Pinnacle: An HIE Success Story in San Diego

EMS is now several years into its quest for better integration of its patient data with hospitals and health care systems. Partnerships have been birthed, nurtured, and grown, and some are now bearing viable fruit. Wednesday at the Pinnacle EMS Conference in Marco Island, Florida, San Diego physician Joelle Donofrio-Ödmann, DO, FAAP, FACEP, FAEMS, described the development and some of the successes of the health information exchange (HIE) now doing that in her city.

The paper charts of old may have had some advantages, said Donofrio-Ödmann, deputy chief medical officer for the city of San Diego and an associate professor of pediatrics and emergency medicine at the University of California San Diego (UCSD), but aggregating data wasn’t one of them. The move toward electronic alternatives that would be better at that started with 2009’s American Recovery and Reinvestment Act, and the next year UCSD received a $15 million grant from the Office of the National Coordinator for Healthcare Information Technology to build their own HIE.

They took a broad approach to partnering with area stakeholders and the amounts of information the HIE would share, which included medications, allergies, diagnoses, treatments, and other key data. Within a few years it was operational and providing clinicians full, robust pictures of even their most challenging cases.

Then in 2015 California passed a bill requiring prehospital ePCR data to be NEMSIS- and CEMSIS (the state-level equivalent California EMS Information System)-compliant. That pointed leaders’ attention to a gap: In the old days of paper reports, EMS records would be turned over with the patient at the ED. Electronic records, conversely, were typically scanned and uploaded by clerks directly into hospitals’ systems, but actual treating ED physicians might never see them.

Donofrio-Ödmann wanted to see how much was being missed. She reviewed the cases of all her ER patients who had EMS notes available to read. Her startling discovery: Most EMS records took 24 hours to be scanned, some took 72, and many were never scanned in at all.

Dishearteningly, much of EMS providers’ work, background, and observations wasn’t necessarily being used to benefit later care.

Those EMS records, Donofrio-Ödmann told her chief medical information officer, are more important than perhaps everyone realized. Lacking information on prehospital assessment and care directly affects later care; can lead to inaccuracies through verbal-only handoffs; may impair timely decision-making by physicians; may create patient-safety issues; and could pose legal liability if ED physicians are assumed to have had access to documents they didn’t. Timely access to these paramedic records, she emphasized, would save lives and improve care.

The other half of the equation involved in that is the EMS caregiver. Routing patient outcome information back to medics, letting them know if their diagnoses and treatments were appropriate or misguided, helps them improve as well and ultimately helps agencies grow beyond traditional systems of care.

This closed-loop system helped fuel several important projects in the San Diego area. One was a familiar SAFR (search, alert, file, and reconcile)-type program that went live in 2017 and saved more than $1.5 million a year in trauma activation fees collected through improved billing and eliminating the costs of scanning and uploading medics’ records.

Donofrio-Ödmann offered some tips for success in EMS HIE undertakings:

• Ensure buy-in from hospitals and agencies that understand the importance of timely, accessible patient information.
• Get people who “speak IT” and bring needed technical expertise.
• Frequent training and QA/QI is required.
• Use people on the ground to ensure the system is working.
• HIE projects require champions at all levels.

Bidirectional data is essential to maximize the value of HIEs for EMS, and San Diego’s HIE was just the second in California to achieve it. Outcomes and ICD-10 codes are automatically sent back to EMS. “This,” said Donofrio-Ödmann, “is what we’ve been waiting for.”

A review after 6 months found the system working: Paramedics were successfully obtaining patients’ problems, medications, and allergies from the HIE; patient information was getting to hospitals prearrival; access to paramedic PCRs was faster; and EMS was getting hospital outcomes back.

But there were some kinks as well: A need became apparent to translate NEMSIS data elements into more physician-friendly SOAP note formatting (a solution is in the works), and streaming data into the EMS narrative was being stopped at the transfer of care (a fix has since extended that window to 4 hours post-transfer). As well, if a destination hospital isn’t selected by EMS, no linkage is created. An unexpected problem was diagnosis overload, particularly with complex patients. Some 70,000 possible diagnoses are possible under ICD-10, many of them very similar.

A newer project is adding POLST (physician’s orders for life-sustaining treatment) orders to the HIE to better honor patients’ end-of-life wishes. Medics are accessing around 200 POLST orders a month, Donofrio-Ödmann said.

The HIE has also yielded important data that’s been used to help high utilizers. Authorities ranked their top callers and reviewed their cases using the CP’S MERITS framework. Combining that information with aggregate HIE data helped clinicians develop comprehensive care plans for their most persistent users. In one case, that plan was able to help a meth addict get clean and become a stable, productive member of society.

Data integration, and specifically the return of data to EMS, is what’s made it possible, Donofrio-Ödmann said: “We need to demand closed-loop communication. This is not an option.”