One sector that has been excluded from the health information exchange ecosystem, however, is emergency medical services (EMS). Even though many EMS agencies have adopted electronic patient care reporting (ePCRs) software, those systems use different data standards than the electronic health records (EHRs) used by hospitals, making interoperability difficult.
So what happens today when paramedics transport patients to the hospital and hand them off to emergency department staff?
“In the current scheme, they print out or photocopy their run sheet recorded in the field,” said Dan Smiley, chief deputy director at California’s Emergency Medical Services Authority (EMSA). “Even if it is done on an ePCR, they will print out a version and hand it off. The capability of hospitals using EHRs to work with a paper record is limited. It is not searchable, and there is no way of linking that data. It is not interoperable.”
In a 2013 survey conducted for EMSA by Lumetra Healthcare Solutions, California EMS agencies were asked if their ePCR currently interfaces to hospital EHRs. A majority of agencies (94 percent) indicated that the ePCR does not interface with hospital systems. When asked if the hospital EHR data interfaces to providers in the field, all agencies replied that they did not receive data from the hospitals. When asked what data elements needed to be interfaced between the ePCR and the hospital EHR, the most common response was that patient outcomes and discharge data were needed.
EMS agencies and hospital emergency departments would like patient information to flow in both directions to speed diagnoses and improve care and efficiency. With a $2.75 million, two-year grant from the federal Office of the National Coordinator for Health Information Technology (ONC), California EMSA is getting ready to set up pilot projects with regional health information exchanges (HIEs) and EMS agencies to work on both day-to-day patient handoffs as well as how data about displaced patients could be accessed during an emergency such as an earthquake.
Smiley said the goal is to make EMS a full participant in the electronic exchange of health information, with the capability to:
• Search a patient’s health record for problems, medications, allergies and end-of-life decisions to enhance clinical decision-making in the field;
• Alert the receiving hospital about the patient’s status directly onto a dashboard in the emergency department to provide decision support;
• File the emergency medical services patient care report data directly into the patient’s electronic health record for a better longitudinal patient record; and
• Reconcile the electronic health record information including diagnoses and disposition back into the EMS patient care report for use in improving the EMS system.
Partnering with California’s regional HIEs makes sense because they already play a role in transmitting data from one setting to another, according to Smiley. “Right now that is the only hub we have, the only infrastructure to be able to search multiple sources of information,” he said. When paramedics see a patient, they don’t know at which hospitals the patient has been seen before. “So the HIE is the only place we can go to query and return information from a multi-site search. If we only had one ambulance provider and one hospital in a small town, that model might be different, but most larger systems in California have multiple ambulance providers and multiple hospitals, so we need to have a hub.”
“We are hoping to achieve bi-directional exchange of information in a pre-hospital setting, but the whole idea has some problems associated with it,” said Robert “Rim” Cothren, executive director of the California Association of HIEs, which is working with EMSA on the project.
First, Cothren said, the data standards used in ePCRs are not a direct match for the standards used in hospitals. “People look at it and say HL7 is driving both of those, but there is very little overlap between standards used in ePCRs and EHRs. That translation is going to be a problem we haven’t even started to address yet.”
Second, Cothren asked, how do you ensure you have the correct patient if the only information you have is a 911 call and an address? One of the big challenges is patient matching: how to identify the patient and where to find records associated with that person.
Another challenge is making sure paramedics aren’t flooded with too much information in clinical documents containing the patient’s entire record. “The truth is they need to know very little — perhaps a problem list, allergies and medications,” Cothren said. “They don’t need a family history or most recent labs. They do not want a barrage of information.”
Cothren agrees with Smiley that the HIE is a natural fit as an intermediary between EMS and hospitals. First, it has the same footprint as EMS — both are regional services. “HIEs integrate data between a broad set of stakeholders,” he added, “and this is merely another stakeholder managing a patient in a different part of the care life cycle. But the first thing to do is develop trust among the community. That is in the sweet spot of what HIEs do.”
Although data sharing between EMS agencies and hospitals is far from commonplace, there has been progress made in a few cities and states. For example, the South Metro Fire Rescue Authority in Colorado’s Douglas and Arapahoe counties has joined the state HIE, CORHIO, to enable its paramedics to receive real-time hospital and lab information via a Web portal.
In 2010, the Rochester Regional Health Information Organization in western New York started integrating EMS data into its exchange to improve care coordination. Research there showed that in 25 percent of EMS calls, patients are not transported anywhere. “Primary care doctors have no idea what kind of care is going on in the community in those cases,” said Jill Eisenstein, the organization’s interim executive director. So the HIE connected electronic pre-hospital care documents from two vendors to the HIE.
Although EMS data is quite different from clinical data, they put together a style sheet so doctors could easily find the information they were looking for. “We have those documents automatically sent to the HIE at the close of an encounter,” Eisenstein said. “We send an alert to anybody signed up as a provider for that patient. It is also available in our query portal.”
Perhaps the most progress has been made in San Diego. For the past six years stakeholders there have been working on pre-hospital communication and the development of an EMS hub hosted by the San Diego Health Connect HIE. Built with help from federal grant funding, the EMS Hub is a standalone, cloud-based system that collects 911, computer-aided dispatch and ePCR data from all the agencies that transport patients and combines those sources under a single presentation. “Then we had to figure out which situations and use cases it is appropriate for in real-time to forward ePCR data from an ambulance en route to the emergency department,” explained San Diego Health Connect Executive Director Daniel Chavez.
San Diego Health Connect is about halfway through implementation with all the emergency departments and EMS agencies in San Diego County. Some emergency departments use a Web portal to access the information, and others are integrating the data feed directly into their EHRs.
“A big challenge is the data governance to get hospitals to share clinical data so EMS agencies can close the loop,” Chavez said. San Diego identified the narrow data set that EMS needs for quality improvement and automated putting that information in the EMS Hub. “Hospitals don’t want others to do reporting on their data,” Chavez said. “We had to create specific rules and guidelines for that data. We make it available for seven days after the close of an incident, and it is incumbent on EMS to close out their staff work in seven days. It is not the best solution, but a compromise. As we learn to work together, we hope to extend that seven-day window.”
Another challenge, Chavez said, is getting all the stakeholders engaged early on. “EMS agencies will say, ‘Come back, HIE, when you have all the [emergency departments] up and running and then we will get on board.’ That makes sense, but that is not the way network effect works,” he said. “You have to come on board and learn with the whole community. It is a multi-year process. You have to invest. You can’t just sit back and say, ‘I am not going to talk to you until it is all done.’”
MedStar Mobile Healthcare in Fort Worth, Texas, is just starting to deploy a health-care integration engine called Infor Cloverleaf that helps exchange ePCR data with emergency departments.
MedStar, the trade name of the Area Metropolitan Ambulance Authority, which serves Fort Worth and 14 other cities in the north Texas area, started by deploying a new ePCR from ImageTrend, said Paul Trusty, MedStar’s IT manager. The ePCR exports a file that Infor Cloverleaf can process and either deliver certain data elements to the hospital, or the hospital can choose to just receive a PDF file and attach it to the medical record.
Trusty said that MedStar couldn’t count on an HIE to play the middle man. “One of the challenges with HIEs in this area is the number of them,” he said. Almost every hospital chain has its own private HIE, and there is one sponsored by the state. “It ends up that even with the promise of HIE, the data is not all in one place; it is scattered everywhere.”
Like EMS agencies in other states, MedStar wants the data flow to be bi-directional. “We want medications and allergies information on the front end,” Trusty said. “That is a future direction we would like to go.” As well as working in IT, Trusty was a paramedic for several years. Sometimes the information you are given doesn’t match the patient’s presentation, and paramedics have to decide whether to treat or not, he said. “That could be answered if we had better patient history information. I think that is better care for the patient and better systemwide. We also want to get data back electronically on patient outcomes and demographics to optimize our processes here.”
Another use case that California EMSA is addressing with the ONC grant involves connecting first responders, doctors and nurses to patient records in an emergency.
Scott Afzal, director of health information systems at Audacious Inquiry, a Baltimore-based health policy and technology firm, was asked by ONC to make recommendations about how health information could be better shared in disaster response. His team targeted two geographic areas that are vulnerable to a high number of natural disasters: California and the Gulf Coast (Louisiana, Mississippi and Texas). “We traveled throughout California with Dan Smiley and met with regional EMS leaders and heard from them and HIE leaders in their communities,” he said.
Afzal said one lesson from Hurricane Katrina also informed their thinking. The e-prescribing network provider Surescripts enabled responders to use its medical history query function on an emergency basis to look up which medications people were on. “That was a valuable service focused on an important data type,” he said. “It was set up ad hoc on the fly with no planning. With some planning, we could figure out how you might credential first responders and volunteers for access to this information and re-establish connectivity to sources of information and work flows.” That is what the California team is now pursuing. It’s building some disaster response infrastructure to pilot and validate the efficacy for broader use around the country.
The pilot project is called PULSE (Patient Unified Lookup System for Emergencies). Smiley said the exact technology infrastructure they will use is still unclear. “We want to make sure any provider can go directly from their EHR and search for and find information in a systematic manner,” he said. “But in a disaster situation, in mobile field hospitals or care sites, where an EHR is not immediately available, then the pathway of a Web portal is probably the easiest methodology.”
EMSA already has an online system to authenticate credentials for disaster volunteers. “We want to make sure that all of our disaster health-care volunteers who need access to records in an emergency can get it,” Smiley said.
