System, is working with ESO to include the ability to populate patient information based on CAD information. Imagine being able to review patient history and previous encounter information before you even arrive at the patient’s side. It’s smart, revolutionary and coming soon.
Some larger EMS companies have developed their own proprietary in-house charting systems, but these options do not typically integrate with the hospitals, which limits their effectiveness. The 2012 CMS definition of an electronic health record makes it hard to argue that these non-integrated software options truly meet the definition of an EHR.
Barriers to EHR implementation
If paramedics are to successfully move away from a fee-for-service transport model, it will be critical for us to have access to extensive patient medical records. Surviving on the data gleaned from a single call is no longer adequate. We owe it to our patients to use the technology available and rise above this level of care.
For all the EHR companies, the largest hurdle continues to be the reluctance on the part of health care systems to allow access to their patient data. This hesitation will decline as hospital administrators realize the vital role EMS can and does play in their patients' health
Training is the gateway to EHR success
Any time an emerging technology is introduced, managers should anticipate growing pains. To reduce the pain, managers must put a heavy emphasis on training.
Organizations that fail to adequately train their employees on a new software system will invariably experience a great deal more implementation pain. Employees get frustrated, erroneous data pollutes system metrics, managers incorrectly adjust system settings and patients experience a lower level of care. Many software design complaints can be traced back to user error when a setting is changed by a well-meaning manager.
In 2016, the NAEMT conducted its National Survey on EMS ePCR Usability. The survey found that the level of training EMS for providers predicted who found the software usable. EMS providers who received no training rated the software 3.7 out of 7. EMS providers who received interactive training rated the software consistently higher at 4.66 out of 7. It is critical that EMS organizations and EHR vendors work together to provide adequate training.
High-performing EHR vendors are aware that paramedics and EMTs will quickly become frustrated with their product, so they provide training to their customers prior to an organization implementing the software. If you are considering a vendor that does not provide training as part of your purchase, be very cautious. You may be setting your organization up for failure.
The transition from paper charting to electronic patient care reports depended on more than the availability of software and hardware. It required input and vision from EMS leaders, collaboration between local agencies and state regulatory agencies and carefully considered implementation schedules and training.
The next phase, the transition from ePCR to EHR, will take a similar level of vision and dedication to success. It will require that EHR vendors listen to and engage EMS providers, managers, visionaries, health information management professionals and regulatory agencies to ultimately achieve success. We will all enjoy the improvements, but ultimately our patients will see the greatest benefit from the well-informed and well-connected EMS providers arriving at their sides.
1. Electronic Health Records. (2012, March). Retrieved from CMS.gov: https://www.cms.gov/Medicare/E-health/EHealthRecords/index.html
Dorothy Leonard-Barton, W. K. (1985). Implementing New Technology. Harvard Business Review.
ESO. (n.d.). Retrieved from ESO: http://www.esosolutions.com/software/ehr
NEMSIS. (n.d.). Retrieved from NEMSIS: http://nemsis.org/index.html
Physio-Control Products. (n.d.). Retrieved from Physio-Control: http://www.physio-control.com/ProductDetails.aspx?id=2147496412
ZOLL RescueNet. (n.d.). Retrieved from ZOLL RescueNet: https://www.zolldata.com/rescuenet-epcr/features/