Elderly people and veterans are among the chronically neglected when it comes to American medicine. We know who these people are, so why do they still die alone in their homes?
Why do at-risk former warfighters go without potentially lifesaving mental healthcare? Why did an 87-year-old lady suffer a heart attack at a nursing home in Bakersfield, California — and even after she died, why was it unclear whether she wanted to be resuscitated?
Why don’t we look up patients’ clinical details in the field, leveraging technology for insight about such basic decisions as whether or not to apply paddles to the chest or insert a breathing tube?
We know who belongs to the most under-served groups, and through technology (as well as old-school follow-up care) we can keep track of them. We can make advance directives available in an instant, where and when people suffer critical emergencies. Why don’t we?
We can, and should, debate national identification numbers. What we should not debate is whether solutions that can bring the healthcare system in line with our expectations – that it is smart, connected, open, equitable, and committed to our well being – are worth cultivating from both technological and financial (read: investment) sides.
The Bakersfield tragedy seemed like an extraordinary event, but it was far from being one. The public’s naivete was the tragedy here, for while ignorance may be bliss, it is also very dangerous and wildly expensive. I work in the emergency medical services business, and I can tell you that if I had a nickel for every time someone expressed shock that today’s EMS, fire, police and other public safety organizations rarely rely on integrated systems that move data seamlessly from a 9-1-1 call to dispatch to field provider to receiving hospital, my startup wouldn’t need funding!
To the contrary, few areas of public infrastructure other than Emergency Medical Services — especially those deemed critical and integral to the soundtrack of city life — still see the “state of the art” as paper and a clipboard. The reasons for this go beyond the scope of this essay, but they should spark outrage all the same: innovation is infrequently demanded in the emergency services market, and when it does comes through it often takes the shape of an unfunded mandate created by medical directors for medical directors, divorced from technology best practices (and not necessarily considerate of the field-use needs of EMS professionals).
Or worse, public demands for “innovation” lead bureaucrats to draft Requests for Proposal seeking every feature under the sun…without a budget to pay for them … and even with technical features that conflict or are impossible. (Case in point: I have seen EMS agencies ask for iOS applications they can run on a Panasonic Tough book PC.)
The state of emergency medical services in 21st century America is labyrinthine, from low-bid technology stalwarts who haven’t innovated in a decade to crisscrossed regulations at every level of government to a simple lack of choice – Do you know who your local ambulance provider is? At the end of the day, few legislators or integrated hospitals want to take responsibility for what long-serving medics themselves frequently call the “bastard stepchild of the healthcare system.” (That such a moniker may be bestowed on such sacred work reflects the public’s perception but breaks my heart.) Ambulance services therefore must fend for themselves and often languish.
Americans widely believe that EMS works the same across the country, which isn’t necessarily true. There’s much variation in the form and structure of emergency services across the country, based on politics, weather, and even terrain. What everyone neglects to note is that EMS is not compensated like the rest of the medical establishment. Ambulance agencies cannot submit for reimbursement with billing codes for treatments performed, and they are required by a very powerful federal law called EMTALA to provide care whether or not their patients are willing to pay. Moreover, Medicare makes ambulances bill by the mile, like souped-up taxis charged with patients’ survival, even though EMS agencies are at least as exposed as other caregivers (if not more so, given what they do all day) to liability in the case of a patient’s death or morbidity.
With so much complexity, the emergency medical services industry forms its own barrier to entry, but we can leverage solutions from other industries to bring insight to the field. For example, using a patient’s Social Security Number to aggregate health data including so-called Advanced Directives (such as Do Not Resuscitate orders), then making those available to EMS providers arriving on scene-like a prehospital Health Information Exchange. My own firm has developed interfaces inspired by analogues from online banking to Android phones.
This highlights the good news: those of us who smash through the health industry’s barriers do so armed with disruptive innovations and business-case justifications, plus a cohort of customers that is literally starving for something new and different. EMS providers that can’t bill for new technologies need a reason to buy in the absence of a mandate. They’re willing and ready to listen, if but someone would speak to them in actionable language. (In the case of my firm’s MEDIVIEW™ software platform, we’re the first to leverage the triumvirate of telemedicine, online-offline GPS, and a SaaS portal for near-real-time access to pre-hospital data as a trio of methods to help EMS agencies “connect the dots” from the field to the hospital, cut operating and overtime cost, and speed completion and movement of pre-hospital patient data into the receiving care facility.)
Yet where people — especially the indigent — don’t pay for ambulance services, EMS providers struggle to pay for innovations that can enhance both patient care and operational efficiency. Much technology therefore stays on the shelf, away from the people and places it could most immediately help. This paradox of healthcare IT has led to “clustering” around well-worn, less-desperate problems.
As a former firefighter/EMT (in Oregon) who has lived most of my life in Seattle there is no question that technology can be a life-saver but Seattle has had amazing save rates long before we all had laptops or smart phones.. Start with your policies and your funding and worry about the tech later..
BTW everyone who works in HealthIT knows you can's use (act of Congress) nor do you need to use a SS as the unique identifier.. Did you know your credit card number is actually more unique? There are plenty of ways to track patients without it.
As a former Captain for the Dept. of Defense Federal Fire Service and former EMT Instructor, I can say I really enjoyed your article. Today is my first day as a member and I could not have been more welcomed into the group, than by your article. I would like to point out some issues from the inside perspective into why the ole' paper and pen are the true reliable method for documenting in the field.
Technology and Firefighting
I'm sure you are looking at this sub-title thinking, "Well I was thinking more about the ambulance worker, not so much the firefighting response vehicle" Fact of the matter is, all across America, cities and counties, municipalities and boroughs are looking to find the cheapest way to provide emergency medical first responder services. The answer is simple, these are the types of incidents that the media loves to stick on the front page..."Elderly female dies at home, EMTs response was delayed due to manpower" Therefore, they will make sure to staff the ambulance with a qualified Emergency Vehicle Operator, who has their EMT certification and its easy to see why the firefighters, already working the 24 hour shift are picked to head up this task.
Firefighter equipment is comparable to SEAL or other Special Forces equipment; rugged, weather-proof and dependable. Notice I didn't say reliable, reliable doesn't save lives, the piece of equipment MUST work 98.99% of the time for a firefighter to rely on it. Unfortunately, not too many pieces fit the bill, especially when we consider pricing. EMS departments are some of the least or poorly financed departments and purchasing a $2500 EHR mobile device that has poor battery life, connectivity issues and compatibility issues with the surrounding ERs and hospitals is not likely to stay on the budget table too long.
Connectivity and Compatibility
Oftentimes, its hard enough to find two hospitals in the same city that use compatible equipment, EHR systems or are able to share information from one software interface to another. Getting the Mac folks to talk and share nicely with the Android or Windows people is as likely as a Republican, from Texas to chat with a democrat from Mass. about gun control. This is a sad reality, but a reality nonetheless. So, between the gingerbread software products collecting dust and the Macintosh issues slowing mobile devices to a crawl...I just don't see a bright end.
In my days as an Emergency First Responder to my later years as Incident Commander, there were a handful of tools I knew we could count on; wooden axe handles and metal grips on the tactical nozzles were not part of those. Rarely, except for some of the later version thermal-heat guns, did those include an electronic piece of equipment. Rechargeable flashlights, instead of batteries. PASS (personal alert safety signal) devices attached to our jackets, heard so clearly in the West Texas Fertilizer Explosion video were some of the few electric devices we consider dependable. Despite the fact that firefighters adapted well to GPS for address verification, GIS for pre-planning and on-site tactical operation, other technology, like mobile access to EHR has never come to fruition.
The technological gains that can be made in Emergency Medicine Departments across the country are quite vast; however without capital investments into the technology needed and the lack of federal funding for these devices I am afraid we will need to continue to rely on paper and pen documentation. The market is ripe for the picking, unfortunately the picking seems greener in other Healthcare pastures. Will the Affordable Healthcare Act change this? very unlikely. The movement must be pushed by smaller, more agile and responsive start-ups and they need to find and bind the capital required. Desperately needed, highly sought after, and life saving technology is right over the horizon. Let's just hope it keeps up with the demands of those who use it.
Community Health Worker
McKesson Health Solutions
Interesting article indeed. You raise a few points that I find challenging, and I am reasonably sure you've heard the challenges already. Just in case you haven't, however, a few minor points in no particular order:
1. EMTALA. I must assume you know the rationale for EMTALA. The idea is that, if someone cannot afford emergency services they still get served. While I think everyone agrees the system is not perfect, what would you suggest instead? The idea of first responders acting as accounts receivable agents at the scene strikes me as terrifying. And if they couldn't agree on reimbursement, would they withhold services? I get the problem, but I don't see a solution.
2. National ID Numbers. This would be great if only (in this example) first responders would get the IIHI, and only when they need it. But there's no way to ensure that. This is especially problematical as health care information systems are usually required to failsafe open (i.e. when authentication fails, they can still reveal PHI in support of the delivery of health care), whereas most other secured information systems fail closed (Credit cards, for instance). The easier it is for a legitimate caregiver to access patient data, the easier it is to effect inappropriate access. National ID numbers do nothing to solve this particular problem, nor does in-the-field access. I'd love to hear a solution that solves both the medic's need for good PHI, and also protects the patient's privacy as well.
3. SSN's are a terrible way of uniquely identifying patients. When the SSN system was designed, it was decided that SSN's would never be used as identification. As such, not a lot of work has gone into converting SSN's to IDs. Some of the problems one confronts are: (a) Canada, for instance, uses a similar numbering system, and I've seen cases where Canadian citizens have the same number as Americans. (b) Even in America, these numbers aren't unique. I've seen the case files on lots of folks that have multiple SSNs, and even cases where more than one person shares an SSN. I get the idea -- just SSNs won't work as the solution at this time.
I hear the passion. I'd love to hear some of the solutions.
Jonathon, great article on an important topic that is rarely front and center in the healthcare debate.