Chapter 73 Greg Mears Emergency medical services, along with health care in general, has progressed in the last decade from a paper-based documentation system to an electronic health record. The short-term goals for this evolution were to improve operational efficiencies, with a strong focus on billing and risk management. The long-term goal should be integrated health information systems that support the “Iron Triangle” of health policy: improving access, improving quality, and controlling cost [1]. In the next 10 years, health information systems will continue to evolve. Current medical devices and software that function as tools in service delivery and patient care of an EMS system will become true members of the health care team. Devices and software will become real-time assistants assuring patient safety, providing recommendations based on evidence-based guidelines, and ultimately improving operational effectiveness and efficiency. By embracing this new health care doctrine and infrastructure, EMS will no longer be isolated as an expensive source of transportation. It will be held accountable for response times, service quality, medical care, and cost or value to the customer (citizen). EMS will be held to standards based on an overall “system of care” approach, integrated with other health care specialties. EMS must prove its effect on patient outcome as a justification for its existence. Finally, EMS will be truly integrated with the rest of the health care system at the local, regional, state, and federal levels through the exchange of health information [2]. The US Department of Health, Education, and Welfare defined 15 components of an EMS system within the 1973 EMS Act [3]. Although an information system was not listed as one of the 15 components, each component was shaped or defined as a piece in a puzzle. The puzzle, when completed, requires a significant amount of data to interact and monitor each of the pieces or components through a coordinated patient record. It was not until 20 years later that the National Highway Traffic Safety Administration (NHTSA) developed a consensus document defining 81 data elements important to an EMS information system [4]. The purpose of the Uniform Prehospital Dataset (version 1.0) was to allow EMS systems to benchmark their service, patient care, personnel performance, patient outcome, and data linkage with other organizations or larger datasets. Perhaps even more important than the data elements themselves was the creation of a standard definition for each element, critical for any information system. In 1996, NHTSA published the EMS Agenda for the Future, which addressed EMS as a community-based health management system, fully integrated with the overall health care system [5]. The goal of the agenda was to improve the quality of community health, resulting in more appropriate use of acute health care resources. To meet this goal, the agenda recommended development of 14 distinct attributes of EMS, one of which was information systems. Formal recommendations within the information systems attribute were as follows. The EMS Agenda for the Future Implementation Guide [6] was published by NHTSA in 1998 and reinforced the concept that an EMS information system is the backbone connecting every component of the EMS system. In 1991, an international consensus group published the “Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: the Utstein style” [7]. As the first major document to specifically address EMS systems and their performance with respect to patient outcome, the Utstein criteria were a standard dataset with standard definitions for measuring and reporting cardiac arrest survival across systems. The Utstein criteria required the exchange of information between the dispatch center, the EMS system, and the hospital. A revised version was published in 2004 unifying the hospital, prehospital, and pediatric templates, providing a more usable standard for outcomes measurement [8]. A second revision of the Utstein dataset is under way. The first formal funding for an EMS information system came in 2001. Based on a 1999 Health Resources Services Administration Emergency Medical Services for Children program feasibility study demonstrating it was possible to create an organized EMS data system, NHTSA formally funded the National EMS Information System Project (NEMSIS). The NEMSIS project has four primary goals and objectives. NHTSA Uniform Prehospital Dataset (Version 2.2.1) is currently in use with more than 400 data elements defined [9]. This national standard has been adopted in principle by all 56 US states and territories. At the time this chapter was written (fall, 2013), a total of 43 states have operational state data systems that are NEMSIS compliant and submit data to the national EMS database. In 2012, 19,831,189 records were added to the national EMS database, submitted to state repositories by 8,448 local EMS agencies [10]. This represents 54% of the 36,698,670 EMS responses and 42% of the 19,971 EMS agencies identified by the National EMS Assessment in 2011 [11]. Every state and US territory has a goal, pending resources and funding, to establish a NEMSIS-compliant state EMS data system. Data are used differently at each level of EMS (local, state, and national). A national dataset was identified consisting of data elements especially relevant to describing EMS at the national industry level which can be used to better target EMS needs, national policy, advocacy, educational curricula, and reimbursement. Each state EMS office works with its local EMS agencies to define a state EMS dataset that can be implemented locally. At the state level, EMS data determine how state and federal resources are applied, target legislative initiatives and funding, assure EMS coverage and service delivery, develop and maintain educational programs, and promote performance improvement initiatives that ultimately assure quality patient care. Locally, EMS data are used to determine resource allocation, service delivery, personnel performance, and patient care. Beginning in 2005, NHTSA funded the NEMSIS Technical Assistance Center (TAC), which houses the national EMS database and provides technical assistance to states implementing NHTSA dataset. The TAC ensures that software programs used to document EMS care at the local level are compliant with the current NEMSIS standard. In 2006, four states (North Carolina, Minnesota, Mississippi, and New Hampshire) began providing data into the national EMS database. Today, more records are received each month than were received in that complete initial year of data collection. Information on NEMSIS and access to the web-based reports associated with the National EMS Database can be found online at www.nemsis.org. In addition, an aggregate NEMSIS research dataset is released each year and can be accessed at www.nemsis.org/reportingTools/requestNEMSISData.html. In 2012, NHTSA Uniform Prehospital Dataset was revised to Version 3.0. As the dataset was revised through EMS industry consensus, it was also processed through the Standards Developing Organization (SDO), HL7, and included the federally required migration to ICD-10. The NEMSIS HL7 CDA is now ready to be approved by the American National Standards Institute (ANSI) as a US health care standard. ANSI approval is a requirement to be included in the National Healthcare Information Infrastructure (NHII) initiative that has a presidential mandate for all health care entities to be using integrated electronic health records by 2014. The implementation of integrated electronic health records empowers health information exchange, a key component of the Affordable Care Act and US health care reform. In 2006, the Institute of Medicine released Emergency Medical Services at the Crossroads [12] reflecting a very detailed evaluation of EMS, including the current organizational structure, EMS service delivery, and financing of EMS services and systems from a national perspective. Recommendations from the report specifically addressed the need for standardized EMS data and information systems, including: Trauma registries serve as valuable descriptive and quality management tools for trauma centers and trauma systems. Containing detailed information regarding the course and management of patients within the trauma system, trauma registries capture some EMS data. A link with EMS data is extremely important to complete the description of trauma care from event through hospital discharge or rehabilitation. The American College of Surgeons Committee on Trauma maintains the National Trauma Data Bank (NTDB), a standardized dataset based on the National Trauma Data Standard. Developed in cooperation with NEMSIS and incorporating the same data element definitions as NHTSA Uniform Prehospital Dataset, the NTDB currently contains more than 5 million records from trauma centers in the United States and Puerto Rico [13]. Access to the NTDB can be obtained through the American College of Surgeons website at www.facs.org. Currently the Centers for Disease Control and Prevention’s Paul Coverdale National Acute Stroke Registry is active in 11 states documenting the incidence, treatment, and outcome of stroke [14]. Data associated with EMS care are critical to stroke registries to understand and optimize stroke systems of care. Outcome data from stroke registries are also critical for EMS to evaluate their service delivery and care. ST-elevation myocardial infarction (STEMI) registries are being implemented to document incidence, treatment, and outcome including clinical performance parameters such as time from onset of symptoms until definitive care or reperfusion. Integration with EMS data provides a complete picture of STEMI care from first medical contact to patient outcome. The Cardiac Arrest Registry to Enhance Survival (CARES) focuses on improving the survival associated with out-of-hospital cardiac arrest (OHCA). CARES is housed at Emory University and while it was initially funded through the Centers for Disease Control and Prevention (CDC), it is currently funded through combination of for-profit and non-profit organizations. Data collection through CARES began in 2005 and is currently implemented within 40 communities within 26 states, including eight state-wide implementations. More than 40 EMS agencies and 900 hospitals currently participate in CARES [15]. The Cardiac Arrest Registry to Enhance Survival helps local EMS administrators and community leaders establish and improve a cardiac arrest system of care. One unique attribute of CARES is its interface with hospitals to obtain OHCA outcomes. Hospitals are given access to the web-based application. When an OHCA victim is brought to a specific hospital, email notification prompts the hospital to log in to the system and securely enter the patient’s outcome. This method has allowed EMS agencies using CARES to obtain outcome information on well over 95% of their OHCA events. Several other health care-related databases and information systems exist at local, state, and national levels. Most states have some form of hospital insurance or admission/discharge database. These databases may or may not capture information on patients who are not admitted to the hospital, such as those seen in the emergency department and released. Each state maintains vital statistics and medical examiner’s databases that record information on all births and deaths. Most states also have some form of public health and/or injury surveillance database. The amount of information and usefulness of these databases vary greatly from state to state. At the state and national level, motor vehicle crash data are collected and maintained through either the US Department of Transportation or law enforcement. The various state motor vehicle departments also maintain databases of information with respect to drivers and vehicles. Both of these data sources have potential interaction with EMS information systems. NHTSA has a program, known as the Crash Outcomes Data Evaluation System (CODES), which uses probabilistic linkage to match state data from law enforcement, EMS, and the emergency department or hospital. CODES uses a collaborative approach to generate medical and financial outcome information relating to motor vehicle crashes, and uses this outcome-based data as the basis for decisions related to highway traffic safety. CODES has been in existence since 1992, and it is currently working with 16 states [16]. The National Hospital Available Beds for Emergencies and Disasters (HAvBED) Project consists of a standardized dataset to monitor hospital bed availability. The system provides a national hospital bed tracking system that can be used to address any surge of patients during a mass casualty event. The system is maintained by the Office of the Assistant Secretary for Preparedness and Response within the Department of Health and Human Services. Information on the HAvBED project can be found online at https://havbed.hhs.gov/v3/.
Data management and information systems
Introduction
Historical foundations
Existing registries and health care databases
Health care databases
Law enforcement database
Disaster and preparedness data systems
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