When paramedics arrived on the scene, the patient's vital signs were abnormal, but he resisted transport to the hospital. The EMTs eventually acquiesced, but only after they reviewed his medical records. If having access to patient records in an ambulance sounds oxymoronic, it's not, at least not in Indiana.
Welcome to Indiana, the most medically wired state in the country, where EMS uses the Indiana Network for Patient Care to view medical records, reassuring them in this case that the readings were normal for this patient.
In the Midwestern state, particularly in Marion County, home of Indianapolis, and nearby Hamilton County, emergency medical technicians and paramedics with certain emergency medical services have secure access to the electronic medical records of the patients they are treating. An extension of the mission of the Regenstrief Institute, an internationally recognized informatics and health care research organization, the program is dedicated to improving patient health by also enhancing the quality and cost-effectiveness of health care. Regenstrief sits on the campus of the Indiana University School of Medicine in Indianapolis, is supported by the Regenstrief Foundation, and is closely affiliated with the IU medical school and the Health and Hospital Corporation of Marion County.
The system was tested last May and June, officially beginning operations in July. By this past January, seven emergency medical services agencies had signed a legal agreement to take part in the service, with potential for 23, said John T. Finnell, MD, a Regenstrief Institute investigator and an associate professor of emergency medicine at the Indiana University School of Medicine, who developed the link between electronic medical records and emergency treatment in the field.
“We piggybacked on a network that already existed here,” said Dr. Finnell. In the 1990s, two hospitals in Indianapolis began sharing information. That electronic sharing has now extended statewide and to emergency departments across the region.
“In the emergency department when patients arrive, a signal is sent to Regenstrief to allow access to statewide emergency records,” said Dr. Finnell. Since 2002, the process has allowed them access to record for 24 hours.
“My colleague, Charles Miramonti, began to talk about the utility of such data in the prehospital field,” said Dr. Finnell. “We applied through [the U.S. Department of] Homeland Security for a grant to establish connectivity between tablet PCs [in the ambulance] and the data at Regenstrief.”
“No one else has the technology to do this,” said Dr. Miramonti, an assistant professor of clinical emergency medicine and a deputy medical director of the division of out-of-hospital care at the University of Indiana School of Medicine. “We have taken advantage of several local resources and opportunities to make it all happen. We were the right people at the right time with the right money to make it all come together.”
Dr. Miramonti's interest stems not only from his work with emergency medical services but also in disaster preparedness. His aim has been to connect the hospitals to the community, health centers with emergency medical services to create the big picture. “This project is a marriage of all these things,” he said. “Dr. Finnell oversees data management and emergency care. We look at how to do what we do every day better, but also to build a better infrastructure for patient care that will help get us through any disaster.”
Appropriate records can be sent to providers at the scene of everyday EMS calls, but he said the win for the project was that they can do the same in a disaster. As EDs become overwhelmed, the system can establish new venues as clinics and direct patients to other sites, all because they can send medical records wherever patients are. “If people have to be evacuated, we can do that and make sure everyone is on the same page with their treatment,” said Dr. Miramonti, also the deputy medical director for the Wishard Ambulance Service and the Indianapolis Fire Department.
The huge statewide database is maintained at Regenstrief, Dr. Finnell said. Combining the EMS database with the statewide system enables prehospital providers to look up a patient in the field. “Using a name, date of birth, and zip code, we can see if there is a unique match. If there is and the paramedic is approved to receive such data, the system sends the data back as a PDF. If there is more than one match, we don't send anything back,” he said of the safeguard that prevents privacy violations. Assuming everything works, field providers receive a standard set of data within 10 seconds of request.
The database began in Indiana's emergency departments because emergency physicians said they could provide better care if they had access to patients' previous records. Under the Regenstrief rules, they have access to the information for 24 hours. If a patient is admitted to the hospital, hospitalists and internal medicine specialists have access for up to 30 days or until the patient is discharged.
In determining what went into the PDF, the team had to decide what information made sense in the prehospital field, said Dr. Finnell. “They wanted things we don't. What kind of bodily fluid precautions are needed? Should we notify next-of-kin, and who is that? What hospitals have they been in before? If the patient received most of his or her care in one facility, it makes sense to transport that person back to that facility. We didn't capture that kind of stuff. It was enlightening for us to understand what they need.”
In fact, the record is still in its infancy, he said, and they are still trying to determine if it is helpful to send previous vital signs, laboratory results, or x-ray data. “The paramedic on the street doesn't need to know that your last glucose was 150,” Dr. Finnell said.
While the project is still in its infancy, early results show the cost of tests can be reduced by approximately $25. “What we think anecdotally is that if someone has had multiple imaging studies, we don't have to repeat them,” he said. Although laboratory tests don't change a lot, he noted, they are less expensive, and they might do another hemoglobin if the patient is bleeding.
Dr. Finnell also may study whether it would be valuable to send electrocardiogram data, he said. “Patients often come in with good stories and abnormal EKGs. If they are unchanged, you might find it is safe to send them back home with an urgent medicine appointment the next day. If we didn't have the data, we could end up admitting them.”
With the first version of the record done, he and Dr. Miramonti are working on signing up local EMS services, he said, and assessing whether the system is useful and what other data they might need in the field. “The next layer of research is looking how it [affects] care. When paramedics transport a patient with congestive heart failure or chronic obstructive pulmonary disease, does having the data make a difference in the outcome?” Obtaining those answers will be more difficult and require a larger sample of patients, he said.
“There is a learning curve,” said Dr. Miramonti. “Many of the learning hurdles are out of the way, and we are getting better at teaching people how to use it.”.
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