MAY2015

How data & technology are revolutionizing patient care

An exclusive editorial supplement to JEMS, sponsored by ZOLL, FirstWatch, ImageTrend and Physio-Control Inc. Advancing Care with Data-driven Solutions

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Zoll_JEMSsupp_1505 1 3/24/15 8:37 AM •contents• •introduction•

2 By Greg Mears, MD The Star Trek Tricorder In some way, each of us grew up with Star Trek—the original TV Still a vision of the not-so-distant future series, The Next Generation or the current prequels. We marveled at By Alan Craig the ability to “beam me up” using the transporter, or using the medi- cal tricorder to diagnose the ill. Star Trek creator Gene Roddenberry’s 6 imagination and vision raised everyone’s awareness of the value of Next Generation 9-1-1 technology—for EMS it raised expectations of how easy it should be I texted 9-1-1 & was resuscitated to use and integrate into our everyday lives. through social media EMS, as with healthcare in general, has become busier and more By Troy D. Hogue, BS complex. Rightfully we’ve focused on how we achieve better patient outcomes, and the amount of data we collect each day has increased 9 logarithmically. The future is a place where technology comes Community Paramedicine together with complex protocols, clinical guidelines and destination decisions driven by definitive care expectations to help determine the Successful health information technology implementation in patient-centric EMS patient’s final outcome. By Brenda Staffan In January 2014, JEMS published “Data Drives Care,” a supple- ment exploring how data collection and its use helps save lives. With this supplement, we’ll go a step further, exploring the future of tech- 12 nology from a device and data perspective. As technology advances, Golden Age of Data our expectations are for it to integrate into our service and clin- Modern approaches to health ical care delivery model, making life more manageable and more information exchange productive. By Matt Zavadsky, MS-HSA, EMT In these pages, some of our industry’s most respected leaders share their thoughts on a number of topics, including: patient moni- 17 toring; extending our care through social media; exploring medical Clinical Decision Support records from a patient-centric perspective; the positive impact of Data systems & devices promote health information exchange; creating a culture that will embrace improved clinical decision-making technology; and methods to keep your operations centered in tech- By Greg Mears, MD nology while keeping you alerted to issues that need attention now. In our attempt to cover the important data and technology trends, 19 we outgrew this supplement. Two other connected articles will Educated to Be Data Centric appear this year in JEMS. In this month’s issue, Bentley J. Bobrow, How can EMS agencies & educators MD; Daniel W. Spaite, MD and Bryan F. McNally, MD, provide an over- best prepare the workforce for our future? view of the of the CARES CPR metrics and how they can be used to By Brian LaCroix improve outcomes. In November, Frank Gresh writes an article on IT implementations that will serve as a great tool for 23 EMS to use in their software evaluation and purchase decisions. Drowning in Data, There’s one common fiber that connects technology and all the Thirsting for Knowledge topics we explore in this supplement: There will be a point in health- The benefits of real-time & care where devices, data and technology will seamlessly fuse with near-real-time data feedback clinical care. It’s known as “clinical decision support” and it’s our By John Tobin & Todd Stout ultimate destination ... to boldly go where no man has gone before.

VICE PRESIDENT/GROUP PUBLISHER Ryan R. Dohrn ADVERTISING SALES Amanda Hope, Cindi Richardson EDITOR-IN-CHIEF A.J. Heightman, MPA, EMT-P ART DIRECTOR Josh Troutman MANAGING EDITOR Ryan Kelley COVER PHOTO Photo courtesy ZOLL Medical Corporation SUPPLEMENT COORDINATOR Greg Mears, MD

ON THE LEADING EDGE: HOW DATA & TECHNOLOGY ARE REVOLUTIONIZING PATIENT CARE is a sponsored editorial supplement published by PennWell Corporation, 1421 S. Sheridan Road, Tulsa, OK 74112; 918-835-3161 (ISSN 0197-2510, USPS 530-710). Copyright 2015 PennWell Corporation. No material may be reproduced or uploaded on computer network services without the expressed permission of the publisher. Subscription information: To subscribe to JEMS, visit www.jems.com. Advertising information: Rates are available at www.jems.com/about/advertise or by request from JEMS Advertising Department at 4180 La Jolla Village Drive, Ste. 260, La Jolla, CA 92037-9141; 800-266-5367.

MAY2015 1 A Supplement to JEMS PHOTO COURTESY PARAMOUNT PARAMOUNT COURTESY PHOTO HOME ENTERTAINMENT

Still a vision of the12- not-so-distant and 15-lead ECG, noninvasive future , By Alan Craig temperature, invasive inputs and now carboxyhe- moglobin, all crammed into new bump-outs on hink ahead: Wouldn’t you like to open the defibrillator’s bulging housing, driving up the back doors of your just-delivered weight, footprint and battery demands. T 2019 and find it equipped But for all its simplicity, the LifePak 5 had a fea- with one of Star Trek’s wireless “medical tri- ture we predict will make a comeback: the ability corders,” allowing you to assess and diagnose to detach the monitor module from the defibril- patients simply by waving a handheld sensor? lator module. Lots of us would routinely slide We’re not there yet, but today we’re on the off the LifePak 5’s defibrillator side when head- leading edge of a complete revolution in EMS ing into a or other situations where biometric technologies. We’re about to see data the ECG module alone was safe and most useful. collected and presented to responders in new Since we only shock about 0.5% of patients, ways, data from new sources such as consumer and defibrillators are getting smaller and lighter, technologies on smartphones, and data shared splitting these two functions makes a lot of sense. wirelessly across the care continuum. Two manufacturers are showing us the way on this, and others are likely to follow. History Lesson The Bavaria-based GS Elektromed corpuls3 But first, let’s hit the rewind button and look at device—now gaining popularity in Europe, Asia some of the early monitor defibrillators such as and Australia—features a 2-lb. compact wireless the Physio-Control LifePak 5, the ZOLL 1600 and biometrics package (containing all leads, ECG and others that us “old guys” lugged around. They sensor features, and a backup screen) sits with the were pretty basic: a screen, a single-lead ECG strip patient, but can be re-docked with the defibrillator recorder and a synchable defibrillator. Over time, and large display screen when needed. Full wire- every new generation of monitor bolted on one less connectivity between the modules (and back

biometric sensor after another—SpO2, EtCO2, to hospitals and host data networks) is coming, a

MAY2015 How data & technology are revolutionizing patient care 2 feature that will revolutionize its flexibility. patients, particularly as hyperbaric oxygen treat- The Tempus Pro from English manufacturer ment remains controversial. RDT sheds the defibrillator entirely, but pro- Blood alcohol content (BAC) measurement: vides a dense package of all the regular sensors Many EMS systems are using handheld “breath- and ECG features, along with encrypted commu- alyzer” BAC measurement as part of screening nications capabilities, including live video, voice patients for diversion to detoxification centers and still transmission, as well as onboard ultra- and behavioral health facilities instead of EDs. sound and video laryngoscopy devices. Designed Point-of-care blood lab testing: Potentially to link a remote consulting physician directly to useful for lactate in suspected shock, particularly the scene of the emergency, it also has embedded sepsis, as well as other “panels” such as cardiac full-feature electronic patient care record (ePCR) enzymes. It’s also potentially useful in mobile software, allowing bedside documentation and integrated healthcare and remote primary care immediate integration of biometric trend data programs, but may be subject to substantial reg- for both the medic and the consulting physician. ulatory controls, including the need for a mobile As our understanding of resuscitation grows, health lab license in some jurisdictions, as well as a compact defibrillator makes a lot of sense. Do mandated calibration and other quality controls. you really need batteries that deliver 200 shocks Tissue perfusion monitoring: This technol- in a row? And moving shock data around on data ogy, which identifies hypooxygenation and/or ris- cards or flash drives—really? Direct wireless trans- ing CO2 in peripheral tissue in shock patients, is mission of defibrillator data to ePCRs isn’t far off. very promising. The European Society of Inten- Beyond changes in packaging, new on-scene sive Care Medicine’s November 2014 consensus diagnostic and biometric capabilities are emerg- on shock management indicates large-scale trials ing. Before we look at these, it’s worth asking of these technologies are still needed and recom- some important clinical questions: mends they should remain used in research only • What scientific evidence supports a new sen- at this time. sor’s ability to enhance patient outcomes or Ultrasound: EMS-based devices able to pro- decisively alter prehospital care in our system? vide on-scene ultrasound imaging may eventually • Does this device promote situational aware- prove useful in austere or remote environments ness or contribute to information overload, where studies such as an early focused assessment particularly for less experienced providers? with sonography for trauma exam might be use- • Does this device help us understand a ful, to assess cardiac wall motion in pulseless elec- patient’s progression over time, or simply trical activity, or to assist in placement of certain bombard us with snapshot values that pro- IV lines. While there’s some evidence medics can viders have to integrate in their heads? be trained to perform these exams, it remains • Is this the best way to spend EMS dollars? unclear whether this is a transformative technol- As in all of medicine, there are lots of things ogy for most prehospital decision-making. we could do on-scene, but only a limited number Telepresence: We can’t always bring a doctor to of things we should do. Knowing the difference is the scene, but we can bring the scene to our phy- key. Above all, new medical devices shouldn’t be sicians through telepresence audio-video links. bought for bragging rights. Although initially proposed to “let the trauma So let’s look a bit of what’s out there. doc see his patient before arrival,” in most EMS Novel noninvasive blood pressure (BP) systems, telepresence is likely to find its niche monitoring: BP derived from in cases when are considering not sensors or from pressure transducers may give us transporting a patient or referring them to other continuous BP measurement and reduce errors health resources, or when patient appearance or arising from conventional cuff-based devices. symptoms perplex on-scene providers. This is potentially very useful (think post-arrest Voice-activated interfaces: Wouldn’t it be patients), particularly if more accurate than epi- great to dictate your assessment findings at sodic manual monitoring using a classic cuff. the patient’s bedside right to your ePCR with- Carboxyhemoglobin monitoring: This tech- out touching a keypad? Consistently reliable nique is being heavily marketed in EMS and voice-activated ePCR recording or device opera- may be useful in detecting occult carbon mon- tion remains a future prospect in the noisy and oxide poisoning in the asymptomatic patient. stressful environment of EMS. However, today’s It remains unclear whether it will substan- sensor-packed and data-rich “big-box” moni- tially alter the prehospital care of symptomatic tors currently do have a downside. Fast-changing

MAY2015 3 A Supplement to JEMS technologies such as wireless data transmission can ensure CPR is started and assist in managing can mean your new monitor may be obsolete in the arrest before 9-1-1 responders can arrive? some way even before the check clears. At this When airbags deploy, many cars report the point, the complexity of FDA device recertifica- crash to highly sophisticated call centers oper- tion and the business model surrounding defi- ated by OnStar or ATX. The automatic crash brillator sales discourage vendors from offering notification (ACN) data flow sent from onboard fully modular designs allowing stepwise upgrades sensors can tell us a lot about crash dynamics that would keep devices continuously current. and severity, but few EMS systems actually use this data to decide an appropriate response, and Consumer-Supplied Data & Data Integration transmission of this data to responders is nearly Perhaps we’re on the edge of something even unheard of. Ironically, the on-scene picture could bigger—new ways to really know what’s going be even clearer. There remains great reluctance to on with a patient before the ambulance is even transmit some key data via ACN because some dispatched. EMS providers pride themselves in vehicle owners and litigation attorneys may not “starting care when the phone rings” through want 9-1-1 to receive an indisputable record of EMD pre-arrival instructions and carefully certain parameters at the moment of the crash. designed caller interview questions. But wouldn’t As technology advances, we’re seeing the lines real patient vitals, even an ECG, be helpful too? between traditional devices and traditional uses In a world of hypervigilant obsessive people, con- of the 9-1-1 system blurred through convergence sumer-level biometric monitoring is a reality of consumer data, defibrillator data, biometrics, on smartphones today and therefore instantly EMS ePCR systems and the patient’s ongoing transmissible worldwide. Let’s start to use it! master electronic medical record (EMR). Do we Consider the following case: A 58-year-old man really need a full-function laptop running stand- calls 9-1-1 and says he’s “feeling faint.” Without alone ePCR software, or should that live on the other symptoms or specific history, EMS call pri- monitor, or maybe on a smartphone? Since we see ority algorithms might classify this as low pri- many patients more than once, we should have ority, eligible for an extended response time. full access to all previous EMS and ED encoun- What if this patient could place his thumb on an ters, including 12-leads and other key data. iPhone sensor and send us a basic ECG? Internet-based data systems will increasingly That’s not the future, that’s today! A $75 free us from owning and maintaining our own iPhone clip-on allows patients to record and data hardware and software, and will be key transmit a usable Lead I ECG. It’s not a home to knitting together the patient’s full medical 12-lead, but a tracing that looks like v tach or per- story, both to better inform on-scene decisions, haps bradycardia at 30 beats per minute would and to ensure our findings and care are avail- change this call interview from guesswork to a able to everyone else who sees the patient. We’re real emergency. Once in the dispatch center, this seeing fledgling products emerge to test all of data should appear on the responding crew’s these possibilities, but, like in-hospital EMR mobile data terminal and move right into their systems, we’re a long way from seamless data. ePCR record like CAD times do today. With home Wi-Fi and contemporary con- Conclusion sumer technologies, we can now receive a wide As we put away the EMS crystal ball, a final real- range of patient biometrics, including blood ity check: We treat patients, not monitors. Lots

pressure, pulse rate, SpO2 and blood sugar. So of patient data is great, but it must be presented many of our dispatch questions are geared to in a timely and useful manner. It’s our cumu- inferring alterations in these vital signs—a guess lative clinical experience and training that lets at best—that real data would at least alert us to us interpret that data and decide what a patient possible alterations that deserve a rapid response. actually needs during EMS care. These devices When really bad things happen, getting EMS will never be a substitute for being astute clini- real-time data really counts. Wouldn’t be it incred- cians, nor for the kindness and gentle touch of ibly helpful if every AED called 9-1-1 the moment a person who cares. ✚ it was powered up, sending dispatchers and all responders the exact GPS coordinates of the car- Alan Craig is formerly deputy chief of Toronto EMS, diac arrest, and ECG segments on arrival and after where he transformed an all-ALS system to a tiered every analysis or shock? How about opening a two- model. He’s currently the vice president of clinical strat- way voice link directly to the device so that EMDs egies at American Medical Response.

MAY2015 How data & technology are revolutionizing patient care 4 “ FirstPass shines a bright light on the clinical cases that matter, including STEMI, stroke, cardiac arrest, and airway management. It enables us to recognize excellence in patient care, as well as identify in a timely fashion opportunities for improvement to our crews caring for these critical patients. ” DAVID SLATTERY, MD Medical Director, Las Vegas Fire & Rescue

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FirSol_JEMSsupp_1505 1 3/20/15 9:43 AM The York, Poquoson and Williamsburg Emergency Communications Center in Yorktown, Va., was the first in the nation to use an office application of a text-to-9-1-1 service, which was developed by Verizon Wireless and TeleCommunication Systems.

PHOTO COURTESY YORK, POQUOSON AND WILLIAMSBURG ECC

9-1-1

I texted 9-1-1 & was resuscitated increasingly mobile nation. This lead to what is currently referred to as Next Generation 9-1-1 through social media (NG9-1-1). Since the description of this need, NENA and the U.S Department of Transporta- tion have been working to make the NG9-1-1 sys- By Troy D. Hogue, BS tem a reality, developing plans for the required infrastructure and a path to transitioning the t’s been almost half a century since the cre- nation’s 9-1-1 system to the digital realm. ation of a nationwide emergency telephone The NG9-1-1 project is designed to replace leg- I number. Like other advancements in tech- acy switched telephone network technology with nology, while the beginnings were steady and IP-based technology to allow digital information deliberate, the concepts and possibilities of 9-1-1 exchange in all directions to and from the public, are now growing exponentially from year to year. the 9-1-1 network and responders. In 1987, 20 years into the development of the NG9-1-1 can be thought of in two distinct lay- concept, only about half of the nation’s popu- ers. (See Figure 1, p. 7.) First, there’s the people lation was covered. Today, we’ve reached nearly layer: This layer deals with human interactions, complete national coverage and are witnessing whether it’s via a phone call, text message, dis- an evolution in what 9-1-1 means. patcher to responding crew radio transmission, And today’s 9-1-1 discussions are no longer lim- etc. The second layer is the technology layer. This ited to the phone number itself, and also no longer layer is responsible for moving the actual data focused solely on receiving phone calls for help. required through the 9-1-1 call (or text, or video chat) all the way to wherever it’s needed: field Somebody Text 9-1-1! response, treatment at the hospital or the jail, etc. Around the turn of the century, the National These two layers must function in tandem. Emergency Number Association (NENA) began In early discussions, the ideas revolved around to look at the future of 9-1-1, with a specific functions such as 9-1-1 centers being able to focus on developing an Internet Protocol (IP)- receive text messages. The explosion of social based system that would meet the needs of an media and the integration of small, portable

MAY2015 How data & technology are revolutionizing patient care 6 electronic devices are creating new potential for request, but the patient’s smartphone gives them NG9-1-1 and beyond. Social media allows users an exact GPS location and a call-back number. to create and instantly share digital comments, Emergency responders designated for that loca- location information, photos and videos with tion are automatically dispatched. The patient anyone connected to the same network. Portable doesn’t answer the return phone call, or update electronic devices are becoming more powerful text message inquiries from the 9-1-1 calltaker. from year to year, and already allow intercon- The computer-aided dispatch system recog- nectivity capabilities far beyond what’s widely nizes the patient’s smartphone number as that used. Smartphones have raised the bar for per- of a high-risk cardiac patient in a database of sonal portable devices. Connected through social patients registered with a health information medial networks, these tools continue to break exchange network. Given the history, the initial down barriers to information flow. Connecting request and the inability to make contact, the the general public to a variety of resources via request is treated as a possible cardiac arrest. On this technology is creating new opportunities for their smartphones, neighbors in the immediate more rapid, efficient and effective response to area receive automatic notifications of the poten- emergency situations. tial cardiac arrest, along with the exact location of the patient and the closest registered AED. Two The Future Is Today of the neighbors are able to respond, and with a Imagine a reporting and response system mak- simple tap on their phone, alert the 9-1-1 center ing the following story possible: A patient with of their intended response, their location and the a known cardiac history begins to experience phone number 9-1-1 can reach them at. Instruc- chest pain while alone doing some house clean- tions on how to perform chest compressions are ing. He sits down to rest and begins to feel worse. available on the responding neighbors’ phones if Using his smartphone, he sends a text message to needed. The calltaker is able to reach one of the the 9-1-1 center, alerting them to his request for responding neighbors by phone, just as the good help. Not only does the 9-1-1 center receive the samaritan enters the home of the patient. Figure 1: NG9-1-1 community model IMAGE COURTESY UNITED STATES DEPARTMENT OF TRANSPORTATION OF DEPARTMENT UNITED STATES COURTESY IMAGE

MAY2015 7 A Supplement to JEMS rate and stream that information to a smart- phone app. Imagine the potential for using this information to help determine the appro- priate level of response to a scene, or to capture objective information on what was happening before responders arrived on scene. • The Jawbone UP3, a wrist-wearable device that uses bioimpedance to monitor heart rate and respirations, recognizes a person’s activity level and also streams data to a smartphone. • Drone-delivered AEDs have been in the news recently, with the potential to deliver PHOTO COURTESY NICE SYSTEMS COURTESY PHOTO an AED to the patient’s side in far less time Screenshot of Inform NG9-1-1 platform developed by NICE Systems. than most responding vehicles. The potential Dispatchers can view text message conversations, video surveillance for these devices to stream video and heart and simultaneous incidents all on one customizable screen. rhythm data to responders en route is well within current technology abilities. The patient is found to be conscious, but • PulsePoint, a smartphone app that can alert very lethargic. The calltaker is able to offer care nearby users of the location of a potential car- instructions over the phone while the emergency diac arrest patient and the nearest AED. This responders are on the way to the scene. All of this product and others like it are already in use information has been made available in real-time in communities around the country, and are to the responding units via their vehicle’s mobile mobilizing both bystanders as well as off- data terminals. As responders arrive and enter duty responders with great results. the home, their patient care reporting tablet • AED cabinets with automatic notification already contains information on the patient, his to 9-1-1 centers when opened are beginning medications and history and recent ECGs. to be a helpful tool nationwide. Nothing in this story is outside of current tech- • In Case of Emergency apps are gaining mar- nology. Many of the components described are in ket penetration, with some systems describing place in various communities around the coun- plans to securely link emergency responders try. There are however, logistical, financial and to health information exchange networks. operational limitations that have prevented this • Augmented reality apps, like Yelp Mon- scenario from becoming routine. Technology is ocle, add Web-based information overlaid advancing at a rate far greater than the current on a smartphone’s live camera view when infrastructure has been able to implement. pointed at buildings. Although the current The integration of current and future tech- focus is on sales and marketing opportu- nologies, and the funding required to match nities, the technology’s potential for scene capability with reality, have become major benefits, such as preplanning information, focus points for systems around the coun- may soon offer helpful information to dis- try looking to fully implement NG9-1-1. patch centers and emergency responders. Several stakeholder agencies continue to work With these and other technology advance- toward standards development, funding models ments growing at a rate most current 9-1-1 and implementation plans. systems aren’t designed to keep up with, the The majority of states have begun some form of efforts to get the NG9-1-1 infrastructure widely implementation of NG9-1-1, with a small num- implemented will be key to utilizing the many ber already having state-level systems in place. tools available to emergency responders. Status updates are made available on the www.911.gov Tomorrow’s Potential and www.NENA.org websites. The future is Technology, in the form of social media capabil- bright, and the possibilities are endless. ✚ ities, software development and new portable— even wearable—hardware devices, seems to be Troy D. Hogue, BS, currently serves as regional man- showing no boundaries. Examples of products ager for Rural/Metro Medical Services of Central N.Y. He recently in the news include: has over 30 years of EMS experience in urban, suburban • The Ralph Lauren Polo Tech Shirt is and rural settings involving a combination of field, edu- designed to monitor heart rate and respiratory cational and administrative duties.

MAY2015 How data & technology are revolutionizing patient care 8

Successful health information technology implementation in patient-centric EMS

By Brenda Staffan

he need for EMS providers to implement more advanced health information technology (HIT) sys- T tems is accelerating at a rapid pace. Through numer- ous federal healthcare reform initiatives, EMS providers are beginning to participate in various programs, such as the Beacon Project, the Health Care Innovation Awards and other Centers for Medicare & Medicaid Services (CMS) Innovation Center initiatives. Certainly, HIT systems are an essential structural compo- nent to any organization implementing a mobile integrated Mobile Integrated Healthcare programs like healthcare (MIH) program. With so many new developments, REMSA’s community health paramedics will only emerging technologies and the need for advanced informa- be successful if they can demonstrate value to tion systems, EMS managers responsible for managing these patients and payers. complex projects—especially those without previous IT exper- tise—often find a daunting task ahead of them. This article PHOTO COURTESY REMSA

MAY2015 9 A Supplement to JEMS shares some lessons learned from the perspec- the information component of the HIT sys- tive of a non-IT manager leading a project with tem simultaneously with the technology com- significant HIT components. ponent. This strategy assures the specifications of the technology procurement include access HIT Objectives to the data necessary to manage and sustain In “A Framework for Selecting Digital Health the program. Data will need to be collected and Technologies,” the Institute of Healthcare analyzed for several purposes: Improvement (IHI) states the purpose of HIT • Establish and track implementation mile- is to “provide the greatest value to health sys- stones in the HIT launch plan; tems working to achieve the Triple Aim.” 1 Effec- • Monitor operational performance via inter- tive MIH programs seek to achieve this Triple nal dashboards; Aim: improve the quality and experience of care • Perform clinical quality improvement; for patients, improve the health of populations, • Comply with HIPAA and other legal and reduce per capita costs. With this as a guid- requirements; ing principle, what’s the organization trying to • Provide performance reports to new custom- accomplish with investments in HIT systems? Is ers; and it trying to improve the experience and quality • Measure outcomes for research and of care for patients? Improve the coordination sustainability. of care in the local health care system? Assure As MIH programs are emerging and maturing, the MIH program achieves certain milestones new technologies must facilitate access to the for new MIH customers? Reduce unnecessary right data at the right time. In addition to estab- utilization? By placing the patient at the cen- lishing internal operational dashboards and pro- ter of the HIT investment, EMS providers can cess measures, MIH programs must be prepared begin the process of integrating with the rest of to measure and report on the outcomes achieved, the healthcare delivery system. including: quality of care, patient safety, patient satisfaction, service utilization, cost of care, and Measurable Outcomes impact on other health care components. The MIH programs will only be successful if they MIH program manager must learn how to track can demonstrate value to patients and pay- and trend the right data to measure progress ers. There’s a strategic advantage in designing toward achieving the Triple Aim.

Table 1: Examples of individual HIT systems and their corresponding purpose System Purpose Element Electronic medical record Electronic medical record for community health Clinical decision support tool paramedics Integrated nurse navigator system Integrated system for call prioritization, nurse triage Clinical decision support tool and caller navigation Ambulance transport alternatives Field documentation of transport to alternative Clinical decision support tool documentation destinations Data monitoring and reporting Collect and aggregate data from various internal Data management tool system sources for analysis and reporting Health information exchange Electronic exchange of patient care records among Care coordination tool health care providers

Table 2: Sample functionality model for a community electronic medical record Example: Community Paramedic Electronic Medical Record Source data Community paramedic uses system to document patient demographics, condition and treatments. Data mapping/analytics System creates patient, referring provider, insurer databases. Specifications Users are community paramedics, utilizing a mobile software application with fields to document protocol-driven care delivered in the field. End user response Medic sends electronic medical record to the health information exchange for other medical providers to access to enhance care coordination. Intended effects Avoid hospital readmissions, reduce unnecessary utilization of ED care.

MAY2015 How data & technology are revolutionizing patient care 10 HIT Characteristics Below are some initial steps to get started: The HIT system is a critical structural compo- • Obtain sponsorship at senior executive level; nent of MIH programs and must effectively per- • Assess technical expertise needed to support form several key functions. Table 1 gives several HIT systems and to assure integration and examples of individual HIT systems and their compatibility of HIT systems with current corresponding purpose. and future IT systems; Each individual technology will have unique • Obtain management support for HIT ven- functional attributes as both a stand-alone sys- dor selection and contracting, system tem and in concert with other components of implementation, technology installation the overall HIT infrastructure. In other words, and monitoring; and how does the HIT system function and what • Develop training plans to insure IT sup- does the system allow its users to do? Table 2 port can effectively meet current and future shows a sample functionality model for a com- HIT demands. munity paramedic electronic medical record. Professional IT expertise—either outsourced

There’s a strategic advantage in designing the information component of the health information technology system simultaneously with the technology component. Getting Started or in-house—is critically important. The MIH In order to avoid wasting resources on systems program manager’s role is to clearly articulate that don’t achieve the desired aim, it’s useful to the aim (what’s to be accomplished), secure invest time up front in developing a strategic adequate financial support and establish a sys- plan for what the HIT system is trying to accom- tem of project monitoring to assure the invest- plish. This can be accomplished with a driver ment in HIT accomplishes its desired objectives. diagram that describes the overall program aim, Below are a few websites that may be helpful: outcome measures, primary drivers (system com- • Institute of Healthcare Improvement: ponents) and secondary drivers (interventions). www.ihi.org/resources The HIT system itself should be one of the • Health IT for Providers: primary drivers, as the system is a key structural www.healthit.gov/providers-professionals component critical in achieving the overall objec- • Health IT Toolboxes and Webinars: tives of the MIH program. As an example, below www.hrsa.gov/healthit ✚ are the primary and secondary drivers of REM- SA’s health information technology system: Brenda Staffan is the director of Community Health • Enable exchange of data/communications: Programs for REMSA in Reno, Nev. The project described New health information technologies link was supported by Grant Number 1C1CMS330971 from emergency ambulance delivery system and the U.S. Department of Health and Human Services, the broader healthcare delivery system. Centers for Medicare & Medicaid Services. The contents –Design integrated health information of this article are solely the responsibility of the authors technologies and uniform electronic pa- and do not necessarily represent the official views of tient care reporting system across multi- the U.S. Department of Health and Human Services or ple healthcare providers and facilities. any of its agencies. –Ex change patient care data across target- ed patient care delivery settings and net- References works (including 9-1-1 system, hospital 1. Ostrovsky A, Deen N, Simon A, et al. (June 2014.) A framework for selecting digital health technology: IHI innovation report. ED, urgent care centers, physician offices Institute for Healthcare Improvement. Retrieved Feb. 5, and medical home). 2015, from http://www.ihi.org/resources/Pages/Publications/ It’s important to assess whether the organiza- AFrameworkforSelectingDigitalHealthTechnology.aspx 2. Berwick DM, Nolan TW, Whittington J. The triple aim: Care, tion’s current IT staff has the adequate capacity health, and cost. Health Aff (Millwood). 2008;27(3):759–769. for project management, procurement, con- tracting, installation, administration, mainte- nance and troubleshooting of these systems.

MAY2015 11 A Supplement to JEMS Health Information Exchanges allows a patient’s electronic healthcare record to follow the patient from their first contact with the healthcare system through to their current episode of care.

PHOTOS COURTESY ZOLL MEDICAL CORPORATION

Modern approaches to health By Matt Zavadsky, MS-HSA, EMT

information exchange magine this current-state scenario from the EMS perspective: Medic 26 responds I to a patient who has been shot six blocks from the local Level 1 Trauma Center. On arrival, the crew finds an adult male, shot once in the chest and once in the groin, respiration rate 32 with a sucking chest wound, Glasgow Coma Score of 4, negative radial pulses and positive carotid pulses. They do a short head’s up radio report from the scene to the ED, knowing this will be a quick scene time and transport. Police on scene has the victim’s driver’s license in hand and begins to rattle off the patient’s name, date of birth (DOB), address, etc. The crew, knowing this is a time-critical incident, asks police if they can bring the driver’s license with them, but for very appropriate reasons they decline. With a seven- minute scene time, the crew transports the patient to the trauma center, the patient is brought to the trauma room and care is transitioned to the trauma team. After clean-up, the crew leaves the hospital wondering how the patient will do, and wishing they didn’t have to enter everything into their PCR as a “John Doe214,” knowing the business office staff will have the task of finding all the patient information—if only the police had allowed us to take the patient’s driver’s license. Three weeks later, the crew recalls the patient interaction and sighs with frustration that they still do not know what happened with the patient.

MAY2015 How data & technology are revolutionizing patient care 12 Hospital Perspective for one episode of care, or as high level as the Now if you would, reconsider the same total number of pediatric asthma patients seen current-state scenario from the hospital per- for acute symptoms in the past 12 months. The spective: The ED is notified of the trauma alert concept of “big data” in the healthcare system with an estimated time of arrival of 10 minutes. is drawing EMS into the significant discussion The trauma team is alerted to report to the ED about effectively sharing data with hospitals, and an OR suite is prepped. other healthcare providers and payers. The hospital team receives the patient in the ED trauma room and begins assessments, labs Desired-State Scenario and radiology. Everyone asks the crew for the Let’s imagine a desired-state for the scenario we patient’s name, so they can do a quick registra- described above. tion and test results can be properly assigned. A device attached to the EMS electronic patient Unfortunately, all the crew knows is he’s “Tom” care record (ePCR) system scans the patient’s and he’s about 25, but explains that police have driver’s license QR or bar code and auto-popu- the patient’s ID and will be along “shortly.” lates the crew’s ePCR. The police officer can keep The patient is put into the hospital’s elec- the license. If the EMS agency has encountered tronic health record (EHR) as “John Doe2761” the patient in the past, information regarding without the benefit of any cross reference to see the date of encounter, chief complaint, clinical if he has been a patient at the hospital before. impression, vital signs and hospital destination They find numerous internal injuries and also populates into the ePCR. This assists with whisk him off to the OR. After 12 hours of care coordination and potentially determining surgery, the patient stabilizes and the trauma the most appropriate hospital destination. surgeon comments to his team that the quick Then, once the destination hospital is selected, actions of the EMS team saved this guy’s life— that information is automatically e-transmit- how do they recognize them and let them know ted to the destination hospital and auto-popu- what the injuries were and who this patient is? lates the hospital’s quick registration program, The police haven’t arrived with the ID. even before the EMS crew arrives at the hospi- Three days later, the trauma registry coordina- tal. With the name, DOB and address verified, tor is slugging through mounds of faxed paper the past medical records feed into the new medi- reports gleaning off the information from the cal record for the patient, ready for the ED team PCRs that they are required to manually enter to access. In this scenario, they can even access into the state’s trauma registry. All the while, it prior to the patient’s arrival, note the patient wondering, “There has to be a better way.” has A-positive blood type, is allergic to penicil- lin and the last time the patient was there three Give & Take months ago, they were treated for hypoglycemia. This scenario plays out multiple times a day This information is crucial to effective care man- across the country. The concept of sharing health- agement transition. care information has been the elusive holy grail of our healthcare system since the days of Mar- Feedback & Quality Improvement cus Welby. On the transactional side of our indus- Because the EMS ePCR and the hospital’s try, EMS providers lament about the general lack records are integrated, the EMS crew can be of feedback on patients brought to the hospitals. easily identified and cross-referenced with the Hospitals lament about the lack of quick registra- EMS agency’s contact list to facilitate a secure tion and accurate patient IDs to help speed treat- transfer of information regarding the patient’s ments and look up past patient records. status. The EMS agency’s quality improvement On the transformational side, the one that officer is also copied on the notifications for is more and more desirous of achieving the evaluation and follow-up. Triple Aim as articulated by the Institute for Healthcare Improvement (IHI)—improved Registry Data & System Improvement patient experience of care, improved heath of With a true information exchange, instead of populations and reduced costs—payers and manually entering the required fields for reg- accountable care organizations want access to istry information at the hospital, the pertinent information across the continuum of care. This fields from the EMS ePCR can be identified, information can be as granular as an individual reviewed for accuracy and simply uploaded to patient’s course through the healthcare system the registry. This data set can also be used to

MAY2015 13 A Supplement to JEMS To properly integrate with a health information exchange, EMS needs to move from an incident-based record keeping system to a patient-based electronic medical record system.

identify run chart trends on EMS system and interface where the EMS professional can hospital performance that should be enhanced login and search for a specific patient by or corrected. Trauma scene times, clinical bun- name, social security number, DOB, etc. dles for STEMI, stroke, asthma, hypoglycemia 2. The ability for the EMS EHR to follow and other clinical metrics can be measured over the patient through their current epi- time to identify opportunities for system clini- sode of care, in its entirety. This is the elec- cal improvements. tronic transmission of the EMS EHR using Does this all sound too good to be true? Well, health level 7 (HL7) international stan- maybe not so much. Some systems are moving dard, or some other IHE standard, into the down this path already, with enhancements to receiving healthcare facilities EHR system come in the near future. using HL7, or some other standards based Several manufacturers have developed hard- approach. This needs to be discrete and spe- ware and software that facilitate the scanning cific data elements must be able to be popu- of driver’s license info into the ePCR. Several lated directly into an EHR in the healthcare states have passed laws that allow EMS agencies system. It’s much more than simply a faxed to access this information as well. The Interme- report that gets attached to the EHR, which dix EMTrack system is one example of using a is of little value to the nurse or physician at barcode scanner during disaster management. the patient’s side in the hospital. The ZOLL ePCR solution has the capability to 3. The ability to query for an EMS patient and capture, interpret a driver’s license and popu- download discrete data about the patient and late a PCR using an iOS device camera. the care they were provided. This includes billing and outcome data for operations and Integrating with Health clinical performance enhancement. Information Exchanges Hospitals, physicians and payers have predomi- In the general sense, a Healthcare Informa- nately utilized HIEs to help improve patient out- tion Exchange (HIE) facilitates with sharing comes and reduce cost. Over the past few years, of health information between healthcare pro- these entities have recognized the value of includ- viders. In its simplest of terms, for an HIE to be ing more providers, such as EMS, into their HIEs. effective for EMS and the patients we encounter, In 2010, at the American Medical Informatics it must be able to provide three key elements: Association (AMIA) annual symposium, John T. 1. The ability to search and find the medi- Finnell, MD, MSc, and J. Marc Overhage, MD, cal record, across the local healthcare sys- PhD, presented a research project in Indiana link- tem, of a patient at the time of their EMS ing EMS with the Indiana Network for Patient care. This is typically a secure, Web-based Care (INPC).1 They were the first regional HIE in

MAY2015 How data & technology are revolutionizing patient care 14 the country to connect preexisting health infor- (MCHD) EMS and HCA.4 With this pro- mation to EMS providers. The system currently gram, hospitals will be able to view criti- includes data from 30 hospitals in five health cal prehospital patient information directly systems, the Marion County Health Department from within their electronic medical record and various physician practices. These hospitals (EMR) system. They also have access to the account for over 95% of all beds and ED visits raw EMS data they need to report to regis- in Indianapolis, which has a population of 1.6 tries, trend patient populations and develop million. metrics. MCHD, in turn, will have views into The primary goal of the integration was to the data they need to institute comprehensive allow Marion and Hamilton County EMS pro- quality management programs based on clin- viders to exchange data with the INPC, not only ical outcomes. to share their information with the hospitals, • The Cloverleaf Integration and Information but also to have real-time access to patients’ Exchange Suite, developed by Infor, has been past medical history while in the field. in use by several health systems and essen- Their research illustrated the quantitative and tially serves like a Rosetta Stone, connecting perceived benefits of access to medical records different data exchanges, and has recently in the prehospital setting. The medical informa- been courting EMS agencies to become part tion provided in the INPC EMS abstract allows of the healthcare information integration.5 prehospital personnel to collect a more detailed Infor also released their EMS Integrated medical history and allows for more informed Healthcare Suite in February 2013.6 This sys- treatment decisions. tem helps transmit and receive patient infor- mation, allowing hospitals and providers to Integration Trend Setters exchange historical patient data in real-time Here are some other examples of the systems to present a full picture of a patient’s health- available for integrating EMS systems into HIE’s care record. MedStar Mobile Healthcare in across the country: Fort Worth, Texas, is currently working with • ZOLL Medical Corporation implemented an Infor to implement the Cloverleaf and EMS exchange of clinical and administrative data Integrated Healthcare Suite to exchange for Poudre Valley Hospital EMS and the hos- ePCR data, as well as the health informa- pital’s electronic medical record systems using tion utilized in MedStar’s mobile integrated HL7.2 ZOLL’s new HL7 for EMS solution healthcare programs. operates as a component of RescueNet ePCR. While these efforts are a great start, they don’t Poudre Valley EMS was the first service to yet address all three of the key elements artic- facilitate this automated data exchange when ulated earlier for effective HIE integration with it transmitted patient health record data from EMS. The major need that has yet to be effec- Poudre Valley’s ZOLL ePCR to a University of tively addressed is this ability for EMS to see the Colorado Health’s electronic medical records discrete patient level clinical details in order to system (EPIC) in March 2014. The Emergency more effectively manage the patient’s medical Medical Services Authority (EMSA) in Tulsa condition during the EMS encounter. and Oklahoma City, Okla., began submitting It’s vitally important that the entire EMS HL7 PCR files from the ZOLL ePCR system to community continue to express—or better yet, the MyHealth Access HIE and the SMRTNET push—our ePCR vendors toward developing the HIE in Oklahoma. Field crews have the abil- two key things we need to enhance our ability to ity to log in to the HIE from the field and per- manage our patients in the field: form lookups of patients in both HIEs. 1. The ability to access patient medical infor- • ImageTrend has rolled out their EMS Ser- mation—real time—in the field, to include vice Bridge that integrates EMS ePCRs into notes from hospitalizations, physician and systems such as the integration between New clinic visits, and even rehab notes. Orleans EMS and the Greater New Orleans 2. To move our ePCR from an incident-based Health Information Exchange (GNOHIE),3 record keeping system, to a patient-based implementing integration platforms for EMS EMR system. to be able to tap into HIEs. This will not only facilitate better patient man- • ESO Solutions has developed a Healthcare agement on an episodic call, but also support Data Exchange (HDE) that’s currently in use mobile integrated healthcare programs that are by Montgomery County Hospital District expanding across the country.

MAY2015 15 A Supplement to JEMS Emergence of Carequality the advent of ALS care and paramedics. We’re In February 2014, Carequality (“care-e-quality”) finally being understood as healthcare provid- was announced. Carequaility is a new initia- ers and being called upon to become part of the tive dedicated to accelerating progress in health solution to meeting the IHI’s Triple Aim. On the data exchange among multi-platform networks, micro level, the ability to access real-time clini- healthcare providers and EHR and HIE vendors. cal information on the patient we treat in the Carequality’s goal is to facilitate agreement on a field, and to quickly transfer information about common national-level set of requirements that our encounter with the patient to the rest of the will enable providers to access patient data from healthcare partners across the patient’s contin- other groups as easily and securely as today’s uum of care, is essential to furthering this trans- bank customers connect to disparate banks and formation. On the system level, providing and user accounts on the ATM network. accessing information about the needs of the A rapidly growing community of healthcare communities we serve, and our healthcare sys- providers, payers, consumer groups, IT com- tem partners will allow us to effectively demon- panies and software vendors are signing up to strate the value we bring to those who pay for, join this effort and shape the future of interop- and benefit from, the services we provide. erability in the U.S. Twenty-six organizations EMS providers need to become actively had pledged a commitment to join Carequal- involved in the development and implementa- ity as founders as of the announcement date, tion of systems to integrate and exchange health including Epic, Kaiser, Intermountain Health- information across the healthcare system—start care, CVS Pharmacy and Walgreens, as well as today! If you don’t know if your healthcare sys- several HIEs. ZOLL Medical deserves special tem has an HIE, find out. If they have one, begin recognition for currently being the only EMS the discussions on why it’s important for EMS software data company to be part of this initia- to be a part of that system and how you can plug tive. Carequality appears to be the best example in to your local HIE. Our patients deserve it. ✚ of a true HIE that meets all three of the key ele- ments of an effective HIE for EMS. Matt Zavadsky, MS-HSA, EMT, is the director of public affairs at MedStar Mobile Healthcare, the exclu- Federal Assistance sive emergency and non-emergency ambulance pro- In February 2014, the Division of Health Sys- vider for Fort Worth and 14 surrounding cities in tem Policy and the Emergency Care Coordi- North Texas. He holds a master’s degree in Health Ser- nation Center (ECCC) and Assistant Secretary vice Administration and has 30 years of experience for Preparedness and Response hosted a day- in EMS, including volunteer, fire department, pub- long workshop themed Health Information lic and private sector EMS agencies. Contact him at Exchanges and the Prehospital Environment. [email protected]. This workshop brought key EMS leaders and several representatives from HHS’ Office of References the National Coordinator for Health Informa- 1. Finnell JT, Overhage JM. Emergency medical services: The fron- tier in Health Information Exchange. AMIA Annu Symp Proc. tion Technology (ONC) to discuss how EMS 2010; 2010: 222–226. can more effectively integrate health infor- 2. ZOLL Medical Corporation. (March 11, 2014.) ZOLL Imple- mation with the rest of the healthcare part- ments HL7 for data exchange between healthcare providers. Retrieved Feb. 4, 2015, from www.zoll.com/news-releases/ ners. One of the products of that workshop 2014/03/11hl7-data-exchange-healthcare-providers. was the launch of ASPR Collaboration Com- 3. Louisiana Public Health Institute. (n.d.) The strength of a com- munity on IdeaScale, which can be viewed at munity partnership. Greater New Orleans Health Information http://phegov.ideascale.com/a/index. Exchange. Retrieved Feb. 4, 2015, from http://gnohie.org/ This platform is designed to facilitate the partners. 4. PRWeb. (July 25, 2012.) ESO Solutions announces launch exchange of ideas for health IT (HIT) between of groundbreaking healthcare communication plat- users, providers and vendors in an effort to form. Retrieved Feb. 4, 2015, from www.prweb.com/ develop products and programs that will be releases/2012/7/prweb9726242.html. essential in furthering the connections between 5. Infor. (n.d.) Infor Cloverleaf Integration and Information Exchange Suite. Retrieved Feb. 4, 2015, from www.infor.com/solutions/ EMS and healthcare systems. cloverleaf. 6. Marketwired. (Sept. 5, 2013.) Infor unveils innovative solution for The Horizon emergency medical services. So-Co-IT. Retrieved Feb. 4, 2015, The EMS profession is undergoing one of from www.so-co-it.com/post/293878/infor-unveils-innovative- solution-for-emergency-medical-services.html. the most significant transformations since

MAY2015 How data & technology are revolutionizing patient care 16

The vision that unites devices, technology & care

By Greg Mears, MD

What if your cardiac monitor and ePCR were “following” the patient with you?

PHOTO COURTESY ZOLL MEDICAL CORPORATION

e’ve been fighting a long time. We’re been a leader in each of these areas and the vision outnumbered by machines. We can’t of the EMS Agenda for the Future seems even W escape the software, devices or tech- more applicable today as we extend into mobile nology. They all arrived with a mission to improve integrated Health and patient directed care. operations and patient care. But something is The EMS Agenda for the Future states: “Emer- missing. It seems much harder than it should be. gency medical services (EMS) of the future will be com- I know this sounds like something more munity-based health management that is fully integrated out of Terminator than Star Trek. Machines with the overall health care system. It will have the ability becoming aware: Was that Skynet, FirstNet, or to identify and modify illness and injury risks, provide the Internet? acute illness and injury care and follow-up, and contrib- The reality is that there’s something missing in ute to treatment of chronic conditions and community EMS when we try to implement software, tech- health monitoring. This new entity will be developed nology and data. I would suggest to you, what from redistribution of existing health care resources and we’re missing is an awareness of things impor- will be integrated with other health care providers and tant or critical to patient care that our data sys- public health and public safety agencies. It will improve tems and machines could be alerting us to as community health and result in more appropriate use of we’re providing care to a patient. acute health care resources. EMS will remain the pub- We’ve hit significant technical milestones over lic’s emergency medical safety net.” 2 the past ten years both from a device and soft- We have complex medical devices that moni- ware perspective. We’ve united around standards tor and resuscitate the critically ill and injured we such as National EMS Information System, the encounter in the field. We document the services Internet, and XML data exchange. Yet we con- and care we provide using software that gives us sider devices and software external to our EMS unlimited analytic capability on the backend. We service delivery and clinical care. combine our data with data from other health- The goal of the Institute for Healthcare care providers and outcome sources. In the end we Improvement’s Triple Aim is to improve the define, measure, analyze and improve following patient care experience (quality and satisfaction); key performance improvement processes. and improve the health of our community while Is this all there is to the EMS universe? I think not. reducing healthcare costs.1 EMS has historically So what’s next?

MAY2015 17 A Supplement to JEMS Clinical Decision Support with the provider to assure completion of specific The future of healthcare rests with clinical deci- bundles of care (i.e., , 12-lead ECG, etc.). sion support (CDS). CDS combines the tools we CDS isn’t intended to replace clinical judg- use in EMS (e.g., devices, software, protocols) to ment but through integration with clinical create a new “member” of the healthcare team. guidelines and other diagnostic databases con- CDS systems, by definition, provide knowl- nected through a variety of platforms, it can edge and guidance to the healthcare provider to assist care teams in making timely, informed and enhance the care of the patient. The knowledge higher quality decisions. provided is specific to the patient and appropri- CDS systems will evolve to provide real-time ate and organized for the time and presentation diagnostic support. Then, CDS systems will be of the medical condition. able to provide valuable information to care Imagine if key details from our treatment pro- teams as patients present with a cluster of symp- tocols were configured toms, assessment findings, and diagnostic results. Table 1: Clinical decision into our ePCR system. For The Centers for Medicare and Medicaid Ser- support opportunities instance, a chest pain pro- vices (CMS) has included a requirement for CDS Computerized alerts tocol would “expect” two in Stage 2 of Meaningful Use Requirements for Reminders sets of vital signs, docu- hospitals and physicians in the implementation Clinical guidelines (evidence-based) mentationof a past medi- of EHRs. CDS requirements are to be extended in cal history and medication Stage 3 Meaningful Use requirements. Specific order sets list, a 12-lead ECG, aspirin CMS has identified five key requirements for Focused patient data reports & summaries administration, and patient CDS systems to be of maximal benefit in health- Documentation templates transport to the closest care. CDS systems must provide: appropriate destination. 1. The right information (evidence-based guid- What if your cardiac monitor and ePCR were ance, response to clinical need); “following” the patient with you? As the patient 2. To the right people (the entire care team, is processed and evaluated, the monitor/defibril- including the patient); lator would communicate with the ePCR. Device 3. Through the right channels (e.g., EHR, data would be accepted by the ePCR software to mobile device, patient portal); document the patient care event, and the ePCR 4. In the right intervention formats (e.g., order data would be accepted by the device to provide sets, flow-sheets, dashboards, patient lists); and assistance in the care of the patient. 5. At the right points in workflow (for decision CDS systems can provide several types of feed- making or action). back to assist the healthcare provider. Com- Ultimately, CDS systems, when implemented puterized alerts currently exist in most medical appropriately, can improve quality of care, devices. These can be as simple as a minimum or improve outcomes, decrease errors and adverse maximum alarm based on a vital sign parameter. events, improve efficiency for both the provider But they can also be much more. It could be an and the patient, while controlling cost. alert that the patient has been seen recently by We’ve been fighting a long time. We’re outnum- EMS or another healthcare provider. bered by machines. We can’t escape the software, Another alert might be that the patient is aller- devices, or technology. They all arrived with a mis- gic to a specific medication that’s a component of sion to improve operations and patient care. It’s the clinical guideline directing that patient’s care. time the machines become “aware.” ✚ The idea is the alert combines information known at the time of the patient’s care with meaningful Greg Mears, MD, is medical director of ZOLL Medi- information derived from other healthcare elec- cal Corporation and former EMS director for the state tronic healthcare records (EHRs) or data sources. of North Carolina. He specializes in data, EMS perfor- In CDS, “reminders” are similar to alerts mance improvement and systems of care for ZOLL. He except they provide information that may have can be reached at [email protected]. otherwise gone unrecognized. For example, a reminder might be provided to repeat the vital References signs because greater than the protocol’s defined 1. Institute for Healthcare Improvement. (2015.) The triple aim. Retrieved March 24, 2015, from www.ihi.org/Engage/ interval of every 15 minutes has elapsed. Initiatives/TripleAim/pages/default.aspx. Clinical guidelines can be implemented with 2. EMS Agenda for the Future. (1996.) National Registry of Emer- the assistance of CDS systems. And templates gency Medical Technicians. Retrieved March 24, 2015, from and order sets can be implemented to interact www.nremt.org/nremt/about/emsAgendaFuture.asp.

MAY2015 How data & technology are revolutionizing patient care 18 Providers should understand how data collection improves patient care.

PHOTO SCOTT OGLESBEE

How can EMS agencies & educators best prepare the workforce for our future?

By Brian LaCroix It was met with my partner’s typical response, “Sort of—the general direction—but give me he high-pitched tones and the dispatch- details when we get close.” er’s scratchy voice broke the silence in The two of us navigated together, with me T our sleep room. My partner and I wres- barking out turn-by-turn instructions for tled to our feet and in one motion we slipped my partner. on our shoes, grabbed the large and heavy VHF It was nighttime and we were pleased to have radios perched in their chargers and headed recently acquired new spotlights that plugged out to the truck. As my partner pulled out of into the cigarette lighter. Those old school vehi- the garage, I shuffled through the wooden box cle-mounted swivel spotlights usually broke between our seats and found the county map after a short time. You had to be sure and among the pile of paper maps in the folder. remember to turn off the switch, or run the risk I asked my typical initial question, “Do you of starting a fire in your ambulance. know where this is?” At the patient’s side, the tools were simple but

MAY2015 19 A Supplement to JEMS practical: A manual blood pressure cuff, oxy- For years public safety dispatchers have lived gen and a two-lead cardiac monitor where you in an analog world, contributing greatly to the had to be sure to grab both side of the handles, care of the sick and injured over the telephone, otherwise the defibrillator side of the machine offering a calm voice in the midst of chaos, would embarrassingly fall to the floor when you helping callers stop the , deliver a baby picked it up. or perform CPR. This was in the mid-‘80s and I was working Now we have Next Generation 9-1-1. What 24-hour shifts at a hospital-based ambulance happens in the brave new digital world when a operation in the upper Midwest. By today’s dispatcher receives a text message with a photo standards, the technology we used in dispatch, of the caller’s dying grandmother? Or stream- our vehicles, and in the field a generation ago ing video of the shooter standing over the mur- was rudimentary. In general, EMS crews weren’t der victim? trained in the use of technology to guide patient As the old technological platform sunsets, care from a quality standpoint. we’re on the threshold of having to manage a However, we still did our best to deliver great never before encountered set of EMS issues not service, and the one thing technology will never in the field, but in the communications center. replace is a compassionate crew. In fact, technol- ogy can sometimes be a barrier to a great patient Operations & Patient Care experience. But there’s no denying we’ve come So much new technology—GlideScope, Auto- a long way in a relatively short period of time. Pulse and LUCAS, Google Glass, telemedicine, Here we will discuss the type of education, ori- SimMan, impedance threshold devices, ultra- entation and attitude that helps us best leverage sound—what’s a prehospital clinician to do? that technology for the benefit of the patients The clinical interventions we provide in the we serve. field should be analyzed to support our clini- cal practices. Gone are the days when we should Explosion of New Technologies tolerate doing things we do just because we’ve Consider this: In 1803, when Thomas Jefferson always done them that way. Today’s practitio- sent Lewis and Clark to explore the uncharted ners should be taught and expected to challenge West, nothing moved faster than a horse could protocols and practices that aren’t supported by take it. Not a person, not a product, not an idea. evidence-based analysis. Enter the steam engine, the automobile, jet air- craft, and eventually the Internet. Vehicles In his book The World Is Flat Thomas Fried- The need to collect and analyze data on vehicle man describes the pace of technology changes operations has been recognized for years. Until as happening at a rate never experienced before. recently, that need has been frustrated by lim- The growth of technology from a historical itations on the amount of information readily standpoint has seen more advances in the past available and the ability to communicate the 30–40 years than in all of recorded history. information in a timely manner. When you stop to think about that, it’s pretty Three recent advances in technology have mind-boggling. relieved these frustrations: It wasn’t very long ago when only nations 1. Vehicle manufacturers are constantly and large corporations had the opportunity to increasing the amount of information be relevant on a global scale. Now any teenager monitored and stored in the vehicle’s elec- with a computer and an Internet connection lit- tronic control module and improving the erally has worldwide reach. access to that information via on-board In order to be successful in this new environ- diagnostic ports. ment, the required skill set of students, workers 2. The U.S. government has increased the and leaders is quite different than in the past. scope and reliability of GPS and has made it readily available to commercial users. Dispatch 3. Cellular communication has expanded its First developed in the 1930s, the FM radio capabilities and reduced its cost to the point “handie-talkie” or “walkie-talkie” was widely it is an efficient method of communicating used in World War I. Original models weighed large amounts of information quickly. approximately 35 lbs. and had a range of These three technological advances are being 10–20 miles. combined to accumulate and communicate

MAY2015 How data & technology are revolutionizing patient care 20 vehicle operating data and location informa- cornering, engine idle and seatbelt use can tion. This combination of technology is often be programmed into the system. referred to as “telematics” or “infomatics.” The b. Vehicle operation outside your set param- numerous vendors providing telematics distin- eters can be tied to an individual driver guish themselves by their ability to present the and communicated to leadership. information in a form and format that’s useful c. In-cab audible tones can alert a driver to the vehicle operator and management. that they’re approaching unsafe operating Accepting the fact that the technology exists parameters and a second set of tones can and works, and that the return on investment is be activated when parameters are exceeded. often expressed in months vs. years, the pertinent d. Driver score sheets can be generated

EMS organizations have a responsibility to be clear to their staff why data collection is relevant. question is “what can it do for the EMS agency?” that assign a numeric score to the driv- The answer to that question is varied but can be er’s performance. Those score sheets can summarized under a few broad categories: become part of a driver coaching or award 1. Vehicle Operations program. a. Vehicle location can be displayed on a cur- All the data collected is only beneficial if it’s rent basis, a historical basis (breadcrumb delivered effortlessly to the end user. Most of trail) or tied to a preset map position the systems available commercially will deliver (geofence). information electronically on a scheduled, b. Vehicle speed can be compared to posted exception or ad hoc basis. Telematics systems speed limits or a finite speed and then be can enable leadership to create a safer, more reported for emergent and non-emergent efficient operation via the use of data currently operations. available without the users spending time in c. Engine idle time can be tracked and data collection or manipulation. The produc- monitored. tivity and efficiency of both the vehicle and d. Vehicle operations immediately prior to a human asset can be advanced by the proper use crash can be captured and retained. Both of a telematics system. law enforcement and insurance investiga- EMT and paramedic vehicle operators, tors are very appreciative of the informa- mechanics and managers alike need the skills tion you can provide. to monitor, collect and analyze this informa- e. Fuel economy and be tracked and moni- tion so it can be used to improve service, keep tored. employees safe and better manage budgets. 2. Vehicle Maintenance a. Engine “codes” can be communicated to Learning your maintenance vendor on a live basis According to the University of Minnesota’s and analyzed before the unit has to be Carlson School of Management, in today’s taken out of service. hyper-connected world, U.S. consumers gener- b. Vehicle mileage and engine hours are ate 2.5 billion gigabytes of data each day. These available at any time. data are derived from web analytics, real-time c. Critical engine data (e.g., RPMs, temper- sensors, social media behavior and more. Hid- ature, voltage) are recorded and available. den in this massive pool of data are invaluable d. Manufacturers’ recalls are available to you business insights that demand sophisticated as soon as they are released. analytical minds to parse out. e. Service due needs can be tracked and com- Academic institutions around the globe municated from within the system. are offering degree programs in an entire new 3. Driver Behavior area of study often referred to as data or busi- a. Your desired vehicle operating character- ness analytics. Central to these programs is istics for speed, acceleration, deceleration, the goal of translating this mountain of data

MAY2015 21 A Supplement to JEMS into meaningful information that can be acted help facilitate the realization of this goal. upon. EMS practitioners are among the bene- The “standards” are available for review at ficiaries of this movement. Data and its collec- www.ems.gov/EducationStandards.htm. tion, interpretation and use are more important than ever. Distractions & Other Deadly Sins EMS organizations have a responsibility to be Just because we can do something doesn’t mean clear with their staff why data collection is rel- we should. A discussion about data and the use evant. If not, the staff will not embrace its col- of technology would be incomplete without a lection. If an ePCR is loaded with required data few words of caution. elements that are never used, it’s easy for EMTs Like many of you, when I was in paramedic and paramedics to become cynical about proper school I often heard the reminder, “treat the collection of such information. Each agency patient, not the machine.” Good advice. Savvy should therefore strive to build connections EMS providers already know this, but the cues between what the organization is asking its per- people look for when forming impressions about sonnel to collect and the impact of that infor- others are simple. Never let technology get in the mation on the service provided. way of a human interaction. Good advice.

Never let technology get in the way of a human interaction.

We’ve all likely heard, “what gets measures Driving is the single most dangerous thing gets managed.” But being able to ascertain the most EMS providers do. It’s not helpful to pack relevant vs. distracting—the need-to-know vs. the cab of the ambulance with more and more nice-to-know—is crucial. technology that glows, beeps and takes atten- We rely on academic institutions to produce tion away from the road. smart providers with great technical skills, are No one in EMS likes the term “ambulance able to think critically and possess strong inter- driver.” But it’s a simple fact that we do indeed personal skills. That’s no easy task. EMS curricula drive . And, just like airline pilots, are dictated by the national standard curriculum we need to let vehicle infomatics do their work authored by the National Highway Traffic Safety and collect data that can be reviewed after the Administration (NHTSA). The most recent ver- run is complete, and wholly concentrate on sion was published in January 2009. driving whenever we’re behind the wheel. EMS leaders would be wise to consider educa- tors, providers and agencies as partners in mak- Conclusion ing a concerted effort to include data analytics The techies among us may enjoy exploring new in the next revision. An aspirational statement gadgets, crunching numbers or using the latest articulated in the 2000 “Education Agenda for toys. But what does all of this fancy technology the Future: A Systems Approach” states: do for us and our patients? “EMS education in the year 2010 develops com- The magic of medicine happens when a pro- petence in the areas necessary for EMS providers to vider puts his or her hands on a patient, looks serve the health care needs of the population. Educa- into their eyes and listens intently. With all the tional outcomes for EMS providers are congruent with possible data available to EMS practitioners the expectations of the health and public safety services today, what really matters is translating that that provide them. EMS education emphasizes the inte- information into protocols and practices that gration of EMS within the overall health care system. street level providers, dispatchers, mechanics In addition to acute emergency care, all EMS educa- and all the rest can easily understand, and see tional programs teach illness and injury prevention, true, meaningful value in. ✚ risk modification, the treatment of chronic conditions, as well as community and public health.” Brian LaCroix is president of Allina Health EMS and a The use of technology, collection of data member of the board of directors for the National EMS and transformation of that data into action- Management Association. able information, should be included in any updated EMS education standards to

MAY2015 How data & technology are revolutionizing patient care 22 Taking advantage of real-time and near-real-time feedback from today’s modern monitor/defibrillators can improve provider and overall system performance.

PHOTO COURTESY ACADIAN AMBULANCE

The benefits of real-time & near-real-time data feedback

By John Tobin & Todd Stout a combination of the two. When assessing for quality measures, all we had to go on was the here’s a growing body of research in EMT and paramedic’s documentation. education,1 behavior change2 and per- Now when we look at an entire patient encoun- T formance improvement3,4 that shows ter, not only do we have the crew’s documenta- “timely” feedback measurably improves the tion in the electronic patient care report (ePCR) effectiveness of that feedback as well as future and data from the ECG monitor/defibrillator, performance. but also the patient data from computer-aided Some feedback should be delivered in real- dispatch (CAD), emergency medical dispatch time5—as the event is occurring—so that the and, in some systems, the hospital ED and dis- person doing the task can use that feedback to charge diagnosis information. Technology has adjust their activity or technique to improve the made it possible to determine how well our sys- outcome of that event. tem and crews are doing by comparing data col- Other feedback should be delivered as soon as lected across these sources. practical after the event—near-real-time, either Analysis of the data can tell us a lot: Are we to avoid distraction during the event, or because doing the suggested 100–120 compressions per the activity isn’t recorded or measurable until minute and compressing at least two inches? Do after the event is concluded. we know we’re actually ventilating the patient Until recently, we were severely limited in our 10 times per minute? Are we giving our patients view of on-scene performance. We were unable the right treatments at the right times, based on to know if the patient’s outcome was due to the their condition? Does our medical director know crew’s performance, the patient’s condition, or we’re following established protocols based on

MAY2015 23 A Supplement to JEMS evidence-based guidelines? Are we documenting patients. The advent of real-time feedback has our patient findings and care accurately and in a been around for years and whether you know it way that allows our service to improve, get reim- or not, you’ve been using it.

bursed and reduce risk? Monitoring oxygen saturation or SpO2 shows Real-time and near-real-time feedback devices us in real-time if our efforts with oxygenation are and software that analyze data and performance effective. Before most of us knew the usefulness are revealing that we may not have been as good of for CPR performance, we only as we thought. This new technology allows pro- used it to verify tube placement and then moni- viders to see exactly how they’re performing dur- tor ventilations to avoid hyperventilation. These ing the call or shortly thereafter, ensuring the are examples of real-time monitoring. patient receives the best possible care. It also Newer versions of this technology in today’s allows administrators and medical directors to monitor/defibrillators take care to the next level. review quality measures and see exactly how the The screen has an organized, audiovisual dash- crew performed in order to provide feedback for board the user can see and use to guide care. Most providers so they can learn from each call while of the feedback is used to assist CPR performance, it’s still fresh in their minds. but this too is evolving. Depending upon the manufacturer, there’s information on rate, depth, Real-Time Feedback release/recoil, pauses, elapsed time, a countdown

The ECG monitor/defibrillator is an invaluable timer, SpO2 monitoring and EtCO2 monitoring. tool that continues to evolve. New technologies Although many EMS agencies have real-time are giving us ways to better evaluate and help our software on their defibrillators, few actually use it. Not using feedback devices is like driving on Figure 1: Cardiac arrest resuscitation a highway at night without your headlights on; without feedback you can do it, but it’s more dangerous and less Examples of resuscitation WITHOUT feedback – NO ROSC effective than driving with them on. Depth = 1.39 in. Rate = 148 CC/min CPR fraction = 51% Shock Summary Using Real-Time Monitoring The American Heart Association (AHA) Con- sensus Statement on CPR Quality, published in Depth (in) June 2013, sets out the most current evidence- based guidelines on CPR.6 But, how do we know 0.0 we are complying with the AHA’s guidelines? You Compression quality guessed it, by using real-time feedback technology. When performing chest compressions, posi- Rate (cpm) 140 tion one crewmember so they can see the dis- play screen and hear the audio cues on the 0 defibrillator. Information on the screen clearly 11:16:17 11:51:51 displays what the compressor is doing regard- ing rate, depth and pauses. If performance isn’t Figure 2: Cardiac arrest resuscitation within the AHA guidelines, there are cues that using CPR dashboard make corrections easy. Examples of resuscitation WITH feedback Figures 1 and 2 show a visual representation Depth = 2.25 in. Rate = 98.66 CC/min CPR fraction = 93% of two cardiac arrests created by the manufac- Shock Summary turer’s software after uploading the code file from the monitor to a PC. In the depth box, Depth (in) each blue line is a compression. Yellow indicates a pause, and the green stripe across the top of

0.0 this box is the ideal depth. In the rate box, each Compression quality brown dot is the rate for each compression. Figure 1 shows a cardiac arrest where the crew Rate (cpm) 140 didn’t have the CPR dashboard visible. They were performing “blind,” relying only on their train- 0 ing and what they felt was the best care. You can 11:16:17 11:51:51 see the rate (148 compressions per minute) and FIGURES COURTESY JOHN TOBIN/TODD STOUT depth (1.39 inches) aren’t within the guidelines

MAY2015 How data & technology are revolutionizing patient care 24 and there are excessive pauses. The CPR fraction Along with CPR performance metrics, other is only 51%, meaning compressions were only issues that decrease CPR performance were identi- being done half the time during the arrest. fied: compressor fatigue, transportation, advanced

Figure 2 shows a cardiac arrest where the crew airway placement and EtCO2 monitoring. used the CPR dashboard. You can see the rate, We now have a visual representation of how depth and pauses are all within the guidelines. fatigue affects the compressor’s ability to do The improvement is striking! high-quality chest compressions and know that, This technology makes it easy to hit 100–120 after about two minutes, even the fittest person compressions per minute and achieve a depth starts to lose effectiveness. They may tell you of greater than 2” every time. It also helps maxi- they’re not tired, but you can see compression mize the chest compression fraction by alerting depth starts to suffer, and they unconsciously the user when pauses occur and facilitates and speed up the rate to compensate. To avoid this, organizes cardiac arrest management with the use your countdown timer and change compres- use of a countdown timer. sors every two minutes! When the timer gets to zero and resets, the It makes sense, but now we’re able to quan- crew knows to check the rhythm, defibrillate tify that our CPR quality goes down during if appropriate, and change compressors. Those transport. Not only are the members at great running the scene can more effectively moni- risk because they’re most likely not seat-belted tor the performance and coach those at the task in the back of the ambulance, but compression level. Crews are able to see if they are complying quality suffers. More and more evidence is find- with the AHA’s recommendations for high-per- ing that the best care for cardiac arrest is to work formance CPR. the patient on the scene until return of sponta- neous circulation, field termination or the use Does It Affect Outcomes? of mechanical compression devices. EMS organizations that use devices that have real- Compressions also suffer during advanced air- time CPR feedback are showing improvement in way procedures. Unless you have a policy and cardiac arrest survivability. One study in Mesa, train to intubate without interrupting compres- Ariz., showed significant improvement in cardiac sion depth or rate, chest compressions will suffer. arrest survival.7 By conducting scenario-based Dan Spaite, MD, a prominent researcher training and using real-time CPR feedback, both at the University of Arizona, has dubbed the

Guardian Medical Transport and the Mesa Fire phrase, “EtCO2 monitoring—that isn’t.” As and Medical Department (MFMD) significantly part of his research with EMS agencies, he has improved out-of-hospital cardiac arrest survival. found when EtCO2 is being applied, few provid- The MFMD’s compression fraction went from ers are actually monitoring and correcting what an average in the low 60% range to the mid 80% the monitor is telling them. If we don’t use this range. Before implementing this change, the information to guide our ventilations, it merely MFMD’s survival to discharge for patients with documents us hyperventilating the patient. a witnessed shockable rhythm was 26.3%. After But just because you have the coolest, new- these changes were applied, survival to discharge est technology doesn’t mean that your front increased to 55.5%. These patients were 2.72 line crews will know what to do with it. Crews times more likely to survive.7 Although it’s not a need to be educated on the components of high double-blind study on the use of real-time feed- performance CPR and why they’re important. back, it’s a great indicator of the significance of Small group, in-person training is the corner- this technology. stone for transitioning to this technology. Also remember, just because the information is in Identifying Performance Deficiencies front of your face doesn’t mean you are looking Before the study, MFMD weren’t measuring key at it. Your crews need to know the importance parameters. The initial phase of the study identi- of the information being presented on the dash- fied the average chest compression fraction was board and taught not to get distracted from it. in the low 60% range. Average rate and depths This technology can also easily be used in a weren’t hitting the mark and pre- and post-shock training mode on manikins to improve perfor- pauses totaled over one minute. Needless to say, mance on the streets. You can quickly upload MFMD officials were stunned by actual perfor- the data during the training session and show mance. If you’re not measuring performance, the crews exactly how they did. And, if you you don’t know how you’re doing. incorporate this type of training at the onset,

MAY2015 25 A Supplement to JEMS Richmond Ambulance Authority Chief Operating Officer Rob Lawrence trains his staff using FirstWatch’s real-time dashboards.

PHOTO COURTESY FIRSTWATCH

doing it for quality improvement purposes is an feedback during the call, but feedback should easy transition. still be provided in a timely manner. A challenge in providing timely feedback is Near-Real-Time Feedback when the data or the monitoring mechanism Near-real-time feedback in EMS can mean dif- aren’t black and white and requires some human ferent things to different people, but many peo- review, context and discussion. EMS systems are ple consider it to mean feedback from any time now overcoming this challenge by using technol- after the end of the call to the end of the same ogy and automation to analyze call information shift, or in some cases early into the shift, or at in near-real-time, and use the software to review least during the next shift worked. all possible aspects of the data that can be done The goal is to provide feedback while the call by technology, saving the human reviewer’s time is fresh in the person’s mind, when they can so it can be used to review aspects of calls that recall the details of the call, including timing, only a human can handle. In other words, they patient condition, treatments, dosages, etc. This let the computers do what they do best, and save is important because it may vary from, or provide the humans for the parts of the QI review that more context to, the documentation. require judgment, experience, and often, a sense The most effective time for feedback can rea- of the bigger picture. sonably vary. It can be extended, for example, in Below are some examples where near-real-time smaller or rural systems where crews run only a few feedback can be used to improve EMS: calls each shift, or it may be shorter in very busy Communications center improvement: It’s a pri- systems where crews take a large number of calls mary goal of all communications centers to per shift. Also to be considered are systems with decrease the time it takes from when a 9-1-1 shift schedules with gaps of several days between call is received until enough information has shifts, since it may be difficult to recall details been gathered from the caller, so that it’s avail- across several days, or where the person works in able in the CAD system and an EMS unit can another EMS system in between shifts, etc. be assigned. After months of trying to improve The research doesn’t explain why timely feed- call-taker performance through traditional ret- back is more effective, but we speculate that the rospective reporting, CenCom (New Jersey) more timely and concrete the feedback is, the Manager Gareth Williams began to display live easier it is for the EMT or paramedic to person- gauges showing the percentage of compliance alize the feedback and incorporate the lesson over the last 12-hour period to their call-taking into their behavior, while more delayed feedback performance goal on large screens in the com- becomes more abstract and less personal—like a munications center showing the overall perfor- regular class that applies to everyone equally. mance of all call-takers in the center. It’s important to note that some data isn’t Without even having to review individual per- easily available to monitor during the call, and formance, provide additional training, or use dis- can only be gathered and effectively analyzed cipline, CenCom’s call-takers improved their own after the call, so it’s not always feasible to give performance from 77% to 92% over a few months.

MAY2015 How data & technology are revolutionizing patient care 26 Automatic near-real-time monitoring of dis- was called into court for other reasons, so early patch data has another benefit: Sunstar (Pinel- discovery, feedback and the resulting improve- las County, Florida) uses automatic alerts to ment was important. reduce the workload of communications center If an EMT or paramedic doesn’t document staff by automatically sending out management complete patient information, it could take your notifications for certain kinds of calls, such as billing office hours to track down the informa- first responder transporting, medical helicop- tion needed to complete a single patient record. ter usage notification, multiple unit responses, The Richmond (Virginia) Ambulance Author- calls with long response times, etc. ity (RAA) uses FirstWatch, which allows them This is especially helpful, because these mes- to monitor in real-time from a variety of data sages, although important, create a great deal of sources: CAD systems, ePCRs, records manage- related work in the communications center, and ment systems, public health, even emergency management notifications are often a lower pri- departments and hospitals. The software pro- ority and can be delayed or even missed. vides them with a real-time solution, allowing Operational improvement: The San Miguel Fire them to make interventions right away rather Department in San Diego County decided to than waiting to run a report. Duty supervi- improve their out of chute times, and used near- sors receive a near-real-time alert for every real-time feedback via desktop and mobile dash- incomplete ePCR that they can then immedi- boards along with automatic alerts for each unit ately direct to the appropriate field crew mem- on each shift to provide same-shift feedback to ber. This allows field providers to correct the crews. This near-real-time feedback improved missing ePCR information before they’ve even their performance from 75% to over 90%, and ended their shift. Since implementation, miss- gained buy-in for the value of real-time feedback ing ePCRs a day have gone from as many as 7–8 from their leadership at all levels. times a day to either once or none each day. The Orange County (Florida) Fire Rescue This illustrates how near-real-time feedback Department has been working to reduce their has the power to affect change. Other EMS hospital offload times, and uses automatic near- agencies have adopted this approach, and had real-time alerts to notify their battalion chiefs similar success, including the highly regarded (BCs) when an offload exceeds 30 minutes, so North Shore-Long Island Jewish EMS system. the BC can go to the hospital, determine the cause for the delay, and take over patient care if Quality Improvement necessary, releasing the EMS crew to return to The data collected in real-time and near-real-time duty and be available for another call. is also invaluable for improving quality. “Review Clinical improvement: St. Charles County Ambu- of the quality and performance of CPR by profes- lance District in Missouri uses near-real-time sional rescuers after cardiac arrest has been shown alerts to notify their EMS BCs when the scene to be feasible and improves outcomes. Despite time for STEMI and stroke calls are greater than this evidence, few healthcare organizations apply 10 minutes. This allows the BCs to follow up these techniques to cardiac arrest by consistently with crews later in the same shift if their scene monitoring CPR quality and outcomes.”7 time for these time-critical patients was long. This technology can also be used to conduct Next to providing the highest level of patient performance reviews and show crews exactly care and ensuring safety for all involved, prop- what went well and what didn’t go so well. erly documenting the call, patient’s condition Automated systems that evaluate performance and care provided is one of the most important in the communications center and in the field things EMS providers can do. One missing data (operationally and clinically) can help dramati- field can be the difference in whether or not your cally reduce the amount of work required for organization gets paid for patient transport, or is a quality improvement (QI) review and conse- liable if a legal question about the call arises later. quently reduce the time from the call to the deliv- Williamson County (Texas) EMS recently ery of effective feedback. used automatic monitoring of their ePCR data Many systems are now using their data sys- to determine that some paramedics were incor- tems and hardware to reduce in-house staffing rectly documenting their administration of fen- and workload. For example, Sedgwick County tanyl in milligrams, rather than micrograms. The (Kansas) EMS has worked to have FirstWatch actual dose provided was correct in each case, but and FirstPass to take all possible review work could have raised questions if any of those cases off of the shoulders of their QI staff member, so

MAY2015 27 A Supplement to JEMS they can focus their attention on aspects of the common sentiment heard in paramedic training QI process that requires a human touch. programs around the world. The availability of The previously mentioned RAA uses First- technology doesn’t preclude this statement. While Watch and FirstPass to review 100% of their calls crew members performing tasks on scene should within minutes of the dispatch, ProQA or clini- concentrate on the job at hand, when possible, cal data hitting their databases. The initial, auto- there should be a team leader that watches over mated review happens immediately, and patient the entire scene to help provide real-time direction care that doesn’t comply with RAA’s protocols, and feedback. Crews can see what they are doing or is simply outstanding, are made available right while they are doing it and it improves outcomes. away for human review. Real-time and near-real-time information and RAA staff routinely provide complete QI feed- feedback shows leaders where their system is back on acute calls to their crews within an hour headed. It gives our patients the best chance at of the call, and non-acute calls worthy of feed- the best outcomes, and gives our EMS systems back during the same shift or by the next shift. the best chance to improve and provide measur- Prior to implementing the automated near- able outcomes. ✚ real-time feedback system and approach, they reviewed 100% of the cardiac arrests, and about John Tobin is the alarm room captain for the Mesa Fire 25% of all other calls. Their goal was to review and Medical Department where he’s served for 17 years the cardiac arrests by the next day, and the 25% in a variety of positions such as /paramedic within several days. and EMS captain. He’s currently also a lead educator In addition to this near-real-time feedback on with the University of Arizona’s EPIC Project, a statewide a per call basis when appropriate, RAA is able to initiative to implement the Brain Trauma Foundation’s use past calls and overall system protocol com- recommendations for traumatic brain injury care. He can pliance to identify which issues are really system be reached at [email protected]. issues, rather than issues with individual med- Todd Stout is the president and founder of First- ics, and incorporate that information into their Watch (www.firstwatch.net), a public safety technol- system’s continuing education, and into indi- ogy company that helps more than 300 communities vidual preceptor activities. in North America turn their dispatch and patient data This automated, near-real-time review of into meaningful and actionable information. He’s served information about all calls, from multiple data as an EMT, paramedic, flight paramedic and manager sources, provides visibility into system and crew in a variety of high performance EMS agencies across performance which helps provide context about the country. the system, the crew’s past performance and other crews’ performance in similar circumstances to References give as complete a picture as possible, and avoid 1. Dean CB, Hubbell ER, Pitler H, et al: Classroom instruction that works: Research-based strategies for increasing student knee-jerk reactions. And, EMS systems that use achievement, 2nd edition. Association for Supervision & Cur- statistical process control-based approaches (e.g., riculum Development: Alexandria, Va., 2012. Six Sigma) in their QI programs can base their 2. Shuger SL, Barry VW, Sui X, et al. Electronic feedback in a diet- and physical activity-based lifestyle intervention for weight analysis, alerting and feedback on only those pro- loss: A randomized controlled trial. Int J Behav Nutr Phys Act. tocols or measures where it’s appropriate. 2011;8:4. 3. Stockford P. Good to great: Rapid results with real-time perfor- Summary mance management [white paper]. SaddleTree Research: Progressive EMS organizations need to be moni- Scottsdale, Ariz., 2012. 4. Robinson DG, Robinson JC: Performance consulting: Moving toring, capturing and measuring data continu- beyond training. Berrett-Koehler Publishers: Oakland, Calif., ously, in real-time and near-real-time to ensure 1996. quality patient care and optimum clinical and 5. Shute VJ. Focus on formative feedback. Review of Educational operational performance. Previously, this required Research. 2008;78(1):153–189. exhaustive staff time and efforts, cobbling data 6. Bobrow BJ, Vadeboncoeur TF, Stolz U et al. The influence of sce- nario-based training and real-time audiovisual feedback on together manually from various sources. We can out-of-hospital cardiopulmonary resuscitation quality and now use EMS technologies to make useful, action- survival from out-of-hospital cardiac arrest. Ann Emerg Med. able decisions in near-real-time based on the data 2013;62(1):47–56. 7. Meaney PA, Bobrow BJ, Mancini ME, et al. Cardiopulmonary we collect—all as close to the event as possible. resuscitation quality: Improving cardiac resuscitation out- While technology is fantastic, it’s still very comes both inside and outside the hospital: A consensus important to keep an overall focus on the patient. statement from the American Heart Association. Circulation. “Treat the patient, not the monitor” is a very 2013;128(4):417–435.

MAY2015 How data & technology are revolutionizing patient care 28 BETTER DATA MEANS BETTER OUTCOMES

What if:

Your medics could focus on their patients while still capturing an accurate ePCR? Your billing specialists could ensure you account for every service provided? Your quality managers could spot which clinical and operational processes to improve frst?

They can, with the HealthEMS® Patient Management System from Physio-Control.

The HealthEMS Patient Management System is a patient-centered ePCR that helps paramedic teams create complete, accurate care records without taking their hands off their patients. Integrating data from CAD systems, driver’s licenses, patient monitors, and your own patient database, the HealthEMS System relieves the burden of documentation without sacrifcing data quality.

Because in everything you do, quality matters.

To put your data to work for you, visit www.physio-control.com/datasolutions

©2015 Physio-Control, Inc. Redmond, WA GDR 3323221_A

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