EMS1’s special coverage series, Driving Change by Embracing the Data Revolution in EMS, sponsored by ESO, explores strategies for improving data collection, analysis and application to strategically effect improvements in EMS operations and patient care.
By Mic Gunderson
Clinical data registries are powerful tools for quality improvement. They provide a valuable piece of infrastructure that collects data that can then be analyzed and reported for feedback in standardized way. Registries typically gather data for all patients seen by the participating agency or hospital with a specific clinical condition or who have received a specific type of procedure or intervention.
At a national level, the only registry where EMS agencies directly submit data and directly receive feedback reports is from the Cardiac Arrest Registry to Enhance Survival (CARES) report. It tracks performance on cases of out-of-hospital cardiac arrest.
After EMS provides care to a cardiac arrest patient, a specific set of data elements is either extracted from the ePCR system or is entered manually through data entry screens. After EMS enters its data set, a prompt is sent to a designated contact person at the receiving hospital to fill in the hospital data elements on the case. Calculations are then made, which are then used to generate various reports. The most commonly used report from CARES is the survival report which can be generated at the individual EMS agency, state or national level.
Combining EMS and hospital data
There are other national registries EMS can participate in, but they are limited to a small quantity of EMS data elements entered by the receiving hospitals. That information is typically obtained from the copy of the EMS chart in the hospital’s electronic medical record system. This approach is used in registries for:
- Acute myocardial infarction (ACTION Registry, Get With The Guidelines – Coronary Artery Disease).
- Trauma (National Trauma Data Bank/Trauma Quality Improvement Program).
- Stroke (Get With The Guidelines – Stroke).
Bringing data together from EMS and hospitals begins to bring insights on how well their combined performance measures up as a system of care for the acute phase of treatment.
When an EMS agency participates in a clinical registry program, the agency can get feedback not only it its own performance, but also on how its performance compares to others. For example, the results shown in a CARES survival report for a specific EMS agency can be compared to the same report at a state or national level.
It is important to recognize that individual case feedback reports are not the same as clinical registry reports. For example, many hospitals that care for ST elevation myocardial infarction (STEMI) patients will send a report back to the EMS crew that transported the patient to their facility. The reports will typically provide a summary of the patient’s care, and often include angiography images showing the artery before and after the blockage was cleared. While these reports provide valuable feedback to a specific EMS crew on a specific patient, they do not reflect on the overall STEMI care provided by the EMS agency, hospital or their combined efforts as a system of care for STEMI on the basis of all the cases they have cared. That’s where a clinical registry fits in.
EMS data accessibility
Apart from CARES reports, clinical registry reports currently are not directly accessible to EMS agencies. Hospitals submit the data and pay the fees to participate in the registry, so they own the reports. Hospitals can individually decide if they will share the reports with the EMS agencies that bring them patients. However, if the hospital receives patients from multiple EMS agencies and the EMS agencies take patients to multiple hospitals, dissecting the cases apart to give each EMS agency feedback on the group of patients it cared for across multiple hospitals is a challenge.
Some progress is being made to provide more information to back to EMS. The American College of Cardiology (ACC) recently sent out a press release stating it will begin making reports available on AMI cases in the ACTION Registry directly to the EMS agencies that transported them to the receiving hospitals. The new report service, called eReports – EMS, will include “selected metrics of aggregate performance of EMS care, hospitals and the overall system of care – information that is most important to EMS providers,” the ACC noted.
“Although they will not be able to access individual patient level data, eReports – EMS will give EMS providers overall data on how their patients fare at a particular hospital. For instance, they’ll be able to see if they correctly diagnosed patients, if their work was performed quickly, and how many patients improved and went home. Importantly, the reports are based on data aggregated across all of the hospitals that the EMS agency transported patients to, if the hospitals are participating in the ACTION Registry,” The release explained. Unfortunately, similar reporting is not yet available for stroke or trauma cases.
While EMS aggregate reporting from these registries is a step in the right direction, these are fundamentally hospital-centric registries designed to support hospital quality improvement efforts. EMS and the overall systems of care would benefit tremendously if there were EMS-centric clinical registries with broad participation, like we see with the CARES report.
EMS would then have the same sort of quality improvement infrastructure that hospitals now have for their care. The EMS and hospital registries could then be linked to provide a very robust picture of performance for the overall system of care.
Measuring performance
Altruistic motives to improve care at the EMS and systems level may not be the trigger that brings about more EMS-centric registries. A major motive for hospitals to participate in clinical registries is largely attributed to requirements to measure their performance by accreditation bodies, payers and for public accountability requirements.
Many hospitals seek service-line accreditation for their trauma, stroke and STEMI care. To obtain that accreditation, they are required to objectively measure their performance and use that data to demonstrate they are meeting the applicable service-line accreditation performance standards.
Federal and private insurance payers are increasingly insisting that hospitals demonstrate high quality care through performance measures in clinical registries. This is happening as payers shift from traditional fee for service programs to so-called alternative payment models, where the level of clinical quality and financial efficiency impacts a provider’s payment and profit.
Public reporting of hospital performance is becoming more common as well to establish public accountability for the quality of care that hospitals deliver. This allows consumers to make better informed choices about the hospitals they utilize. The most prominent public reporting system is from the federal government. It allows the public to examine and compare performance of hospitals, physicians, nursing homes, home health agencies, dialysis facilities, hospice agencies and other care provider categories .
Failure to measure and perform will impact that agency’s funding. The federal government has not announced when EMS will be included in the public reporting system, but the general idea is to have all provider categories become publicly accountable for the quality of the care they provide.
The EMS community wants to be recognized as a full participant in the healthcare system. With this level of integration comes the accountability for the quality of care it provides. Clinical registries are a key piece of infrastructure that EMS needs to get ready to step up.
About the author
Mic Gunderson is the president of the Center for Systems Improvement – a consulting firm specializing in design and value improvement for high-risk time-sensitive care.
His prior positions include national director for clinical systems at the American Heart Association; EMS system director for Kent County EMS in Grand Rapids, Mich.; president at Integral Performance Solutions; national director for quality, education and research with the Rural/Metro Corporation; director of research and education with the Office of the Medical Director in the Pinellas County, Fla., EMS system.
Over the course of his career, he served as a field EMT, paramedic and firefighter, clinical manager and director with military, private and governmental EMS agencies. Mic has authored and edited a wide range of articles and textbooks, and has served on the boards of directors for several national EMS organizations.