The Missing Link

April 10, 2013
Albert Villarin, M.D. For many hospitals, the majority of admissions come through the emergency room. And if a patient is delivered by ambulance,
Albert Villarin, M.D.
For many hospitals, the majority of admissions come through the emergency room. And if a patient is delivered by ambulance, what happens to clinical information gathered in the ambulance before the patient hits the ED? So far, work being done in this area has been focused on defining the standards for the information exchange between the point of care first responder and the hospital — and increasingly, from the primary physician's office or the patients themselves. But there are many obstacles that must be overcome before hospitals can extend the electronic continuum of care from before the patient's arrival to the time the ambulance pulls up to the door.
Todd Rothenhaus, M.D.
The Centers for Disease Control and Prevention (CDC, Atlanta) estimates that there were over 110 million emergency department visits in 2004, making the ED chart one of the most important medical records in the hospital. Today, the pre-hospital emergency department record is largely paper based. “The guys in the back of an ambulance are delivering life-saving care,” says John Halamka, M.D., CIO of Boston's Beth Israel Deaconess Medical Center and Harvard Medical School — and an emergency physician himself. “There's not a huge amount of electronic documentation going on during the ambulance run at this time.” The one exception, he says, is some telemetry EKG information that can be sent wirelessly to the ED.

“There's no question that this is a huge demand,” says Albert Villarin, M.D., CMIO of Albert Einstein Healthcare Network, a two-hospital network in Philadelphia. Villarin, like Halamka, is also an emergency physician. According to Villarin, a big problem with first responder interoperability are potential implications that may arise down the road because each state is creating its own law to promote the exchange of information from the EMS crew to the hospital. The standards, he says, are “being facilitated by each state and each EMS network independently, and they're picking what they think is best.”

In Villarin's ED at Einstein, EMS workers often finish the report after they leave the ED and fax it to the trauma area, where the secretary puts it in the chart. “Unfortunately, if something goes wrong and it's not documented at the time of action, there may be a discrepancy between what actually happened and what's documented by the EMT,” Villarin says. The only “system” in use with the ambulances is the telephone — with live interaction between an ED physician at base command in the hospital and the ambulance.

According to experts, the closest hospitals get today to incorporating the EMS record into the EDIS is scanning the pre-hospital document into the ED system or downloading it from an EMS tablet in the emergency room. “It's not an interoperable piece, but it is available to the providers,” says Todd Rothenhaus, M.D., an emergency physician who is senior vice president and CIO of six-hospital Caritas Christi Health Care System in Boston. “There are now quite a few EMS systems for documenting care rendered by the pre-hospital care providers,” he says. “In Boston, the pre-hospital providers walk around with Panasonic (Knoxville, Tenn.) Toughbooks.”

Unfortunately, he says, the penetration of EMS systems is fairly low — and they are paper products that does not flow information into the EDIS. The tablets can communicate wirelessly to their own servers, however, and the information is available securely to caregivers via the Internet.

Villarin uses a similar tablet system in Philadelphia, where he says Hewlett-Packard (Palo Alto, Calif.) had the contract for data entry on tablets. Once in the ED, “it gets synched up and prints a hard copy,” he says.

With these types of systems, says Rothenhaus, it's important to consider patient information bi-directionally — that means also coming to the ambulance from the hospital or physician office. “Specifically, I don't know of anyone anywhere who's doing anything besides scanning the document,” he says. “It's really new stuff.”

Changes on the way

But it may not be for long. There is a tremendous body of work being done through standards organizations like HITSP (The Healthcare Information Technology Standards Panel, administered by the Washington-based American National Standards Institute in cooperation with partners such as Chicago-based HIMSS). Halamka is HITSP's chairman and is actively involved in formulating first responder standards. “What we've done through HITSP is specified all the electronic standards, including information going to the ambulance, so that a first responder can get data from hospitals and doctors' offices, as well as transfer information to the hospital on arrival,” he says. “All those standards have been specified.”

Rothenhaus has also been active in working on interoperability protocols through his work with NEMSIS (National EMS Information System, Salt Lake City), a private-public consortium that has created an XML scheme for documenting pre-hospital care. Last year, says Rothenhaus, NEMSIS began work on making the XML standard official.

Though none of these standards are in use anywhere yet, there are still more problems with interoperability to be dealt with. “Every hospital network has its own EMR project, and sometimes the base platform that EMS uses does not communicate well with the EMR,” Villarin says. “As we move to speaking the same language, there's going to be a push for those EMS systems to speak our language.”

Rothenhaus points out yet another hurdle — the EDIS itself, which often operates as a best-of-breed system separate from the enterprise EMR. “Not only are all the ED systems different, they are often different from the rest of their own hospital,” he says.

Integrating the Health Enterprise (IHE), a global initiative of healthcare professionals that promotes and coordinates use of established standards such as DICOM and HL7, created an integration profile called ED/EHR where all the documents having to do with emergency care are kept. “Where we are right now is we have the XML standard for the pre-hospital record, but we have not harmonized that so we can get data from the patient care record into the ED system,” Rothenhaus says. “And that's the work that is being done right now.” He adds that ED interoperability is also on CCHIT's (Certification Commission for Healthcare Information Technology, Chicago) roadmap, but it probably won't be addressed until at least 2011.

Most experts in the space agree that having patient information available to pre-caregivers is going to have a positive effect on patient care. “From a Katrina standpoint, wouldn't it be nice if you have your health info available?” asks Halamka. He says he believes that in the near term, the industry is more likely to see information from hospitals and physician offices available electronically in the ambulance. “The idea that an ambulance will send a medical record to a hospital, that's going to take some time.”

And that concept of having health information available to first responders extends to the patient's personal health record as well. “You're starting to see companies like CapMed (Newtown, Pa.) putting personal health records on USB drives,” Halamka says. “Patients who feel like they want to manage their own data could offer that information to first responders.”

So where does that leave a CIO who might not even have an EDIS in the first place — or is considering an enterprise versus best-of-breed system in the ED? “CIOs need to be aware of this issue,” Rothenhaus says. “I think most CIOs are sensitive to the fact that to deploy an EDIS system well, it needs to be very integrated — and they need to think about more than lab and ADT and radiology.” He says in particular that some of the EDIS vendors are fairly small, and that may affect their horsepower when it comes to pre-hospital information interoperability.

Though the pre-hospital record is still on the horizon for most hospitals, the future is moving ahead quickly.

“I think we're at a nice tipping point now that we've got standards,” Halamka says. “We're going to see products coming on the marketplace, and I think next year we'll see a lot more adoption.”

Healthcare Informatics 2009 January;25(13):20-22

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