How EMS can improve the continuum of care with better patient stories
The EMS patient care report needs to tell a deeper and more comprehensive story of the patient to inform other health care providers
By Nick Nudell, EMS1 Contributor
EMS providers are great storytellers. Stories are a big part of our identity, our culture, and our profession.
Friends and family ask for our “worst call” and we regale our partners with stories of past calls or how we reacted to various scenarios. We have blogs, Facebook groups, and hashtags (#MyEMSDay) to tell our story contemporaneously. We teach new providers with case studies, another form of a story, asking them to work through the anecdote as if they were living it.
We also compile stories during calls that are not shared on social media, in social settings, or in many cases not used for educational purposes. These stories document the scene, and the SOAP narrative describes our observations and what we were told by the patient, caregiver or bystander.
We may be under some pressure from our employers to rapidly return to service, so we complete the writing of our story to be defensive and supportive of whatever we did or did not accomplish on the call, while creating enough evidence of a medical need that the billing office can submit a bill. If taken to court our description of the car crash, the blood patterns on the wall, the exact quotes of the abuse victims, or the obviously inappropriate oxygen delivery device from the nursing home can be known to all. The story plot usually follows our protocols and procedures, step by step, just as required by our medical control authority.
For most EMS providers this form of storytelling is the reality, which is unfortunate, not only for us as professionals, but also for the patients we serve.
The origin of EMS storytelling
For the first 35 years of the EMS profession, documentation was typically a bubble sheet or a form with checkboxes and fill-in-the-blank spaces. Those forms were periodically submitted to the state EMS office.
In the late 1990’s the National Association of State EMS Officials (NASEMSO) convened a workgroup to develop a uniform prehospital dataset, modeled in large part by the forms that police officers used for traffic accidents. This was the start of EMS storytelling.
Over the following decade these run sheets, often printed on carbon copy paper for immediate duplication, were converted into electronically collected records following a major effort by paramedic data system (PDS) pioneers to develop a National EMS Information System (NEMSIS). Through these efforts EMS agencies worked with their state data managers to improve prehospital data collection practices, so that EMS could tell a standardized story.
Today NEMSIS is in the midst of rolling out its third version of the data standard, which closes loopholes and other issues discovered only with widespread adoption. The update continues to provide EMS agencies flexibility in how the electronic patient care reports are configured.
EMS needs to tell a different story
Throughout the history of EMS and PDS, the stories we’ve been telling about our calls have gone largely unchanged. In some cases software has helped make data collection easier or more accurate (spell check, for example), but the software has done nothing to help us tell the right story. What is the right story?
Although we are often caring for someone on their worst day, it is only one day of their entire life. That is equivalent to one blink of an eye in two weeks. In the last two weeks a single eye blink does not represent the whole two weeks.
If you picked up the patient from a medical clinic or hospital you may get some other patient records like an X-ray or CT scan and an envelope stuffed with discharge and diagnosis instructions, care notes, vital sign records and medication lists, which are also not the patient’s “story.”
What story should we be telling?
Whose story should we be telling? Should it be a story of all the calls we went on in a given shift? How many cardiac arrests we did last year? Or bad car crashes we’ve been sent to? Or all the lift-assists we get sent to in the middle of the night?
During your short time with the patient, you are in their home or their workplace - you are in their environment where you can observe their situation like no one else can. You can see if it is clean and free of hazards, if they’re having difficulty putting groceries in the cupboard, or problems taking prescribed medications. Your unique access provides a window into the patient's world and should be considered during the post-discharge planning that will eventually occur.
We should be telling a complete story of 89-year-old Mrs. Jones, including how she has struggled to take her diabetes and hypertension medications because her vision has deteriorated from macular degeneration and she is unable to read the labels. How the opened food in her refrigerator is long past its expiration dates with the lids kept off because she doesn’t have the strength to open them if sealed. How her bathroom is dirty because she cannot see the stains and lacks the dexterity to clean it well. How the Christmas decorations have spilled over into the walkway such that she has already tripped and fallen twice. How her aging children are incapable of providing daily support for her although they take her to every appointment where the doctor wrongly assumes they’re taking adequate care of her.
We need to tell her complete story through our documentation! If the EMS documentation explained more than her complaint of hip pain after a fall more health care providers would take notice because it would be found inside her medical record, not just attached to it. The EMS document belongs inside her medical record. This is integrated health care. This does not require a new type of training course nor does it mean we cannot collect important business information.
Barriers to telling the story
To tell Mrs. Jones’ story requires more than an electronic patient care record (ePCR) from the EMS agency to be printed, handed to the triage nurse, later scanned by someone in medical records, and then attached to the chart. Mrs. Jones’ deserves better and we can do better.
What can we do? A copy of our paper PCR is being stapled or scanned into the patient’s chart. Our verbal report is usually short and focused on the immediate treatment and vital signs. It is just a report, not the patient’s story. In busy hospitals we may not be able to fully inform the ED staff let alone the hospitalist, surgeon, critical care nurses, discharge planning team, or the patient’s primary care physician.
To tell the right story requires a paradigm shift in our prehospital and “emergency” culture. We need our PDS to allow us to DIRECTLY insert the patient’s story into the patient's medical record.
That story cannot merely be an attachment along with the legacy paper records, scanned EKGs, letters between providers and insurance companies, and photographs. For the patient’s own safety, health, and well-being we must demand that medical record systems integrate with our PDS. We need to drive this agenda forward.
About the Author
Nick Nudell, MS, NRP is an EMS and Information Systems consultant and partner for PrioriHealth Partners and is serving as the Project Manager for the National Association of State EMS Officials' EMS Performance Measures Initiative. He also serves as the data manager representative to the National EMS Advisory Council (NEMSAC) and as a founding board member of the Paramedic Foundation. Nick has a Bachelors in IT Management and a Masters in Information Security. He's been a licensed paramedic for 15 years in Glacier County Montana but has also worked in New Jersey, San Francisco, and at Burning Man in Nevada. Contact Nick at email@example.com.