ePCR implementation: Changing a hard-copy culture

New York EMS volunteers swap paper reports for digital documentation


Electronic patient care reports (ePCR) have become as common in EMS as 12-lead EKGs. Like pricey monitors, though, ePCR can be more of a burden than a solution for volunteer organizations with modest call volumes and tight budgets. That doesn’t make automation a bad idea – just a frustrating process sometimes. Here’s how one suburban New York agency met that challenge.

Mining in-house expertise when selecting an ePCR system

When the Huntington Community First Aid Squad started charging for their services in 2017, the biggest obstacle to collection wasn’t patients; it was paperwork. “Our PCRs weren’t legible,” says Second Deputy Chief Ryane Como. “The company handling billing for us said we’d either have to switch to digital documentation or risk losing revenue.”

HCFAS is one of the busiest EMS agencies in Suffolk County, Long Island’s 86-mile-long eastern segment. Suffolk’s 1.5-million residents rely on 100 mostly-volunteer departments like Huntington to answer over 100,000 911 calls annually. (Photo/HCFAS)
HCFAS is one of the busiest EMS agencies in Suffolk County, Long Island’s 86-mile-long eastern segment. Suffolk’s 1.5-million residents rely on 100 mostly-volunteer departments like Huntington to answer over 100,000 911 calls annually. (Photo/HCFAS)

After unsuccessful attempts at adopting ePCR in 2012 and 2016, HCFAS was understandably reluctant to try again. “The first system we installed was supposed to be used throughout the county,” Como was told. “That never happened, partly because it was cumbersome and couldn’t be customized to the needs of individual agencies. By 2014, the vendor had stopped updating the software and was becoming less responsive to our calls.

“The second system wasn’t much better. It was hard to use and didn’t look like a good long-term fit. We never got past having paper PCRs to back up computer-generated reports.”

Other automated options were out there, but before trying again, HCFAS realized they’d have to take responsibility for making the sophisticated software work. They formed an ePCR committee stocked with EMS, business and database-management experience. One member had a background in computer technology; another was an IT director who’d helped his volunteer fire department transition to the same software the squad was considering. Como, an insurance-industry veteran and EMT-CC (advanced certification unique to New York), joined too. It wasn’t long before the committee started to steer Huntington in the right direction.

“We worked closely with ESO (the vendor) to customize the system,” Como says. “Most important was integration with our CAD system so we wouldn’t have to re-enter scene information and times. We also wanted to change some of the required fields and make it easier to input interventions. ESO was very responsive to our requests.”

The ePCR era had begun at HCFAS, but not without implementation issues common to volunteer providers.

Navigating a learning curve when implementing ePCR

HCFAS is one of the busiest EMS agencies in Suffolk County, Long Island’s 86-mile-long eastern segment. Suffolk’s 1.5-million residents rely on 100 mostly-volunteer departments like Huntington to answer over 100,000 911 calls annually. Next to member recruitment and retention, keeping pace with technology is often the biggest challenge.

“Planning and preparation are key,” says Como, of Huntington’s latest ePCR effort. “Your leadership has to be fully committed to what will likely be a difficult transition from paper. That means having people in place to train members, some of whom ride only a few hours a week and have been carrying clipboards instead of computers for 30 years.”

Como and the other ePCR committee members used a train-the-trainer approach to prepare for their new system’s roll out. “ESO gave us a three-hour class on their software,” she says. “Then we went to each shift and taught members one-on-one. Anyone who joined after that has to be trained individually before they start taking calls.”

But all the instruction in the world couldn’t anticipate every problem when ePCR went live at HCFAS on Jan. 1, 2018. “There were glitches in the interface with CAD,” Como recalls. “Also, our ambulance fleet wasn’t configured for mobile electronics. We had to change the way our network was designed.”

Another concern with almost all ePCR software is real-time reporting. Even Como finds it hard to keypunch data while treating patients. “Depending on how critical the call is, I might not have time to start typing until we get to the hospital,” she says. “We’re lucky our system is flexible enough to allow documentation after the fact.

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“I carry a small notebook that I still use to jot down important information on scene. That’s how I prefer to work unless the patient is stable enough for me to start the PCR.”

Speaking of data entry, Como calls Huntington’s purchase of state-of-the-art laptop computers “a very important part of our [ePCR] journey.”

“The Toughbooks we had from before were outdated and caused all kinds of issues with connectivity. We switched to newer devices that were durable and lightweight with swiveling screens, so they could be used as tablets, too. Most members carry the computer right to the patient.”

Como likes the advantages of internet-based software. “We can access the system from anywhere and get updates automatically. If the website is down, we enter our PCRs as we normally would, then upload them later.”

ePCR payoffs

Once the hardware and software are up and running, users have a right to expect payback for their efforts. For Huntington, improved revenue collection secondary to more-legible documentation had already been identified as a major gain.

Other benefits, like improved information access and accuracy, are harder to quantify, but Como is certain ePCR gives HCFAS more robust quality-improvement tools. “Right now, we’re looking at cardiac cases,” she says. “Was an EKG obtained? If so, was it transmitted? What meds were given? Were protocols followed? We can drill down to a week or several months’ worth of calls.

“Prehospital crews and even hospitals (with ESO software) can get patient details in real time,” the 34-year-old adds. “Someday, we hope to make data sharing a bigger part of QA/QI.”

Such growth in systems sophistication will continue to depend on top-down support of a coordinated process. Como calls Huntington “all in” on that philosophy. “If what you try doesn’t work, you try something else that gets you closer,” she says. “Pretty soon, you have something viable that you can continue improving.

“The important thing is not to lose sight of your goals. Problems are to be expected. Just don’t let them get in your way.”

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