History of EMS Data• We can date it back to the “modern age of

EMS” – 1966: Accidental Death and Disability

“A review of ambulance services in the United States indicates a paucity of information and a limited framework for the collection of data on and the evaluation of current ambulance services.” (Page 13)

More Recent History?– 2003:The EMS Outcomes Evaluation Project:

“No local, state, or federal databases were suitable for use due to inconsistent data definitions, inconsistent data formatting, and variation in inclusion criteria.” (Page 8)

http://www.nhtsa.dot.gov/people/injury/ems/emsoutcomes03/

Status: United States

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KEY:

Active Data System

No Active Data System

Did Not Respond to Survey Source: NEMSIS TACCapability Survey, 2006

So What Happened In Between?

• Largest event happened in 1992-1993– The NHTSA EMS Data Elements Version 1

• Great try, the spirit was there

• Too loose of a standard

• EMS relatively uneducated to the potential of computer technology

Enter the NEMSIS Project• Late 90’s, the National Association of

State EMS Directors decided there was a NEED for uniform data collection

The Need• EMS Education

– Curriculums– Local Education

• EMS Outcomes– Something other than death– System evaluation

• EMS Research– Generate hypothesis– Evaluate cost-effectiveness– Identify problems and target issues

• EMS Reimbursement– National fee schedule and reimbursement rates

The Money• NHTSA

– EMS Division (Primary)

• HRSA– EMS-C, Trauma, and EMS

• American Heart Association– Support for EMS Software Development

The ConsensusProfessional Organizations

• AAA• AAMS• ACEP• ACS-COT (NTDB)• AHA (NRCPR)• EMSOP• IAFC• IAFF• NAEMD• NAEMSP• NASEMSD• NENA

Federal Partners

• CDC• FEMA• HRSA-EMSC• HRSA-EMSC/NEDARC• HRSA-EMSC/NRC• HRSA-ORHP• HRSA-Trauma/EMS• NHTSA

This Desire…• Turned into the revision of the National

EMS Dataset

• More than just a dictionary– Why each element exists– What each element’s purpose and use– How to store and send the data– How they interact with each other

Overview of the NEMSIS Standard

Where We Need to Be• EMS is one piece of

a health care puzzle

EMSSystem

EmergencyDepartment

Hospital

Rehabilitation

Prevention

911System

The Data Sources

Linkage

MedicalDevice

DomesticTerrorism

Outcomes

QualityManage-

ment

Personnel

System

CardiacArrest

Trauma

Patient

Incident

Dispatch

NHTSA2.2

NEMSIS Overview• Composed of two components:

– Demographic dataset: • Standardized set of data fields that

describe an EMS system

– EMS dataset:• Standardized set of definitions describing

an EMS event

NEMSIS Overview• Both have the following:

– XML (eXtensible Markup Language ) formats – XSD (XML Schema Definition)

• Provides the capability of moving data from one system to another

• XML provides the method on which data is stored

• XSD provides the definition and rules for a field

NEMSIS Overview• Date of Birth

– You don’t want to have people enter any data into the field.

• You need them to:– Complete the field– Format: MM/DD/YYYY– Range: Today’s date to 125 years ago

NEMSIS OverviewNumber of fields to be collected:

Nat’l

State

Local

List in current dictionary

Mass’ List is Being Developed

States/Regions set the minimum number of fields

Why?• Portability means:

– Ease of movement of the data

– Commonality of the elements to be moved

– Software vendors developing applications that can be used across the country

Portability!

Patient Care Report Software

Agency C’s Software

911Center

Patient Care

Report

Agency A’s Software

Patient Care

Report

Patient Care

Report

Agency B’s Software

What Happened With The

Original NEMSISProject?

Success!• The Standard was adopted

• A pilot “national” EMS database was created

• Software Vendors are moving to the new standard

• National Effort

The Standard• Over 400 different elements to choose

from– No, you don’t have to enter all for each run– Choices, choices, choices– A State’s data dictionary will be smaller

• A standard that will be seen throughout the country– No other healthcare provider is even close

Pilot National Database• One of the final deliverables for the

NEMSIS Pilot Project

• Four states with an existing data system were to provide 30k reports to Dr. Mears– Delaware– Minnesota– Mississippi– North Carolina

Pilot National Database• Three out of four states provided data

• The data were combined into a common database and a query engine was built – First time that EMS data was combined from

multiple states– If this could be done, then there should be

limited issues with scaling to accept the entire nation

Software Vendors• Estimated to be over 70 EMS software

vendors in the nation

• As of March 24, twenty vendors have entered the compliance certification process– Certifications will be awarded in early June– An number of vendors are going for the Gold

standard

States Using the NHTSA Standard

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KEY

100% of the EMS Data Dictionary Uses Using the NHTSA 2.2 Standard

Not 100% of the EMS Data Dictionary Using the NHTSA 2.2 Standard or No Answer

Did Not Respond to Survey

HI

National EMS Database

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KEY

Submitting in 2006

Reporting as Capable of Submitting in 2007

Reporting a Date After 2007 or Unknown

Did Not Respond to Survey

Part Two • The Next Steps:

– Federal Support– NEMSIS TAC– Software Compliancy– NEMSIS Freeware, etc.– National EMS Database

Federal Support• Already discussed about the Federal

commitment to the new process

• NHTSA, HRSA, CDC have all made a financial and political commitment to the cause

• Here’s how…

Federal Support• Provided money to establish a NEMSIS

Technical Assistance Center – $600k year one– Possibly $1 million for Year Two– Talk about providing more money

• NHTSA has established a funding source for states who are making a NEMSIS system

Other Funding Source• The Federal Register published that 34.5

million will be offered each year over the next 4 years to States– Non-competitive– $300,000 - $500,000 per application

• The “catch” is tying NEMSIS in with traffic crash data

NEMSIS TAC• The TAC picked up the work at the end of

the Pilot phase of NEMSIS (Sept 2005)– University of Utah received the grant– Utah contracted with University of North

Carolina to continue their efforts

• The Goal is to collect data from States and Territories to create the National EMS Database

NEMSIS TAC• Simple goal, complicated objectives

• This means that the TAC will be offering assistance to:– States– Local EMS agencies– Software developers

NEMSIS TAC Resources• www.nemsis.org • Reference Documents• Communication and Public Education• Maintain Dataset and XSD• Development Tools• Direct Technical Assistance• National Database Development• Other

www.NEMSIS.org

Software Compliancy• On March 1, 2006, the TAC began testing

software developers for compliance

• At the end of March there were over 15 applicants (multiple software packages too)

• There are two levels of compliance:– Gold– Silver

Silver and Gold Compliance

Silver

• Must have the National elements

• Any additional elements must comply with the standard

• Must create the right XML/XSD files

Gold

• Must be able to offer all of the elements found in the NHTSA dataset

• Must create the right XML/XSD files

Compliance• Upon successful completion of the

compliance certification, the developer and application will be posted on the NEMSIS site

• Always remember to be an informed customer (There is the possibility of cheating the certification process)

Compliance• At this time, no one has been certified in

either the Silver or Gold level

• The first ones will be posted in early June– The website can be (and is) updated on a

frequently basis (i.e. daily)

National EMS Database• 2006- Five states will be submitting data

– North Carolina– Minnesota– New Hampshire– Mississippi– Nebraska, North Dakota, or Tennessee

• The TAC will collect the data for the NCSA

• The TAC will also design the reporting system to extract data

• This reporting section will analyze data from a national, state, and local level

• The TAC is creating 10 report sections for the National EMS Database

National EMS Database

The Ten Categories• Data Quality Section

• Overall Section

• Times Section

• Medical & Trauma Section

• Disposition Section

• Agency Section

• Cardiac Arrest Section

• Delay Info Section

• Financial Aspects Section

• “Other” Section

The Reporting System• Plans call for:

– Canned Reports

– User-defined Reports

– Logic built into the reporting section

– A quality score for each report

– Multiple output formats• Screen, PDF, etc.

Let’s Go Over the Fields

What is in it for You?• Performance Improvement Initiatives

• National Trauma Registry, etc.

• Data Element Recommendations

• Massachusetts' needs

Performance Improvement• More Money Parts 1 & 2

• Changing the Business Logic– Protocol Development (Evidence-based)– Time Related Analysis & Interventions– Capability & Consistency– Dynamic Unit Deployment

More Money, Part 1• Situation:

– Volunteer EMS need money to survive– Saw data system as an unfunded mandate

• Truth:– Cost of computer, printer, internet: $1,400– Yearly cost: About $250– Time to complete reports: Unknown cost

More Money• Results:

– EMS entered agreement with billing company– Virtually eliminated the “EMS secretary”

position– It did take longer to write a patient care report– Revenue increased for the agencies– Turnaround time for $$ was faster

Advantages of Electronic• Completeness check (edit check)

– Can’t bill unless to have the information

• Not applicable data is hidden

• Electronic means closer to invoicing– Invoices should be mailed within 72 hours

from the time of service*

*Prehospital Care Administration, pg 386

More Money Pt. 2• University of North Carolina is combining

their system with money from a Duke Endowment

• The Performance Improvement Center will analyze EMS data to determine:– What resources are needed– How much $$ an agency could use

Paramedics review anddetermine protocol

changes

Paramedics revise theprotocols and back it up

with evidence

Paramedics meet withthe Medical Directors and

review the proposal

The Medical Directorsdiscuss and vote on

changes

The changes then followthe standard bureaucratic

path

Most changes are madestatewide

Protocol Development

• The “Total Airway Package” was the paramedics reviewing every aspect of respiratory distress and how the Delaware EMS system operated

Total Airway Package

Intubation Asthma Congestive Heart FailureSurgical Airway

Nasal ETT

Oral ETT

Oxygen

Albuterol

Peak Flow

“Needle Cric” Oxygen

Lasix

Nitro

Morphine

Rescue Airway

Drug-facilitated Atrovent

Steroids

Dilatation Cric

CPAP

Total Airway Package

• CPAP: Changed the respiratory emergency world in Delaware– How would you like to turn a CHF patient

around in 5 minutes?– Decreased Nasal ETT attempts = More

patients successfully intubated

Total Airway Package

NEMSIS = Improved Services

• Mainly because:– We will have more data

– We will have consistent data

– We will be able to put computers to work

– The local efforts will turn into national ones

ResponseTime

On-SceneTime

TransportTime

RestockTime

What the PublicCares About

911Answer Call

ProcessingAffects Response Times

Time Related Analysis

Time Analysis• Averages are “old school”

• “Fractiles” only tell you so much

Our Average Response Time is:

7.5 Minutes

Time GraphsReponse Time Percentile Graph

8.3%

20.9%

81.1%

90.3%

99.2% 100.0%

32.7%

95.7%

61.8%

55.9%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

110%

EMS Agency

Average90% Mark

Interventions• The same can be said about EMS

interventions– We have inconsistent definitions– We have inconsistent protocols– We have inconsistent equipment– We have inconsistent way to measure

Example: Intubations• We are interested in

monitoring the percent of successful intubations completed in the field

90% 86% 94%

89% 86% 93%

88% 92% 91%

93% 84% 88%

87% 91% 90%

95% 89% 92%

91% 90% 84%

83% 85% 97%

88% 87% 87%

91% 90% 91%

Our Data:

Capable and Consistent• The argument has been:

– “Who should say what is good for one location is good for another?”

• The logic has been that each EMS agency is different– Service area– Types of organization and providers– Patients, hospitals, equipment, etc.

Start by graphing the data:

Intubations

65%

70%

75%

80%

85%

90%

95%

100%

105%

110%

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

Time Intervals

Ob

serv

atio

ns

Does this tell us anything?

Add the Mean and Control Limits:

Intubations

65%

70%

75%

80%

85%

90%

95%

100%

105%

110%

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

Time Intervals

Ob

serv

atio

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Events

Mean

UCL

LCL

The control limits are three standard deviations above and below the mean.

Deployment of UnitsUnit Distribution-

Let the computer do the thinking

-Red dots are posting locations

-Polygons are response areas for each unit

Software: MARVLIS

Track district coverage on a real time basis

DeploymentSoftware: MARVLIS

National Trauma Registry• Currently being re-written and in the final

stages

• Great news: About 40% of the TR dataset’s elements come from the NEMSIS dataset– Electronic highway (two-way) for data to be

submitted to hospitals and back

Data Element Recommendation

• This is not an “official” list

• Some of the potential elements you can use from the NEMSIS dataset

• Let’s go over it

What are Massachusetts’ Needs?

Any Other Questions?

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YOU