Data Drives Care - NAEMT

JANUARY2014
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How data collection and

use helps save lives
An editorial supplement to JEMS, sponsored by

ZOLL, Sansio, FirstWatch, Ferno and ImageTrend
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Paramedicine
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Regulatory
egulatory
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Clinical, Financial, Operational
Reporting
Taking Care to the Cloud Æ

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• c o n t ents•
4
Introduction:
The Data-Driven Paradigm
5 keys to success in the new, performance-driven,
integrative EMS environment The
By Greg Mears, MD 6 Clinical Hub
6
Saving Lives Begins Here 24
New data sources & technology transform the dispatch From the Field to the ED
center into a clinical hub Technology exists to transform patient assessment, but
By Jerry Overton standardization & regulation are needed
By Raymond Fowler, MD, FACEP
10
Safety on the Streets 28
Event data recorders, driver safety monitoring A Seamless Exchange
& traffic light control systems are key to reducing Standardizing processes & sharing data across the
ambulance crashes healthcare continuum is key to improving quality
By Dave McGowan By Mic Gunderson & Greg Mears, MD
14 32
The Case for AED Registries Beyond Traditional Response
Integrating novel strategies to measure & increase EMS data use in mobile integrated healthcare,
bystander CPR & AED use—& save more lives mass gatherings & MCIs
By Bentley J. Bobrow, MD By Jeff Beeson, DO, FACEP, EMT-P, Michael Potts,
CCEMT-P, & W. Heath Wright, BA, LSSGB, EMT-P
18
The “Perfect” EMS Event 36
What will it take to embrace the full potential Show Me the Money!
of existing & developing technology? EMS is a business, like it or not
By Greg Mears, MD By Rob Lawrence
Senior Vice President/Group Publisher Lyle Hoyt supplement editorial coordinator Greg Mears, MD
Editor-in-Chief A.J. Heightman, MPA, EMT-P Advertising Sales Cindi Richardson, Paige Rogers
editorial director Shannon Pieper Art Director Josh Troutman
data drives care: how data collection & use helps save lives is an editorial supplement sponsored by ZOLL, Sansio, FirstWatch, Ferno and ImageTrend and published
by PennWell Corporation, 1421 S. Sheridan Road, Tulsa, OK 74112; 918-835-3161 (ISSN 0197-2510, USPS 530-710). Copyright 2014 PennWell Corporation. No material may be reproduced
or uploaded on computer network services without the expressed permission of the publisher. Subscription information: To subscribe to JEMS, visit www.jems.com. Advertising information:
Rates are available at www.jems.com/about/advertise or by request from JEMS Advertising Department at 4180 La Jolla Village Drive, Ste. 260, La Jolla, CA 92037-9141l 800-266-5367.
january2014
3 A Supplement to JEMS
•introdu c tion•
The Data-Driven Paradigm

5 keys to success in the new,
performance-driven, integrative 2 EMS operations often can’t be separated
from the medicine. Other areas of healthcare are
just now beginning to figure this out, including trauma,
EMS environment STEMI, and stroke systems of care. We have known it
from the beginning. EMS must continue to evaluate,
By Greg Mears, MD evolve and integrate our operations with our clinical care
It is an exciting time in EMS system development. So and our community healthcare systems. That is the only
many external forces have driven us over the years. In way to maximize our impact on outcomes.
the 70s we were born; during the 80s we focused on
operations and their impact on patient care; during
the 90s came the development of trauma centers and
3 Outcomes are difficult to measure, but
critical to our success. There is a saying, “In
God we trust, all others bring data.” EMS is the most
the beginning of “Systems of Care”; during the 2000s, complex component of healthcare but that complex-
we focused on data systems, billing and high-perfor- ity is what allows performance improvement and
mance implementations. outcome measurement to be successful in driving
The decade leading up to 2020 will continue to our future. NEMSIS, CAD systems, electronic medical
build on these foundations, with an increased need to devices and our early adoption of electronic health
show our ability to provide quality service and patient records are incredible resources we are just beginning
care at a reasonable cost or value. to ride as we take off on this journey.
To be competitive in this new affordable healthcare
model, EMS must expand its focus beyond individual
patients to the health and wellness of the community.
4 EMS is not an island; it’s the bridge. EMS
was the first medical specialty to realize that
healthcare cannot be successful if delivered in silos.
This integration with healthcare systems, focusing on The future is in “systems of care.” We are the bridge
the needs of both the patient and the community, will to success in performance-driven healthcare across
determine our success and our outcomes. communities.
Integrative EMS service delivery also changes our
historic operational focus, from managing multiple
patient-centric events—most of which require
5 Software and devices are a part of the
healthcare team. This is a “Terminator” type of
thought, but the machines have evolved. We are in the
transport—to a community-centric approach, where middle of a paradigm shift. Devices were once tools
patients are managed based on their true clinical and in our toolbelt we used as needed in the provision of
social needs, often without transport. patient care. Devices are now much more that that—
In this new paradigm, there are five keys to our they are now a member of our healthcare team. They
success. These five things represent both the dogma provide information, guidance, insight and a level of
for the EMS 2020 movement and an organizational intelligence directly connected to positive outcomes.
approach for success. This special supplement to JEMS was designed with
1 EMS is the practice of medicine. EMS is

much more than a friend of the community or a
ride to the hospital; it is the practice of medicine. We
great thought and input from industry leaders. Its goal
is to provide an overview of how technology and data
touch each of the components of an EMS system of
are practicing medicine and have a responsibility to care. Learn why and how the incorporation of data
provide high-quality care derived from evidence-based and technology, as a member of your healthcare team,
performance measures and outcomes. is critical to success as we move toward EMS 2020.
january2014
Data Drives Care: How Data Collection & Use Saves Lives 4
ALEX GARZA MD, MPH
FirstWatch medical director
and former chief medical
ofﬁcer for the U.S. Department
of Homeland Security
Join the
Evolution
A NEW ERA of quality, value and effectiveness is taking root in
EMS—one in which information plays a pivotal role.
TRANSFORMING QUALITY
IMPROVEMENT IN EMS
The care delivered by EMS practitioners is becoming more complex.
Ensuring that care is appropriate, consistent and adds value to the BY ALEX GARZA, M.D.
patient experience is the next big challenge.
The traditional approach to QI is labor intensive and time consuming, DOWNLOAD DR. GARZA’S
FREE REPORT
leaving little time to actually “improve” care. There is a better way.
Æ
It’s called FirstPass . It monitors and analyzes patient care data,
identifying deviations rapidly, consistently and automatically. What used
to take days or weeks can now be accomplished in minutes, allowing www. ﬁrstwatch.net/fpds
agencies to see in near real-time how the system is performing.
More importantly, it frees up valuable staff time to actually work with
providers to improve the quality of care. It’s the natural evolution of an
information-driven approach to EMS
Join more than 300 agencies across the U.S. and Canada that use
real-time 911 and EMS patient data for early detection, situational
awareness, enhanced operations—and now improved clinical care.
Let us show you how FirstPass can help. Every Record. In Real Time. Automatically.
Today, the dispatch center is no
longer really a dispatch center; it
now functions as a “clinical hub.”
Photo Kevin Link
Saving Lives
Begins Here
New data sources & technology transform
the dispatch center into a clinical hub
By Jerry Overton changed. Now, with responsibilities that include
protocols for “hear and treat” and “see and
N
ot that long ago, the dispatch center treat,” and interfacing on a regular basis with
was just a room located in a basement the other components of the healthcare com-
or the back of an office, staffed by a munity, it truly can be termed a “clinical hub.”
person “trained” to answer a telephone and push To be effective and efficient in this role, accu-
a microphone button, with a data set generally rate data is needed—because data drives out-
gathered on a paper log with a pencil. Times have comes. This article will provide an understand-
really changed. ing of the diverse data sources and the uses of
One needs look no further than the “Chain data in this new world. It all begins here.
of Survival” to understand the importance of
today’s dispatch center. Immediate activation Ensuring That the First,
of response agencies, early CPR, rapid defibril- First Responder Is First
lation and early and effective ALS initiation The first point at which accurate data on any
all emphasize the need for minimizing time emergency can be captured in most systems is
and accurate decision-making. The success of when outside communications are received at
each of these important components is directly the initial answering point. However, response
impacted by trained dispatchers and the tech- time in most systems starts when the call is
nological tools at their disposal. received at the EMS dispatch center. I mention
One of the axioms of EMS response is that this now because this is “lost” data, and, more
if it doesn’t go right at dispatch, there is little importantly, a lost opportunity.
chance for the patient. In the modern world of With immediate activation of response empha-
fewer unit hours, increased demand for ser- sized as the first link in the Chain of Survival,
vice, higher expectations and stressed revenue obtaining this data is extremely important for
sources, that axiom is now: If it doesn’t go right analytical purposes. Ironically, technology may
at dispatch, there is little chance for the system. not be the limiting factor, because these centers
The dispatch center is no longer really a dis- often employ sophisticated Computer Aided
patch center. About 10 years ago, it could have Dispatch (CAD) hardware and software pro-
been termed a control center, but even that has grams. Rather, there seems to be a reticence by
january2014
Data Drives Care
many initial answering points to provide that over the next three years.1 Similar studies have
data because of the concern that it will disclose shown the accurate identification of chest pain,
a significant delay in call processing. This data seizure and stroke patients.
becomes increasingly important, however, as the Equally important for EMS systems today is
focus on response times transitions from out- the use of data by the EMD to identify the non-
puts, where arbitrary response times are mea- acute patient. This is not only feasible using a
sured and outliers penalized, to clinically signifi- structured dispatch protocol system, but peer-
cant, evidence-supported outcomes. reviewed research has proven that it can be
done—and is safe. In fact, in one study it was
“Okay, Tell Me Exactly What Happened” found that 99% of the calls triaged as “alpha,”
After capturing the address of the emergency the lowest acuity category, did not meet any
and the call-back number, the highly trained higher acuity criteria.2
Emergency Medical Dispatcher (EMD) starts This data is extremely important for the dis-
the clinical assessment of the patient in a mat- patch center. Not only does accurate triage save
ter of seconds. Similar to the paramedic’s field valuable ALS resources for the critical call, but
protocols, the protocols used by the EMD are accurate triage of these calls by the EMD can
medically approved and founded in clinical evi- provide that caller with better, more appropriate
dence. They require the EMD to interrogate the resources outside the traditional 9-1-1 system.
caller for demographics, characteristics and the For example, by linking the MPDS dispatch
patient’s general problem, and then ask further software to nurse triage software, the Louisville
specific systematized questions to determine the EMS system and MedStar Mobile Healthcare
acuity level of the patient and the proper system in Fort Worth, Texas, have safely implemented
response needed. This is all driven by data! telephone triage, or “hear and treat.”
Without a doubt, every EMT and paramedic This type of dispatch system is also a key for
reading this article has responded to a “short- community paramedicine. Without data driv-
ness of breath” call with red lights and siren, only ing the process, the community paramedic, or
to arrive and find a non-acute patient breathing advanced paramedics as they are called in Eng-
relatively normally. That can lead them to ques- land, would not be as successful as they are now.
tion the reliability of the data, if, in fact, dispatch With the rapid spread of community paramedi-
protocols are so data-driven. It is an interesting cine to the United States, it is imperative that
question with an explainable answer. the dispatch system, and clinical hub concept,
The Medical Priority Dispatch System be founded on dispatch data, and that data be
(MPDS) is the mostly widely used protocol. It clean, unbiased and accurate.
is also the most studied and has a large evidence
base to support its clinical foundation. Every- The CAD: Data, Data, Everywhere
thing MPDS does is based on data. The pencils and paper logs are long gone, hope-
First, it is important to understand that fully, replaced by all kinds of new CAD tech-
the MPDS is designed to over-triage patients nologies. In fact, in many dispatch centers, it is
because the EMD is not actually with the hard to find a piece of paper anywhere. It is all
patient and can’t see the patient. This will prob- software-driven, with complex interfaces link-
ably change as technology evolves, but for now ing the call-taking to the CAD and the CAD
it is the reality. Hopefully most people will agree to the field. With these programs, there truly is
that it is better to over-respond to the patient data, data, everywhere, and the chances of the
not in respiratory distress than to under- data being accurate are almost 100%, as long as
respond to the patient who was actually breath- it’s entered accurately—which often requires no
ing agonally and is found to be in cardiac arrest. more than a push of a button.
Second, the published peer-reviewed evidence More can now be learned sooner to speed the
shows that the MPDS process really does work. response with the right resource. In the past, most
Each action of the EMD is captured as a data dispatch programs just captured times as follows:
point within the MPDS software, resulting Call Received; Unit Alert; Unit En Route; At
in the assignment of a patient condition, or Scene; En Route to Hospital; At Hospital; and
“determinants.” Currently there are more than In Service.
300 determinants in the system. Of course, there were variations, but those were
After the MPDS system was introduced at the the basics. The data was then converted into
London Ambulance Service, it showed a 200% reports as follows, with the first leading the way:
increase in the identification of cardiac arrest Response Time; Response Time Exceptions;
january2014
Data Drives Care
Photo FirstWatch
in real time along with software like ProQA,
which provides structured dispatch protocols.
With this combination, even the “unstruc-
tured” information that a dispatcher enters into
the “notes” field can be monitored for key words
or phrases. Some centers link their phone, CAD
and ProQA data systems to interface with First-
Watch from first call ring throughout the call-
taking/dispatch process. Many EMS systems
then link that call center data to ePCR data, and
some, like Sedgwick County EMS in Kansas,
even link that to hospital data, for measurement
of performance outcomes.
Regardless of the evidence, the focus on some
semblance of a response time standard will never
be eliminated. The key will be to ensure that
there is sufficient coverage to meet a standard
and at the same time maintain resources to treat
The Los Angeles Fire Department uses a HIPAA-compliant the vast majority of the patients accessing the
“dashboard” system to monitor operational indicators such as system in an economically challenged environ-
dispatcher call-processing times, track unit locations and determine ment. With real-time data collection, interpreta-
coverage gaps. Such systems can also be used to alert the comm tion and feedback, this has become much easier.
center of the early signs of a chemical, biologic, radioactive or Understanding the possibilities is a first step,
nuclear attack. beginning when the 9-1-1 call is received. With
the appropriate interface, both the address and
Dispatch Processing Times; Unit En Route the telephone number automatically populate
Times; and Percent of No Transport. the call-taker’s screen. Within 30 seconds the
Those reports and others allowed system man- call-taker uses MPDS to process the call as life-
agers to attempt to identify outliers and hope- threatening and, using another interface, trans-
fully, make positive changes in a timely manner. fers the data to the CAD, which then automati-
That timely manner often actually meant pro- cally populates the dispatch software.
viding feedback a month or two later. With data At this point, based on available software
driving care, this would all be a little late. applications and real-time data, the dispatcher’s
A supervisor involved in strategic deployment decision becomes one based on education rather
strategies, or as it is more commonly known (and than assumption. Many EMS systems use Auto-
often despised), system status management, matic Vehicle Location (AVL) software that con-
faced even more obstacles. Hand-entered data, tinually transmits vehicle location and availabil-
maps on walls, and acetate with erasable mark- ity to the dispatch center using another interface.
ers were the tools of the day. It is no wonder the At a glance, the dispatcher knows the options.
skeptics had the advantage. By the time a system Other programs, specifically mapping, also may
status plan could be developed, it was outdated. be available to show coverage, or lack of cover-
Fast-forward to 2014 and the world of real- age, the best route for the vehicle, any obstacles
time data. With a plethora of CAD systems and that might be encountered (think bridges, trains,
software applications, the opportunity for care road work), and, based on time of day, traffic.
to be driven by data instantaneously, and in a The decision is made and the rest is a push of
“predictive” manner, is almost limitless. Again, a button. The crew is notified, the time auto-
it all begins at dispatch—the hub. matically stamped, and even the route automat-
Many communications centers, such as those ically recorded. Another push of the button by
serving Louisville; Reno, Nev.; Fort Worth, the crew on arrival at the scene and an accurate
Texas; and Richmond, Va., use FirstWatch soft- response time is recorded. Dispatch then looks
ware to monitor operational indicators such as at the real-time map again, determines both the
dispatcher call-processing times to provide 9-1-1 location of the coverage gaps and the likelihood
center supervisors and dispatchers with real- of where the next life-threatening emergency will
time feedback. Information captured by a dis- occur, and moves the remaining available units.
patcher or call-taker and entered into the CAD These actions take only seconds, and the cover-
can be monitored automatically by FirstWatch age plan remains optimized.
january2014
Operationally, the collection of data like nuclear attack, or for naturally occurring events
this quickly opens new doors for supervisors like epidemics.
and managers. Every aspect of the operation FirstWatch can also send an automated page
can be monitored and performance measured. or email, or both, to provide advance warning
Although it’s true that the focus of data collec- of an event. When I was the chief executive of
tion can be on the individual dispatcher, in a the Richmond (Va.) Ambulance Authority, for
performance-based EMS agency, the collection example, FirstWatch predicted a flu outbreak in
and use of data is best served when it is used to the city two days before the public health direc-
make system analysis easier and system changes tor received his notification. Automatic alert-
faster. Understanding the complex nature of a ing software such as this reduces workload and
dispatch center and the almost overwhelming increases awareness by automating key notifica-
responsibilities involved with the data are inex- tions for sentinel or situational awareness events,
tricably linked to better clinical care. such as the explosion of a bomb or suspicious
Clinically, real-time dispatch center data also clusters of patients that could be an indicator of
saves lives. Using mapping, or GIS, the locations an epidemic.
of past cardiac arrests can be plotted along with Where the U.S. lags is in the registry of auto-
the time of day and response times. This leads matic external defibrillators (AEDs). For
to interfacing with coverage maps, AVL and the instance, in Denmark there is a National AED
ultimate timely response. Although evidence Network that has placed an AED for every 1,100
has proven that the eight-minute response time people, and the appropriate dispatch center
standard is arbitrary, the same evidence shows knows where each is placed and can direct the
that interventions at the four- to five-minute responder to the closest location. While AEDs
mark after a cardiac arrest markedly improve clearly play a part in the chain of survival, where
survival. This is data that saves lives. they are can be a mystery without a registry. The
In addition, by combining the MPDS sys- time has come to be aggressive, and the place to
tem with dispatch notes, medical directors and link the registry is in the clinical hub.
clinical supervisors can be automatically noti-
fied of specific clinical events, including car- Driving the Chain
diac arrests, chest pain or high-risk pregnancy. With the changes in dispatch technology over
Combining this dispatch data with the data col- the past 10 years, one can only speculate about
lected on board the unit, such as 12-lead EKG or the future. Whatever the direction, the concept
specific PCR documentation, can create quick of the chain of survival and the need for speed
and effective quality improvement loops. will remain as new methodologies, medications
and techniques are discovered. For these new
Expanding the Clinical Hub elements to reach the patient, the dispatch clini-
Data can also play a part in driving clinical care cian will need the best data available to initiate
through the use of non-traditional applications all links in the chain. It all starts at dispatch. ✚
within the clinical-hub concept. The following
are but two examples. Jerry Overton serves as the chair of the International
The threat of anthrax terrorism following the Academies of Emergency Dispatch, the organization
events on Sept. 11, 2001, along with the SARS charged with setting standards, establishing curricu-
outbreak experienced by Toronto EMS in 2003 lum and conducting research for public safety dispatch
and the more recent panic when it was believed worldwide. Previously, he served as the president/CEO
that H1N1 would create the biggest influenza for Road Safety International, CEO for the Richmond
epidemic since 1919, clearly demonstrated the (Va.) Ambulance Authority and chief executive of the
need for syndromic surveillance. The U.S. is Kansas City, Mo., EMS system. As an expert in EMS sys-
unique in that it has real-time detection tech- tem design and response deployment strategies, Over-
nology developed by FirstWatch that uses trig- ton was named one of the 20 most influential leaders
ger alerts based on accumulated MPDS data to in EMS by JEMS magazine.
detect possible disease outbreaks.
FirstWatch data, which uses secure processes References
and meets HIPAA requirements, is presented on 1. Heward A, Damiani M, Hartley-Sharpe C. Does the use of the
Advanced Medical Priority Dispatch System affect cardiac
“dashboards” so users can instantaneously see arrest detection? Emerg. Med. J. 2004;21(1):115–118.
the status of any dataset. FirstWatch is also set 2. Hinchey P, Myers B, Zalkin J, et al. Low acuity EMS dispatch crite-
by many systems to alert the comm center of the ria can reliably identify patients without high-acuity illness or
injury. Prehosp Emerg Care. 2007;11(1):42–48.
early signs of a chemical, biologic, radioactive or
january2014
Data Drives Care
Safety
on the Streets
Event data recorders, driver
Photo Chris Swabb

safety monitoring & traffic
light control systems are key
to reducing ambulance crashes
lance crashes are the number one cause for pro-
By David R. McGowan, ASHM vider deaths and injuries and the resulting finan-
cial burden is nearing $750 million annually.2,3
Unlike our colleagues in the aviation industry,
I
f a proposal by the National Highway Traf- however, we don’t have enough data to pinpoint
fic Safety Administration (NHTSA) is suc- all the contributing factors of ambulance crashes.
cessful, by 2014, all new vehicles sold in the
U.S. will be required to have event data recorders Catching Up with the Clinical Side
(“black boxes”) installed. In fact, a recent report Without data, and the means to collect, inter-
by the New York Times estimated that this technol- pret, recommend and report it, improvements
ogy is already standard on 96 percent of all new will be slow or non-existent. EMS is a dynamic
cars and light duty trucks.1 In passenger vehicles, industry and the strides it has made to date to
the event recorders will capture specific data to improve patient care and outcomes could not
assist law enforcement in their investigation to have happened without robust and accurate
determine culpability in crashes. Fourteen states data. Electronic capture of this information and
now allow access to the data via warrant. its communication to data sources is seamless
The data contained in these recorders will and relatively effortless today.
eventually find its way to safety researchers to In the U.S., organizations such as NEMSIS
assist in designing safer vehicles. It’s unknown and CARES provide clinicians and leaders with
how or when the data will go beyond technical accurate and concise data to help improve their
research and into other “legitimate” interested efficiencies and clinical outcomes. With regard
parties—it’s not a matter of if, but when. to patient safety, several organizations now allow
Black boxes aren’t new technology; the aviation for anonymous event reporting and data analysis
industry began using a first-generation device that can be used to develop policies and training
in the 1940s. In 1965, all commercial airliners programs that will prevent unsafe patient events
were required to have a voice and data recorder industry wide. E.V.E.N.T (EMS Voluntary Event
installed on all their aircraft. These flight record- Notification Tool) is an excellent example.
ers assisted in the investigation of air crashes and Unfortunately, ambulance crash data has not
provided invaluable information that has shaped evolved at the same pace as clinical and opera-
the safety standards in commercial aviation. It’s tional metrics. Crash data in the U.S. is largely
no coincidence that travel by air today is the saf- collected by state government agencies and for-
est mode of transportation by distance traveled. warded either by request or mandated to federal
As EMS emerges from the days of Cadillac agencies for their review.
ambulances, it’s becoming obvious that in spite Each state is unique in the data it captures;
of the advances in equipment, training, lead- some don’t even have a vehicle classification
ership and clinical oversight, EMS staff, their for ambulances. On the federal level, one of the
patients and the public are still at a risk. Ambu- most widely respected organizations is NHTSA.
january2014
Within the organization there are several other
groups that receive and analyze crash data: the
Image ZOLL
National Automotive Sampling System, Special
Crash Investigators State Data System, Crash
Outcome Data Evaluation System and the Fatal
Accident Reporting System.
Beyond the scope of data that each of these
organizations collects and analyzes is another
subset of data that is not retrieved. Ambulance
providers now have a powerful tool to collect data
and change unsafe driver behavior. Just like the
event data recorders found in aircraft and pas-
senger vehicles, EMS and fire organizations now Intelligent dispatch systems that track fleets by
can install safety devices that are engineered to GPS are constantly collecting data: vehicle speeds
be deployed in emergency vehicles. Such devices by location, day of the week and time of day. By
are similar to the black boxes found in aircraft; “learning” this information, dispatch systems can
they record vital vehicle operation inputs such as provide preferred routes to a given call, reducing
speed, g-forces, engine RPM, seatbelt usage and response times and fuel consumption.
the operation of a backup spotter, lights, sirens,
turn signals and brakes. There are two advanced identification—to proactively stop factors
capability “black box” systems available to EMS leading to aggressive and unsafe driving.
operations today: Ferno’s Acetech system and • Reliability. Many vehicle safety products are
ZOLL’s RescueNet Road Safety System. primarily focused on large fleet applications
The data from these devices are constantly such as commercial vehicles and mass tran-
downloaded, reviewed and interpreted by trained sit. Is the vehicle safety technology proven
individuals. The data that is collected not only to withstand the rigors of EMS? How long
measures vehicle, but driver performance as well. has the technology been successfully used
The system provides an instant audible alert to in accident investigations and litigation? Are
the driver if unsafe driving parameters are closing customers willing to vouch for the system’s
in or exceeded, which effectively changes behav- performance and financial impact?
ior. These parameters are user-defined, which • Designed to grow as EMS evolves. Will the
allows for flexibility determining the scope and technology expand in functionality as the
location of the provider. EMS agency grows (e.g., wireless communica-
The systems use an algorithm to score indi- tion and software application technologies)?
vidual drivers to determine if they are compliant How committed is the technology vendor to
with agency driving policies. It measures miles the emergency response industry? When fea-
driven and then calculates the number of viola- tures are added to the system, how disruptive
tions (speed, high g-forces, seatbelt not fastened is this upgrade to the EMS operation?
and no spotter for reverse operation) and pro- • Emphasis on safety training. A committed
vides the driver with a score between 1 and 10 technology vendor will act as a partner to help
(the higher number being less unsafe). Service guide and instill safety practices throughout
operators will determine a minimum number an organization—not as an afterthought.
that all drivers must meet. What services are offered to ensure that the
Having this data available has other far-reach- vehicle safety system is used to its full poten-
ing benefits. If the ambulance is involved in a tial? What guidance is offered to customers
crash, the data from the vehicle can be used to to implement best practices?
factually dispute false claims by other parties. • Implementation and support. How sea-
The same is true when speeding complaints or soned is the team that will install, train staff
semaphore violations are received from the pub- and support the vehicle safety system? Were
lic. The data will confirm or refute the claim. past customers satisfied with the implemen-
When evaluating and selecting a vehicle safety tation process?
question, consider the following factors:
• Focus on safety of first responders. Vehicle Reporting & Sharing
safety technologies must monitor key safety As of today there is no voluntary reporting of
parameters—including backup spotters, lights ambulance crash or driver safety data to any orga-
and sirens, seatbelts, turn signals and driver nization. Service operators do not want to allow
january2014
Data Drives Care
this information to fall into the wrong hands that otherwise would be congested with heavy
because it could have deleterious effects on the traffic or numerous intersections. In predictive
organization. Withholding this information, dispatch systems, the data can enhance dynamic
however, will only delay the progress of achieving vehicle deployment by placing ambulances in
a much safer medical transportation mode. positions that historically have the highest call
Our colleagues in the aviation industry have volume by time of day and day of week.
this figured out, and its success is well docu- Getting an ambulance closer to a call not only
mented. The Aviation Safety Reporting Sys- reduces response times, it enhances efficiency
tem (ASRS) is a confidential, voluntary and and reduces fuel consumption. From a safety
non-punitive organization that allows submis- aspect, an ambulance that does not have to travel
sions from all aviation sources. Where EMS has a great distance and avoids heavy traffic is less
E.V.E.N.T., their submissions do not include likely to be involved in a potential crash.
ambulance crash information to the degree that
can be impactful. Continuous Improvement
A relatively new organization in EMS that is Data drives EMS leaders to make informed deci-
taking strong strides to mirror that of ASRS is sions, relying on facts rather than conjecture.
the Emergency Medical Error Reduction Group The data gleamed from the above technology,
(EMERG). EMERG’s mission is to facilitate a when combined with PCR, dispatch, billing and
cultural shift within EMS to embrace a fully scheduling data, provide agencies the essential
integrated, rapid and continuous improvement information to evaluate performance and make
effort that reduces the occurrence and impact of improvements if warranted.
accidents and preventable errors on providers, As this data become more readily available,
patients and the populations served. As a U.S. EMS services have an obligation to share it with
federally certified patient safety organization, non-profit EMS improvement organizations,
EMERG may be the right destination for our who in turn can benchmark performance and
ambulance crash and event recorder data. identify best practices.
With much talk about pay-for-performance as a
Other Response Technologies reimbursement model for EMS in the future, how
Another device that has successfully improved an EMS system performs and its percentile rank-
vehicle safety controls the signal lights at an inter- ing in key areas will be critical to its revenue stream.
section. Developed more than 35 years ago by 3M Aside from clinical performance, a key metric that
in St. Paul, Minn., Opticom (or Emergency Vehi- should not be overlooked is patient injuries due to
cle Pre-emption) has a proven record of reducing an ambulance crash. Vehicle event data will be a
intersection crashes for emergency vehicles. This significant driver of these rankings. ✚
signal priority control system eliminates right-of-
way conflicts at intersections. As emergency vehi- David R. McGowan, ASHM, has more than 34 years of
cles approach the intersection, an emitter on the experience in EMS, serving as a clinician and adminis-
vehicle sends a signal to the traffic control proces- trator for fire- and hospital-based services. He is an
sor. The processor then changes the intersection accomplished expert in ambulance safety initiatives and
signals to stop all traffic with the exception of a presenter at several national EMS conferences on the
the direction the emergency vehicle is traveling. If topics of ambulance safety and the culture of safety in
another emergency vehicle approaches the inter- EMS organizations. McGowan is currently employed with
section from another direction, a white signal ZOLL as a consultant for their Road Safety System. He
light located on top of the signal stanchion will can be reached at dmcgowan@zoll.com.
flash or remain on, indicating which vehicle has
priority in the intersection. This system now uses References
GPS technology to trigger the system where line 1. Trop J. (July 21, 2013) A black box for car crashes. New York Times.
Accessed Oct. 22, 2013 from www.nytimes.com/2013/07/22/
of sight to the intersection is hindered. business/black-boxes-in-cars-a-question-of-privacy.html?_r=0.
In addition, data derived from GPS systems 2. Grant CC, Merrifield B. (September 2011) Analysis of Ambulance
has improved efficiency and safety for EMS and Crash Data: Final Report. The Fire Protection Research Founda-
tion. Accessed Oct. 22, 2013 from www.nfpa.org/~/media/files/
fire organizations. Intelligent dispatch systems research/research%20foundation/rfambulancecrash.ash.
that track fleets by GPS are constantly collecting 3. National Highway Traffic Safety Administration. (n.d.) The economic
data: vehicle speeds by location, day of the week burden of traffic crashes on employers: costs by state and
and time of day. industry and by alcohol and restraint use. Publication DOT HS
809 682. Accessed Oct. 22, 2013, from http://www.nhtsa.gov/
By “learning” this information, dispatch sys- people/injury/airbags/economicburden.
tems can provide preferred routes to a given call
january2014
Data Drives Care
iStockPhoto/jsteck
The Case
for AED
Registries
Integrating novel strategies
to measure & increase bystander
CPR & AED use—& save more lives
By Bentley J. Bobrow, MD Because time is so critical in cardiac arrest,

immediate bystander action is the cornerstone of
B
maximizing the effectiveness of subsequent EMS
ystander CPR is a critical link in the and hospital interventions and ultimately survival.
chain of survival. It has been shown
to more than double a victim’s chance
of surviving an out-of-hospital cardiac arrest
(OHCA).1 Using an automated external defi- of survival depends on the preceding links—the
brillator (AED) in addition to performing whole is greater than the sum of the parts.
bystander CPR further improves the chances Because of this, EMS (in fact, our entire
of survival.2 Yet, both bystander CPR and AEDs healthcare system) has a vested interest in the
are not provided in a majority of OHCA events.1,2 delivery of care before the arrival of professional
Because time is so critical in cardiac arrest, rescuers on scene. Everything EMS does to
immediate bystander action (calling 9-1-1, per- improve the readiness of lay rescuers (training,
forming CPR, and early defibrillation) is the public awareness, 9-1-1 pre-arrival instruction,
cornerstone of maximizing the effectiveness of assistance locating AEDs, etc.) will pay heavy
subsequent EMS and hospital interventions dividends in an increased survival rate in our
and ultimately survival. This is especially true in communities.
rural and congested urban areas with prolonged
response times. Measuring Interventions
Bystander CPR lengthens the duration of There is wide and unacceptable variability in
ventricular fibrillation (VF) and provides criti- cardiac arrest outcomes between communities,5
cal blood flow to the heart and brain during which likely results from differences in imple-
cardiac arrest.3 This improves the likelihood of mentation and performance of important inter-
shock success, return of spontaneous circula- ventions such as 9-1-1 pre-arrival CPR instruc-
tion (ROSC), survival, and the chance of a good tions, bystander CPR and early defibrillation.
functional outcome.3,4 The combination of Continuously measuring these interventions
quickly calling 9-1-1, immediately doing chest and analyzing their impact is the only way to
compressions and applying an AED as soon as know specifically what needs improvement and
possible works synergistically to increase sur- whether a system is functioning as intended.
vival. Each of the successive links in the chain Current registries exist to help communi-
january2014
ties measure their cardiac arrest incidence and one minute into the call. And yet both callers
outcomes. The CARES (Cardiac Arrest Regis- received “pre-arrival CPR instructions.”
try to Enhance Survival; https://mycares.net) The state of Arizona and King County,
registry is a national data collection system for Wash., have piloted a data collection tool and
OHCA. This registry includes data collection on reporting system for suspected cardiac arrest
OHCA incidence and process of care, including dispatch calls, which is integrated into their
bystander CPR, AED use and, recently added, OHCA registries and linked to EMS care, hos-
data for 9-1-1 pre-arrival CPR instructions. pital care and patient outcomes. In Arizona,
The need to take this a step further and sys- the 9-1-1 pre-arrival CPR program is part of the
tematically track data from 9-1-1 centers has Save Hearts in Arizona Registry and Education
come about due to the realization that the quality (SHARE) Program, a collaboration between the
of telephone CPR instructions has a significant Arizona Department of Health Services and the
impact on survival. Details such as whether the University of Arizona (see http://azdhs.gov/
cardiac arrest was correctly identified, whether azshare/911/index.htm). The Arizona and King
CPR instructions were provided, how long into County, Wash., models have now been incorpo-
the 9-1-1 call before CPR was started, and what rated into CARES to help dispatch and EMS
type of CPR was given can make the difference systems across the country.
between life and death. There is growing inter-
est in pre-arrival CPR metrics and the need to Why You Need an AED Registry
quantify this critical intervention. To illustrate Like bystander CPR data, AED information is a
the point: If the 9-1-1 system provides pre- critical component of an ongoing cardiac resus-
arrival CPR instructions at eight minutes into a citation system of care. When various data points
call, it will obviously have much less impact on along the continuum of care (bystander CPR,
survival than if the instructions were provided 9-1-1 data, AED placement/use, and outcomes)
Images courtesy PulsePoint
The PulsePoint App sends real-time AED location information to those within a certain radius of a suspected
cardiac arrest, with the goal of increasing both bystander CPR and AED use. At press time, there had been
more than 1,000 activations of the system.
january2014
Data Drives Care
are integrated into a standardized registry, such private foundation offering grants is The
as CARES, an entire system can be measured Ramsey Social Justice Foundation (http://
and improved over time. ramseyjusticefoundation.org), which has
AED information needs to be integrated donated AEDs to communities participat-
into registries in order to know where AEDs ing in the SHARE Program in Arizona. An
are placed, if they are checked for maintenance example of a government AED grant is the
(pads, batteries), if potential users are trained one offered through the U.S. Department of
on-site, when they are used, and the ultimate Health and Human Services’ Rural Health
patient outcome. Event data should include the program.
location of the arrest, who did CPR, what kind
of CPR was performed, who applied the AED, Finding AEDs with Social Software
and whether a shock was delivered. Detailed Keeping tabs on the locations of existing AEDs
data after an AED is used should be made avail- has been a challenge. There have been several
able to other healthcare providers such as emer- large-scale efforts to locate AEDs within com-
gency physicians and cardiologists. munities. One such program in Philadelphia
What follows is a closer examination of why used a crowdsourcing approach. In 2012, the
you need an AED registry: MyHeartMap Challenge (www.med.upenn.edu/
• You can’t use them if you don’t know where they myheartmap) set up a competition and offered
are: We know AEDs are extremely safe and monetary awards for those submitting the most
effective.2 We also know they are only used by AED locations. Using a smartphone applica-
the public in approximately 4% of OHCAs.6 tion, participants photographed and recorded
Knowing where AEDs are located and if they GPS coordinates for AEDs they found through-
are being used is important information. out the city.
For example, if AEDs are placed in a certain Also using mobile phone technology, the
area of town but they aren’t being used in PulsePoint App (http://pulsepoint.org) takes
cardiac emergencies, likely more public edu- locating AEDs one step further—tying the loca-
cation is needed. In contrast, if cardiac arrest tion of the AEDs directly to nearby cardiac
is occurring more frequently in a certain arrest incidents through the community’s 9-1-1
location where few AEDs are available, then system. The mobile app (iPhone and Android)
more attention should be given to acquiring sends real-time AED location information to
and placing additional AEDs throughout those within a certain radius of a suspected
that community. cardiac arrest with the goal of increasing both
• You can’t use them if they’re not maintained: Just bystander CPR and the use of the life-saving
as an AED that is not found cannot save a devices.
life, neither will an AED that is not properly Potential lay rescuers must normally wit-
maintained. Maintenance includes making ness an arrest to take action. PulsePoint seeks
sure expired pads and batteries are replaced to improve the efficiency of both CPR-trained
and software upgrades are installed. A Web- citizens and publicly available AEDs by mak-
based AED registry can assist in ensuring ing bystander rescuers aware of cardiac events
the functionality of AEDs by sending main- occurring nearby so they can retrieve an AED
tenance reminders. Just as fire departments and begin CPR while paramedics are making
check fire extinguishers in a community, it their way to the scene. No one is in a better
makes sense that you need to have a system position to make a difference in the first few
to ensure that all AEDs are maintained in a minutes of an OHCA than a nearby CPR/AED-
ready-to-use state. trained individual. PulsePoint has been success-
•Y ou can’t use them if they’re not there: Another fully implemented in many U.S. cities.
reason for having an AED registry is the fact
that the information can be useful in the Disparity Issues: Location of Arrests
submission of grants for the deployment of The location of a cardiac arrest has a significant
additional AEDs. To secure and receive either influence on patient survival. Patients who arrest
private foundation or government grants, in public have a higher probability of having
a Public Access to Defibrillation (PAD) pro- their arrest witnessed, receiving bystander CPR,
gram needs accurate data—both utilization and receiving defibrillation with an AED—all of
and patient outcome information. AED which strongly increase the chance of survival.2
grants can come from both private foun- National data on bystander CPR and PAD
dations and government. An example of a programs have uncovered large and unaccept-
january2014
able disparities. For example, using the CARES another. In the future, AEDs will include tech-
registry, Sasson and colleagues found that in nology (perhaps GPS, WiFi, Bluetooth, or other
low-income black neighborhoods the odds of methods) that will allow tracking in real time,
receiving bystander-initiated CPR was approxi- thereby allowing more efficient monitoring of
mately 50% lower than in high-income non- the units’ placement and readiness. This tech-
black neighborhoods.7 Their study showed that nology will likely be integrated into CAD sys-
both the racial composition and the median tems in the future, aiding dispatchers in locat-
income of a neighborhood have a significant ing AEDs and relaying that information to
effect on the likelihood of receiving bystander callers, in an effort to increase AED use. And of
CPR. Studies like this help identify where to course, more AED use and more bystander CPR
concentrate public training and education will translate into more lives saved. ✚
efforts.
In Arizona, Dr. Sungwoo Moon (a visiting Bentley J. Bobrow, MD, is a professor of emergency
professor from Korea University) found OHCA medicine, Maricopa Medical Center and University of
victims in mainly Hispanic neighborhoods Arizona College of Medicine, Phoenix. He is the medi-
received bystander CPR less frequently and cal director for the Bureau of Emergency Medical Ser-
had worse neurologic outcomes than those in vices and Trauma System and its Save Hearts in Arizona
mainly white, non-Hispanic neighborhoods.8 Registry & Education (SHARE) Program at the Arizona
Using Geographic Information System (GIS) Department of Health Services, and co-Principal Inves-
technology and SHARE Program OHCA event tigator of the Arizona Heart Rescue Project. He is a cur-
data, Dr. Moon was also able to identify the rent member of the American Heart Association ECC
areas where OHCAs occurred most frequently and past-chair of the BLS Subcommittee.
but where AEDs were lacking. This is a great
example of how important it is to have both car- References
diac arrest event and AED location data.9 1. Sasson C, Rogers MA, Dahl J, et al. Predictors of survival from
out-of-hospital cardiac arrest: A systematic review and meta-
analysis. Circ Cardiovasc Qual Outcomes. 2010;3:63–81.
A Variety of AED Registries 2. Hallstrom AP, Ornato JP, Weisfeldt M, et al. Public-access defibril-
AED registries can take different shapes. Most lation and survival after out-of-hospital cardiac arrest. N Engl
J Med. 2004;351:637–646.
states require reporting of AED locations to
3. Eftestol T, Wik L, Sunde K, et al. Effects of cardiopulmonary
local EMS and/or dispatch centers. However, resuscitation on predictors of ventricular fibrillation defibrilla-
it varies widely as to how agencies capture and tion success during out-of-hospital cardiac arrest. Circulation.
actually use this information. 2004;110:10–15.
Arizona’s SHARE Program AED registry 4. Bobrow BJ, Spaite DW, Berg RA, et al. Chest compression-only
cpr by lay rescuers and survival from out-of-hospital cardiac
is voluntary; however, it fulfills the statutory arrest. JAMA. 2010;304:1447-1454.
requirement that AED owners enter into an 5. Nichol G, Thomas E, Callaway CW, et al. Regional variation in
agreement with a physician to oversee a PAD out-of-hospital cardiac arrest incidence and outcome. JAMA.
program. In the SHARE registry, medical direc- 2008;300:1423–1431.
tion is free of charge to those complying with 6. Weisfeldt ML, Sitlani CM, Ornato JP, et al. Survival after applica-
tion of automatic external defibrillators before arrival of the
the training and reporting requirements. The emergency medical system: Evaluation in the resuscitation
registry uses a Web-based data entry system. outcomes consortium population of 21 million. J Am Coll
AED owners must keep their units function- Cardiol. 2010;55:1713-–1720.
7. Sasson C, Magid DJ, Chan P, et al. Association of neighborhood
ing and registries can play an important role characteristics with bystander-initiated cpr. N Engl J Med.
in helping to ensure that AEDs are always in a 2012;367:1607–1615.
ready-to-use state. A Web-based AED registry 8. Moon S, Kortuem W, Kisakye M, et al. Disparities in Bystander
can send general reminders to registrants or CPR and Neurologic Outcomes from Cardiac Arrest According
to Neighborhood Ethnicity Characteristics in Arizona. Poster
targeted reminders based on expiration dates presentation to the American Heart Association, Resuscita-
entered into the system. Several companies tion Science Symposium, Scientific Sessions in Dallas, Texas.
offer subscription services to assist with this. November 2013. Circulation; in press.
9. Moon S, Kortuem W, Kisakye M, et al. Analysis of Out-of-Hospital
Cardiac Arrest Location and Public Access Defibrillator
The Future of AEDs Placement in Metro Phoenix, Arizona. Poster presentation
Tracking AEDs that are placed in static loca- to the American Heart Association, Resuscitation Science
tions is one thing; however, tracking the loca- Symposium, Scientific Sessions in Dallas, Texas. November
2013. Circulation; in press.
tion of AEDs that are mobile, such as those used
during high school athletic events, requires a
higher level of sophistication. Also, many AEDs
are moved from one “permanent” location to
january2014
A simple motor vehicle crash can
be used to visualize the “perfect
EMS event”—one that brings
together all of the complex EMS
operations, clinical care and
service delivery required for any
patient scenario.
Photo Bob Bartosz
The “Perfect” EMS Event

What will it take to embrace the full potential
of existing & developing technology?
By Greg Mears, MD Once the crew arrives on scene, they evaluate
both patients. All data from their cardiac moni-
O
ne of the best ways to visualize the tor, as well as voice recordings, barcoded infor-
future in EMS is to imagine what mation on procedures documenting the time
would happen if we combined all of and use of supplies (using RFID), and video from
technology in existence (or in development) on-vehicle and helmet cameras, are automatically
today to describe the “perfect EMS event”—one downloaded to the patient care report (PCR).
that brings together all of the complex EMS oper- The driver is packaged as a “green trauma.” The
ations, clinical care and service delivery required EMS crew obtains a 12-lead ECG from the pas-
for any patient scenario. Let’s give it a try … senger that indicates a STEMI (with left bundle
A motor vehicle crash (MVC) occurs. From the branch block); they confirm that the new ECG
vehicle’s automated crash notification system, is different than the baseline tracing from the
dispatch receives the following information: the patient’s medical record. No injuries are noted.
mechanism of the crash (low-speed front-end The PCR software system is able to recognize
collision) and scene location; probability of seri- the chest pain component as well as the abnor-
ous injury (low in this case); number of occu- mal ECG and recommend that the EMS crew
pants (two); and the occupants’ baseline medical consider administering aspirin as well as to
history (linked from personal medical records). recheck the patient’s vital signs every five min-
Dispatch identifies the closest EMS vehicle utes. The software also identifies the closest PCI
and electronically dispatches it to the scene with center and notifies the center of the incoming
navigational directions. While EMS is en route, patient, while also forwarding the 12-lead ECG
Emergency Medical Dispatch (EMD) is per- and activating the cath lab.
formed, identifying that the passenger is expe- En route to the PCI center, information from
riencing chest pain and is known to have coro- the patient’s personal medical record, crash
nary artery disease. The driver does not have any detail from the automated crash notification
complaints. An existing 12-lead ECG is obtained system, all information associated with the EMS
from the patient’s medical record and forwarded event, and real-time vital signs are transmitted
to the EMS crew en route. to the receiving hospital. On arrival, the patient
january2014
Data Drives Care
is evaluated in the ED to ensure no significant dardized format; therefore, integrating data

traumatic injury was present before he’s trans- from multiple sources in a real-time fashion
ported to the cath lab. A 100% LAD lesion is remains a challenge.
identified and reopened with a symptom-onset- • Software is only beginning to engage in
to-reperfusion time of 65 minutes. decision support to assist in the prevention
After the hand-off of the patient, all of the infor- of patient care errors, ensure protocol com-
mation from dispatch, medical devices, voice, pliance and optimize EMS operations.
RFID and pertinent personal medical informa- • Technology and its integration are expensive.
tion, as well as the care provided to the patient, EMS agencies must look at their implemen-
are aggregated to create the PCR. The EMS crew tation from an IT and integration perspec-
quickly adds and adjusts the documentation tive. Devices and software are members of the
based on feedback from the software. Once the healthcare team. Let’s go through a brief over-
PCR is complete, it’s routed to the supervisor view of the device and software needs of an EMS
for review, to the hospital medical record system agency with an eye on integration and optimiz-
using the NEMSIS HL7 CDA, and to the EMS ing operations and patient care.
agency’s same-day billing department.
After the patient is discharged from the hospi- Vehicles
tal, outcome information is relayed electronically Other topics within this supplement describe
back to the EMS agency using the secure HL7 how data and technology can greatly impact
CDA and incorporated into the PCR system. and enhance dispatch, scheduling, education,
Weekly, monthly, quarterly and yearly reports etc. It’s important to also consider the impact
based on performance measures and outcomes of the ambulance (or vehicle) itself. An EMS
are also generated for the EMS agency and vehicle should provide a safe environment for
the regional area for review and performance the treatment and transport of both the crew
improvement initiatives. Aggregate informa- and the patient, but should also serve as a center
tion is posted on community websites, high- for patient care and the hub of our communica-
lighting the performance of the integrated tions and technology.
system of care, including EMS operational and Data coming into the vehicle should include
clinical care outcomes. Individual patient data dispatch and navigational information through
from EMS is also linked with hospital, trauma, a communications link. The vehicle also must
stroke, STEMI, cardiac arrest, airway and other have a connection to the Internet for data
registry systems to more critically evaluate the exchange. This can be accomplished through
care provided to specific patient populations. the development of a Wi-Fi hotspot within the
Ultimately, performance improvement pro- vehicle that connects to the Internet through a
cesses are identified, including the need to con- cellular data modem. Other forms of connectiv-
sider medical conditions even when the EMS ity, such as Bluetooth or radio frequency identi-
event appears to be traumatic in nature. This fication (RFID), may also be included.
information is included in the next continuing The Wi-Fi hotspot can be created using a
education offering for both EMS and the ED. standalone solution within the vehicle, a built-in
Wi-Fi solution within a vehicle safety product
Why Not Today? (e.g., Road Safety), or a solution built into a medi-
All of the technology associated with the perfect cal device (e.g., monitor defibrillator). Once the
EMS event exists today—so why are we not all Wi-Fi hotspot is created, the existing software
using it? There are several reasons: and devices that need to integrate and commu-
• Most EMS systems only have a portion of nicate can be connected. These include vehicle
the technology described in place. safety devices, cardiac monitors, defibrillators,
• The technology that is in place does not central patient monitors, PCR software, supply
often integrate with other technology. inventory systems and other medical devices.
• The technology is not ready for this com- Externally, the Wi-Fi hotspot allows for the
plete level of implementation. exchange of data between the central EMS data
• The infrastructure (such as Internet connec- systems as well as hospitals, dispatch and other
tivity) isn’t ready for this level of integration. healthcare-related data systems and/or providers.
• Leadership at the IT, hospital and EMS lev-
els are not ready for integration at this level. Medical Devices, Monitors & Defibrillators
• Devices and PCR software solutions across Medical devices are becoming more compact yet
the industry in general do not use a stan- more functional, capable of assisting the EMS
january2014
COORDINATING FIRST RESPONSE DELIVERING THE GOLD STANDARD
FROM DISPATCH TO PATIENT CARE IN MONITORING AND TREATMENT
RescueNet® Dispatch, Navigator, and Road Safety RescueNet ePCR

X Series® Monitor/Defibrillator AutoPulse and X Series Monitor/Defibrillator
®
To learn more about ZOLL’s solutions, visit us at

www.zoll.com/realtimedata or call 800-804-4356.
© 2013 ZOLL Medical Corporation. All rights reserved. AutoPulse, RescueNet, X Series and ZOLL are trademarks or registered trademarks of ZOLL M
Advancing Care with
Data-driven Solutions
CONNECTING PROVIDERS IN IMPROVING BUSINESS PROCESS

REAL TIME TO EXPEDITE CARE TO DRIVE EFFICIENCY
RescueNet Link RescueNet Billing, Resource Planner, and Crew Scheduler

RescueNet 12-Lead RescueNet FireRMS and Insight Analytics
Medical Corporation in the United States and/or other countries. All other trademarks are the property of their respective owners. MCN EP 1310 0010
Data Drives Care
The hub of information associated Finally, there has been a significant

with any EMS event is the PCR. focus on the outcomes of sud-
den cardiac arrest. The use
of external CPR devices has
professional in their patient assess- become commonplace within
ment, treatment, decision-making EMS agencies. These devices
Image ZOLL
and monitoring. It’s imperative have been shown to provide
that the data collected, analyzed CPR equal to high-quality
and presented to the EMS profes- manual CPR. Many of these
sional in the field be closely devices also capture data on
incorporated into the PCR and, CPR metrics and can transmit
when needed, relayed to the it into PCR and code review
receiving healthcare facility. solutions. This data should
This data exchange and be used to identify, measure
movement should be based and improve the resuscita-
on existing standards, such tion outcomes of cardiac
as the National EMS Infor- arrest victims.
mation System (NEMSIS) and HL7. (For more
information on NEMSIS and HL7, see www. Clinical Decision Support
nemsis.org.) In the past five years, EMS has made tremen-
There is an increasing interest in the EMS use dous progress in the resuscitation of the victims
of diagnostic devices from a laboratory mea- of out-of-hospital cardiac arrest (OHCA). This
surement and imaging perspective. Examples success has not been the result of a new inter-
include ultrasound imaging, measurement vention, device or medication. Rather, it is the
of cardiac ischemia and markers of sepsis. As result of a focus on providing high-quality CPR as
these technologies come into commonplace opposed to just providing CPR.
use by EMS, their data and images must also This has been one of the many success stories
transmit through this network and be included where devices and technology have integrated
in the PCR. with the provider to improve outcomes. Medi-
Real-Time Performance quality metrics for STEMI, stroke, trauma, cardiac arrest and
airway management patients. The protocols are configured
Monitoring with standard quality metrics, but the agency has the ability
Technological advances have given EMS agencies an ever- to add metrics specific to their locality.
increasing amount of data from 9-1-1, CAD, structured call The quality metrics are segmented into four components:
triaging tools such as ProQA, and electronic patient care system performance measures, clinical performance mea-
reporting (ePCR). Paradoxically, most EMS agencies now sures, patient safety/risk reduction performance measures,
have less time and fewer resources to review this moun- and financial performance measures.
tain of data to identify challenges and opportunities for Insight Analytics starts with industry-standard Key Perfor-
improvement. mance Indicators (KPIs), but allows any user to create and
Two products designed to help agencies do just that: First- publish customized new dashboards. The product is designed
Pass, from the creators of FirstWatch software, and ZOLL’s to help EMS leaders monitor and track performance improve-
Insight Analytics. Both of these products allow users to track ment initiatives, compliance goals, cash flow, departmental
and benchmark their organizations across clinical, opera- protocols and productivity at a glance.
tional, managerial and financial metrics in near real-time. Users can compare their performance against similar organi-
FirstPass is a clinical measurement and protocol monitor- zations, then tap into a Facebook-style community to discover
ing tool designed to alert users to deviations in expected how others have solved similar problems. Up-to-date visual
treatments to medical protocols. It’s a workflow-driven tool displays of current status and historical trends let users make
that is customizable and capable of operating in combination immediate and informed decisions to improve quality and
with FirstWatch tools anywhere there is Internet connectivity. maintain compliance. Medical directors and EMS supervisors
FirstPass provides continuous monitoring of ePCR to can track protocol compliance and quickly identify data outli-
quickly identify and provide real-time alerts concerning ers, see outstanding A/R status of billing claims, track depart-
protocol deviations, incomplete “care bundles,” missing data ment or employee productivity and quickly identify which
elements or urgent patient safety issues. Users get a stan- trips were non-compliant and drill further into a call report to
dard bundle of “protocols” designed to measure predefined determine the cause.
january2014
cal devices, often attached to a monitor/defi-
Image ZOLL
brillator, can provide real-time feedback to EMS
professionals, improving the quality of CPR and
the outcomes of OHCA victims. The use of CPR
quality software and devices are quickly becom-
ing standard of care within the AEDs used by
first responders and the lay public.
Beyond devices, PCR software is now capable
(with FDA approval) to monitor the assessment,
treatment and care of a patient in such a way
that the software can provide patient safety rec-
ommendations as well as ensure that protocols
are followed. This ability to guide or provide rec-
ommendations on the clinical care of a patient
will increase as we move toward 2020. ZOLL is
currently the only EMS PCR solution that has
received FDA approval for this capability. The information making up the PCR is split between direct data entry
by the EMS professional and electronic data from other sources (e.g.,
PCR Documentation dispatch, EMD, medical devices, other software data feeds).
The hub of information associated with any
EMS event is the PCR. The information making
up the PCR is split between direct data entry by • Export capability for entering information
the EMS professional and electronic data from into the billing system, registries (CARES,
other sources. trauma registry, etc.) and state systems (via
The ultimate goal of any EMS agency is to NEMSIS).
maximize the linkage and use of electronic data Ultimately, each EMS agency must customize
sources while minimizing the amount of data their ePCR solution based on the balance of the
that has to be directly entered by the EMS pro- critical features noted above; integration with
fessional. The electronic movement of data into other data systems or devices; data analysis and
a PCR from an external source not only is more messaging capability; ease of use and reliability;
efficient for the EMS agency and the provider; it and cost.
is also more timely, complete and accurate. No solution is perfect in all of these require-
PCR solutions vary in their implementations ments, and it’s critical to find a solution that fits
based on the following features: your system’s current needs and will evolve and
• Hardware and IT requirements, including grow as your EMS system embraces new con-
whether the PCR is hosted on location of cepts (e.g., community paramedicine).
the EMS agency or a cloud-based Software
as a Service (SaaS). Within Reach
• Front-end user interface design, including Technology and data are key components of any
ease of use, security and type of device (iOS, EMS system. It is critical that EMS agencies con-
Android, Windows, etc.). sider medical devices and software as members
• Integration with medical devices, including of their patient care team. How data and tech-
monitor/defibrillator, 12-lead ECG, video nology is managed at the organizational, EMS
cameras and others (ultrasound devices, professional and patient levels will determine the
glucose monitors). success and future of EMS. ✚
• Integration with other software, such as dis-
patch/CAD, EMD and billing software. Greg Mears, MD, is the medical director for ZOLL,
• Data-analysis capability, including struc- specializing in data, systems of care and EMS per-
tured reports, user-configurable reports, formance improvement. Dr. Mears, through the non-
performance improvement reports and out- profit Emergency Performance Inc., leads the devel-
come reports. opment of the National Fire Operations Reporting
• Communication and messaging capability, System (N-FORS). He’s an adjunct professor in Emer-
including the ability to route documenta- gency Medicine at the University of North Carolina
tion or alert EMS staff when certain events at Chapel Hill and has served in multiple EMS lead-
occur or when benchmarks or thresholds ership roles within North Carolina and nationally.
are hit (or missed).
january2014
Photos ZOLL
From the Field to the ED
Technology exists to transform patient assessment,
but standardization & regulation are needed
By Raymond Fowler, MD, FACEP (Above) ECG transmission from ambulances—
across an ECG transmission software platform—
I
t’s mid-evening on a busy night, and the is possible currently, but differs among
radio crackles in the emergency depart- manufacturers. Standardization of ECG
transmission technology is needed to fully
ment (ED): “General Hospital, this is Res-
realize the benefits of this technology.
cue 80, on the scene of a 76-year-old woman
with right-sided weakness and facial droop. Her
speech is slurred, and she appears confused. is becoming more and more specialized. Com-
Her last time to be known normal was about 45 bine the two, and suddenly a dilemma emerges:
minutes ago, when she said to the family that Would this little lady benefit from bypassing
she didn’t feel well and went to lie down. When a peripheral hospital that might be pressed to
they checked on her, they found her in the cur- give “state of the art” stroke care, for an extra
rent condition. Her vital signs are: BP 175/90, 17-minute ride to a “stroke center”—while some
pulse 88, respirations and pulse ox are normal. 2 million brain cells a minute are dying in the
We are eight minutes from your facility or 25 ischemic focus inside her head?
minutes from the Stroke Center at Excelsior EMS Medicine is the practice of medicine in
Hospital. What do you advise?” the prehospital area. It is a subspecialty of medi-
And, so we face the current essence of EMS cine; the first physician certification examina-
medicine: The critical care medic’s assessment tions were offered in October 2013. With this
and field management skills are becoming step, EMS Medicine becomes a new member of
more and more sophisticated. At the same time, the “House of Medicine.” All participants in the
the treatment of many critical care conditions process of patient evaluation and management
january2014
Data Drives Care
in the prehospital environment must strive to phase through which all medical emergencies are
bring the best care possible into play. managed. Training standards are found in fed-
Key to this progress: a vast increase in infor- eral guidelines. Equipment is generally similar
mation transfer capability from the field. Elec- from system to system, with variations induced
tronic medical records—based strictly upon a by the marketing influence of manufacturers.
federal data management and transmission However, significant variations exist among the
standard authored in part by the principal various producers of the spectrum of machinery
author of this JEMS supplement, Dr. Greg and software used by many systems. For exam-
Mears—now are the standard of clinical prac- ple, at least three different software methods of
tice around which all patient care information ECG transfer exist across the spectrum of pre-
is centered. Sophisticated EMS systems across hospital care, resulting in the inconsistent ability
the country and around the world now oversee of municipalities to provide for fully coordinated
trauma, stroke, STEMI, burn, pediatric, and
soon-to-be sepsis networks to optimize the out-
come of these patients. Time intervals in these
patients are tracked closely: 90-minute symp-
tom onset to arterial reperfusion for STEMI
is a sought-after standard; soon, 60-minute
door-to-thrombolysis windows for some 50% of
patients who are victim of ischemic strokes will
become the norm.
How then, in this increasingly complex tech-
nical infrastructure, can EMS systems play the
dynamic part that they are destined to perform?
The Need for Standardization

When I started medical school in 1973, if a man
came to the hospital having a heart attack, we
would put him in the coronary care unit (which
were just emerging at the time), treat his pain Smartphones and tablets hold amazing promise
with morphine, give him oxygen, give him for EMS, but for now, providers must be cautious
furosemide and digitalis if his lungs filled with when using this technology in the field, due to the
potential to violate HIPAA regulations or FDA rules.
fluid, keep him there for two weeks, and hope
he wouldn’t die.
Today, the acute coronary syndrome has transmissibility across all platforms for ECGs
emerged to be recognized as an acute arterial within any single EMS system. The solution
vascular emergency, the treatment of which is required is generally single-proprietary adher-
heavily based upon the role that EMS systems ence of product across that given system. In this
play in overall assessment and management. reality is the opportunity for improvement.
And brisk progress has been made. STEMI It is reasonable to anticipate that similar pres-
networks have sprung up across the nation. sures that drove computer development—the
The entire state of North Carolina is an orga- “plug and play” generation of hardware and
nized acute cardiac care network. Dallas County software progress across various computer and
(Texas) recently completed the organization of software makers—will drive similar progress in
a county-wide STEMI network coordinating the realm of open architecture among the pro-
the care of patients with acute coronary syn- ducers of ECG transmission technology. This
drome across 25 EMS agencies and 15 emer- would continue to streamline the free exchange
gency receiving facilities, with a common EMS- of data across platforms in the provision of field
hospital linked dataset, uniform EMS protocols patient care.
and uniform clinical pathways for hospitals.
Uniform ECG transmission from all ambu- Telemedicine & EMS
lances—across an ECG transmission software Telemedicine is driving medical development in
platform—has been achieved, and some of the an accelerating manner. Example: Tele-neurol-
treatment successes are staggering. ogy, in which a neurologist evaluates a stroke
A generally standardized set of training pro- patient remotely, is now considered a normal
grams and equipment exists in the prehospital part of stroke assessment and treatment. Tele-
january2014
Data Drives Care
The assessment of infants, of accident victims,

of burn patients, and of other cases would also
seem to benefit from this process. And patients
refusing transport could be videotaped and the
records filed for medico-legal purposes.
One has to be cautious, however, with the
application of new software and devices directly
into the stream of patient care, as opposed to
“after the fact review” within a quality manage-
ment program. The FDA has a direct role in the
approval of items that fall within the evaluation
and management of a patient, requiring what
is called a “510K Clearance.” A recent article
by a medical student in a prominent newspa-
per asked, “Will your next physical be done by
smartphone?” 1 However, it says almost noth-
ing about the smartphone participating in the
direct line of patient evaluation from a critical
All participants in the process of patient evaluation care perspective.
and management in the prehospital environment Thus, at this time, EMS providers should
must strive to bring the best care possible into play. be cautious about using any sort of audio and
Key to this progress: a vast increase in information video devices directly in the line of patient care.
transfer capability from the field. An example of this would be calling the hospi-
tal and sending a video of the patient directly
ICU monitoring has also emerged, allowing to a receiving device, most likely another smart-
critical care nurses and physicians to monitor phone, through which a provider at the ED,
the status of patients from off site in a safe, such as an emergency physician, would then
prompt manner. make a treatment decision. It theoretically
EMS telemedicine has emerged more slowly. It might not be allowed under FDA rules, and it
is interesting to watch a re-run of one of the old certainly has the potential for a HIPAA violation
Emergency! shows and watch the live transmis- with regard to patient privacy.
sion of the patient’s rhythm to Rampart Hospi-
tal. One would have thought that by now, some The Evolution Continues
40 years later, the streaming of patient informa- Advancing EMS opportunities, such as the
tion on a live platform from the field would be community paramedic effort sweeping the
customary. I recall well the live-streaming wave- world, will dictate the need for continuing to
form on the old Motorola screen in a small ED improve the communication resources between
in eastern Georgia as I discussed the case with providers. Optimizing what can be assessed on
the medics in the field. the scene, providing the care in the field that is
Vital sign “pushes” in a non-real-time manner based on best evidence, and linking up appro-
are available from equipment producers, giving priate providers to assist in management while
vital signs updates as frequent as every minute. preparing hospital-based facilities where indi-
This availability requires a proprietary software cated, will continue to evolve as patient needs,
platform. Another manufacturer provides high- provider skills and technology development
quality Web-based audio, video and monitor lead us. ✚
information to the local base station.
Raymond Fowler, MD, FACEP, is professor of Emergency
Smartphones & EMS Medicine (Surgery), chief of EMS Operations and co-
It’s interesting to wonder when EMS will capi- chief in the Section on EMS, Disaster Medicine, and
talize on the technology provided by a typical Homeland Security at the University of Texas South-
smartphone. Excellent quality audio and video western Medical Center at Dallas. He is attending emer-
could be sent to the base station in a very inex- gency medicine faculty at Parkland Memorial Hospital.
pensive manner, allowing the medical direc-
tion team to hear and see the patient. This Reference
would seem very appropriate in the setting of 1. Parikh R. (July 22, 2013) Will your next physical be done by smart-
phone? Washington Post.
the evaluation of a stroke patient, for example.
january2014
Photos ZOLL
A Seamless Exchange
Standardizing processes & sharing data
across the healthcare continuum is key to improving quality
By Mic Gunderson & Greg Mears, MD (Above) Electronic patient care report (ePCR) systems
have been shown to improve billing and collections
E
MS systems exist to provide high-quality and facilitate mandatory data submissions to state
care to the patients we serve. There- and national EMS data repositories. However, the
ePCR systems in most EMS organizations fall far
fore, one of the major goals of a state-
short of their full potential to facilitate improvements
of-the art EMS data system is to help ensure in patient care.
that the care you provide is meeting your stan-
dards; another goal is to help improve that care
over time. In this article, we look at what’s on instantaneous answers to a wide variety of on-the-
the horizon for clinical quality assurance and fly questions that previously took several hours
improvement and how EMS systems are using or even months to complete, depending on the
data to integrate with the rest of with the rest of number of reports that had to be accessed in file
the healthcare system. drawers full of paper patient care reports.
However, the ePCR systems in most EMS orga-
Standardizing Process nizations fall far short of their full potential to
& Outcomes Measures facilitate improvements in patient care. The
Electronic patient care report (ePCR) systems have weak link has not been so much in the design
been shown to improve billing and collections, of the ePCR data collection software or hard-
facilitate mandatory data submissions to state ware, but in the reporting. In the past, most of the
and national EMS data repositories, and allow for reporting features provided by software suppli-
january2014
Data Drives Care
A health information exchange allows EMS agencies, individual physician offices, hospitals and clinics to
share records on the same patient.
ers have tended to focused on billing and activ- Example: In cardiac arrest, the outcome goal is
ity reports. The activity reports on the clinical patient survival without long-term neurologi-
side typically include pre-configured reports cal or other functional damage. One of several
on metrics such as the numbers of responses, process goals, addressed in the design of the
number of medical procedures or medication protocol, is to minimize interruptions in chest
administrations, success rate percentage for compressions. The applicable standardized out-
medical procedures, percentage of responses come measures for cardiac arrest are found in the
with transports, and response-time intervals. Utstein criteria for out-of-hospital resuscitation.
These reports, although good, don’t directly The standardized process measure for chest
address the goal of using data for clinical qual- compression interruptions is the compression
ity assurance. To be clear, clinical quality assur- fraction—the percentage of time that compres-
ance in EMS is the overall process used by an sions were actually performed during the time
EMS provider organization and/or regulatory the patient was pulseless. The local standard in
agency to ensure that clinical care meets appli- one EMS system may be a compression fraction
cable standards. of more than 70%, but it may be more than 90%
One of the major obstacles is configuring the in another system. By standardizing the process
reporting features of the ePCR software in a way measures, each system can set its own thresh-
that compares care delivered to the applicable olds and use the same metrics to monitor its
standard(s). Because every EMS system can have performance on individual cases and in aggre-
different standards, developing such reports gate for the entire EMS provider organization
has been a huge barrier. or EMS system.
Progress is being made, albeit slowly, on devel- As the EMS profession matures in its use of
oping standardized measures of process and quality management, and as the Centers for
outcomes performance. Protocols are typically Medicare and Medicaid (CMS) increases the
built around the ideal for how a process should use of pay-for-measurement and pay-for-perfor-
be carried out (e.g., cardiac arrest, STEMI), but mance strategies, more and more process metrics
the goals of the process remain the same even if will become standardized and required nation-
the standards differ. wide. How much an EMS provider organization
january2014
gets paid by CMS may vary with its use of appli- Obtaining Outcomes Data from Hospitals
cable clinical process performance metrics. Even if we have standardized patient outcome
We see this in hospitals with “core measures.” measures, they do little good if we cannot access
Hospital that do not track and report their core the outcomes information from the hospital we
measures get paid less. Among those hospitals brought our patients to. This has been a huge
that track and report their core measures, the barrier in many EMS systems. The good news is
ones that show better outcomes on their core that hospitals are being asked by payers for pro-
measures get paid more. CMS has stated that cess and outcomes data and to show improve-
core measures will be coming to all aspects of ments over time to maximize their revenues (i.e.,
healthcare it pays for—including EMS. The only pay for performance). This is now limited to a
question is when. Accountable Care Organiza- handful of core measures, but will be growing
tions (ACOs) will also be looking for such met- very quickly with the implementation of ACOs
rics and the accountability they bring from their and associated incentives.
EMS system partners. The typical pushback from hospitals when
If we have processes in place to measure our EMS agencies ask for outcomes data relates to
clinical performance against our standards for privacy concerns. This is a bogus argument. The
quality assurance purposes, we have much of real issues seem to be more related to the time
what we need to facilitate quality improvement. and effort that hospitals have to expend to give
In this context, quality improvement in EMS EMS the data it wants. Now that the hospitals
is the overall process used by an EMS provider have some motivation (requirement) from the
organization and/or regulatory agency to change payers and hospital accreditation bodies to look
processes with the intent of getting better out- at the whole continuum of care and need EMS
comes. This may be in terms of process out- data to help their own improvement efforts,
comes (e.g., better compression fractions); bet- their resistance has been diminishing.
ter patient outcomes (e.g., higher survival rates); One method for obtaining outcomes data is
better operational outcomes (e.g., shorter task based on manual queries. For example, an EMS
times); or better efficiency outcomes (e.g., lower agency might ask a hospital for the outcome
cost to get the same process, patient or opera- and some event time data for cardiac arrest,
tional outcomes). STEMI or stroke patients. In the request, the
The current level of process performance is agency would have to include some information
assessed using applicable process and outcomes to allow the hospital staff to look up the patient
performance metrics. Here is where standard- record in their hospital medical record system.
ized process and outcomes measures come to The problem: Protected health information
the rescue again. Statistical tools are used to (PHI) is usually needed, such as patient names,
compare the control group results with the dates of birth, addresses, etc. Sending PHI back
experimental gtoup results and determine the and forth via email creates security risks. Encryp-
likelihood that the difference was not the result tion or other mechanisms may be needed to
of simple chance. address those concerns and keep the whole effort
This raises the bar for our software tools, the compliant with HIPAA and other regulations.
people designing them, the people using them Common workarounds include crews recording
and the people interpreting the results. Our a hospital chart number on the EMS report, or
EMS software tools will need the ability to add doing the queries over the telephone or in person
in modules or updates that utilize standardized to avoid having PHI exchanges in writing.
process and outcomes metrics. As more met- So long as the volume of such queries is small,
rics are developed and as existing metrics are manual methods can work. For larger EMS sys-
refined, the software will need to keep up. tems and hospitals, however, this approach may
The vocabularies of best-practice EMS orga- require dedicated staff time—and expense.
nizations will be expanding to include terms A complicating factor to consider is when
like dependent, independent, extraneous and the EMS data set needed for quality assurance
confounding variables; statistical significance; or improvement purposes involves more than
statistical power; statistical process control and one data system or more than one organiza-
control limits; and user specification limits. tion. Inside a single EMS provider organization,
These terms are central to the methods used by clinical process metrics may require informa-
top-performing improvement programs and tion from the ambulance communications
must be among the skill set of whoever you pur- center, which may not be integrated with the
chase data collection software from. ePCR data and therefore requires a process to
january2014
Data Drives Care
pull data from both sources and place it into a erability of health information technology.
separate file. The National EMS Information System
Alternatively, the data from multiple sources (NEMSIS) has worked with HL7 to develop a
can be linked using relational database systems NEMSIS Version 3-specific CDA to promote
from which queries and reports can be gener- the exchange of EMS data with hospitals and
ated. If more than one organization is involved, the rest of the healthcare industry.
such as a 9-1-1 center, a medical first-response Using this approach, EMS provider organiza-
provider and an ambulance provider, the pro- tions send a file of data elements in the speci-
cess becomes complicated. fied format to the hospital. The information is
The databases you may want to query or link to used to place a copy of the EMS PCR into the
are often out of any one organization’s control. hospital’s medical records system.
Like the hospitals, this requires organizational In return, software on the hospital side can be
cooperation. Also like the hospitals, that’s much programmed to send a compatible file back to
more likely to happen if all organizations with the EMS agency containing the outcomes infor-
needed data have an interest in the performance mation for the patient after they leave the emer-
metrics or share accountability for quality assur- gency department (ED) or are discharged from
ance and improvement efforts. the hospital. The NEMSIS Version 3 HL7 CDA
To minimize the labor on the hospital side, has been successfully implemented in two hospi-
some EMS systems rely on getting copies of data tals through a collaboration between ZOLL Data
the hospital has already collected for its own Systems and the NEMSIS Technical Assistance
internal purposes. For example, if the hospital’s Center.
cardiac catheterization laboratory participates A more robust approach uses an intermedi-
in the ACTION Registry for acute coronary ary computer system called a health informa-
syndrome cases, the data that EMS is interested tion exchange (HIE). Think of an HIE as a data
in—and that the hospital typically needs from “middleman” that attaches to the computer
EMS—are all included in the ACTION registry systems in one or multiple organizations, pro-
data set (www.ncdr.com/webncdr/action). viding a portal for each organization to search
Because the hospital has already made the que- and retrieve information on patients across all
ries to enter their information into the ACTION of the participating organizations. Multiple hos-
registry, EMS agencies can help provide their pitals and groups of individual physician offices
data, and then both entities can share the com- or clinics that participate in an HIE can share
pleted data sets for patients they mutually cared records on the same patient—to obvious advan-
for. Similar approaches are possible for stroke tage. If EMS is included in the HIE, sharing data
and other cases where registries are utilized. back and forth for continuity of care and quality
Ideally, all of the organizations involved in assurance/improvement is readily accomplished.
the continuum of care participate together The HIE infrastructure includes appropriate
on standing quality assurance/improvement security controls so individuals and organiza-
committees and collaborate on ad hoc quality tions can only access the information they’re
improvement project teams. authorized to (e.g., ambulance services are only
able to search and retrieve data on their patients).
Electronic Data Exchange Imagine a process that queries the 9-1-1 com-
The downsides of getting outcomes and process munications center, the medical first-response
data from multiple organizations are obvious in provider, the ambulance provider and the hospi-
terms of time, expense and hassle. The newest tal to assemble all of the data needed on an epi-
approaches use software to help the process and sode of care and then generates specified reports
outcomes data move between organizations and pushes them out to designated recipients—
more efficiently. There are two primary meth- automatically. That’s the power of an HIE.
ods to accomplish this: data file interoperability
and health information exchanges. Healthcare System Integration
Data file interoperability uses a standardized Almost every effort to improve the efficiency
data format to send and receive information and effectiveness of healthcare delivery involves
between provider organizations. Health Level healthcare integration—smoothing out the
7, a Standards Developing Organization, devel- rough spots when a patient transitions from
oped the HL7 Clinical Document Architecture one organization, or care unit within the same
(CDA) standard (www.HL7.org). This standard- organization, to the next. The many rough spots
ized format is recognized worldwide for interop- in those transitions are the source of untold
january2014
numbers of problems and enormous costs. The Possibilities Ahead
Most healthcare system integration issues are The gathering of healthcare data can make it
related to data. Example: The 9-1-1 communi- possible to do things we could only imagine in
cations center gets a call. Somehow, it needs to the past. Consider the HIE being able to look at
pass the caller and whatever information it col- data on a diabetic patient from 9-1-1, medical
lected to the medical first-response agency dis- first response, physician offices, EDs, hospital
patcher and/or the ambulance dispatcher. One specialty-care units, general wards, and reha-
of those dispatch centers may be the provider of bilitation facilities. It would be possible to spot
emergency medical dispatch services to perform dangerous trends that would never be detected
medical triage and give pre-arrival instructions by any other means and alert the patient and
to the caller. Some of that information must be appropriate care providers to allow intervention
passed along to the responding crew(s). That’s sooner—with better outcomes and at a lower
a transition point with several potential rough total cost.
spots. If the medical first responders arrive first, And consider looking not just at one patient,
they will gather information as they make their but an entire community. Trends may be spot-
initial assessment and begin care. When the ted to detect the emergence of geographic or
ambulance arrives, the information must be time-associated patterns of disease or injury.
passed along to them—another transition point We see the very basic elements of this type of
and lots of other potential rough spots. trend detection capability in syndromic surveil-
And so it goes, from the ambulance to the ED lance software systems used with public health
to the specialty-care units (e.g., cardiac cath labs, data and emergency medical dispatch data.
trauma center, stroke center, ICU, etc.) to the The bottom line: Technology can and will do
general wards to the attending physician(s) and amazing things for the treatment of individual
to any rehabilitation services. patients and the advancement of mobile inte-
The software tools to manage data across the grated healthcare. We have a long way to go
transition points are just one element of health- before the systems that need to communicate
care integration. Healthcare system integration seamlessly can do so, but the promise of bet-
also involves the same patient in multiple care ter care at lower costs should compel each of us
settings on multiple occasions. in EMS to strive for standardization of process
A well-integrated healthcare system would measures, sharing of data with all organiza-
allow each provider at each transition point tions within the healthcare continuum, and the
to have access to pertinent information in development of reporting tools that help us use
real time. Example: A call is made to 9-1-1 and this data to its greatest potential.
transferred to medical first responders and the The data is out there—it is up to us to figure
ambulance service. They both can access per- out how to share and use it. ✚
tinent information on prior calls to the same
patient. They might also see alerts (“do not Mic Gunderson is the president of Integral Performance
resuscitate” orders, or other advance direc- Solutions, a firm that has specialized in system and
tives) that are important to know before making process design, assessment, education and improve-
patient contact. ment in EMS, fire and 9-1-1 communications. He also
In this model, the crews would also be able serves as executive director of Kent County EMS, based
to access the patient’s past history, medica- in Grand Rapids, Mich., and was a section editor for the
tions, allergies and emergency contacts. When NAEMSP textbook, EMS and Disaster Medicine: Clinical
considering the right destination, they would Practice and Systems Oversight. Contact him at mic@
consult information on the in-network hospital onlineips.com.
and its ability to care for the patient’s current
condition. If the patient is low severity, perhaps Greg Mears, MD, is the medical director for ZOLL,
they don’t go the ED. It may be best to make specializing in data, systems of care and EMS per-
an appointment for follow-up with their family formance improvement. Dr. Mears, through the non-
physician or specialist. This starts to engage the profit Emergency Performance Inc., leads the devel-
processes of care commonly discussed in com- opment of the National Fire Operations Reporting
munity paramedicine programs. The value and System (N-FORS). He’s an adjunct professor in Emer-
utility of an HIE to facilitate healthcare integra- gency Medicine at the University of North Carolina
tion is what’s likely to make them popular as at Chapel Hill and has served in multiple EMS lead-
the economic benefits and regulatory mandates ership roles within North Carolina and nationally.
to do so increase.
january2014
All photos courtesy MedStar Mobile Healthcare
Beyond
Mass gatherings and other large-scale events create a
strain on any EMS organization. The ability to collect
data and quickly apply it can help mitigate issues and
allow organizations to be more prepared to meet the
Traditional demands of the event.
Response EMS data use in mobile integrated

healthcare, mass gatherings & MCIs
By Jeff Beeson, DO, FACEP, EMT-P, have limited ability to query their database and
Michael Potts, CCEMT-P, & pull records from previous experiences. The
W. Heath Wright, BA, LSSGB, EMT-P result is another spoke.
In fact, the data gathered by EMS systems
E
MS systems have data, mountains of has a much larger potential. Three key areas
data. Most, however, are unsure how to where EMS data should be used are integration
use it outside of fairly standard resource of mobile healthcare delivery, mass-gathering
deployment and clinical benchmarking. Often, events and mass-casualty incidents.
the problem is data integration. Healthcare is
delivered by many different providers in different Mobile Integrated Healthcare
locations. These are often described as spokes on If you haven’t heard the term Mobile Integrated
a wheel, with the patient being the center, or hub. Healthcare Practice (MIHP), you’ve probably at
As the patient rolls down the street, the spokes least heard the term Community Paramedicine.
themselves are weak, but when aligned and sup- The concept of utilizing EMS personnel in non-
ported by the rim, they become part of an equal- traditional roles is not new. In fact, some com-
ized, strong machine. munities have been doing it for decades. The
While the development of electronic health Affordable Care Act has simply accelerated this
records has brought new focus on the need for development. As a result, EMS systems are ques-
integration in healthcare, most EMS electronic tioning the longevity of their current deployment
record systems continue to be episodic. They styles. The days of “you call, we haul” are ending.
january2014
Data Drives Care
Although many systems want to establish a edge of the others, the patient can be navigated
MIHP, they’re often unsure of what they hope to programs that meet their needs. In many com-
to accomplish. The first step should always be a munities, there is unused capacity in these pro-
needs assessment: Analyze the data. Utilize the grams—but often, it goes unrecognized. When all
expertise of public health programs to identify the various resources meet, the individual orga-
gaps in the delivery of healthcare in your com- nizations access their own data and create an in-
munity. EMS data includes location and types person data exchange with others. Although not
of calls within an area. Hospitals and health pro- very technical, it has become the greatest asset in
viders have data on their patients and types of our MIHP. It is simple integration.
visits. EMS providers that do inter-facility trans- A simple starting point is to capture the address
ports have additional data of where patients are and or phone numbers of individuals identified
moving through the healthcare system. These in the needs assessment, a service provided in
systems must talk to each other and allow EMS the 9-1-1 infrastructures in most systems. When
agencies to learn the final patient outcome and dealing with CAD, this is known as ANI (Auto-
be a true partner in the healthcare system. matic Number Identification) and ALI (Auto-
Data collection, storage and retrieval are matic Location Identification). The number (or
becoming extremely important in the dispatch residence) can then be tagged in the CAD with
discipline of EMS systems. In addition to real- specific information—specialized medical equip-
time notification of critical information to ment or needs, appropriate responses, etc.
responders, EMS agencies can use this informa- You can also tag a specific location as a known
tion to analyze previous calls. Such analysis may area that may have dangerous activity, such as a
lead you to identify the need speed up or slow drug lab or area with violent patients or history
down response to specific calls, and/or send dif- of previous domestic violence calls, which can
ferent resources. And it can be done on individ- automatically initiate a police response along
ual addresses or phone numbers or general geo- with medical personnel. In the MedStar system
graphic areas. Identifying multiple occurrences in Fort Worth, we flag addresses where an AED is
of the same activity or type of response is a great on property. In the event one is needed, the 9-1-1
way to reveal volume increases with geographi- call-taker can direct the caller to its location. We
cally significant patterns. also flag individuals with specific healthcare
Many MIHP programs begin with a focus on needs, including patients with home ventilators,
high utilizers. Every community has a popula- ventricular assist devices, or those with emer-
tion that frequently utilizes EMS or the emer- gent medical needs. In addition, we flag hospice
gency department (ED) for primary care needs, patient addresses so that when the family calls
no matter how many times we direct them to 9-1-1, we can notify the hospice providers.
appropriate care. What would happen if we spent In 2009, we began our needs assessment by
the time to find out why these patients return? reviewing CAD and electronic medical record
A simple needs assessment can be performed by data. We identified specific addresses and
reviewing EMS and hospital data to identify his- patients who utilized 9-1-1 frequently. We went
torical trends. into our community to locate these patients. We
Community resources are the backbone of a assessed their needs, both medical and social,
MIHP. Most communities have a number of dif- and then connected them with resources in the
ferent types of agencies, medical providers, ser- community. Many of the patients had issues
vice systems and ancillary programs—additional with mental health, drug addiction and basic
spokes in the wheel. Separately, their data is uti- understanding of navigating our healthcare sys-
lized to provide the specific service(s) they focus tem. Most had transportation needs.
on, but communication between these entities is Our MIHP started with our EMS Loyalty pro-
often lacking. Imagine if the individual programs gram. We identified a need to better respond to,
worked together and shared their data. As a com- manage and navigate this subset of the popula-
munity of resources, the possibilities expand. tion within our healthcare system. We worked
At MedStar in Fort Worth, we hold a monthly with community resources to create a plan of care
“meeting of the minds.” Social workers from for these individuals. We flagged their addresses
hospital systems sit at the table with commu- in the CAD, and worked with our hospitals to
nity mental health workers and folks from meal- create notifications in their electronic health
delivery programs, homeless coalitions and records to identify these patients. The result has
religious organizations. The purpose is to share been an integrated healthcare delivery that has
data. When each individual “spoke” has knowl- decreased the 9-1-1 and ED use in this popula-
january2014
Data Drives Care
tion. They are getting better healthcare with bet- be diverted and where first aid or treatment areas
ter outcomes, and in a more economical setting. will be located. By utilizing the similar concepts
of unified command, all responding organiza-
Mass Gatherings tions can easily communicate available resources
Any time a few thousand people get together for and known events and seamlessly share data.
an event, incidents are going to happen. Mass After-action meetings and reports are also a
gatherings create a strain on any EMS organiza- significant source of data. By discussing what
tion; in fact, the strain is often felt throughout worked well, and where future changes should
the entire healthcare system. Issues from traf- be made, organizations can improve the services
fic congestion to lack of resources provided by they provide. These reports also become data ele-
the event promoters create significant concerns ments that can be shared with others.
for EMS systems. The ability to collect data and The Texas Motor Speedway in Fort Worth is
quickly apply it can help mitigate these issues. a NASCAR venue where all of our data comes
Many resource deployment tools and needs together. With attendance in the tens of thou-
assessment calculations exist for mass gathering sands, this venue becomes a city within our city.
preparation. If the event has occurred before, data We have more than 15 years of data from previ-
on types and numbers of patients handled is avail- ous NASCAR races and other events held at that
able and should be used in planning. The type of location, and we use it to work closely with the
event, environmental exposures and expected venue, promoters, on-scene medical teams, fire
participants will each have an effect on how busy responders and police to ensure the attendees
the EMS provider will be. A NASCAR event will and sponsors have a good event. MedStar utilizes
have a much different crowd than a symphony the MARVLIS software to show the shift in geo-
concert in the park. graphical demand during the week of the events.
Planning is the key. Software applications, such Our PULSE process allows us to review previ-
as FirstWatch, can monitor current system per- ous events and preview expected system delivery,
formance, while processes, such as PULSE (Per- such as unit hours scheduled, time shifts in peak
formance, Utilization, Lost unit hours, Special call volume and resource utilization, then create
Events & Excellence) can help evaluate previous a staffing plan for the event. Weather forecasts
and future system performance. Deployment are evaluated to determine any changes needed
simulation software systems such as MARVLIS in our plan. During the event, our unified com-
can model the potential impact the mass gath- mand, on-scene supervisors and system control-
ering could generate on system demand. These lers utilize FirstWatch to monitor continuous
types of programs also allow a service to make system performance and make needed changes
changes to the system in a simulated environ- to staffing and posting locations based on call
ment, so planners can see the effects. volume. We monitor our receiving hospital’s sta-
Working with the venue operators, promot- tus on Web-based data systems to ensure even
ers and local public safety and healthcare orga- distribution of patients to appropriate locations.
nizations allows an integrated approach for Data allows us to not only prepare, but also shift
response. You should understand how traffic will the system rapidly if unexpected events occur.
This graph illustrates the call volume an event creates and the staffing to cover the demand. The consumption
area in the background includes the time it takes for the unit to complete the call and the time it takes to
return to the event.
january2014
This graph shows the amount of resources used in the system and any dedicated mass gathering. This
allows for Logistics and/or Fleet to increase staffing in advance to mitigate an increase in workload. The unit
consumption is based on the time a unit is in service or being prepared by Logistics for the next shift.
Mass-Casualty Incidents real-time data to those responsible for decision-

When buses, multiple cars or mass gatherings making to allow for better tracking of resources
experience problems, they are usually big ones. and patient movements during the event.
The simplest definition of a mass-casualty inci- Such technology maked patient tracking easier
dent (MCI) is when the number of casualties and more accurate for field providers and receiv-
overwhelms the available resources. One of the ing facilities. Web-based applications are great
most important pieces of data at an MCI is the tools for the providers working the incident, the
ability to track patients. Patient tracking applies emergency operations center monitoring the
in several different areas of EMS, including MCI incident, and receiving hospitals determining
evacuation/relocation, mass-gathering events what their demand will be. Continuous data is a
and sheltering locations. key to successfully managing an MCI.
Web-based patient-tracking tools can inte-
grate with EMS patient care reports and hospital It’s What You Know
medical records. Recent versions integrate track- Data should drive most things in EMS. How it’s
ing numbers or barcodes from scene triage tags. applied is limited only by the minds of those who
Having a Web-based tool gives the entire incident choose to use it. As EMS transitions into more
team the ability to obtain information, deploy healthcare delivery, the non-traditional uses of
resources, track movements and develop plans. data will become more important. As a partner in
Once an incident is created, a series of pre- the healthcare system, our significance will only
planned events occur. When a scene size-up is be recognized when we reveal what we know. In
entered, automated alerts notify hospitals and any setting—from MIHP to mass gatherings to
require them to update their bed status. EMS MCIs—that recognition comes from our data. ✚
responders then receive the bed status reports to
help formulate a plan for transporting patients Jeff Beeson DO, FACEP, EMT-P, is medical director for
to appropriate receiving facilities. As patients the Emergency Physicians Advisory Board of Fort Worth,
are triaged, and transportation is assigned, the Texas, which provides medical oversight for MedStar
software will track movements via the unique Mobile Healthcare and the 15 first responder organi-
identification number. Once a hospital has been zations of the system. He’s an emergency physician, a
assigned a patient, they can view the type and licensed paramedic and a registered nurse.
numbers of patients that are inbound and pre-
pare to receive them. Michael Potts, CCEMT-P, is the special events supervisor
Hospitals acknowledge electronically that they for MedStar Mobile Healthcare in Fort Worth.
have received each patient, allowing the incident
commander to continuously update their patient W. Heath Wright BA, LSSGB, EMT-P, is the operations
count and assign resources more appropriately. manager for MedStar Mobile Healthcare.
This system-wide integrated approach provides
january2014
Show Me
the Money!
EMS is a business, like it or not
All other photos/images courtesy Rob Lawrence

Image Kermit Mulkins
By Rob Lawrence think response and intervention—the machines
and monitors that spew out information to
T
his section of the supplement is about improve the next rotation of care. But EMS sys-
the EMS business and the systems that tems can only be successful if they have the right
support it. No, it’s not! Deep down, it’s amount of appropriately qualified providers, in
about the money—making it, and, importantly, enough correctly maintained vehicles, loaded
using it to achieve great patient outcomes. with sufficient amounts of equipment, with the
In these cash-strapped times, I encourage every means of recording the patients’ history and
EMS leader to adopt the Richmond Ambulance demographics, to generate a fee for service, to
Authority (RAA) fiscal philosophy: At RAA, we fund the next turn of the response cycle.
say we have a “bucket of money.” If we submit All of these seemingly mundane functions cre-
complete, correct and billable call sheets, we fill ate the conditions that enable EMS to physically
the bucket. If we use personnel hours wisely and happen and are the power behind the punch of
don’t crash the trucks and take care of the equip- service delivery. All require enormous amounts
ment, we will use some of the cash in the bucket, of attention to detail and most directly affect the
but we will also have sufficient reserves for such bottom line. System efficiency can only occur if
things as newer, cooler equipment—and even pay prudent leaders develop an understanding of a
raises. Put a hole in the bucket of money, how- devil’s amount of detail in these business areas.
ever, through bad or poor practice, and the first In fact, the definition of the “quality unit
things to go are the nice things. hour” is simply two fully trained medics in a
The bottom line: Running your EMS system like fully equipped vehicle for one hour. The unit
a business is an absolute necessity, especially in hour is in fact a unit of currency because every-
the current political and fiscal climate. thing costs something. Unless that unit hour is
When we think EMS data, we automatically deployed wisely, no income can be obtained.
january2014
Data Drives Care
Scheduling: The Most Important Asset ment the best opportunity to correctly categorize
In any organization, EMS or otherwise, staff are the bill into the appropriate fee for service.
the most important and the most expensive asset. In addition, data analysis around the patients
Too many staff on duty for the level of call vol- served, and bills generated, does more than just
ume means unit hour utilization falls. Although indicate potential income. The payer mix, once
crews may have a more relaxing day in that situ- identified, provides a clinical cross-section of the
ation, cash hemorrhages from the organization. population served; by understanding the Med-
So, scheduling the right amount of staff on icaid, Medicare or private-pay status of those
duty is a critical financial activity. Before anyone served, managers can better understand the
is placed in a shift, a detailed demand analy- return on billing.
sis must occur to deliver the amount of unit Example: No EMS system achieves a 100%
hours needed for each day of the week (see graph income on the fees charged. The Medicare rate
below). Once the accurate demand forecast is may be less than the bill, or local insurance car-
known, then the placing of staff into shifts, sta- riers—particularly in the Affordable Care Act
tions or vehicles can begin. era—may not pay all that is expected. Analysis of
The simplest scheduling systems include the both payer and the entity that pays out must be
basic sign-up sheet where volunteers identify understood to identify the return on bills sent.
their availability or the Excel-type spreadsheet A thorough understanding of your billing time
systems that calculate hours worked. At the is also key. Knowing how quickly bills issued
upper end of the spectrum, Web-based, interac- result in money back to your organization also
tive specialist software systems allow manage- assists in setting the budgetary tempo. Consider-
ment to easily manipulate and extract informa- able analysis by both billing and finance staff as
tion in a cost-effective manner. to the solvency this income brings determines the
A useful piece of technology developed in- rate of service delivery.
house at RAA, with the cooperation of our sched- Paid bills are the cash that fills the mythical
uling vendor, is the ability to overlay demand bucket, so understanding billing data becomes
analysis with the actual staffing on any particular a critical requirement. Just as response times or
day. The combination of these two data streams ROSC stats are important for the operational
allows managers to see where “pinch points” or team, so is billing data for the admin team.
operational pressures will develop and facilitates
getting the right amount of people on duty. Vehicle Maintenance: Catch It Before It Fails
Preventive maintenance is the only way to ensure
Billing: The Birthplace of the Budget the patient never has to wait any longer than
Medical billing is an entire industry in its own necessary for an ambulance, or worse, wait in a
right; and it’s critically important to EMS organi- broken-down ambulance on the side of the road
zations. Many dyed-in-the-wool veteran provid- for a replacement vehicle to arrive.
ers, however, don’t give a second thought to what Data is as much a key requirement in car-
happens after the call sheet has been completed ing for vehicles as a toolbox full of wrenches. In
and “sent to file.” many states, comprehensive vehicle records are a
Assuming the department actually bills for permitting requirement, and they’re certainly a
service (and most services now do), the bill is the “must have” to attract any form of formal accred-
birthplace of the budget. This year’s income deter- itation, such as that awarded by the Commission
mines next year’s spend, just as last year’s activ- on Accreditation of Ambulance Services.
ity informs you of this year’s demand. Accurate Vehicle maintenance records provide evidence
report completion provides the billing depart- of failures and their frequency. They can reveal
january2014
Data Drives Care
ficient understanding of other fleet metrics

will allow the timing and intensity of servic-
ing to be adjusted to ensure a cost-effective
level of treatment.
• Inventory: Understanding inventory, both
what is on the shelves and what has been fit-
ted to the vehicle, informs stock control.
Supply Management: Money Management

Let’s face it, EMTs and medics are hoarders. In
environments where stations have their own
running stores or the same crews look after the
same vehicles day in, day out, there’s a tendency
to “add” equipment to the vehicle because “you
never know.” This might seem like a good idea,
Data is as much a key requirement in caring for but there is a high probability that it will lead us
vehicles as a toolbox full of wrenches. to purchase more equipment and supplies than
we need, only to watch it expire and be disposed
of—the equivalent of throwing cash straight into
equipment trends and inform maintenance or the dumpster.
replacement decisions. For instance, if you can The key is to have a system that accounts for
identify when key components break on a partic- stock and identifies both fast-moving items (so
ular type of equipment, you can design a service you can ensure that sufficient levels are main-
or replacement plan to take care of the problem tained) and slow-moving items (so you can
before the equipment fails. ensure that such items are rotated to vehicles or
The term “unscheduled maintenance” is code stations that will use them before they expire).
for cash hemorrhage. If a truck and its crew have Your data system should also analyze the fre-
to leave the street with zero notice, unit hours quency of equipment used. Example: The use of
(EMS currency) are wasted. The net effect is one an expensive item, such as an IO needle, can be
less vehicle available on the street when the care- tracked against clinical activity to confirm that
fully constructed, data-driven demand analysis the expenditure of such high-dollar disposable
says you need them. equipment is appropriate. The RAA system iden-
Poor maintenance, then, potentially equates tifies where and when high-cost items are used to
to poor patient service and a reduced revenue ensure that they’re not being employed where a
stream. Use of a data system and the establish- more cost-effective device could be used.
ment of a “mean time between failures” (MTBF) Data and usage assessment also minimize
chart for key equipment and abiding by it will equipment storage. The adoption of a “just in
ensure that unscheduled maintenance remains time” system means that only a few days of stock
at a minimum. This alone will pay for your invest- is stored on site and regularly circulated onto
ment in a vehicle maintenance data program. the trucks. An item of unused stock on the EMS
Many types of maintenance tracking systems store shelf is money that could be used for a bet-
exist in the marketplace, but consideration ter patient outcome elsewhere or increase your
should be give to systems that capture: earned interest on those dollars.
• Assets: Your vehicles by their VIN and type. In terms of logistics management, there are
• Retired assets: Keeping data on old vehicles and now a number of data-related products in the
vehicle types allows for comparative analysis marketplace that will track, monitor and even
against new or updated units. locate pieces of equipment. Radio frequency iden-
• Work orders: Who did the work (one mechanic tification (RFID) systems communicate with an
may fair better at a repair vs. another). Also, a electronic reader mounted in your ambulances to
record of parts used on every truck allows for identify the presence of an item of stock or part.
cost-benefit analysis of the relative worth of RFID can also be used to identify new stock arriv-
a vehicle, particularly as they near end of life ing into your agency’s “store” location and load it
and determinations need to be made about into the stock-management system; after the item
disposal or continued service. is loaded onto the truck, RFID records its loca-
• Preventive maintenance: Maintenance is the tion, and the inventory status is updated.
“public health” program for vehicles. A suf- Key pieces of equipment, such as expensive
january2014
monitors, stretchers, stair chairs, suction units
and first-in bags, can also be fitted with RFID
chips and programmed to alert the crew if the
vehicle moves away from the allocated device. If a
piece of equipment is inadvertently left on scene,
it will send an alarm before the crew get too far
away, allowing them to retrieve it—clever stuff!
The same RFID system can also help you
clinically monitor when the equipment leaves
the vehicle to ensure that monitor and suction
units leave the ambulance as the crew arrives at
a cardiac or unconscious patient call. This helps
ensure that cardiac patients are not walked down
two flights of steps and out to the ambulance
before being monitored or suctioned.
UPC (universal product code) bar coding is The key to EMS supply management is to have a
another stock-control system that is seen every- system that accounts for stock and identifies both
where from supermarkets to the bottom of the fast-moving items (so you can ensure that sufficient
computer this article was typed on. Code read- levels are maintained) and slow-moving items (so
ers write to a database, which assembles stock you can ensure that such items are rotated to vehicles
control and is then able to report information or stations that will use them before they expire).
trends, usage and expenditure.
Education & Credential Management and state-mandated training providers must

How quickly would your organization make it to maintain today, a system that not only captures
the front page of the local paper if one of your data, but also sends alerts, is the only way to go.
providers made a mistake and then it came to
light that they weren’t even certified or up-to- The Last Word
date on the particular skill that caused the issue This section of the supplement appears last for a
in the first place? How much more egg on the reason—not because it’s the least sexy of the top-
face would there be if management had no idea ics, but because readers must be left with the last-
that said EMT or medic was not current or actu- ing impression that EMS is a business, and we
ally qualified to do the job? I can hear the litiga- need to run it as such.
tion cash register “kerchinging” as I type! Knowing our business means understanding
Information technology systems abound with every possible metric out there, even in the back
databases to capture employee credentials and office. And this applies to every type of EMS
manage them for you. Some products are even agency: Not-for-profit organizations need money
capable of generating email reminders to the to make payroll; volunteer organizations need
provider and their supervisor that qualifications money to buy equipment; in the public sector,
and certifications are nearing expiration. the days of bailouts and bottomless municipal
This notification system is especially useful coffers are a thing of the past; and in the private
and cost effective in larger departments, where sector, failure can lead to new ownership before
it can be difficult to track requirements for a you can say “hostile merger and acquisition.”
large number of personnel. Although it should Put simply: The consequences of not paying
always be the provider’s responsibility to remain attention to the “business side” of the business
current, the system can monitor who and what are dire. ✚
is expiring or up for renewal. This can save you
from a lawsuit and that equates to big dollars. Rob Lawrence, MCMI, is chief operating officer at Rich-
The RAA system, for example, counts down mond Ambulance Authority and was named a JEMS EMS
a provider’s time to certification or credential 10: Innovator of EMS for his work on the Rider Alert pro-
expiration. In the worst-case scenario where gram in 2011. Lawrence is a graduate of the U.K.’s Royal
something expires (good management should Military Academy, Sandurst, and spent his first career
prevent this, of course), the employee “clock-in” as an active-duty Army Officer in the British Royal Army
system, which is integrated with the credential- Medical Corps, after which he held various senior leader-
ing system, refuses to allow the provider to book ship roles in U.K. ambulance services before moving to
on-shift. With the plethora of required courses Richmond, Va. to join RAA.
january2014

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JANUARY2014

How data collection and

An editorial supplement to JEMS, sponsored by

Taking Care to the Cloud Æ

emssales@sansio.com 877.506.2747 www.HealthEMS.NET

The Data-Driven Paradigm

1 EMS is the practice of medicine. EMS is

patient experience is the next big challenge.

Photo Chris Swabb

By Bentley J. Bobrow, MD Because time is so critical in cardiac arrest,

Images courtesy PulsePoint

The “Perfect” EMS Event

is evaluated in the ED to ensure no significant dardized format; therefore, integrating data

RescueNet® Dispatch, Navigator, and Road Safety RescueNet ePCR

To learn more about ZOLL’s solutions, visit us at

CONNECTING PROVIDERS IN IMPROVING BUSINESS PROCESS

RescueNet Link RescueNet Billing, Resource Planner, and Crew Scheduler

The hub of information associated Finally, there has been a significant

The Need for Standardization

The assessment of infants, of accident victims,

Traditional demands of the event.

Response EMS data use in mobile integrated

Mass-Casualty Incidents real-time data to those responsible for decision-

EMS is a business, like it or not

All other photos/images courtesy Rob Lawrence

ficient understanding of other fleet metrics

Supply Management: Money Management

Education & Credential Management and state-mandated training providers must

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