C.Q.I., Data Capture and Sharing, and Use of Charting Technology (ePCR) in a Classroom Setting
This white paper reviews the emerging opportunity for prehospital Fire/EMS training programs to blaze pedagogical trails by reframing the prehospital patient care documentation as a modular, customizable training tool. Adapted from presentations at the Northwest Arkansas Trauma Symposium, the National EMS Educators Assn., and the International Roundtable on Community Paramedicine (2017).
The thesis of this objective is simple: that technology should be an integral part of Fire/EMS education.
A theme of the 2017 National Association of EMS Educators (NAEMSE) conference in Washington, D.C., was that across the U.S. — and even around the world — EMS educators have gravitated to cost-effective means of bringing real-world practicums into the classroom, as they seek to prepare students to “hit the ground running” at any Fire or Emergency Medical Service department that hires them post-graduation. In addition to lifesaving technical and essential human skills, from intubations to empathy, burgeoning EMS professionals are being introduced to the idea that data are no longer an afterthought.
Data have become a pervasive demand for every level of practice; every practitioner, from EMT-Basic to Community Paramedic, at paid and volunteer services alike, is now obliged to produce data and learn from them. The reason is as simple as it is controversial: arguably more than any other time in the history of Fire or EMS, agencies are being charged with justifying the cost of their own existence. Data have therefore never been more critical, since what goes into an electronic patient care record (ePCR) for EMS, Fire (NFIRS), or Community Paramedicine / Mobile Integrated Health (CP/MIH) encounter will be used to convey details about the care that was provided on-scene and in-transit, and then analyzed again for managerial and budgeting purposes. This theme shows no sign of abating.
Some of the most progressive thinkers in EMS today — like Tony Spector, Executive Director of the Minnesota EMS Regulatory Board — have questioned the value of tasking EMS providers with collecting data that even appears to lack immediate tangible value. So let’s ask: does the information have immediate value? If not, then “why bother collecting it” is the perfect inquiry. But what if the data have value, yet the dots that justify their mandate have never been explained? Perhaps some sunshine on three brief but fundamental questions would convince industry leaders like Mr. Spector:
· What is the purpose of an ePCR?
· Why does the contained within an ePCR follow such rigid — and seemingly random — rules?
· How can mining the data within an ePCR provide a more effective view of agency operations?
1. The importance of documentation, and what is the difference between ePCRs and EHRs?
Fire and EMS agencies that are being asked to justify the cost of their services in an unprecedented fashion, distinguish themselves from home health agencies, and care for a population that is expanding, aging and increasingly mobile, face a piercing reality: cities are growing but budgets aren’t. For example, according to Chris Samples, Captain and Paramedic at the Flagstaff (Arizona) Fire Department, the agency’s call volume has grown about 8–12% per annum for the past decade, while the personnel budget remains flat, operating with twenty-one full-time on-duty personnel — the same number it had in 1992 — despite a response volume growth to around 15,000 calls (projected) in 2017.
Furnishing real-time, interoperable data — especially while bridging the gap between prehospital and in-hospital care — is key to demonstrating how Fire and EMS agencies help their communities. But in an informal survey conducted by roll call, on questions spanning several dimensions of healthcare IT, at the 2017 Northwest Arkansas Trauma Symposium found less than 5% of the roughly 230 attendees responding favorably when asked: “Do you trust the electronic patient record system you use?” This included prehospital documentation (an ePCR) and in-hospital/in-clinic documentation (an “electronic health record”). The use of different terms are used to describe two things that are so similar tends to confuse the market, but the main distinction between ePCRs and EHRs is that an EHR is longitudinal in nature by default — the sum total of a patient’s individual visits — and is subject to Meaningful Use.
Data captured in an ePCR conforms to the National EMS Information System (NEMSIS), but for agencies that are seeking to engage in emerging practices like Community Paramedicine, or to share data with a receiving care facility in a consumable fashion, NEMSIS v3 is insufficient since its standard information is geared to the concept of “one patient, one record,” without the details that are required to hand off the record in a format that is compliant and interoperable across the health IT ecosystem. That ecosystem looks at patient information over time, including data elements like “family history” and “past encounters” that are generally not relevant in 9–1–1 contexts — but which no hospital or nursing home would neglect to investigate as a vital means to understand the patient’s broader health context.
By contrast, EHRs are based on a standards established by an organization called Health Level Seven (“HL7”), that does not produce rules or compliance requirements per se. Rather, HL7 provides a constructive language for data capture and transformation that is analogous to NEMSIS. Languages do not determine the value of their words and phrases — that task is left to those who use them. Consider English. Like HL7, it is a language, so it abides many flavors that ultimately may or may not be understood by both sides of an exchange (e.g., American English, British English, Old English, medical English, pidgin English, English slang, and so on). They are all somehow related and can therefore can be translated (at least theoretically) into one other with the appropriate codex.
Similarly, HL7 tells healthcare systems that data which wants to be shared is translatable, but it does not tell the systems how to transform or use the data. Those who need to read, write, and speak using the HL7 language are responsible for agreeing on the forms of communication, and the organization makes sure that those who wish to use the language have access to its associated phonics.
Turns out, our taxes have already paid for the creation of precisely such schemas: the federal Office of the National Coordinator of Healthcare Information Technology (ONCHIT), the National Institute of Standards and Technology (NIST), and other federal agencies have published documentation on how to use HL7 — including ways to translate NEMSIS into HL7 for use in exchanging prehospital data.
NEMSIS is frequently criticized for focusing on statistics rather than clinical care, but a better way to look at NEMSIS is as a starting point with a mission to capture emergent, case-specific information. In non-emergent clinical contexts, EMS agencies have attempted to use myriad different data systems to collate the insights they need to do their jobs — with mixed results. For example, The Center for Emergency Medicine at the University of Pittsburgh Medical Center captures Community Paramedicine program data using a template modeled on the Outcome and Assessment Information Set (OASIS), which is geared to home health nursing. Several programs across the country capture data using a terminal that accesses a hospital-side EHR (or even one provided by an insurance payer), but these tend to exist where non-transporting Community Paramedicine programs are considered outside of the EMS system; as such, their records may not have to be submitted to the state’s EMS regulatory authority (which does its data analysis using NEMSIS). In places like California, where EMS providers must submit their Community Paramedicine-oriented “over-time” data to a regulatory body, using a hospital’s EHR or the OASIS form will not provide information in the proper language to assess the value of Community Paramedicine program vs. “standard” Fire or EMS care: rather than comparing apples-to-apples, such a relevant but incomparable data set is more like apples-to-fruit salad, or Spanish to French: some words overlap, but not enough to glean detailed nuance of a phrase.
It should be noted — and might not be a coincidence — that some states where non-ePCR data are permitted to track prehospital care over time are encountering challenges when it comes to approving legislation or budgets for Community Paramedicine / Mobile Integrated Health.
To make EMS records shareable with hospital-side EHRs, ePCRs must be — and can be — augmented to include longitudinal data based on the Clinical Document Architecture (CDA), such as a Continuity of Care Document (CCD) or Consolidated CDA (C-CDA), which are standardized under the ONCHIT framework called Meaningful Use. The data in these interoperable documents helps to frame the measurable — financial, social, clinical, operational — value provided by EMS practitioners. Like the proverbial tree falling in a forest, if an ePCR is incomplete and not shareable, has the crew be credited for delivering “meaningful” care? If an ePCR is intended as a “source of truth,” then before data can be shared, it must be adequately and accurately captured. Here, Fire and EMS educators come in.
2. “PRACTICE MAKES PROFICIENT”: Learning to document well evolves how clinicians think
Conveying relevant, rich patient care data across the care continuum is a learnable skill that must be practiced. Changing how prehospital data is seen by practitioners who likely don’t enjoy completing extra paperwork (because really, who does?) begins with recognizing its value. Conservative EMS training programs in areas that are still early in demanding, and adopting, prehospital documentation technology are more likely to view ePCR in an educational setting as superfluous at best, rather than broadly applicable to the cognitive development of diligent, informed clinicians. Consider the vantage point of Gregory “Scott” Rose, Director and Coordinator of California’s Napa Valley College EMS Program, “At this time the Napa Valley College EMS Program does not utilize a [sic] E-PCR program. We as an instructor group don’t find value focusing on a particular documentation program when there will be many different programs used for students. The NVC EMS program focuses more on preparing our students to produce an appropriately written narrative than working on an electronic documentation.” Data written in a narrative is certain better than data not written at all, but it cannot be efficiently mined for the sort of nuanced insights that governmental regulators — and the taxpaying public — are increasingly demanding to justify the actions, and budgets, of Fire and EMS agencies.
Elsewhere — even in some unexpected locales — a cadre of trailblazing Fire and EMS training programs are pioneering the perspective that strong patient care documentation is a fundamental prehospital skill that should be taught during the earliest days of EMS education, much like assessing a patient’s vitals or inserting an intravenous line. They know that prioritizing data quality steers Fire and EMS providers toward thinking about their practice with an eye to continuous quality improvement, knowledge management, and adaptability to future clinical opportunities. According to Steve Sims, Fire Chief of the Bella Vista (Arkansas) Fire Department, “it does not matter which ePCR” new recruits train to use — he looks for a “way of thinking” when interviewing potential team members.
Given nationwide mandates regarding the National EMS Information System, Version 3, virtually every Fire and EMS agency at which a student will hope to find employment after graduation must complete digital documentation following a patient encounter. ePCRs generate a cornucopia of data that are useful not only in teaching clinical and narrative writing skills, but that can be repurposed as fodder for parallel healthcare education programs like medical billing and Community Paramedicine. Estrella Mountain Community College’s (EMCC) SouthWest Skill Center, part of the Phoenix Valley’s (Arizona) Maricopa County Community Colleges, was the first EMS training program in the U.S. to incorporate NEMSIS v3 charting software into its training courses. EMCC’s EMT program adopted a NEMSIS v3 ePCR for educational use back in 2014. According to Jennifer Kline, Assistant Program Manager:
“We teach and stress to our students the importance and relevance to quality documentation. The documentation that we provide for each and every call is a direct reflection of the care in which we have provided to our patients. So we have our students ask themselves, ‘Do you want to be perceived as a good clinician who advocates professionally for your patient by providing quality care, or do you want to reflect that you are a poor clinician who takes short cuts and does the bare minimums and doesn’t care about the overall outcome?’ With this in mind, our students take their documentation very seriously. We have implemented an interdisciplinary approach in which we have the EMT students write their ePCR and it then gets routed through the QA and billing process. The EMT instructors do clinical QA and the Medical Billing and Coding students code it.”
Half a world away, independently but in parallel with EMCC’s efforts, the Griffith University School of Medicine’s Paramedicine Program in Queensland, Australia (directed by Duncan McConnell, seen below), is among the first — if not the first — non-U.S. EMS degree programs to incorporate ePCR into prehospital training as “a great way to close the loop in patient care education.” Griffith University chose MEDIVIEW by Beyond Lucid Technologies as its charting technology because of the software’s ability to selectively activate or deactivate the various components of the record, so that each student is exposed to a particular portion of the chart in turn, to coincide with his or her training. During the 2017 International Roundtable on Community Paramedicine, Professor McConnell described how his program is using ePCR technology in the portion of their EMS course that focuses on respiratory care:
“Most recently, they [the students ] completed their 2nd year respiratory assessments, where they went in as teams to do a respiratory assessment on a patient, be it asthmatic, anaphylaxis, COPD, a couple of pediatric cases. They were randomly picked, and once they completed …that end of semester assessment, they then had to complete this for their patient and then hand that in, and that was the end. Along with our ePCR…and working in a WiFi network within a university…we have the ability to start introducing the students to future technology. We’re going to send that ECG up to the medical students or the emergency department as they’re bringing that simulated patient in. We’re going to send that ePCR up to them as well so that when they’re doing the receiving, the handoff of that patient, they’ve already got a bit of an idea of what’s happening to the patient, what’s been done treatment-wise, and what to expect when they walk through the door….If something big happens between when they start to when they graduate, what do we need to do to re-contextualize that program, so they’re on board and their graduating at the same level as what they’re walking out to — not graduating with something that we haven’t done years ago.”
According to Darrell DeMartino, Assistant Professor & Clinical Coordinator in the Paramedicine Department at St. Louis-based (Missouri) Lindenwood University, his department needed a tool for students to use “both in the classroom (i.e., mock patient data) and in a clinical setting (where there are real/live patients),” where they “focus on documenting the situation, history, care provided. We currently do this on paper today.” But pedagogy is as much an art as a science, of course, and the most innovative Fire and EMS educators — like all teachers — constantly seek ways to keep their students engaged, especially when the stuff of learning gets “dry” and detailed. Some, like Art Groux, the Suffield (Connecticut) EMS Chief & Emergency Management Director, and President of the Connecticut EMS Chiefs Association, have devised ingenious methods to liven up ePCR simulation and training: Suffield EMS invites its crew to craft absurd scenarios as a way to explore the content and layout of a new ePCR, then awards a small prize (say, a logo wear sweatshirt) to whoever creates the most insightful record. One winner featured a happy ending: ROSC to an inebriated squirrel that got caught in the spokes of a bike wheel before suffering cardiac arrest…a “nutty” case review, indeed!
3. Unexpected Findings: Prehospital data provides a robust view of what’s actually happening
Fire and EMS are rightfully proud professions. Practitioners thanklessly save lives and property every day, often for far less money than is warranted given their bravery and skill. As such, it is relatively uncommon for agency leaders or field crews to ask themselves challenging reflective questions like “How much of our success today was due to luck?” Or “How often did we get make the wrong call?”
Such questions make the profession better, and researchers — as well as politicians — from across the U.S. and even around the world (budget pressures for EMS agencies in the U.K. were highlighted at the 2017 International Roundtable on Community Paramedicine) — are digging into the question of whether EMS agencies’ self-assessments are on-par with what the data show. The mind-bending book Freakonomics taught readers that perceptions and mathematical reality often diverge when data lead the discussion. EMS agencies are asking similar questions, and inculcating the need for verifiable insights from Day One in training: How often do mismatches occur between prehospital care providers’ assessments and hospitals’ ultimate diagnostic finding? What are the impacts of such mismatches?
When assessing a patient’s heart health (e.g., using a cardiac monitor-defibrillator), students learn to “treat the patient, not the monitor,” since cardiac monitors provide critical insights but the patient’s experience is paramount — and monitors occasionally incorrect. Ronnie Ikeler, Director of EMS at Tomball (Texas) Regional Medical Center similarly advises young Fire and EMS professionals to “treat the patient, not the software.” But he has also noted that his own organization frequently invests hours — sometimes as much as 45 days — in a struggle to reconcile details about a transported patient whose information was incomplete at the moment handoff to the care facility. Without strong upfront data collection and transmission by crews from the field, it is virtually impossible to know how closely an EMS provider’s assessment of the patient matched the care facility’s findings. Such data are also critical to the management of Fire and EMS agencies because frequent material divergence between the opinions of the prehospital and in-hospital care providers may subject the agency to legal liability, and subject the patient to clinical risk (such as avoidable adverse events). Nevertheless, as revealed by the Fire and EMS literature, a divergence between perception and reality are far from uncommon:
· A 2017 study in the West Journal of Emergency Medicine found that patients were under-triage from 3% to 32% of the time, with one study describing “a cohort of under-triaged patients, who EMS professionals felt did not require transport to the ED for care, and who subsequently required admission to the hospital (18%), including a subset who required admission to the intensive care unit (6%). These studies also revealed poor agreement between EMS professionals and emergency physicians about who required transport to the ED for care.[i]
· A 2009 study of prehospital stroke ID in San Francisco found “96 patients…of whom 81 met the diagnosis of acute stroke or TIA. Paramedics identified 49 of these 81 patients (sensitivity 61%). 15 patients were identified as having a stroke…ultimately had a different diagnosis.”[ii]
· A 2008 study in San Diego found that “of 477 patients with a paramedic assessment of stroke using [the Cincinnati Stroke Scale (CSS)], 193 had a final discharge diagnosis of stroke,” for a “sensitivity of 44% and a positive predictive value of 40% for paramedics using CSS.”[iii]
· A 2013 presentation by Patricia Frost, Director of Contra Costa County’s (California) EMS Agency, found that the county health system spent as much as $480,000 on false activations of the county’s catheterization labs, up to 40% of the time, at a cost of $5000 per false STEMI activation. Yet the County congratulated itself on what it called “STEMI 12 lead System-Wide Success,” presumably because its leadership thought that the results could have been worse.[iv]
These error rates underscore the urgency of training crews to leverage ePCR for process improvement from the earliest days of prehospital training. Optimistically, though, EMCC’s Professor Kline sees reason for excitement about the power of ePCR technology to facilitate the long-sought vision of an informed, integrated prehospital ecosystem that simultaneously centralizes the role of Fire and EMS as the logistical-clinical “glue” that connects the healthcare system for both acute and chronic patients:
“The students, both EMT and Medical Billing and Coding get real life work experience while in the classroom and are able to make mistakes, debrief, receive feedback and make corrections. Watching the level of engagement from the students and the ownership they take in their documentation is both rewarding and refreshing. The students are more prepared to enter the workforce and have formed good habits that their future employers would value. This is how we know we are successful!”
[i] Sawyer, NT and Coburn, JD. “Community Paramedicine: 911 Alternative Destinations Are a Patient Safety Issue.” West Journal of Emergency Medicine. 2017 Feb; 18(2): 219–221. Published online 2017 Jan 20. (Accessed online 10–18–2017) < https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5305127 >
[ii] Smith, W., Isaacs, M., and Corry, M. “Accuracy of paramedic identification of stroke and transient ischemic attack in the field.” Prehospital Emergency Care. 2 July 2009. (Accessed online 11–2–2017) < http://www.tandfonline.com/doi/abs/10.1080/10903129808958866 >
[iii] Ramanujam P1, Guluma KZ, Castillo EM, Chacon M, Jensen MB, Patel E, Linnick W, Dunford JV. “Accuracy of stroke recognition by emergency medical dispatchers and paramedics — San Diego experience.” Prehospital Emergency Care. July-Sept 2008. (Accessed online 11–2–2017). < https://www.ncbi.nlm.nih.gov/pubmed/18584497 >
[iv] Frost, P. “Contra Costa County Data Infrastructure Project.” 25 November 2013.