The idea that impacted me the most from the visioncast was what Dr. Isaacs referred to as his “Prime Numbers.”
The concept is simple enough: as patients traverse the prehospital care and emergency medical systems, without anyone knowing where they are at any given moment, their drug-seeking behaviors can persist because to each participant in the system they pop up far fewer times than they should.
When pressed on what “Prime Numbers” meant, Dr. Isaacs explained that he had been thinking of patients who round-robin the healthcare system, especially in search of illicit substances like opiates, opioids, amphetamines and narcotics. Whether these patients “fall off the grid” either accidentally or intentionally — they don’t merely fall off the wagon, they actually get lost in the healthcare system — the end result is the same: Quite a bit is known about who these patients are, and even what they are taking, insofar as their identities and risk factors. But little is known about where they obtain the substances they ingest or inject, or — far more importantly from a clinical perspective — how frequently they actually do so.
Consider San Francisco, not only because it is in my neck of the woods so I know it well, but also because, ironically, Dr. Isaacs served as Medical Director of the San Francisco Fire Department (SFFD) before moving to Dallas Fire Rescue. The City and County of San Francisco has three emergency medical service providers — SFFD, AMR, and King-American Ambulance. However, for non-medical, non-technical reasons like politics and money, today none of these agencies is connected to another from a data perspective.
This would not be unusual elsewhere in the U.S., but San Francisco is of course the “belly of the technology beast,” where prehospital innovations live that can solve such interoperability issues. Therefore, as I have written elsewhere, the backlog of incomplete emergency-related technology projects from which the entire Bay Area suffers is extra-remarkable and presents substantial risk as the clock ticks onward to a next major epidemic, fire, flood, or earthquake.
Today, if a patient in San Francisco calls 9-1-1 three times in three days, he or she may receive help from one service at least one of those three times — and possibly, one time from each service, depending on where the patient is when the call for help is placed. Assuming that the same service doesn’t respond more than once, it will therefore appear to each service as if the patient only called for service one time. Assuming one call daily — but nothing stops the patient from calling multiple times per day — the patient may receive service from the same agency at least once every four days. However, due to a lack of integration, every four days each service will see that the patient has called for assistance only twice.
Dr. Isaacs explained that by “Prime Numbers,” he was referring to the fact that the EMS system as a whole has no idea that the patient has been seen over and over again in between each encounter with a particular prehospital service. What if the patient uses an alias? Our industry doesn’t track biometrics — which, after nearly a decade still makes no sense to me to because it is relatively easy, totally HIPAA-compliant, and would solve countless validation issues!
So, a repeat patient can theoretically go undetected. Factor in the availability of public transportation, walk-in services, cabs, and friends with cars, and a patient could be seen at multiple hospitals, clinics, and pharmacies on a given day—without anyone but the patient knowing about it. A disconnected EMS system thus unfortunately, unintentionally, enables drug addictions by allowing them to persist. Added heartbreak here stems from the one thing we know for certain: that no EMS or Fire agency wants its patients addicted to substances that could kill them.
Almost every facility that patients visit to solicit drugs and other illicit substances is “connected” — just not to each other. The Office of the National Coordinator of Health IT reports that “as of 2016, over 95 percent of hospitals eligible for the Medicare and Medicaid EHR Incentive Program have achieved meaningful use of certified health IT. When parsed by hospital bed size, the majority of hospitals within each hospital type are meaningfully using certified health IT. More than 90 percent of large, medium, small rural, and critical access hospitals were meaningfully using certified health IT. Children’s hospitals have the lowest rate of meaningful use achievement, with over three in four children’s hospitals having achieved meaningful use.”
But electronic health record systems (EHR) on the hospital side, and electronic patient care records (ePCR) on the EMS and fire side, are rarely linked reliably, partly due to a conflict of technical-regulatory requirements, as I have written elsewhere (see “How Different Colors of Money Derail Interoperability Efforts” (EMS World, June 2016).
The remainder of this glaring hole in the healthcare system stems from a failure of communication between EMS and hospital-side teams. Given the amount of effort that goes into prehospital reporting, it is a tragic waste of resources that prehospital patient data are almost universally discarded — or ignored completely — when a patient is handed off at the ED. The only thing worse, perhaps, is the degree to which this degree of disconnection has simply become an expected feature of prehospital care: i.e., that care will be restarted upon transfer to the hospital because some 49.2 percent of critical patient data are lost at handoff to the ED, and data captured in the field tend to find their way into the black hole of a regulator’s dropbox.
EMS personnel have a wealth of knowledge that should be conveyed in a longitudinal fashion. How many “frequent fliers”/“friendly faces”/“repeat customers” can you personally name in your coverage area? As prehospital professionals, your personal knowledge of your patients is intrinsic to both episodic and longitudinal patient care. You know what happened, why you were called in the first place. Why are your insights not shared with the facilities to which you transport, so that they arrive before you do and can be used to activate triage? Why can’t you share insights with your counterparts at neighboring services, to take a regional approach to care like you would for mutual aid during a major natural disaster? There is no HIPAA roadblock to worry about here, and the opioid addiction epidemic is a major disaster.
Art Groux, Chief of the Suffield Volunteer Ambulance Association and President of the Connecticut EMS Chiefs Association, has noted that patients across his state may be visited multiple times weekly and administered Fentanyl or other opiates, yet currently there is no longitudinal patient tracking system in place to follow these patients over time.
In an October 2017 article for STAT News (a Boston Globe Media publication), Dr. Jay Baruch, M.D., associate professor of emergency medicine at the Warren Alpert Medical School of Brown University, expressed a similar concern. He noted that 80 percent of heroin users started by abusing painkillers, then described a patient whose “pain is an 11, off the charts on the standard one to 10 pain scale. But what really drives my understanding of [my patient’s] pain, and my response to it, is the degree to which I believe his story and my emotional connection to it.” He then confesses: “I have doubts. And I doubt my doubts. [My patient’s] medical record reveals multiple visits to the emergency department in the past few months, always in the heart of the night, for the same throbbing ache. Past treatment has included antibiotics, ibuprofen, naproxen, and opioids, though for never more than a few days.”
Have readers of this article felt similarly unsure as to whether the patient’s complaints were accurate — or whether they were a ploy to obtain opiates or similar substances? If the latter is true, does one worry that providing care might actually be feeding the addiction?
We know that access to the body of personal healthcare data, which could provide context about the patient’s medical history, is a privilege that most EMS and fire clinicians do not enjoy today. Indeed, prehospital care units arriving on scene — especially in a lights and sirens mode — usually lack any patient context, including pharmacological history, or the number of occupants in a vehicle that was involved in a crash, or even the presence of a congenital cardiac defect that a monitor-defibrillator is doomed to misinterpret.
The first time I experienced the latter phenomenon was years ago in Pittsburgh, Pennsylvania, on a ride-along during which the monitor kept bleating out a plaintive call to do something about the patient’s erratic rhythm. I asked why the crew wasn’t doing anything about it. They responded: “Oh, his heart has been like that forever.” I learned two lessons that day: First, “treat the patient not the monitor.” Second, that prehospital care providers have a dire need for clinical context, especially when it comes to high triage or repeat patients.
The pointed irony is that we can solve this context problem now; in fact, we have been able to do so for years. Yet for reasons of inertia, confusion, or lack of awareness and comfort with core healthcare information technology, EMS is something like a half-decade behind the rest of the healthcare system when it comes to data interoperability across our clinical ecosystem. Today, prehospital data become part of the patient’s legal record, yet crews’ clinical insights are rarely incorporated into post-handoff patient care on the hospital side. EMS data are perceived by the hospital as being delayed and incomplete, and therefore untrustworthy—or else risky, because doctors at the hospital can be held responsible for relevant details that they only learn about after-the-fact.
If the power of prehospital data could be proven to the crews, then they would more likely see charting care as a critical clinical workflow and not just a “Gotcha!” liability risk.
For example, imagine how good prehospital caregivers will feel to know that they can chart patient care over time, and in the process, identify those who are hurting themselves through the use of illicit substances! They can then share their insights with others who have a vested interest in the patient’s wellbeing (from a doctor or nurse at the receiving facility, to a personal care facility or even a family member) while en route to the ED so that the information has been consumed prior to arrival. Crews may be more likely to undertake the effort (or use ePCR tools that shorten charting time) to fill in data that inform the caregivers on the receiving side of the handoff, if doing so ensures that triage teams and registration are ready, wall times drop and outcomes improve.
In short, providing heads-up data to crews in the field, and to receiving clinicians at a care facility, could change everything. From the vantage point of one Denver-area prehospital care director: “Every trauma activation called into our trauma center generates a rapid response of hospital personnel awaiting EMS arrival. Hospital staff’s access to critical information prior to patient arrival, such as ... past medical history, medications, etc. is almost non-existent.
Such information known prior to patient arrival would accelerate patient care and treatment while simultaneously reducing the potential for iatrogenic errors — such as administering medications contraindicated due to hospital staff being unaware of what medications a patient is currently taking.”
In December 2017, the International Association of EMS Chiefs issued a position statement that included the following language: “Emergency Medical Services agencies and researchers should have access to relevant patient care data and EMS providers to their patients’ complete care records, including outcomes.” An admirable aspiration, but at that conference I posed an unpopular question: “Why do you want that information?”
Access to”complete care records” likely won’t happen for legal reasons unless and until hospitals can exclude irrelevant or prejudicial details from the charts that they share (certain types of health data, like psychiatric assessments and HIV status, have special protections under HIPAA). Additionally, it may actually be impossible to share hospital-side data, for while prehospital care providers may see access to electronic health records as key to gaining a seat at the healthcare table, in reality EHRs are diffusely deployed even within a single institution (let alone across multiple facilities), and notoriously porous when it comes to data. They are arguably less reliable than even the worst PCRs, as anyone who has ever had to transfer EHRs from one hospital to another can attest.
So the more vital question lingered: Why do prehospital caregivers need access to a holistic set of hospital-side health records, assuming that one is accessible? Here we return to Dr. Isaacs’s “prime numbers.”
The ability to collect (i.e., grab), collate (i.e., organize), and correlate (i.e., analyze) data from the many healthcare resources that are working in any given area is the key to intervention on behalf of people who may be a danger to themselves — but who are ultimately enabled by a fractured healthcare system. No one reading this article will find the following statement surprising: prehospital caregivers are not even legally considered part of the healthcare system under CMS — fire and EMS agencies get paid by the mile. Yet these are the same caregivers who ultimately will be called upon to administer lifesaving treatments, to check on patients who might otherwise readmit to the hospital, and who are frequently the most readily welcomed into the living spaces of those who will relapse.
If EMS and fire agencies could follow patients as they travel through the healthcare system, they would be able to identify their patients with an intimacy borne of being first-on-scene.
From ePCRs to middleware meant to connect ePCRs to one another, to electronic health record systems that have opened up the floodgates to data coming in as long as the data is properly vetted and formatted, to regional Health Information Exchanges such as CORHIO in Colorado and interfaced groups in New York (e.g., GRRHIO, SHIN-NY, etc.), to macro interchanges like Commonwealth and Carequality that span large swaths of the U.S. and connect regional HIEs and EHRs, there is no shortage of touch points for high-risk/high-frequency patients to be observed over time and distance.
Some ePCR companies have even gone so far as to enable longitudinal patient tracking, which will allow individual services to care for their neediest patients over time and observe how risk factors decrease while their health indicators increase in the best spirit of Accountable Care.
In other words, longitudinal metrics and a sense of how statistics can be slammed together to find patterns of disease — and opportunities to intervene — are key to tracking patients who suffer from addiction to opiates, opioids, amphetamines and other illicit substances. These patients risk not only themselves but also their families, neighbors and communities. For years, the EMS and fire community has struggled to build momentum for readmission avoidance programs under the banner “Community Paramedicine” or “Mobile Integrated Health.” How is an opioid, opiate, or amphetamine diversion program different from CP/MIH?
If we’re being honest, the difference is one of name only — and of the specific disease in focus. Therefore, here is our opportunity together: unlike CHF, COPD, diabetes and other “high value” patients, one does not see home health nursing groups clamoring to care for opiate-addicted patients. Yet the politics of addiction are so compelling that while CP/MIH programs may be hot button issues, what regulator will protest the use of longitudinal patient tracking to keep substances out of the hands of the millions whose lives they are wrecking?
What if fire and EMS agencies could use technology to track these needy and at-risk patients as they wend their way through the healthcare system? In subsequent articles, I hope to provide technical resources and conversation prompts for EMS and fire agencies to engage in productive conversations with ePCRs and EHR companies, HIE operators, and regional prehospital regulators at all levels of government so that we can close gaps in understanding — stop talking and start doing all that our industry knows (and has known for years) that it must to realize the clinical, operational, and financial benefits of interoperable tech from Hawaii to Houston, from San Diego and San Francisco to the heart of Appalachia.