Integrating EMS for Care Coordination and Disaster Response

March 3, 2016 Robert M. Cothren, PhD Executive Director California Association of Health Information Exchanges

Conflict of Interest

Robert M. Cothren, PhD

Has no real or apparent conflicts of interest to report.

Agenda

• What led to the project?

And for disaster response and EMS integration…

• What are the challenges?

• What are the potential standards?

• What are the benefits?

Learning Objectives

1. Identify why it is important to integrate EMS into the continuum of care

2. Recognize the special challenges of pre-hospital care and disaster response

3. Discuss how can existing capabilities be leverages to address pre-hospital care and disaster response and list them

4. Describe what a replicable disaster response system might look like

An Introduction of How Benefits Were Realized for the Value of Health IT

S Consumers are more satisfied with the continuity of care

T Treatment is improved because providers are better informed

E Makes extensive use of electronic health information when paper not available

P Populations are better served, especially in disaster response

S Better informed care can decrease costs, especially in emergency settings

http://www.himss.org/ValueSuite

What is the vision?

EMS and disaster workers are full participants in HIE with the ability to securely send, receive, find, and use relevant patient information

Why do this?

• Better patient outcomes and experiences

• Improved transitions of care

• More complete longitudinal patient record

• Greater ability to aggregate and analyze system data

• Resilience in the face of disasters

How do we get there?

Develop the technical and administrative infrastructure to enable EMS providers and hospitals to securely share electronic patient information via health information exchange organizations

Are we ready?

Systems and Standards

• ePCR adoption is good

• Providers are interest

• HIE is becoming more available and more capable

• Hospitals support the transition

• EHR implementation of content standards is improving

• NEMSIS 3 implementation and adoption is increasing

Are we ready?

Legislation

• AB 503 (Rodriguez) permits a hospital to release patient-identifiable medical information to an EMS provider, to the LEMSA, or to EMSA

• AB 1129 (Burke) requires an EMS provider, when submitting data to a LEMSA, to use an electronic health record system that is compliant with CEMSIS and NEMSIS standards

• SB 19 (Wolk) requires EMSA to establish the California Physicians Order for Life Sustaining Treatment (POLST) eRegistry Pilot, if funding is available

The Grant

California’s Emergency Medical Services Authority (EMSA) received $2.75 million from ONC to advance HIE

1. statewide during a disaster and

2. regionally in daily emergency medical services

PULSE

+EMS

This is not new statewide HIE

• Will be locally operated using existing health information exchange programs

• Will allow for (and depend upon) peer-to-peer exchange connections using nationally recognized standards

PULSE

• Multiple data sources

• Messaging broker to orchestrate searches

• Search functions for several use cases

• Enabled by the California Trusted Exchange Network (CTEN)

• Integrating the Healthcare Enterprise (IHE) standards

During a disaster

PULSE use cases

1. Patients displaced from their care settings

2. New victims of an event

3. Providers away from their home systems

During a disaster

This is also a big deal

How do we authenticate and authorize disaster healthcare volunteers to access health information?

We know this is hard

PULSE architecture

More at http://wiki.ca-hie.org/PULSE+Architecture

PULSE challenges

• Patient identification and matching when displaced from their normal home for healthcare

• Record location during system and network stress

• Authentication and authorization of health care professionals far from their home systems on which they are credentialed

Plus sustainability of a system only used when “the big one hits” !

More on patient matching at http://wiki.ca-hie.org/Patient+Identification

More on DHV at http://wiki.ca-hie.org/PULSE+DHV

CTEN – the basis for exchange

California Trusted Exchange Network

Using a multiparty data sharing agreement…

…and lightweight technical infrastructure…

…to facilitate standards-based, trusted, peer-to-peer exchange.

More on CTEN at http://www.ca-hie.org/projects/cten

DHV – the Secret Sauce

Disaster Healthcare Volunteers, California’s implementation of

Emergency System for Advance Registration of Volunteer

Health Professionals (ESAR-VHP)

Continuously curated database of disaster healthcare workers…

…and credentials…

…providing the basis for authentication and authorization.

PULSE standards

• ePCR implementing NEMSIS 3

• Transport

– SOAP based XCMP and XCA with SAML authorization

– SOAP or RESTful document access with OAuth2 and OpenID Connect

• Content

– CCD based on C-CDA

– Free-form documents as available

More on standards at http://wiki.ca-hie.org/PULSE+Standards

+EMS

• Retrieving critical patient information

• Updating the hospital while en route

• Maintaining a longitudinal patient record

– at the hospital and

– at the local EMSA

During an emergency

Search

Paramedics and EMTs may look up and display patient problem list, medications, allergies, POLSE, and DNR in the field on ePCR screen

• Improve clinical decision-making

• Improve patient care

Alert

Display patient information on hospital dashboard at ED to alert and share incoming patient information to assist in time-sensitive therapies

• Improve decision support

• Better care transitions

• Improve patient care

File

Incorporate ePCR data into hospital EHR in HL7 format (using NEMSIS 3.4 CDA standards)

• Build better longitudinal patient record

Reconcile

Receive patient disposition information from hospital EHR to add to EMS provider patient record

• Improve population health

EMS

ePCR HIE

Limited CCD:

•Problems

•Meds

•Allergies

•Directives

Demographics:

•Name

•Age

•Address

•Others…

Search Radiology

Labs

Clinics

Hospitals

Pharmacies

Health Sys

Emergency

Department

EMS

ePCR

Alert

NEMSIS 3 XML CDA

to ED dashboard

Hospital

EHR

EMS

ePCR

File

NEMSIS 3 XML CDA

Structured data, not PDF

Hospital

EHR

EMS

ePCR

Reconcile

NEMSIS eOutcomes Measures

+EMS challenges

• Patient identification and matching

1. Before reaching the scene

2. Between the scene and the hospital

3. Once on site

4. After the emergency is over

• Content translation between ePCR and EHR versions of CCD

Other HIE / EMS projects

• Poudre Valley, CO: FILE

• Indianapolis, IN: SEARCH

• Rochester, NY: SEARCH and FILE

• Ft. Worth, TX: ALERT, FILE, RECONCILE

• Tulsa and Oklahoma City: SEARCH and FILE

• Montgomery County, TX: ALERT and RECONCILE

PULSE +EMS relationships

Statewide

During Disasters

PULSE Access tools:

• HIE

• DHV

Local

Daily Operations

+EMS Functions:

• Search

• Alert

• File

• Reconcile

Architecture

Search via HIE

On more thing… POLST

Physicians Orders for Life Sustaining Treatment

• New initiative for an electronic repository for POLST forms

– Critical to meeting patients wishes during an emergency

• The challenge…

…patient matching!

Future component of +EMS?

Where we are

+EMS

• Building out in multiple regions

– Concentrating on Search, Alert, and File for now

– Understanding how to address patient matching

• Addressing standards

– Updating ePCRs to NEMSIS 3.4

– Understanding how NEMSIS CDA maps to EHR care summaries

– Creating dashboards

Where we are

PULSE

• Finalizing an architecture

• Identifying standards…

…for transport and content

…for SSO with DHV

This is meant to be a reproducible solution!

Learn more at http://wiki.ca-hie.org/PULSE

Where we are going…

• Public workgroups addressing the hard issues:

– Patient matching in emergency response, disaster response, and POLST environments

– Authorization for health information disclosure during emergencies and disasters

– Standards alignment across new domains

• Demonstration of PULSE

– A working, table-top drill in early 2017

A Summary of How Benefits Were Realized for the Value of Health IT

S Consumers and providers see smoother care delivery system; no more Katrina

T Patients get better, more appropriate care because providers are informed

E Links together new stakeholders during daily emergencies and disasters

P Populations are better served, especially in disaster response

S More appropriate care can decrease costs, especially in emergency settings

http://www.himss.org/ValueSuite

Questions

Robert M. Cothren, PhD

Executive Director California Association of Health Information Exchanges

robert.cothren@ca-hie.org

@Info_CAIHE ● @RimCothren

https://www.linkedin.com/in/rcothren