EMS Information Systems Project

Emergency Medical Services systems are complex associations of individual service providers. There is an increasing interest today in better understanding and evaluating Emergency Medical Services systems. The understanding and acceptance of evidence-based medicine is one reason. It is now well recognized that the appropriateness of medical care in any setting is best determined by the outcome of the patient. Santa Barbara County Emergency Medical Services (EMS) Agency has a long-standing record of providing efficient emergency medical services to Santa Barbara County residents.

However, as the EMS Agency looks to continually improve care and maintain current technologies, it has become apparent that significant deficiencies in the County EMS data management/information system threaten to slow system-wide improvements. Without adequate capabilities to analyze clinical outcomes in a timely manner, the EMS Agency is limited in its ability to make critical EMS system changes necessary to assure high quality prehospital emergency care. Recent technological advances and new systems standards have made it clear that implementation of an improved data management system is vital to validate system needs and plan for future system developments. Implementation of this crucial project will increase the effectiveness through the rapid exchange of information with all service providers and increase the EMS Agency's responsiveness to the residents of Santa Barbara County.

A second reason a comprehensive information system is needed is the necessity to work with managed-care organizations and other components of the health care financing reform movement. Without accurate and reliable outcome-based information, decisions regarding EMS system financing will be made primarily on a cost basis. Finally, outside interests and organizations (e.g., injury prevention, and public health) use EMS-related information as a foundation for their programs.

One important barrier to the evaluation and improvement of system design and function is the lack of reliable, accurate and integrated information systems. In the National Highway Traffic Safety Administration's EMS Agenda for the Future, five goals are set forth for the information system of the future:

• Adopt uniform data elements and definitions and incorporate them into information systems
• Develop mechanisms to generate and transmit data that are valid, reliable, and accurate
• Develop information systems that are able to describe an entire EMS event
• Develop integrated information systems with other health-care providers, public safety agencies, and community resources
• Provide feedback to those who generate data

Existing EMS data collection and processing systems have several limitations that prevent the accomplishment of these goals:

1. The true starting point of an EMS response - when the 9-1-1 call arrives at the Public Safety Answering Point (PSAP) - is not recorded or associated with the downstream EMS events. The 9-1-1 controller prints this time on a piece of accordion paper that is stacked in a corner and rarely reviewed. This is arguably the cornerstone time in the evaluation of an EMS system performance, and it is virtually never used.
2. Timepieces in PSAPs, fire departments, and ambulance companies frequently vary from Coordinated Universal Time Clock (UTC) by several minutes to over an hour. It is impossible to assess the multiple steps that must occur in the first ten minutes after a cardiac arrest (e.g., 9-1-1 access, CPR, first responder dispatch and arrival, ambulance dispatch and arrival, patient contact, defibrillation) if the events are measured by numerous clocks, none of which are on the same time. For the same reason, ambulance contract monitoring and similar administrative issues are difficult at best. Without UTC synchronization of all EMS system timepieces, meaningful performance analysis is impossible.

   Methods of gathering and recording important data are inefficient and inaccurate. The recording of computer-assisted dispatch (CAD) times is one example. Although initially accurate, the times are later communicated over the phone to EMS personnel who then write down the information and enter it into the patient care record. Data analysis involves one or more additional transfers of data, each of which can introduce errors.

3. Data collection systems almost always focus on the function of individual personnel and service providers, including PSAPs, dispatch centers, ambulance companies, fire departments, and hospitals. They are unable to accurately and reliably link together information from the various providers into a comprehensive EMS response patient care record.
4. Active participation of all system participants is essential for any product to succeed, and participation is directly related to the perceived value of the product. Systems do not allow accurate and reliable information acquisition, transfer, and analysis. Feedback to individual service providers is limited or nonexistent. The service providers have always seen little value in this type of system, and have been reluctant to cooperate, much less be an active member of the system evaluation and improvement team.

Prior attempts have been made to address these issues, but they have been largely unsuccessful. There are numerous reasons for these failures; due to limitations in technological capabilities, EMS system knowledge, and information system design.

1. EMS information systems have not taken full advantage of the operational efficiencies and dramatically improved reliability and accuracy brought by networking.
2. Systems that have been based upon field or hospital-based data entry without real-time error checking have suffered from the traditional "garbage-in-garbage-out" limitations.
3. EMS data programs are commonly written on proprietary databases and often have difficulty communicating with other programs. This is a major issue for EMS databases and has been a virtually insurmountable barrier when considering attaching non-EMS databases, such as PSAPs or CAD information.
4. Recognizing the limitations (cost, durability, size, reliability) of field data entry devices, some EMS data systems have required field personnel to enter information while sitting at a hospital or station-based desktop computer. The requirement for hospital-entry has had some marginal success in very low volume systems where operational efficiency is not a primary concern. However in higher volume systems, with several or more ambulances arriving simultaneously it is unreasonable to expect paramedics to wait to enter information.
5. EMS information systems have been designed by hardware and software vendors with the idea that, once installed and configured, they would run with little purchaser support. Although this does occasionally work for limited single application systems, it is unreasonable to expect that a comprehensive systemwide information system, which includes PSAPs, fire departments, transportation providers (both air and ground), hospitals and other destination facilities can be "plug, play, and forget." In addition, uncertainties in agency budget priorities, staff expertise, and departure of key personnel all contribute to this ongoing problem.
6. The ability to collate, process, analyze, and generate useful and meaningful reports has been, at best, limited. With a focus on the mechanics of data collection, transfer, and storage, EMS information systems have largely ignored the analysis and reporting components. There are numerous reasons for this, including the limited accuracy and availability of data, limitations of networking, and the absence of useful, outcome-based, widely accepted operational and quality standards. The net result is that these systems are widely and accurately perceived as "black holes" of information. This highly visible and well-recognized failure creates a serious perceptual limitation to any further progress.

This grant funded project provides an opportunity to work with Caltrans to research and develop proof of concept for the development of an integrated information system. Through this proof of concept we will show EMS system stakeholder how a comprehensive information system will provide an opportunity for all EMS system participants to have access to specific call information from the very beginning of the of the 911 call through hospital discharge. This project working with UCSB/Caltrans will provide the infrastructure and interoperability to link the information with the other system participants and enable system participants to obtain the needed dispatch information, pre-hospital information and hospital information to complete their records.

The information system will ultimately result in a database of clinical data for a specific incident from the first call to a PSAP through patient outcome at the hospital. Through this technology, the evaluation of the medical aspects of emergency calls and clinical outcomes will provide critical information for system-wide improvement of the EMS system.