“EMS Electronic Health Records – An Opportunity for Integration to Improve Care” Commentary on Kamta et al.

This article refers to:

Improving Emergency Medicine Clinician Awareness of Prehospital-Administered Medications

The team from the University for Rochester, publishing in this issue, is to be complemented for attempting to create a pathway for identification of EMS interventions to guide care of patients in the ED (1). They made good use of a PDSA cycle and shared their failures as they attempted to develop better care for EMS patients who received corticosteroids. They attempted through policy and program development to improve ED interventions. The intervention failed, yet yielded a valuable lesson.

What these researchers identify, and act on, is the need to make sure we are integrating all possible data to optimize patient care. Unlike most other countries, in the US, we use multiple different documentation platforms, teach disparate documentation styles in EMT classes, and then attempt to coordinate the data through NEMSIS, the National EMS Information System database (2). NEMSIS relies upon hundreds of discrete variables being accurately entered into different software packages to create a single dataset that can be then used, at the local, state, or national level, to identify public health trends. This system is not designed to care for patients. In fact, reporting systems centered on single encounters typically focus on the data required for reporting to the government and to billing companies. This approach does not typically allow for information sharing or clinical improvement efforts (3).

If we take a patient-centric approach to data, EMS, which is the first chapter of the story of nearly every critical patient encounter, should have continuity with the rest of the health care continuum. In fact, when one EMS leader asked the AI tool ChatGPT what should be done to improve EMS in the United States, one of the five responses was, “Integration with other health care providers: Coordination and collaboration with hospitals, primary care providers, and other health care providers can help to improve the overall quality of care provided to patients. This can include sharing patient data and providing follow-up care.” (4) Yet in spite of this, when major hospital systems implement electronic health records (EHRs), they frequently fail to integrate actionable EMS data.

In 2015, the president of the Emergency Nurses Association, Matthew Powers, said, “one key to determining a community’s emergency care needs is the collection and analysis of prehospital data…an important aspect is the handoff between prehospital providers and inhospital clinicians” and “the most important attributes of any organized [health care] system … [is] the records necessary to meet the needs of our patients and their families.” (5) Unfortunately we still fail to collect and assimilate this data effectively. Dorsett et al. focused on duplicate corticosteroid dosing, yet the importance of knowing the care provided prior to arrival at the hospital is equally important for all of our patients. Emergency department caregivers must act based on the interventions that have already occurred, as must the other clinicians who follow. For primary care clinicians, integration of the data into an accessible format may also assist in the care of patients who don’t come to the hospital, including older patients who fall, patients with diabetes who were hypoglycemic, or patients with opioid use disorder who received naloxone (6–13).

Electronic health information exchange (HIE) allows clinicians and patients to appropriately access and securely share a patient’s vital medical information electronically—improving the speed, quality, safety, and cost of patient care (14). However, these are designed to allow access to information, not to improve care through data integration. In fact, HealthIT.gov identifies three different forms of data transfer through HIEs (directed, consumer-mediated, and query-based), none of which are true integration (14). We maintain this separation to our peril, as each of these requires action on the part of the next caregiver. If we need to go hunting for something we will never be as successful as if it were presented to us.

When a hospital moves to a new EHR, the staff should work with the local EMS agencies to develop bidirectional record exchange (8). Ultimately, the impetus for integration of EMS records into a bidirectional EHR could come from a mandate through the Centers for Medicare and Medicaid Service, state regulators, the Joint Commission, the American Heart Association or American College of Surgeons as part of hospital certification, from hospital systems recognizing potential value, or even from the EHR industry itself. EMS clinicians and patients should demand this, as quality assurance, protocol development, and clinician education cannot exist without knowing patient outcomes, and no EMS patient care occurs in a vacuum. For hospitals this would ultimately be an investment in the care of their patients, and would decrease readmission rates, increase patient and clinician satisfaction scores, and improve care. A bidirectional application programming interface in the EHR build in Rochester would have created a therapeutic duplication warning for the patients who received dexamethasone, and would have potentially have prevented administration of the additional dose. Seamless data exchange has been demonstrated with the military, and others (15–18). In 2001, the Institute of Medicine established six aims, or domains, of health care quality: safe, effective, patient-centered, timely, efficient, equitable – and bidirectional EMS data exchange satisfies all of these. It is possible.

Bottom line for professional EMS leaders across the country? We must demand that the entirety of a patient encounter exist as a single record for emergency care, ongoing health maintenance, and anonymized public health data collection. We must accept that the differences we treasure in our independence are less disparate than we would like to admit. It has been said that EMS lives in the intersection of emergency medicine, public health, and public safety (19). EMS leaders must make sure that the data they collect are supporting these three missions, adding a view to public policy so that we can influence chance and improve outcomes across the populations we serve (20). However, our primary goal remains taking care of the patient in front of us. Bidirectional data sharing will help ensure that the expert interventions EMS clinicians bring to the patient at the time of crisis will help inform and improve ongoing care.

Michael W. Dailey
Department of Emergency Medicine, Albany Medical College
[email protected]
Warren Hayashi
Department of Emergency Medicine, Albany Medical College

Disclosure statement

No potential conflict of interest was reported by the author(s).