In the aftermath of Hurricane Katrina, so many things went wrong that thousands of damaged or destroyed medical records became, for a while at least, a secondary story. As the long-term effects of that massive loss have become more obvious, however, the missing records have become a rallying point for proponents of improved healthcare information technologies, especially electronic patient records.
Such records are particularly advantageous in emergency care settings. As one study in Academic Emergency Medicine put it, emergency departments are “highly variable, evanescent, contingent, uncertain, poorly bounded, resource constrained, and beholden to many external influences.” In other words, emergency settings are always in flux, resources are scarce, and new incoming emergencies can disrupt an entire system in a moment. The need to find out who patients are, their medical histories, and any comorbidities that might influence their current condition only adds to the chaos.
In such settings, electronic patient records, which gather together information from all the patient’s providers and present it in electronic form, can save precious minutes and help prevent medication reactions, incorrect diagnoses, and repetitions of expensive and time-consuming tests.
All of these concerns are compounded further for EMS providers. Riding in an ambulance to a patient, paramedics have available to them only the information provided by the dispatcher—information, in other words, about the immediate cause of the call for help. They have no access to patient records, limited diagnostic and treatment options, and very limited time. Moreover, they often arrive at the hospital and hand off the patient before their patient report is complete. This means that any information they have managed to gather is only passed on verbally—a real problem given that significant issues were only identified 25 to 30% of the time in such purely verbal hand-offs, according to one study.
Get the Cath Lab Ready!
Given these inherent restraints, EMS may stand to benefit most from healthcare information technologies. In the first place, and perhaps most importantly for the patient, some new technologies are allowing paramedics and EMTs to send incident, patient, and treatment information to the receiving hospital before they arrive. According to one professor of EMS, “Most EMS providers now use some type of electronic patient-care record, and some of them are being electronically transmitted to the hospital ahead of the ambulance’s arrival” (quoted here).
Not only does this allow EMS information to be “folded into” the patient’s larger medical record; it also helps ensure that the hospital can be prepared when the patient arrives. Saving just the 15 or 20 minutes it might take to set up a lab or arrange a particular surgical team can mean the difference between life and death.
Also, increasingly sophisticated diagnostic tools available in the EMS setting—including some that can connect to patients wirelessly to both read and transmit vital signs—mean that high-quality patient information can be forwarded to waiting doctors and nurses in the ED.
At least one system is going further and actually sending electronic patient records to the ambulance. Such records can help paramedics identify, for example, whether an unconscious patient has been diagnosed with diabetes, whether a cardiac patient has previous diagnoses that might indicate a particular line of treatment, and whether a patient has medication allergies that could affect the responders’ choices.
Of course, anyone who has worked with computers knows that they’re not always the world-changers we want them to be—at least, not always in a positive direction. Shari Welch, among others, reports that many physicians have been reluctant to accept new information technologies into the ED, not because they dislike change but because in many cases the technology does not improve productivity the way it’s supposed to.
Physicians, she writes, saw that “many processes that had functioned quite well with paper and pen were cumbersome and faulty when embedded in the new technology.” Productivity often actually fell, systems were sometimes buggy, and slow-downs in records software meant slow-downs across the entire system. Such outcomes may be expected when new technologies are introduced, but they are far less tolerable in an emergency department than in less life-critical institutions.
Any information technology system for EMS will face even greater challenges. Providers are not stationery in a hospital but mobile, rushing to and from a scene in the ambulance and then moving all their gear—including any technologies for gathering and entering patient data—away from the unit to wherever the patient is. Technologies for EMS must therefore be smaller, easily carried, wireless, and easy to operate on the fly. Otherwise, they simply can’t—or wont’—be used.
In addition to possibly disrupted workflows, there are questions of patient privacy, training and uptake, and inefficient design. And one of the biggest problems is a counterintuitive one: too much information. If a paramedic needs to decide, right now, whether the patient should be given a particular medication, scrolling through the hundreds or sometimes thousands of pages that make up a patient chart isn’t an option. Designers of these IT systems will need to consult with EMS providers to create systems specifically tailored to their highly-constrained situation.
The Good, The Bad, and the Inevitable
Perhaps soon we will all carry credit card-sized wallet cards containing all our health records from birth. Immunizations, surgeries, diagnoses, recent tests results—all right there for the paramedics to swipe on their new wireless machines and upload to the hospital so the right team is waiting when we’re wheeled through the door.
Therein, in that picture, lie both the promise of health IT and its potential downsides. Lost cards (or stolen or accidentally-exchanged ones), technical glitches, and privacy concerns weigh on one side of the equation; faster and better treatment and improved resource management weigh on the other.
At this point, though, it’s less a question of whether than how and when. New healthcare information technologies are coming. The electronic patient record exists not in the future but in the present. The next time you call 911, you may well find yourself wirelessly connected to the hospital before you ever set foot in the ambulance.