Integrating Emergency Medical Services Into the Healthcare System

By Greg Mears, MD, an exhibitor at the HIMSS Interoperability Showcase™ at the 2018 HIMSS Global Conference & Exhibition; Medical Director, ZOLL

Paul Smith dialed 911. The emergency medical services (EMS) dispatcher, using a structured set of questions, quickly identified Paul’s chest pain to be potentially a ST elevation myocardial infarction (STEMI or heart attack). EMS was dispatched to Paul’s home and immediately confirmed the diagnosis with a 12-lead Electrocardiogram (ECG). Paul’s chest pain had started 20 minutes ago and EMS now knew he needed to be transported to a Heart Center.

A Heart Center is a hospital with a cardiac catheterization lab capable of emergently inserting a catheter into a patient’s groin and threading it into the heart’s blood vessels to remove a blood clot; the blood clot that cut off the circulation to an area of the heart causing the STEMI. Time is of the essence as this procedure should be completed within 90 minutes of onset of pain to prevent permanent heart damage or death.

The challenge with Paul was deciding where he belonged among the hospitals in the area. . There were three choices, all Heart Centers. Paul had been seeing a cardiologist as an outpatient but didn’t know which Heart Center he served. Paul also had several cardiac diagnostic tests done but didn’t know the results. Ultimately, EMS chose the closest Heart Center as Paul’s destination. EMS called ahead and transmitted the 12-lead ECG to the emergency department, activating the STEMI team and the catheterization lab.

On arrival, the medical team discovered that Paul’s cardiologist practiced at another Heart Center just a few minutes in the other direction, and Paul was now out of his network. Precious time was lost before Paul’s STEMI was treated. “Time is muscle” is a term often used by STEMI patient’s healthcare providers. The longer the patient’s heart is deprived of blood and oxygen, the more heart muscle that is damaged and the patient’s risk of disability or death increases.

If EMS had been fully integrated into the healthcare system, Paul’s cardiologist, healthcare network, past history and medications would have been known. Treatment and transport destination decisions could have been more timely and appropriate. Paul’s experience, outcome and cost could have been improved.

How Does EMS Fit into Healthcare?

EMS is a vital component of healthcare serving every community. Each year EMS responds to over 40 million medical or traumatic events, within the United States, providing emergent care and when needed, transport. Care is provided through an organized network of 911/dispatch centers and emergency response vehicles, all staffed by EMS professionals with physician oversight. EMS is the only acute healthcare provider where the care is physically delivered to the patient, as opposed to the patient physically traveling to the healthcare provider.

At the community level, healthcare is typically organized into Systems of Care. A System of Care is a coordinated network of hospitals, providers and healthcare resources. From an EMS perspective, Systems of Care often focus on acute time dependent conditions such as trauma, cardiac arrest, heart attack and stroke.

For these Systems of Care to function well, EMS must quickly respond, diagnose the patient’s condition and transport the patient to the appropriate destination (trauma center, stroke center, etc.) for definitive care within minutes. Ultimately, these patient navigation decisions and the care provided by EMS significantly impact the patient’s outcome.

This is complicated because most communities have multiple, competing healthcare systems. It’s in the patient’s best interest to receive care where their providers and health information reside. This is where the integration of EMS into the healthcare system is critical and can best be achieved through interoperability.

What Role Does EMS Play in Interoperability?

Interoperability has been defined by HIMSS as the ability of different information technology systems and software applications to communicate, exchange data and use the information that has been exchanged.

A 2015 survey by the American Hospital Association found that 96 percent of hospitals have certified electronic health record (EHR) systems with health information exchange (HIE) capability. EMS also has a mature electronic health record standard known as National EMS Information System (NEMSIS) with near universal adoption. The “last mile” of interoperability is to connect EMS with the greater healthcare exchange.

The Office of the National Coordinator for Health Information Technology (ONC) has established requirements for the exchange of EMS EHRs. This is often referred to as Search, Alert, File and Reconcile. From an EMS perspective, these terms can be defined as follows:

  • Search is the ability to search across healthcare systems for a patient’s individual health record. This could include information on their medical history, medications, allergies and end-of-life decisions. This information should be accessible in the dispatch center as well as at the location of the patient and/or the EMS event.
  • Alert is the ability to notify the receiving hospital or the patient’s healthcare provider of the patient’s condition and status. For an emergent event, such as a STEMI, significant trauma, or stroke, this alert would activate the appropriate hospital assuring they are prepared when EMS arrives to deliver the time-dependent definitive care that the patient requires.
  • File is the ability for EMS to create an EHR representing the EMS service delivery and care associated with the patient event. This EHR should contain structured data that can be electronically transmitted to the receiving facility and the patient’s healthcare provider. This allows the patient to have an integrated longitudinal documentation of their healthcare.
  • Reconcile is the ability for EMS to obtain key EHR content such as diagnosis, disposition, billing and outcome information from the patient’s EHR after the event. This is critical to EMS business, service delivery, quality management and outcome measurement.

Healthcare reform is frequently defined by the triple aim, first coined by the Institute for Healthcare Improvement. The three goals of the triple aim are to improve the patient experience (outcome and satisfaction), focus on population health (public health and prevention), all while controlling/decreasing cost. For EMS to successfully make its full contribution to the triple aim, we must focus on two key healthcare delivery components:

  • Patient navigation
  • Access of each patient's healthcare information

Key requirements for triple aim success are to:

  • Make the best decision on when and where to transport a patient (based on the patient’s condition and need)
  • Keep a patient within their primary care/healthcare providers network (patient navigation)
  • Reduce repetitive healthcare diagnostics (repeat labs, CT scans, etc.)
  • Prevent medical errors (medication errors, adverse reactions, inappropriate diagnostics, etc.)

True interoperability of a community’s healthcare system will never be complete, or reach its potential, without the integration of EMS.

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