Electronically Speaking

Raindrops catch the flashing red lights of your ambulance as you roll up to the house. Your partner pulls the gurney out of the back of the rig while you get the laptop computer out of the cab. The patient's daughter lets you in the front door, and you find your patient lying on her bed, not responding to any stimuli. Your partner starts the patient on oxygen and gets vital signs. When you ask about the patient's medical history, the daughter hands you a small device.

     You open your laptop and insert the device into the USB port. A screen pops up with the patient's name and year of birth, along with her medications, allergies, medical conditions, doctor's name and phone number, and an emergency contact. After reviewing the information on the screen and asking the daughter a few details about the current complaint, you load the patient into the ambulance and transport, taking the device and all the information with you.

     Sound like science fiction? Not so. The technology is a form of personal electronic health records, and patients are already using it.

     Patients with new technology have put money and effort into preparing for an emergency and expect EMS providers to recognize and utilize these new devices. Regrettably, those of us responding might not have the tools or knowledge to put electronic health records to use. Knowing what we're seeing and what patients expect of us is the best preparation for utilizing this new technology.

New Technology
     USB flash memory cards, or "thumb drives," are relatively new devices on the market that allow computer users to store and transport information from one computer to another. They are small, easy to use, and they are finding their way into the personal health record arena. At least two companies already offer flash drives that connect to computers via USB and allow patients to have significant medical information available to emergency medical providers.

     MedicAlert Foundation sells the E-HealthKEY to its members for use in emergencies and to help them manage their medical profiles in MedicAlert's secure database. According to Paul Kortschak, MedicAlert's president and CEO, the "E-HealthKEY actually allows people to go on their computer and synchronize with our database." MedicAlert's goal is to "allow individuals to store their lifetime medical history with us," he says.

     MedicAlert's members can plug the E-HealthKEY into their personal computers and launch a program that helps them keep track of medications, physician visits, surgeries, etc. EKG hard copies, test results, even MRI and CT images can be viewed with the device and printed. In an emergency, the E-HealthKEY can be plugged into a laptop computer at the scene or in the emergency department to gain access to basic information, such as past medical history, medications and allergies. If healthcare providers want more specific information, they can call MedicAlert's emergency phone number and access the database.

     Medic Tag, another USB-enabled keychain device, is not supported with an Internet database like the E-HealthKEY. "Medic Tag isn't really intended as a comprehensive medical record like what MedicAlert is doing," says Edward Ricci, founder and COO of MedicTag LLC. "Medic Tag is for emergency info only--kind of a continuity of care record." Ricci says the Medic Tag device uses common software found on all Windows-based computers currently on the market.

     When providers in or out of the hospital plug in a Medic Tag USB device, it launches a Microsoft Word document, which can be viewed with either MSWord or WordPad and edited with MSWord. There is no need for Internet access with the Medic Tag.

     Both companies are marketing these devices to healthy individuals to help them be more prepared for emergencies. According to Ricci, one trucking company ordered enough Medic Tags for all their drivers. "I asked the woman if they had that many people with medical problems, and she said no," he says. "They just wanted their drivers to carry them because they were hundreds of miles from home."

Barriers
     Medical information is a great use for USB-enabled devices like these, but there are barriers. Both the Medic Tag and the E-HealthKEY are designed to be carried on a keychain, making it necessary to validate the patient's identity before trusting any of the information on the device. An unconscious patient will not be able to identify himself, and each agency has different policies about looking in patients' wallets. The inclusion of birth year and gender helps, but a name alone may not be enough, especially when senior lets junior borrow the car.

     There is also the possibility of contaminated devices infecting vulnerable computer systems with viruses. A rudimentary knowledge of computers is all a malicious individual would need to place a virus on these devices. "It runs with an auto-start file," says Ricci about the Medic Tag device, "but anyone with a little computer ability could open it up and save things on the memory chip."

     Just as a prudent caregiver puts on gloves and eye protection before treating a patient, so should a prudent hospital or EMS agency protect itself. Solutions can be simple, but may not be cost-effective. For example, a hospital could keep a computer in the emergency department that is isolated from the rest of the hospital's network just to access USB devices.

     Of course, there is the much more common problem of not having a computer at all, which renders such advanced technology absolutely useless to responders at the scene. Computers are not yet common in ambulances, and especially not at the patient's side. In the future, much of EMS will probably have a USB socket somewhere in every ambulance, but whether that port is attached to a Windows-based computer capable of accessing the information on either of these devices remains to be seen.

Alternate Access
     There are other, less-technological means out there to allow caregivers access to patients' health histories. Medical emblems are quite common. Scores of companies make and sell medical bracelets and other types of emblems engraved with short words and phrases to aid EMS providers' assessments when the wearers are incapacitated.

     MedicAlert is the granddaddy of all the medical jewelry companies, having turned 50 years old in March of this year. MedicAlert's database sets it apart from many of the other companies selling medical jewelry. The same database that can be maintained with the E-HealthKEY can be accessed with a phone call.

     On the back of a MedicAlert emblem is an emergency phone number with a unique patient ID number. Responders can call the phone number and use the patient's identification number to potentially get a comprehensive medical history, even for an unresponsive patient. The space on the emblem is limited, but the database can virtually hold a patient's entire medical record.

     Several insurance companies and other Web-based repositories can store information on behalf of patients that can be printed out on sheets of paper or as a card. Patients don't need a service; they can do it themselves. Many of us have seen well-organized patient histories, neatly typed with relevant information on hand for emergencies. Of course, most of those patients are parents of EMTs or paramedics.

     Patients can always carry medical information in a wallet or purse. Some agencies are concerned about violating patient privacy if responders rummage through purses or wallets in search of information. Even if found, most of the information carried by patients is often hand-written, hard to read and outdated.

     In fact, the greatest drawback of all patient records is simply that the patient must keep track. If a patient doesn't update his medical information in whatever medium he chooses, it will not matter how we access it.

     Kortschak agrees. He says MedicAlert urges its members to keep their information updated, and the company never deletes information, even if the patient dies. If an emergency call comes in for an outdated membership, MedicAlert will provide what information they have. "Of course," he says, "we will advise the medical personnel that it hasn't been updated in 30 years."

What Does The Future Hold?
     Several organizations are currently looking at ways to make personal health records available through the Internet. Information would be stored by caregivers and accessed through a secure search engine.

     Scott Wallace is president and CEO of the National Alliance for Health Information Technology, a coalition of health-related organizations and other entities working on shared medical information.

     "Connected health information systems would hugely improve care for everyone," he explains, "because all professionals would have the collected medical history of their patients at their fingertips when it's needed the most."

     Wallace envisions a system that EMS can access through the emergency department. "Nurses on the phone with paramedics could call up the record on an incoming patient and relay important findings to the field personnel," he says. "But getting to that state of affairs requires knocking down a whole series of barriers. The biggest problem barring shared medical records is authenticating the information and making sure we get the right information for the right person. It's a problem when Jane Smith is running her credit report and gets her financials mixed up with another Jane Smith. It's a much bigger problem when medical records are jumbled.

     "Unfortunately, healthcare does not have a universal identification system for people like many other industries do," Wallace adds. "The nation must arrive at a standard for authenticating a patient's identity."

     The future sure sounds like science fiction. Plugging a patient's PIN code into the system and pulling up every visit he's ever made to a hospital or doctor's office. Seeing the last time your patient had her prescriptions filled, or comparing the EKG you just did in the patient's living room to the one from her last cardiology appointment.

     Imagine getting all the information on the patient just by getting close. MedicAlert is developing a wallet card with radio frequency identification (RFID) tags built in. These cards could be read by scanners from a distance, without requiring healthcare providers to even see the card. The scanners could access shared medical records or MedicAlert's database.

EMS Still Responsible for Patient History
     Shared medical records would resolve inaccuracies in patient information, whether those inaccuracies were caused by a reluctant patient unwilling to be honest, or just a scared patient unable to recall the name of the pill he takes with dinner. But true shared medical records are years away. For now, comprehensive written patient histories require patients to be diligent.

     No matter which way a patient chooses to maintain a written record of personal health information, from online information repositories to USB memory cards to handwritten notes stored in the refrigerator, the responsibility falls on the EMS professional to obtain a useful history.

     Regardless of whether we find medical files on a computer screen, in a vial behind the milk jug, or coaxed from the patient one question at a time, we must still weed out the extemporaneous information to harvest a clear picture of the patient's chief complaint and pertinent history. It's up to us to utilize all of our resources to best assess and treat our patients.

     Medical jewelry can be helpful. Computerized data storage remains to be proven, and a phone call to the database operator may or may not take too much time. But one thing is certain: Nothing works better than looking your patient in the eye and listening.

     Rod Brouhard is a paramedic for American Medical Response in Modesto, CA, and former director of the EMS program at Modesto Junior College.