Health Information Exchange in Emergency Medical Services
The right information, on the right patient, at the right time, in the right place.
When the $800 billion American Recovery and Reinvestment Act (ARRA) was passed in 2009 it directed $22 billion in funding toward the development of electronic medical record keeping and information exchange. The Health Information Technology for Economic and Clinical Health (HITECH) Act within ARRA created the Office of the National Coordinator for Health Information Technology (ONC) in the U.S. Department of Health and Human Services (HHS) to administer the program with the directive to increase the standardized, secure, and interoperable movement of health information among health care providers.
Over seven years’ time this money was dispersed throughout the nation for efforts big and small, ideas innovative, creative or simply long overdue. But very little of it went to prehospital emergency medical services (EMS).
“Since its inception, HITECH funding has been almost exclusively directed toward hospitals, physicians and community health information exchange organizations,” said Dr. Howard Backer, director of the California Emergency Medical Services Authority (EMSA). “As a result, although most EMS systems and providers have been able to invest in electronic patient care reporting systems, EMS as a whole is lagging behind the rest of the healthcare system in collecting and sharing patient information.”
Now, as HITECH funding is winding down, the federal government is taking a closer look at the healthcare provider categories that haven’t been brought into HIE thus far, including EMS. Encouraged by a use case and early proposal from EMSA in 2012, ONC began to observe the necessity for incorporating EMS and disaster response into the health information exchange dialog. First, the California Office of Health Information Integrity (CalOHII) provided $300,000 in funding to EMSA to study HIE readiness in EMS (Lumetra), put on the first HIE in EMS conference in November 2013, and fund 3 projects related to HIE readiness. In that first HIE for EMS conference, Lee Stevens from ONC outlined the disaster and EMS use case value proposition. This propelled further interest and resulted in a second HIE in EMS conference in November 2014. ONC funded an initial study by Audacious Inquiry in March 2014 that recommended improvements to both disaster and EMS response.
The result of this report was the conceptualization of a disaster response medical history portal called the “Patient Unified Lookup System for Emergencies” (PULSE), which would connect the many disparate HIEs in a state or region and could be activated during and after a disaster to provide authorized users with a summary view of a relocated patient’s medical history. It also recommended the exchange of patient health information for daily EMS use would be extremely valuable.
Following that well received report, the HHS IDEA Lab funded an innovation project to the Assistant Secretary for Preparedness and Response (ASPR) to develop the PULSE architecture and to continue discussion of emergency medical response during disaster and incorporating emergency medical services on a daily basis. This report was completed in February 2015. “One of the primary lessons learned during Hurricane Katrina was that health professionals need access to patient health information to avoid medical errors, renew medication, and coordinate care,” said Kevin Horahan, ASPR senior policy analyst. “Getting a complete and accurate picture of a patient’s medical history is a challenge under normal circumstances, but it is even more difficult – and even more important – in an emergency.”
There is continued national interest as well. In February 2014, ASPR’s Emergency Care Coordination Center (ECCC), in conjunction with ONC and the National Highway Traffic Safety Administration’s Office of EMS, convened a stakeholder meeting to discuss disaster medical response, EMS and their connection to Health Information Exchanges (HIEs).
Over the last three years, ONC and ASPR worked with EMSA and the California Association of Health Information Exchanges (CAHIE) and other stakeholders to examine these missing elements in HIE and disaster medical response.
Last spring ONC announced that they have $28 million available for projects to expand the adoption of HIE technology, tools and services and increase the integration of health information in interoperable health IT to support care processes. The pieces began to come together. EMSA applied for a grant to implement PULSE in California and in July 2015 the grant was awarded.
Over the next two years the funds will be used to develop two health information technology projects: 1) connectivity between health information organizations (HIOs) to support a disaster-focused HIE access point, and 2) technology and infrastructure to bring HIE between EMS field crews and hospital emergency departments to daily EMS operations.
This project will establish connections between four HIOs or health systems via a web portal. When a disaster happens, the web portal will be activated so authorized healthcare professionals can access patient records from outside their own health systems through their existing electronic health record system or through a secure website. Eventually healthcare providers will be able to access electronic health records from all over the state.
In addition, the grant will support the creation of technology, infrastructure and cooperative agreements to enable EMS providers on scene to exchange patient health information bi-directionally with hospitals, called PULSE+EMS. Although most patients now have an electronic health record and most emergency medical services providers use electronic patient care reporting systems, paramedics on scene don’t have access to important health information for the patient they are treating such as allergies, current health problems, medications, and the patient’s pre-directed treatment or end-of-life decisions.
To address the challenges of “real time” information needs during daily emergency operations, EMSA will help develop pilot linkages between ambulance transport providers and emergency receiving hospitals in at least two local EMS areas or regions. This will allow EMS providers to 1) search for a patient record in real time, 2) alert the hospital as to the nature of the patient coming in and receive direction, 3) file electronic patient care reports for the pre-hospital care they provided into the patient’s electronic health record, and 4) reconcile outcome data from the electronic health record back into the EMS record at the conclusion of the episode for system improvement. This framework for examining EMS health information exchange functionality is called “SAFR” which represents the SEARCH, ALERT, FILE, and RECONCILE elements.
Dan Smiley, chief deputy director of EMSA, is the project director and has been working to prepare stakeholders across the state for their role in this project, with the expectation that proposals will be solicited in October. “In light of our ONC grant objectives, we are letting local EMS agencies, HIOs, ambulance providers, and hospitals know that we will expect a ‘coalition’ of committed partners to come forward with a plan for local implementation of the “+EMS” component as part of our upcoming funding opportunity,” Mr. Smiley said.
Much of the necessary HIE infrastructure to accomplish these projects already exists. California has more than 40 HIOs and health care system information repositories, but they are not connected. The project will require that participants work through policy considerations, interoperability issues between proprietary data systems, and cooperative agreements to make the greatest use of the health information infrastructure that now exists.
The grant will also enable the EMS Authority to provide opportunities for collaboration, education, and leadership to encourage hospitals, local EMS agencies and providers across the state to take the steps necessary to incorporate EMS into the local HIE architecture.
“It’s our hope that EMS will become a full participant in the electronic exchange of health information with regular and secure two-way exchange between EMS and other health care facilities,” said Dr. Backer. “Through increased connectivity we will improve care coordination which will help us achieve the goal of better care, smarter spending, and healthier people.”
Anyone interested in following the progress of this project is invited to visit the HIE website, follow the HIE project blog or contact the EMSA HIE in EMS project coordinator, June Iljana at (916) 431-3723 or, via email at email@example.com.