The Importance of Data to Make Prehospital Interventions (Even) Better: A Letter to the Editors of the Wall Street Journal.
Response to “The Hospital Is No Place for a Heart Attack” by Ron Winslow. Wall Street Journal, 2 February 2015.
To the Editors of the Wall Street Journal, and Mr. Winslow:
Regardless of one’s opinion of the Affordable Care Act, particularly its thornier elements (such as individual and corporate mandates, plans that don’t qualify, etc.), the elimination of wasteful spending on care that never happened has been like a welcome appendectomy to most of the country — in other words, it felt painful but the results have been worthwhile. The ACA’s readmission prohibitions keep people from unnecessarily visiting emergency departments, which ultimately will prove to be a positive, whether scored according to reduced hospital overcrowding or greater availability of ambulances and paratransit vehicles, along with a bevy of other applicable quality metrics.
As Mr. Winslow points out, one byproduct of the imperative to keep people from unnecessarily returning to the emergency department is a motivation to leverage technology to identify patients who need to be transported and who don’t — then to prep for the arrival of either one. (In the hospital-doctor-nursing world, this model is called “Accountable Care.” In the emergency medical services world, it is called “Community Paramedicine” or “Mobile Integrated Healthcare.” In the words of one physician, “the ACO model, with its emphases on innovation, collaboration and quality, could be the most viable framework for bringing CP into the Acute Care Continuum.”)
Eventually, when technology says “Treat this person!” resources will be ready to do so upon arrival at the hospital. Patients will be matched with providers will be match with facilities will be matched with records will be matched with facilities, all ready and waiting. Or, there will be an alternative means to interject the right level of care, keeping what could be a routine wellness check from morphing into a cost- and time-sink in the hospital.
But slashing the waste that plagues emergency medical services — specifically, the burden of $3 billion in annual “uncompensated care” (per Troy Hagen, immediate past president of the National EMS Management Association) that most Americans don’t even know they are paying for, and that sat at the heart of the Supreme Court’s decision to view healthcare mandates as a tax — goes beyond convincing patients that calling 9–1–1 is not the most effective conduit to care. We must also ask whether our EMS providers have the tools to maximize their responsiveness.
For example: Mr. Winslow points out that “thanks to major initiatives launched a decade ago, most hospitals have sharply reduced the time to treatment for patients who suffer a heart attack outside the hospital. When an electrocardiogram, or ECG, reveals a major heart blockage, it activates a set plan designed to get the blockage causing the heart attack cleared as quickly as possible.”
Yet as a society and an industry, our emergency medical infrastructure has a distance to go before it can be called robust, not just reactionary. Mr. Winslow highlights “the heart attacks at issue…called STEMIs, for S-T segment elevated myocardial infarction, after the pattern on an electrocardiogram that is the telltale sign of a total blockage.” STEMI intervention takes place in a specialized facility called a catheterization lab. But a 2010 study published in the American Heart Journal found that hospitals in California’s Los Angeles and Orange counties suffered 20% and 23%, respectively, false activation of their catheterization labs.
Contra Costa County, where my company is based, fared worse by similar measures: Contra Costa County EMS director Patricia Frost has written that 26–41% of STEMI activations in the county were false, at a cost of $5000 per incident to the local healthcare system, including taxpayers who support the public hospitals. (The range reflects the county’s six STEMI centers.) Ms. Frost determined that eliminating false activations — a paragon of waste caused by an overreaction to missing data that serves no clinical good but errs on the side of caution — could save $480,000 per year. In just one county. By doing nothing more than avoiding expensive mistakes.
It’s not necessarily a lack of technology that drives wasteful costs, but rather a reliance on — in some cases — faulty tools; or, in others cases, a need for targeted training on how to read and react to data emerging from such devices. According to Ms. Frost, a false-positive is “a paramedic tell[ing] the STEMI Center that a STEMI has been detected on the 12-lead ECG, but upon arrival at the hospital it is determined that the patient’s 12-lead does not show a STEMI. Most of these patients do not need the urgent availability of the catheterization lab.” The Journal of the American Medical Association says “the frequency of false-positive cardiac catheterization laboratory activation for suspected STEMI is relatively common in community practice, depending on the definition of false-positive.” It would be easy, but incorrect, to blame ECG errors on prehospital personnel, because the American Heart Journal study found that “recent surveillance of ‘unnecessary’ cath Lab activations…by ED physicians demonstrated a 5% rate from a single-center experience (n = 249 activations) in Virginia and a 6% rate across 14 hospitals (n = 2,213 activations) in a North Carolina STEMI system.”
Was one of these the same hospital network that Mr. Winslow surveyed?
Emergency clinicians across the gamut — from ambulances to nursing homes to hospitals — face a reality that rarely gets discussed: without the patient’s clinical history and current context, many conditions simply look alike. UCSF researcher Prasanthi Ramanujam challenged the reliability of decision-making by medics in the field, who successfully identified stroke less than half the time. Yet Mr. Winslow reported that “at the University of North Carolina, a study of 275 STEMI patients treated between 2007 and 2011 found 40% of the 48 patients whose attacks occurred in the hospital died before being discharged, compared with a 4% death rate for those brought to the ER.” Assuming that the Affordable Care Act persists through the current Congress, and that the healthcare establishment keeps marching toward the IHI Triple Aim (“better health, better care, lower costs”), our society should mandate a fusion of technology, access to longitudinal care records, and the liberation of data to offer “perfect information” about patients…pre-arrival at the ED. The insurance value alone justifies the investment to eliminate wasteful line-items and resource shortfalls.
 Hagen T. The Value of EMS. EMS World. 1 Sept 2012.
 Rokos, IC, French WJ, Mattu A, Nichol G, Farkouh ME, Reiffel J, Stone GW. “Appropriate Cardiac Cath Lab activation: Optimizing electrocardiogram interpretation and clinical decision-making for acute ST-elevation myocardial infarction.” American Heart Journal. December 2010. 160(6):995–1003.
 Contra Costa County EMS Agency. “Contra Costa 60 Day STEMI System Review: A Great Launch with Challenges Ahead.” Accessed 15 Jan 2015. < http://cchealth.org/ems/pdf/stemi_1st_60days.pdf >. See also: Contra Costa EMS Agency. “Contra Costa County Emergency Medical Services Data Infrastructure Project.” p.11. Published 28 Dec 2013. Accessed online 2 Feb 2015. < http://cchealth.org/ems/pdf/QI-HIE-grant-report-2013.pdf >
 Larson, DM, Menssen KM, Sharkey SW, Duval S, Schwartz RS, Harris J, Meland JT, Unger BT, Henry TD. “ ‘False-positive’ cardiac catheterization laboratory activation among patients with suspected ST-segment elevation myocardial infarction.” J American Medical Assn. 2007 Dec 19. 298(23):2754–60.
 Ramanujam P, Guluma KZ, Castillo EM, Chacon M, Jensen MB, Patel E, Linnick W, and Dunford JV. “Accuracy of Stroke Recognition by Emergency Medical Dispatchers and Paramedics — San Diego Experience.” Prehospital Emergency Care. (2008) 12(3):307–313.
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Beyond Lucid Technologies, Inc., is a San Francisco-area health-and-safety IT firm that builds award-winning software to connect ambulances and hospitals…even before the patient arrives. Online at www.beyondlucid.com
By Jonathon S. Feit, MBA, MA
Co-Founder & Chief Executive
Beyond Lucid Technologies, Inc.