The primary job of an EMS provider is to save lives, not be a blue-ribbon typist. Yet many electronic systems for creating patient care reports (PCRs) require a paramedic to type information into numerous fields while simultaneously attending to patients. This can greatly diminish the quality of patient care and the accuracy of the captured data.
To free paramedics from the keyboard, forward-looking EMS companies are implementing voice technology. This hands-free approach lets EMS providers create a robust, accurate electronic PCR without interfering with what they do best: serving patients in need.
The Push to Standardize ePCRs
As hospitals started racing to implement electronic health records about a decade ago, many responders still used handwritten notes and scanned reports to submit data to receiving hospitals, state regulators and payers. After some time, there became a recognized need for national standards for electronic PCRs and three federal agencies began funding a project called the National EMS Information System (NEMSIS).
NEMSIS has three primary goals:
- Provide a standard data set for collecting PCR data.
- Implement a system for sharing that data across all states using the XML standard.
- Create a national EMS database to help improve patient safety and data quality—and to identify national trends in EMS care.
NEMSIS has received broad support from the major players in EMS, including the American Ambulance Association and the National Association of Emergency Medical Technicians.
The NEMSIS project has made steady progress, but much work remains. About one-quarter of states don’t have an electronic system in place, and many that do are still trying to improve data capture and ensure that electronic PCRs are both timely and complete.
Incomplete Reporting: A Patient Care Issue and More
Since EMS professionals are often involved in life-or-death situations, it has historically been difficult to get prompt, comprehensive PCRs from the field. Understandably, most paramedics take care of patients first, then try to recapture the details of an encounter later—sometimes many hours later. This can often lead to omissions or delays in documentation, which can cause wide-ranging problems.
The first problem, of course, is that gaps in the PCR could cause repercussions in regard to a patient’s treatment plan. Additionally, financial and legal issues can also arise.
In the world of medical reimbursement, organizations are paid based on the level of service required and the care that was actually provided; organizations must have complete documentation to support the claims. Any omissions in the PCR documentation have a direct impact on an EMS company’s bottom line, and the financial hit is not always immediate. Insurance auditors can come knocking years down the road, recouping money for services not documented or insufficiently documented—and potentially levying sizeable fines.
Unless paramedics can document precisely why they offered a service or medication, they also leave EMS companies vulnerable to litigation. Thorough documentation goes a long way toward reducing legal exposure.
Since the full and complete document is crucial to the EMS industry, it’s important to give EMS professionals tools that let them either capture patient care events in real-time or do a recap immediately after an encounter.
Reshaping EMS Workflow
Here’s an example of how voice technology could improve EMS workflow: A paramedic equipped with a current keyboard-based electronic PCR responds to a call from a possible stroke victim. This is clearly not a time to juggle patient care and typing, so the paramedic waits until the end of the transport to enter a report recreated from memory and a few handwritten notes.