Cyber Charting: The pros and cons of electronic PCRs

There is little published evidence evaluating the benefits and risks of implementing ePCR programs


Electronic Patient Care Reports, or ePCRs, are used by roughly half of all EMS services, and that number is steadily increasing1. Unlike Electronic Medical Record (EMR) technologies used in medical offices and health care facilities, there is little published evidence evaluating the benefits and risks of implementing ePCR programs. Whether you use an ePCR or not, questions abound about costs, time requirements, accuracy, legal and operational effects, and exactly how a service should navigate through the maze of different vendors and ePCR platforms. This article will summarize what is known about ePCR utilization and how the future might look.

EMS electronic reporting background
Ten years ago, only ten percent of EMS services used ePCRs. There were few standards, and virtually anyone with a little computer savvy could assemble and market an ePCR program. Early adopters tended to be services looking to gain efficiencies in their EMS billing and collection processes2

Over time, recognizing the need for standardization, the National Highway Traffic Safety Administration (NHTSA) developed a national prehospital EMS dataset, now administered by the National EMS Information System (NEMSIS).  Currently in its third revision, the dataset standardizes electronic EMS data collection and reporting.   

NEMSIS also tests ePCR products to certify them as compliant (Silver or Gold level) with the NHTSA datasets.  When looking at an ePCR product, NEMSIS compliance should be one of your first considerations, verified by checking the NEMSIS site.

Billing remains a driving force for EMS ePCR use, especially in the current day era where every claim is reviewed by payers to determine if the service provided is covered and whether the documentation supports medical necessity for the EMS service delivered.  Denials of payment by insurers for non-covered or medically unnecessary EMS services significantly lower revenue needed to operate an EMS service2.

Is ePCR a timesaver?
Aside from the investment of time needed to properly train EMS providers to use an ePCR system, it is reasonable to compare the time needed to document using paper records to time needed to complete ePCRs.  A time study comparing 17,950 paper PCRs to 19,649 ePCRs conducted in Helsinki, Finland from 2006 to 2007 found a slight increase in total run time (including documentation) in the three months following implementation of an ePCR system with no statistically significant change between paper and electronic PCR thereafter3

Interestingly, before/after EMR studies in hospitals and medical offices consistently show at least a ten percent reduction in charting times, allowing more time for patient care3.  The preponderance of health care studies suggest then, that delays induced by switching to an ePCR system should be transient and, if persistent, are likely related to the ePCR product itself or the platform used for data entry.

Complete documentation an advantage
An immediately visible advantage of ePCRs is elimination of handwriting.  Yet as quickly as proponents tout these advantages, naysayers criticize the rigidity of ePCR systems as a segue to incomplete documentation.  Declines in completeness of medical records have not been observed in hospital EMR studies.  In a before/after Georgetown University EMS study conducted between 2009 and 2010, researchers actually observed an absolute 36% increase in EMS physical exam documentation completeness with implementation of ePCRs4

Concerns for completeness highlight an important advantage of EMS ePCRs: the ability to require a user to complete certain fields in order to close or save the chart. Referred to in the EMS industry as, “closed call rules,” virtually all ePCR platforms allow administrators to define required fields.  While the Georgetown researchers did not require completion of any ePCR fields during their study period4, the Helsinki researchers did establish a series of closed call rules for their non-transport runs3.  While these increased total duration of non-transport runs by 2 to 3 minutes, they resolved repeated insufficient documentation issues seen with paper charts. 

Capturing research data
Is electronic charting is a necessity if we are looking to conduct reliable EMS research?  Researchers in Aachen, Germany studied 4,815 paper PCRs completed in 2007 and 2008 for documentation of parameters needed to calculate scores used in EMS and trauma research5.  These included vital signs such as blood pressure, GCS, heart rate, respiratory rate, pain scale, pulse oximetry, temperature, EtCO2, and diagnostic values such as glucose and ECG rhythm. 

Paper documentation of individual values ranged from 40% to 99% and completeness needed to calculate EMS and trauma scores was poor overall, ranging from 9% to 37%.  The authors found paper PCRs woefully inadequate for scientific research and suggested that ePCRs using closed call rules would likely improve data quality sufficiently to allow rigorous scientific analysis. 

From a data perspective, ePCRs seem to offer a myriad of advantages.

Increased emphasis on evidence-based practice in EMS has led to a substantial increase in scientific analysis of prehospital data.  The sum total of data that could be collected from having all EMS services using an ePCR platform that reports data to NEMSIS would revolutionize EMS as we know it.

Medlegal pearls and pitfalls
Presently, there are no published studies looking at the legal pros and cons of the ePCR.  It is unlikely that an EMS agency or provider would ever be sued for writing a poor PCR, yet when disciplinary action, complaints, and litigation happen, a poorly or incompletely written PCR is likely to offer a poor defense. 

There is no guarantee that ePCRs improve documentation.  Non-functional, unfriendly, cumbersome, poorly administered, and improperly used ePCR systems have as much potential to generate bad documentation as paper PCRs. Yet well documented, in-hospital EMR research have shown improvements in clinical decision making, increased adherence to protocols and guideline based care, better patient monitoring, and less medication errors3

Data interoperability
Few of the current ePCR platforms use true point-of-care (POC) computer devices, and even fewer communicate directly with patient monitors, transferring vital signs and EKGs directly to the ePCR in real time.  Until monitoring manufacturers integrate with ePCR vendors to freely share data between devices, and until ePCR devices become less fragile and breakable, it seems unlikely that field providers will use them as a point-of-care reference tool .

ePCR affects quality improvement
On a larger scale, ePCRs offer the ability to much more effectively and efficiently perform Quality Improvement (QI) activities.  Organizations can readily query datasets for patterns that identify opportunities for improvement in the EMS service as a whole, or with individual providers. 

Electronic databases allow ready analysis and comparison of chute times, IV success rates, medication use, and also allow EMS services to benchmark their data against other organizations.  9-1-1 call centers, large EMS systems, counties, and regions can utilize ePCR data for syndromic surveillance, setting up alerts for unusual illness outbreaks or patterns that might not otherwise be recognized by individual crews. 

On the downside, generating reports is often far from automatic and relies heavily on user input.  For example, identifying all cardiac arrests for a single EMS service in an ePCR database for a one year period would likely require running multiple reports, eventually narrowing results.  Not every cardiac arrest is dispatched as an arrest, not all arrests present on arrival, and not all receive the same interventions.  Selecting any one field to report on will likely miss multiple patients. 

Likewise, when providers inconsistently record information and the ePCR system allows too much (or too little) leeway in data entry before saving a record, it becomes difficult to obtain meaningful reports on the back end.  It can be helpful to regularly run reports that test the integrity of ePCR data. 

For example, many large EMS systems review daily reports of response time outliers so that errors are discovered and corrected before monthly statistics are sent to local government.

Protecting patient information
HIPAA (Health Insurance Portability and Accountability Act) sets standards for sharing health information.  Some of these apply specifically to ePCRs and, while outside the scope of this article, one very basic advantage of ePCRs is the ability to track exactly who created, edited, and viewed every ePCR and when they did so.  While certainly not protected from falling into the wrong hands, ePCRs are considerably easier to track than paper and less likely to be left lying around in places where patient confidentiality might be breached. 

Availability and cost
While ePCR use has exploded over the past decade, current ePCR users tend to be larger, busier EMS services.  A major obstacle to ePCR use in smaller EMS agencies is cost.  User fees and computer equipment can be prohibitively expensive.  Future growth in users is likely to level off unless incentives are offered that would allow smaller services to implement ePCR programs.

 

References

  1. Federal Interagency Committee for Emergency Medical Services (FICEMS). 2011 National EMS Assessment.  University of North Carolina, Department of Emergency Medicine (Project Lead). 2012.
  2. Snyder J.  EMS Documentation.  Upper Saddle River, NJ: Prentice Hall; 2009.
  3. Kuisma M, Vayrynen T, Hiltunen T, Porthan K, Aaltonen J.  Effect of introduction of electronic patient reporting on the duration of ambulance calls.  Am J Emerg Med 2009; 27:948-955.
  4. Katzer R, Barton DJ, Adelman S, Clark S, Seaman EL, Hudson KB.  Impact of implementing an EMR on physical exam documentation by ambulance personnel.  Appl Clin Inf 2012; 3:301-308.
  5. Bergrath S, Skorning M, Rortgen D, Beckers SK, Brokmann JC, Mutscher C, Rossaint R.  Is paper-based documentation in an emergency medical service adequate for retrospective scientific analysis?  An evaluation of a physician-run service.  Emerg Med J 2011; 28:320-324.  
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