Soon after my company began working with Dallas Fire-Rescue in 2016, I conducted a brainstorming session. The goal was to establish a wish list of technology and process improvements.
As Assistant Chief Norman Seals and medical director Marshal Isaacs, MD, warmed up, insights about the transformation and combination of data and opportunities for regionalization of care and surveillance tumbled out. The idea that impacted me most was what Isaacs referred to as his “prime numbers”: As patients traverse the prehospital care and emergency medical systems without anyone knowing where they are at any given moment, unhealthy behaviors can persist because each participant in the system pops up fewer times than they should.We know quite a bit about who these patients are and what their problems may be, but little about their entire health record or past history of hospital visits.
Consider San Francisco. It has three emergency medical service providers: The San Francisco Fire Department, AMR, and King-American Ambulance. However, today none of these agencies is connected to another from a data perspective. If a patient in San Francisco calls 9-1-1 three times in three days, he or she may get responses from all three entities—and if the same service doesn’t respond more than once, it will appear to each service as if the patient only called for service once.
By “prime numbers,” Isaacs meant that the EMS system as a whole has no idea that the patient has been seen between each encounter with a particular service. A disconnected EMS system, unfortunately, thus unintentionally enables potentially unhealthy behaviors by allowing them to persist.
Almost every facility patients visit in the course of a 9-1-1 call is “connected”—just not to each other. Hospital EHRs and EMS PCRs are rarely linked reliably. This is partly due to a conflict of technical-regulatory requirements, but the remainder of this glaring hole in the healthcare system stems from a failure of communication between EMS and hospital teams. It is a tragic waste of resources that prehospital patient data are almost universally ignored when a patient is handed off at the ED.
As prehospital professionals, your personal knowledge of your patients is intrinsic to both episodic and longitudinal care. You know what happened and why you were called—why are your insights not shared with the facilities to which you transport, so they arrive before you do and can be used to activate triage? Why can’t you share them with your counterparts at neighboring services to take a regional approach to major problems?
We know access to a body of personal healthcare data that could provide context about the patient’s medical history is a privilege most EMS and fire clinicians do not enjoy today. Yet prehospital care providers have a dire need for clinical context, especially when it comes to complex or repeat patients.
The irony is that we can solve this problem now; yet for reasons of inertia, confusion, or lack of awareness and comfort with core healthcare information technology, EMS is behind the rest of the healthcare system when it comes to data interoperability across our clinical ecosystem. Today prehospital data become part of the patient’s legal record, yet crews’ clinical insights are rarely incorporated into post-handoff care. If the power of prehospital data could be proven to EMS crews, perhaps they could come to see charting care as a critical clinical workflow and not just a “gotcha!” risk.
Imagine how prehospital caregivers would love to know they could chart patient care over time and in the process identify those who are hurting themselves through the use of illicit substances! They can share those insights with other caregivers while en route to the ED so the information is consumed prior to arrival. Crews may be more likely to undertake the effort (or use ePCR tools that shorten charting time) to fill in data that inform those on the receiving side of the handoff if doing so ensures that triage teams and registration are ready, wall times drop, and outcomes improve.
In December 2017 the International Association of EMS Chiefs issued a position statement that included the following language: “Emergency medical services agencies and researchers should have access to relevant patient care data and EMS providers to their patients’ complete care records, including outcomes.” An admirable aspiration, but access to “complete care records” likely won’t happen for legal reasons unless and until hospitals can exclude irrelevant or prejudicial details from the charts they share (certain types of health data, like psychiatric assessments and HIV status, have special protections under HIPAA).
Additionally, it may actually be impossible to share hospital-side data, for while prehospital care providers may see access to electronic health records as key to gaining a seat at the healthcare table, in reality EHRs are diffusely deployed even within institutions, let alone across multiple facilities, and notoriously porous when it comes to data. They are arguably less reliable than even the worst PCRs, as anyone who has ever transferred EHRs from one hospital to another can attest.
So why do prehospital caregivers need access to a holistic set of hospital-side health records, assuming one is accessible? Here we return to Isaacs’ “prime numbers”: The ability to collect, collate, and correlate data from the many healthcare resources working in a given area is the key to intervention on behalf of people who may be a danger to themselves but who are ultimately enabled by a fractured healthcare system. If EMS and fire agencies could follow patients as they travel through the healthcare system, they would be able to identify their patients with an intimacy born of being first-on-scene.
From ePCRs to middleware to EHR systems to regional health information exchanges and macro interchanges that span large swaths of the U.S., there is no shortage of touchpoints for high-risk/high-frequency patients to be observed over time and distance. Some ePCR companies have even gone so far as to enable longitudinal patient tracking, which will allow individual services to care for their neediest patients over time and observe how risk factors decrease while their health indicators increase.
In other words, longitudinal metrics and a sense of how statistics can be slammed together to find patterns of disease—and opportunities to intervene—are key to tracking "super users" or patients who need further assistance in dealing with their chronic illness.
Stop Talking, Start Doing
For years, the EMS and fire community has struggled to build momentum for readmission-avoidance programs. How is an opioid- (or other drug-) diversion program different? If we’re being honest, the difference is only the disease in focus.
EMS agencies must begin productive conversations with ePCRs and EHR companies, HIE operators, and prehospital regulators at all levels of government so we can close gaps in understanding. Let’s stop talking and start doing all our industry knows—and has known for years—it must to realize the clinical, operational, and financial benefits of interoperable technology.
Sidebar: What Do We Know About the Opioid Crisis?
Roughly 21%–29% of patients prescribed opioids for chronic pain misuse them.
Between 8%–12% develop an opioid use disorder.
An estimated 4%–6% who misuse prescription opioids transition to heroin.
About 80% of people who use heroin first misused prescription opioids.
Opioid overdoses increased by 30% from July 2016 through September 2017 in 52 areas in 45 states.
Jonathon S. Feit, MBA, MA, is cofounder and chief executive of Beyond Lucid Technologies Inc.