© 2017 BY JONATHON S. FEIT FOR BEYOND LUCID TECHNOLOGIES, INC. www.BeyondLucid.com

Can “Perfect Prehospital Data” Eliminate False Activations in STEMI, Stroke, and Other Acute Syndromes?

Three billion dollars in annual uncompensated Emergency Medical Services—that is, care provided to patients by prehospital personnel but that will not be reimbursed due to documentation errors or omissions—coupled with costs tied to inappropriate, avoidable activations of emergency resources in ambulances and hospitals, represents a measurable but addressable risk to public health and homeland security. 1 As Accountable Care graduates from buzzword to bona fide in pursuit of the so-called Triple Aim—better health, better care, lower cost—the emergence of EMS-side concepts like Community Paramedicine / Mobile Integrated Health asks ambulance operators to benchmark against quality metrics that justify the expense of their services. Do prehospital interventions facilitate care, patient throughput or healthcare quality? (If so, how frequently and to what degree?) Do readmission avoidance, post-discharge follow-up, and patient tracking improve the flow from prehospital to in-hospital to post-hospital contexts? We talk about data, but few ask a question that is central to critically assessing our discipline: How can a data company make care providers better? Electronic patient care reports (ePCR) are not diagnostic systems; they are digital documents that collect, store, and transmit data inputted by clinicians or imported from devices and repositories. Troubling statistics emerge when practitioners rely too heavily on automation to make clinical decisions despite the “open secret” that medical devices produce incomplete or incorrect data. We are in an age reminiscent of the film Wall-E, seeking middle ground between manual, laborious methods that make it tough to track information, and the Holy Grail of artificial intelligence where we trust the machines that are becoming like appendages. What resources are wasted on mistakes, like activation of a catheterization lab in anticipation of an ST-elevated myocardial infarction (STEMI) patient even though the incoming patient is not experiencing one? Might access to “perfect” prehospital data—in real-time—reduce such waste? How would EMS agencies benefit? My late colleague Bruce Graham, former Vice President of the Ohio EMS Chiefs Association and Partner-Client Development Manager at Beyond Lucid Technologies, has eloquently noted that “an EMS agency [does] not make a dime more or less if the hospital does or does not pull the trigger on a cath team. Plain and simple…I get nothing from what the hospital does. And if the hospital doesn’t like what I do, their answer is to go for tighter controls. This was one of the points of the ACA and the creation of ACOs: to work together to share the savings.” What savings would justify investment in “perfect prehospital data”? Bruce see training as the bridge from a manual system to one that is technology-enabled. Too much technology can make people dependent, as we have seen from medicine to airplanes. Digital tools are just that—tools; they are meant to help, not replace. In the words of Mark Wittman, MD, MBA, MPH, critical care physician and Chief Medical Officer at Beyond Lucid Technologies: “Healthcare is a combination of data and brains. If data can make brains better, then you have real value.” Technology represents progress, and the ability to collect, connect, and analyze Big Data—instantly—finding trends that heretofore would have been missed. But software cannot supplant the EMS provider; it merely supports his or her readiness to respond. In Bruce’s words: “Software can be set up to allow the entire incident and encounter to be captured, thus allowing others to go back over the

© 2017 BY JONATHON S. FEIT FOR BEYOND LUCID TECHNOLOGIES, INC. www.BeyondLucid.com

incident with the providers, to debrief them. I'm talking about closing the loop: the fact that you get the 12-lead wrong...well, maybe what you thought you saw isn’t what you printed out. Technology will allow us to go back and look at it in the context of the entire call. In the future the entire patient care report will be embedded in the electronic health record in the hospital. Now the emergency medicine physician, internist, interventional cardiologist, intensivist, and even the primary physician can look at the same record. You are indeed closing the loop but most importantly, you are getting feedback, in real-time, so you can go back and say, ‘This is what you missed.’” If EMS providers cannot benefit from field data in real-time, all they are left with are noise and toys. Validating “good data” into the ePCR is essential, so making workflows better, faster, easier and more cost-effective is the ePCR company’s prime objective. There are tangible clinical and financial benefits to be gained from improving documentation quality: For example, obtaining a 12-lead for assessment is S.O.P. when examining a cardiac patient. But without a comparative baseline—a review of the current strip in light of previously captured ones—crews are hard-pressed to deduce whether they are investigating something serious versus a quirk of the individual body. I have seen crews in places like Pittsburgh ignore alerts from monitor-defibrillators because “the patient has had a funky heartbeat for years, and he’s not having a heart attack.” Insight about a patient’s condition over time is rare, especially in emergency contexts, so access to clinical history—putting the current incident in context—is vital to accountable, informed care, whether the patient is suspected of STEMI, stroke, a diabetic event, allergy, seizure, or most complex syndromes.2 Without context, many conditions look alike, which helps explain why Ramanujam et al. (2008) challenged the reliability of decision-making by field medics.3 Cardiac research shows enormous regional variation among false positive cath lab activations. (It would be worth investigating why these rates vary so widely, whether due to matters of public policy, medical direction, technology, or training.) Rokos et al. (2010) found that “recent surveillance of ‘unnecessary’ cath Lab activations…by ED physicians demonstrated a 5% rate from a single-center experience (n = 249 activations) in Virginia and a 6% rate across 14 hospitals (n = 2,213 activations) in a North Carolina STEMI system.” In Los Angeles and Orange Counties, false cath lab activation rates based on paramedics’ interpretation of the ECG were 20% and 23% respectively.4 Contra Costa County EMS describes a false-positive as “a paramedic tell[ing] the STEMI Center that a STEMI has been detected on the 12-lead ECG, but upon arrival at the hospital it is determined that the patient’s 12-lead does not show a STEMI. Most of these patients do not need the urgent availability of the catheterization lab.”5 JAMA says “the frequency of false-positive cardiac catheterization laboratory activation for suspected STEMI is relatively common in community practice, depending on the definition of false-positive.” False activation is also an expensive error: Patricia Frost, CCEMS Director, wrote in 2013 that 26-41% of STEMI activations in her county were false, at a cost of $5000 per incident. Eliminating those could save $480,000 per year.6 (The range reflects variation across the county’s hospital system that includes six STEMI receiving centers.) The insurance value of prehospital technology to provide “perfect information,” and to connect those data to the rest of the care continuum, thus justifies its investment by eliminating the cost of wasteful line-items. Accountable Care—and its EMS corollary, Community Paramedicine / Mobile Integrated Health—have inspired motivations to align clinical, operational and financial efficiencies. EMS has a once-in-a-generation chance to centralize its role as the web that connects the ACO. But what are (a) the risks to the patient, (b) to every provider along the healthcare value chain, from EMS to ED to nurses to physicians, and (c) to the healthcare facility if “bad data” wends its way into longitudinal records that follow the patient over time? At a rising number of hospitals, complex codes like stroke and STEMI are being called by EMS crews with authorization to bypass the ED, theoretically speeding time to treatment while relieving congestion and overcrowding. How reliable are the data being used to call those codes, and how good are the medics at distinguishing true positives from false ones? New health information exchanges and data management files make it feasible to search and import patient clinical histories while at the patient’s bedside—improving prehospital care while lowering costs, and leveraging telemedicine for tailored, informed medical direction.

© 2017 BY JONATHON S. FEIT FOR BEYOND LUCID TECHNOLOGIES, INC. www.BeyondLucid.com

C.Q.I., Data Capture and Sharing, and Use of Charting Technology (ePCR) in a Classroom Setting

This white paper reviews the emerging opportunity for prehospital Fire/EMS training programs to blaze pedagogical trails by reframing the prehospital patient care documentation as a modular, customizable training tool. Adapted from presentations at the Northwest Arkansas Trauma Symposium, the National EMS Educators Assn., and the International Roundtable on Community Paramedicine (2017).

The thesis of this objective is simple: that technology should be an integral part of Fire/EMS education. A theme of the 2017 National Association of EMS Educators (NAEMSE) conference in Washington, D.C., was that across the U.S.—and even around the world—EMS educators have gravitated to cost-effective means of bringing real-world practicums into the classroom, as they seek to prepare students to “hit the ground running” at any Fire or Emergency Medical Service department that hires them post-graduation. In addition to lifesaving technical and essential human skills, from intubations to empathy, burgeoning EMS professionals are being introduced to the idea that data are no longer an afterthought. Data have become a pervasive demand for every level of practice; every practitioner, from EMT-Basic to Community Paramedic, at paid and volunteer services alike, is now obliged to produce data and learn from them. The reason is as simple as it is controversial: arguably more than any other time in the history of Fire or EMS, agencies are being charged with justifying the cost of their own existence. Data have therefore never been more critical, since what goes into an electronic patient care record (ePCR) for EMS, Fire (NFIRS), or Community Paramedicine / Mobile Integrated Health (CP/MIH) encounter will be used to convey details about the care that was provided on-scene and in-transit, and then analyzed again for managerial and budgeting purposes. This theme shows no sign of abating. Some of the most progressive thinkers in EMS today—like Tony Spector, Executive Director of the Minnesota EMS Regulatory Board—have questioned the value of tasking EMS providers with collecting data that even appears to lack immediate tangible value. So let’s ask: does the information have immediate value? If not, then “why bother collecting it” is the perfect inquiry. But what if the data have value, yet the dots that justify their mandate have never been explained? Perhaps some sunshine on three brief but fundamental questions would convince industry leaders like Mr. Spector:

What is the purpose of an ePCR? Why does the contained within an ePCR follow such rigid—and seemingly random—rules? How can mining the data within an ePCR provide a more effective view of agency operations?

1. The importance of documentation, and what is the difference between ePCRs and EHRs? Fire and EMS agencies that are being asked to justify the cost of their services in an unprecedented fashion, distinguish themselves from home health agencies, and care for a population that is expanding, aging and increasingly mobile, face a piercing reality: cities are growing but budgets aren’t. For example, according to Chris Samples, Captain and Paramedic at the Flagstaff (Arizona) Fire Department, the agency’s call volume has grown about 8-12% per annum for the past decade, while the personnel budget remains flat, operating with twenty-one full-time on-duty personnel—the same number it had in 1992—despite a response volume growth to around 15,000 calls (projected) in 2017.

© 2017 BY JONATHON S. FEIT FOR BEYOND LUCID TECHNOLOGIES, INC. www.BeyondLucid.com

Furnishing real-time, interoperable data—especially while bridging the gap between prehospital and in-hospital care—is key to demonstrating how Fire and EMS agencies help their communities. But in an informal survey conducted by roll call, on questions spanning several dimensions of healthcare IT, at the 2017 Northwest Arkansas Trauma Symposium found less than 5% of the roughly 230 attendees responding favorably when asked: “Do you trust the electronic patient record system you use?” This included prehospital documentation (an ePCR) and in-hospital/in-clinic documentation (an “electronic health record”). The use of different terms are used to describe two things that are so similar tends to confuse the market, but the main distinction between ePCRs and EHRs is that an EHR is longitudinal in nature by default—the sum total of a patient’s individual visits—and is subject to Meaningful Use.

Three value propositions offered by prehospital data

Data captured in an ePCR conforms to the National EMS Information System (NEMSIS), but for agencies that are seeking to engage in emerging practices like Community Paramedicine, or to share data with a receiving care facility in a consumable fashion, NEMSIS v3 is insufficient since its standard information is geared to the concept of “one patient, one record,” without the details that are required to hand off the record in a format that is compliant and interoperable across the health IT ecosystem. That ecosystem looks at patient information over time, including data elements like “family history” and “past encounters” that are generally not relevant in 9-1-1 contexts—but which no hospital or nursing home would neglect to investigate as a vital means to understand the patient’s broader health context. By contrast, EHRs are based on a standards established by an organization called Health Level Seven (“HL7”), that does not produce rules or compliance requirements per se. Rather, HL7 provides a constructive language for data capture and transformation that is analogous to NEMSIS. Languages do not determine the value of their words and phrases—that task is left to those who use them. Consider English. Like HL7, it is a language, so it abides many flavors that ultimately may or may not be understood by both sides of an exchange (e.g., American English, British English, Old English, medical English, pidgin English, English slang, and so on). They are all somehow related and can therefore can be translated (at least theoretically) into one other with the appropriate codex. Similarly, HL7 tells healthcare systems that data which wants to be shared is translatable, but it does not tell the systems how to transform or use the data. Those who need to read, write, and speak using the HL7 language are responsible for agreeing on the forms of communication, and the organization makes sure that those who wish to use the language have access to its associated phonics. Turns out, our taxes have already paid for the creation of precisely such schemas: the federal Office of the National Coordinator of Healthcare Information Technology (ONCHIT), the National Institute of

© 2017 BY JONATHON S. FEIT FOR BEYOND LUCID TECHNOLOGIES, INC. www.BeyondLucid.com

Standards and Technology (NIST), and other federal agencies have published documentation on how to use HL7—including ways to translate NEMSIS into HL7 for use in exchanging prehospital data. NEMSIS is frequently criticized for focusing on statistics rather than clinical care, but a better way to look at NEMSIS is as a starting point with a mission to capture emergent, case-specific information. In non-emergent clinical contexts, EMS agencies have attempted to use myriad different data systems to collate the insights they need to do their jobs—with mixed results. For example, The Center for Emergency Medicine at the University of Pittsburgh Medical Center captures Community Paramedicine program data using a template modeled on the Outcome and Assessment Information Set (OASIS), which is geared to home health nursing. Several programs across the country capture data using a terminal that accesses a hospital-side EHR (or even one provided by an insurance payer), but these tend to exist where non-transporting Community Paramedicine programs are considered outside of the EMS system; as such, their records may not have to be submitted to the state’s EMS regulatory authority (which does its data analysis using NEMSIS). In places like California, where EMS providers must submit their Community Paramedicine-oriented “over-time” data to a regulatory body, using a hospital’s EHR or the OASIS form will not provide information in the proper language to assess the value of Community Paramedicine program vs. “standard” Fire or EMS care: rather than comparing apples-to-apples, such a relevant but incomparable data set is more like apples-to-fruit salad, or Spanish to French: some words overlap, but not enough to glean detailed nuance of a phrase.

It should be noted—and might not be a coincidence—that some states where non-ePCR data are permitted to track prehospital care over time are encountering challenges when it comes to approving legislation or budgets for Community Paramedicine / Mobile Integrated Health.

To make EMS records shareable with hospital-side EHRs, ePCRs must be—and can be—augmented to include longitudinal data based on the Clinical Document Architecture (CDA), such as a Continuity of Care Document (CCD) or Consolidated CDA (C-CDA), which are standardized under the ONCHIT framework called Meaningful Use. The data in these interoperable documents helps to frame the measurable—financial, social, clinical, operational—value provided by EMS practitioners. Like the proverbial tree falling in a forest, if an ePCR is incomplete and not shareable, has the crew be credited for delivering “meaningful” care? If an ePCR is intended as a "source of truth,” then before data can be shared, it must be adequately and accurately captured. Here, Fire and EMS educators come in. 2. “PRACTICE MAKES PROFICIENT”: Learning to document well evolves how clinicians think Conveying relevant, rich patient care data across the care continuum is a learnable skill that must be practiced. Changing how prehospital data is seen by practitioners who likely don’t enjoy completing extra paperwork (because really, who does?) begins with recognizing its value. Conservative EMS training programs in areas that are still early in demanding, and adopting, prehospital documentation technology are more likely to view ePCR in an educational setting as superfluous at best, rather than broadly applicable to the cognitive development of diligent, informed clinicians. Consider the vantage point of Gregory "Scott" Rose, Director and Coordinator of California’s Napa Valley College EMS Program, “At this time the Napa Valley College EMS Program does not utilize a [sic] E-PCR program. We as an instructor group don't find value focusing on a particular documentation program when there will be many different programs used for students. The NVC EMS program focuses more on preparing our students to produce an appropriately written narrative than working on an electronic documentation.” Data written in a narrative is certain better than data not written at all, but it cannot be efficiently mined for the sort of nuanced insights that governmental regulators—and the taxpaying public—are increasingly demanding to justify the actions, and budgets, of Fire and EMS agencies. Elsewhere—even in some unexpected locales—a cadre of trailblazing Fire and EMS training programs are pioneering the perspective that strong patient care documentation is a fundamental prehospital skill that should be taught during the earliest days of EMS education, much like assessing

© 2017 BY JONATHON S. FEIT FOR BEYOND LUCID TECHNOLOGIES, INC. www.BeyondLucid.com

a patient’s vitals or inserting an intravenous line. They know that prioritizing data quality steers Fire and EMS providers toward thinking about their practice with an eye to continuous quality improvement, knowledge management, and adaptability to future clinical opportunities. According to Steve Sims, Fire Chief of the Bella Vista (Arkansas) Fire Department, “it does not matter which ePCR” new recruits train to use—he looks for a “way of thinking” when interviewing potential team members. Given nationwide mandates regarding the National EMS Information System, Version 3, virtually every Fire and EMS agency at which a student will hope to find employment after graduation must complete digital documentation following a patient encounter. ePCRs generate a cornucopia of data that are useful not only in teaching clinical and narrative writing skills, but that can be repurposed as fodder for parallel healthcare education programs like medical billing and Community Paramedicine. Estrella Mountain Community College’s (EMCC) SouthWest Skill Center, part of the Phoenix Valley’s (Arizona) Maricopa County Community Colleges, was the first EMS training program in the U.S. to incorporate NEMSIS v3 charting software into its training courses. EMCC’s EMT program adopted a NEMSIS v3 ePCR for educational use back in 2014. According to Jennifer Kline, Assistant Program Manager:

“We teach and stress to our students the importance and relevance to quality documentation. The documentation that we provide for each and every call is a direct reflection of the care in which we have provided to our patients. So we have our students ask themselves, ‘Do you want to be perceived as a good clinician who advocates professionally for your patient by providing quality care, or do you want to reflect that you are a poor clinician who takes short cuts and does the bare minimums and doesn't care about the overall outcome?’ With this in mind, our students take their documentation very seriously. We have implemented an interdisciplinary approach in which we have the EMT students write their ePCR and it then gets routed through the QA and billing process. The EMT instructors do clinical QA and the Medical Billing and Coding students code it.”

Half a world away, independently but in parallel with EMCC’s efforts, the Griffith University School of Medicine’s Paramedicine Program in Queensland, Australia (directed by Duncan McConnell, seen below), is among the first—if not the first—non-U.S. EMS degree programs to incorporate ePCR into prehospital training as “a great way to close the loop in patient care education.” Griffith University chose MEDIVIEW by Beyond Lucid Technologies as its charting technology because of the software’s ability to selectively activate or deactivate the various components of the record, so that each student is exposed to a particular portion of the chart in turn, to coincide with his or her training. During the 2017 International Roundtable on Community Paramedicine, Professor McConnell described how his program is using ePCR technology in the portion of their EMS course that focuses on respiratory care:

“Most recently, they [the students ] completed their 2nd year respiratory assessments, where they went in as teams to do a respiratory assessment on a patient, be it asthmatic, anaphylaxis, COPD, a couple of pediatric cases. They were randomly picked, and once they completed …that end of semester assessment, they then had to complete this for their patient and then hand that in, and that was the end. Along with our ePCR…and working in a WiFi network within a university…we have the ability to start introducing the students to future technology. We’re going to send that ECG up to the medical students or the emergency department as they’re bringing that simulated patient in. We’re going to send that ePCR up to them as well so that when they’re doing the receiving, the handoff of that patient, they’ve already got a bit of an idea of what’s happening to the patient, what’s been done treatment-wise, and what to expect when they walk through the door….If something big happens between when they start to when they graduate, what do we need to do to re-contextualize that program, so they’re on board and their graduating at the same level as what they’re walking out to—not graduating with something that we haven’t done years ago.”

© 2017 BY JONATHON S. FEIT FOR BEYOND LUCID TECHNOLOGIES, INC. www.BeyondLucid.com

According to Darrell DeMartino, Assistant Professor & Clinical Coordinator in the Paramedicine Department at St. Louis-based (Missouri) Lindenwood University, his department needed a tool for students to use “both in the classroom (i.e., mock patient data) and in a clinical setting (where there are real/live patients),” where they “focus on documenting the situation, history, care provided. We currently do this on paper today.” But pedagogy is as much an art as a science, of course, and the most innovative Fire and EMS educators—like all teachers—constantly seek ways to keep their students engaged, especially when the stuff of learning gets “dry” and detailed. Some, like Art Groux, the Suffield (Connecticut) EMS Chief & Emergency Management Director, and President of the Connecticut EMS Chiefs Association, have devised ingenious methods to liven up ePCR simulation and training: Suffield EMS invites its crew to craft absurd scenarios as a way to explore the content and layout of a new ePCR, then awards a small prize (say, a logo wear sweatshirt) to whoever creates the most insightful record. One winner featured a happy ending: ROSC to an inebriated squirrel that got caught in the spokes of a bike wheel before suffering cardiac arrest…a “nutty” case review, indeed!

Duncan McConnell of Griffith University explains a data-centric EMS educational model.

3. Unexpected Findings: Prehospital data provides a robust view of what’s actually happening Fire and EMS are rightfully proud professions. Practitioners thanklessly save lives and property every day, often for far less money than is warranted given their bravery and skill. As such, it is relatively uncommon for agency leaders or field crews to ask themselves challenging reflective questions like “How much of our success today was due to luck?” Or “How often did we get make the wrong call?” Such questions make the profession better, and researchers—as well as politicians—from across the U.S. and even around the world (budget pressures for EMS agencies in the U.K. were highlighted at the 2017 International Roundtable on Community Paramedicine)—are digging into the question of whether EMS agencies’ self-assessments are on-par with what the data show. The mind-bending book Freakonomics taught readers that perceptions and mathematical reality often diverge when data lead the discussion. EMS agencies are asking similar questions, and inculcating the need for verifiable insights from Day One in training: How often do mismatches occur between prehospital care providers’ assessments and hospitals’ ultimate diagnostic finding? What are the impacts of such mismatches?

© 2017 BY JONATHON S. FEIT FOR BEYOND LUCID TECHNOLOGIES, INC. www.BeyondLucid.com

When assessing a patient’s heart health (e.g., using a cardiac monitor-defibrillator), students learn to “treat the patient, not the monitor,” since cardiac monitors provide critical insights but the patient’s experience is paramount—and monitors occasionally incorrect. Ronnie Ikeler, Director of EMS at Tomball (Texas) Regional Medical Center similarly advises young Fire and EMS professionals to “treat the patient, not the software.” But he has also noted that his own organization frequently invests hours—sometimes as much as 45 days—in a struggle to reconcile details about a transported patient whose information was incomplete at the moment handoff to the care facility. Without strong upfront data collection and transmission by crews from the field, it is virtually impossible to know how closely an EMS provider’s assessment of the patient matched the care facility’s findings. Such data are also critical to the management of Fire and EMS agencies because frequent material divergence between the opinions of the prehospital and in-hospital care providers may subject the agency to legal liability, and subject the patient to clinical risk (such as avoidable adverse events). Nevertheless, as revealed by the Fire and EMS literature, a divergence between perception and reality are far from uncommon:

A 2017 study in the West Journal of Emergency Medicine found that patients were under-triage from 3% to 32% of the time, with one study describing “a cohort of under-triaged patients, who EMS professionals felt did not require transport to the ED for care, and who subsequently required admission to the hospital (18%), including a subset who required admission to the intensive care unit (6%). These studies also revealed poor agreement between EMS professionals and emergency physicians about who required transport to the ED for care.7

A 2009 study of prehospital stroke ID in San Francisco found “96 patients…of whom 81 met

the diagnosis of acute stroke or TIA. Paramedics identified 49 of these 81 patients (sensitivity 61%). 15 patients were identified as having a stroke…ultimately had a different diagnosis.”8

A 2008 study in San Diego found that “of 477 patients with a paramedic assessment of stroke using [the Cincinnati Stroke Scale (CSS)], 193 had a final discharge diagnosis of stroke,” for a “sensitivity of 44% and a positive predictive value of 40% for paramedics using CSS.”9

A 2013 presentation by Patricia Frost, Director of Contra Costa County’s (California) EMS Agency, found that the county health system spent as much as $480,000 on false activations of the county’s catheterization labs, up to 40% of the time, at a cost of $5000 per false STEMI activation. Yet the County congratulated itself on what it called “STEMI 12 lead System-Wide Success,” presumably because its leadership thought that the results could have been worse.10

These error rates underscore the urgency of training crews to leverage ePCR for process improvement from the earliest days of prehospital training. Optimistically, though, EMCC’s Professor Kline sees reason for excitement about the power of ePCR technology to facilitate the long-sought vision of an informed, integrated prehospital ecosystem that simultaneously centralizes the role of Fire and EMS as the logistical-clinical “glue” that connects the healthcare system for both acute and chronic patients:

“The students, both EMT and Medical Billing and Coding get real life work experience while in the classroom and are able to make mistakes, debrief, receive feedback and make corrections. Watching the level of engagement from the students and the ownership they take in their documentation is both rewarding and refreshing. The students are more prepared to enter the workforce and have formed good habits that their future employers would value. This is how we know we are successful!”

© 2017 BY JONATHON S. FEIT FOR BEYOND LUCID TECHNOLOGIES, INC. www.BeyondLucid.com

The “5 Rs” of Community Paramedicine and Mobile Integrated Health

At EMS event after EMS event, and Fire event after Fire event, Community Paramedicine and Mobile Integrated Health has come up in conversation. Similarly, every interest group from regional and state regulators to the National EMS Management Association (NEMSMA), the American Ambulance Association (AAA), the International Association of EMS Chiefs Leadership Summit (I-Chiefs), the Paramedic Foundation, the National Registry, and more…everyone has a perspective on the range of topics that include out-of-home care, alternate site transport, non-transport, readmission prevention, and telemedicine. The vantage points represented include clinical, safety, training, and even finance. As an MBA (who also runs the first EMS-facing technology firm that designed patient documentation software specifically with Community Paramedicine and Mobile Integrated Health (CP/MIH) in mind), Fire and EMS agencies nationwide have sought my team’s help to walk down the new care model’s legal line (a dotted line at best in most places) while bolstering sustainability through sound economic judgment. After all, the archetypical CP/MIH models highlighted frequently across the country—including REMSA and San Diego (California), MedStar and Dallas (Texas), Pittsburgh (Pennsylvania), Mesa Fire (Arizona), Eagle County (Colorado)—offer an inspiring set of models that seem to show signs of regional success. However, each is also locally specialized and thus challenging to replicate. In the long-term, most places cannot get paid for CP/MIH (and they won’t be able to for a while)—so below are my “5 Rs of Community Paramedicine and Mobile Integrated Health,” suggestions to guide the efforts of agencies large and small that wish to engage this new care delivery model: 1. REASON – Agency leaders should ask themselves why they want to go down this road. Is it to

improve clinical care, lower costs, or free up resources? Or—if we’re being honest—is it because CP/MIH seems like “the thing to do”? It’s a hot topic, and “the cool kids are doing it.” Are you afraid of being left out? Implementation isn’t easy: a fire chief in Texas once told me he had to “use all his political capital” to push through a non-transport regulation pertaining to frequent transport patients. CP/MIH is at least as complex as frequent transports because its cost-benefit analysis is less obvious, as is the means by which to identify the patients—and providers—who will take part in the program, how patients will be tracked, and who holds command authority. (Add in union issues, and you have a recipe for extensive negotiations.)

2. RIGHTS – Speaking of extensive negotiations: Do you even have the legal permission to engage in CP/MIH? Consider what’s happening in California right now: the state has preliminarily authorized eleven “Community Paramedicine Pilot Projects,” an educational program to be run through UCLA, with statistical oversight by the University of California San Francisco. Given its practical, innovative curriculum and a statewide training model, the program should be a shoe-in—but California tightly restricts ambulance operations, and nursing unions have complained about EMS agencies invading what has traditionally been ”their turf.” Does your state allow you to take patients somewhere other than a hospital?

© 2017 BY JONATHON S. FEIT FOR BEYOND LUCID TECHNOLOGIES, INC. www.BeyondLucid.com

3. REVENUES – Revenue considerations are an interesting question-mark in the age of Accountable Care and the readmission prohibition. Hospitals weigh whether bringing patients in frequent visits is worth a penalty and possible non-reimbursement. (It’s a more complicated calculation than it sounds.) Ask yourself: is CP/MIH a line of business worth the economic loss that your agency will incur by engaging in non-transport activities? Have you considered “the other side of the ledger”? Matt Zavadsky’s presentations stand out among expert discussions on the cost savings promised by CP/MIH, but in his zeal to evangelize system savings, Matt rarely references the costs incurred by EMS agencies—including gasoline, supplies, and the salaries of field providers—that cannot be reimbursed under CMS’s current payment scheme. If you’re going to spend money but not get paid back, you must find another way to justify the expense: Marketing to build community engagement. Crew training to improve bedside manner for chronic patients. Perhaps you want to be your region’s early adopter who is responsible for bringing to life the “EMS Agenda for the Future.” Whatever your metric, you will have to justify foregone revenues.

4. REGION – How supportive is your regional ecosystem? Who’ll pay for your services? What if (as one agency brought to us) your CP/MIH proposal calls for taking patients away from local care providers? Will they cry foul, or support the idea of more professional patient care, despite a loss of revenues from incoming patients? Now the current CP/MIA models start becoming difficult to copy: Medstar’s relationships with Fort Worth’s hospitals is unique. REMSA received a federal CMS Innovation Challenge grant to build its system; Mesa Fire received funding, too. UPMC and Allegheny Health Network in Pittsburgh have a complex competitive relationship that exists in few other places. San Diego’s federally funded Beacon Community a regional data sharing incentive program. What does your region have at its disposal to incentivize and underwrite the costs of a CP/MIH program?

5. RECORDS – I’m admittedly biased by my Day Job on this point, but a shortage of robust and sophisticated documentation software is a chronically neglected component of the CP/MIH process. It’s also a critical reason that almost every CP/MIH program—no matter how clinically well-designed—has stayed small. Unlike traditional incident-specific ePCRs, CP/MIH requires records that are longitudinal in nature, tracking patients over time. Quality Metrics pertaining to Accountable Care and post-discharge follow up to avoid readmissions demand modern tools for data management, aggregation and real-time, high quality statistics. It has been interesting to watch the famous CP/MIH programs try bending pre-existing technology to meet their needs, yet none has succeeded: traditional neither ePCRs nor hospital-side electronic health records collect enough EMS-oriented data about themselves. The question is how quickly agencies will acknowledge CP/MIH’s unique data needs—and the need for appropriately smart technology to measure success.

© 2017 BY JONATHON S. FEIT FOR BEYOND LUCID TECHNOLOGIES, INC. www.BeyondLucid.com

Technically speaking…What is “HL7”?

What is this “HL7” thing, anyway, and what does an HL7 document contain? Creating consensus behind a common healthcare standard is the mission of HL7, which was founded in 1987. "The HL7 Standard was created and has since become widely adopted by vendors worldwide to define content. ‘Interoperability, or the back-and-forth exchange of patient health data among different organizations, is seen as the "ultimate IT goal of the modern healthcare system," when discussing Meaningful Use, HITECH and the Affordable Care Act.’” “HL7 and its members provide a framework (and related standards) for the exchange, integration, sharing, and retrieval of electronic health information. These standards define how information is packaged and communicated from one party to another, setting the language, structure and data types required for seamless integration between systems.”11 Learn more about the federal Health IT standards online at www.HealthIT.gov What is an HL7-interoperable “Continuity of Care Document” (CCD)? “The CCD “fosters interoperability of clinical data by allowing physicians to send electronic medical information to other providers without loss of meaning and enabling improvement of patient care”. In other words, your doctor could send and receive important health data about you to and from other doctors without losing an understanding on what exactly is going on with your health. You may have received a document or two after a doctor’s appointment, and not quite known what to do with it. Do you keep it for years to come? Digitize it? The doctor is already inputting it electronically, why couldn’t they send or give you an electronic copy? This is where CCDs come into play.”12

1 Hagen T. The Value of EMS. EMS World. 1 Sept 2012. 2 O’Donnell D, Mancera M, Savory E, Christopher S, Roumpf S, Schafer J. “The Availability of Prior ECGs Improves Paramedic Accuracy in Identifying STEMIs.” IU School of Medicine at the 2014

NAEMSP Annual Meeting. Accessed online 16 Apr 2015 < http://www.naemsp.org/Documents/2014%20Annual%20Meeting%20Handouts/E-POSTERS%20145-153%20Combined.pdf > 3 Ramanujam P, Guluma KZ, Castillo EM, Chacon M, Jensen MB, Patel E, Linnick W, and Dunford JV. “Accuracy of Stroke Recognition by Emergency Medical Dispatchers and Paramedics—San

Diego Experience.” Prehospital Emergency Care. (2008) 12(3):307-313. 4 Rokos, IC, French WJ, Mattu A, Nichol G, Farkouh ME, Reiffel J, Stone GW. “Appropriate Cardiac Cath Lab activation: Optimizing electrocardiogram interpretation and clinical decision-making

for acute ST-elevation myocardial infarction.” American Heart Journal. December 2010. 160(6):995-1003. 5 Contra Costa EMS Agency. “Contra Costa 60 Day STEMI System Review: A Great Launch with Challenges Ahead.” Accessed 15 Jan 2015. < http://cchealth.org/ems/pdf/stemi_1st_60days.pdf >

See also: “Contra Costa County EMS Data Infrastructure Project.” p.11. Published 28 Dec 2013. Accessed online 2 Feb 2015. < http://cchealth.org/ems/pdf/QI-HIE-grant-report-2013.pdf > 6 Larson, DM, Menssen KM, Sharkey SW, Duval S, Schwartz RS, Harris J, Meland JT, Unger BT, Henry TD. “False-positive’ cardiac catheterization laboratory activation among patients with

suspected ST-segment elevation myocardial infarction.” J American Medical Assn. 2007 Dec 19. 298(23):2754-60. 7 Sawyer, NT and Coburn, JD. "Community Paramedicine: 911 Alternative Destinations Are a Patient Safety Issue." West Journal of Emergency Medicine. 2017 Feb; 18(2): 219–221. Published

online 2017 Jan 20. (Accessed online 10-18-2017) < https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5305127 > 8 Smith, W., Isaacs, M., and Corry, M. “Accuracy of paramedic identification of stroke and transient ischemic attack in the field.” Prehospital Emergency Care. 2 July 2009. (Accessed online 11-2-

2017) < http://www.tandfonline.com/doi/abs/10.1080/10903129808958866 > 9 Ramanujam P1, Guluma KZ, Castillo EM, Chacon M, Jensen MB, Patel E, Linnick W, Dunford JV. “Accuracy of stroke recognition by emergency medical dispatchers and paramedics--San Diego

experience.” Prehospital Emergency Care. July-Sept 2008. (Accessed online 11-2-2017). < https://www.ncbi.nlm.nih.gov/pubmed/18584497 > 10 Frost, P. “Contra Costa County Data Infrastructure Project.” 25 November 2013. 11 http://www.hl7.org/implement/standards; http://www.healthcareitnews.com/news/8-common-questions-about-hl7 12 https://9to5mac.com/2016/06/15/hands-on-hl7-ccd-health-records-ios-10-health-kit

Sources: ANSI, HL7, HealthIT.gov