A few years back, Travis Ogden’s ambulance crew raced to revive a 4-year-old who’d drowned, the color starting to return to her lips as they rushed to the hospital. Normally, their arrival would mark the end of the run: What happens beyond the emergency room doors by and large remains a mystery.
But that day, Ogden’s crew couldn’t accept that reality. They cleaned the rig and restocked its medical supplies in slow motion, trying to stick around and find out whether she survived. When a doctor walked over to her family and knelt, they quietly realized she hadn’t.
‘Unless there’s something super dramatic like that, we don’t get to know,’ said Ogden, an EMT in Homer, Alaska. ‘It’s like going up to a concrete wall and chucking a note over and walking away. It’s brutal.’
advertisement That’s typical for emergency medics, an umbrella term for paramedics, emergency medical technicians, and emergency medical responders, who are regularly the first people to provide care in emergencies from strokes and overdoses to heat waves and hurricanes. However, as experts told STAT, emergency medics, which often operate separately from the health care systems they deliver to, are largely locked out of medicine’s vast information architecture. That means they’re often unable to access a patient’s medical history when they arrive on scene, even though that information would help them make time-sensitive, livesaving decisions. They’re also typically blocked from learning the final outcomes of that critical decision-making — leaving them to cope with unresolved trauma and depriving them of affirmation that their work matters.
advertisement ‘Everybody wants to win when you’re fighting death,’ Ogden said. ‘Not knowing if you win — it’s the same as a loss.’ In one 2017 survey of about 15,800 EMS professionals, nearly half reported not receiving any feedback on their medical care in the past month. Ogden estimated his crew responded to about 165 medical calls in 2021; they got closure on fewer than a dozen.
And while medics might pass along reports to emergency departments with vital statistics, EKGs, and other notes about what they saw on the scene, those details do not always make it into a patient’s electronic health record, where they could improve care down the line.
‘You go through those doors, you put them in a bed, and you leave,’ said Rebecca Cash, an assistant professor of emergency medicine at Harvard and former paramedic and EMT. ‘The course they take next is sort of a black box.’ All around, she said, ‘there’s a huge amount of information loss.’
Experts say unless it’s fixed, this siloing will continue to hold back a field we increasingly rely on — during pandemics, after natural disasters, and alongside an aging population. ‘We’re not asking for chrome caps on our ambulances,’ said Michael Levy, president of the National Association of EMS Physicians. ‘It’s not some luxury.’
In the United States, emergency medical services are provided by a patchwork of municipal, county, volunteer, private, and hospital-owned services.
This is, in part, an outgrowth of the field’s grassroots genesis: The country’s earliest ambulances were unregulated ‘scoop and run’ operations by undertakers, police departments, and volunteers. In just a few decades, EMS rapidly professionalized and began providing not just transportation to hospitals but lifesaving clinical care on scene and along the way. But it has yet to fully shake free from the pejorative perception among some hospital staff that emergency medics are nothing more than ambulance drivers.
That cultural legacy has had wide-ranging ripple effects. For one, the field remains housed under the auspices of the Department of Transportation, not the federal health department. Ambulances can bill Medicare and Medicare per mile — but not for services rendered. And emergency medics have never wholly been brought into the fold on patient records, despite being covered under HIPAA.
‘It’s not necessarily the technical issues’ that get in the way of bridging EMS data access in 2021, said Rachel Abbey, a public health analyst at the Office of the National Coordinator for Health Information Technology, which regularly works with the DOT on EMS interconnectivity. ‘There’s a need for a cultural shift.’ The field does maintain its own data repository — the National EMS Information System — that houses a billion-plus entries and has informed hundreds of peer-reviewed papers. (In 2020, NEMSIS grew by 44 million entries, allowing researchers to document reduced 911 call volume, fewer car crashes, and excess at-home deaths and opioid overdoses during the pandemic).
But that database is not linked to patient outcomes. That means that while NEMSIS may be able to shed light on siren use, racial and gender disparities in violent trauma, or the socioeconomic underpinnings of cardiac arrest survival, it cannot tell individual medics whether they are intubating properly, accurately identifying strokes, or unnecessarily putting in IVs.
Until more formal connections are forged, medics will have to continue informally scrounging for information on how the people they cared for fared. ‘It’s still them mostly calling on the phone, saying, ‘How’s my patient?” N. Clay Mann, a NEMSIS researcher and professor of medicine at the University of Utah, told STAT.
Without consistent feedback, experts say, medics are like high jumpers training without a bar to clear.
‘Ninety percent of medicine is experience — there’s a reason you’re not a doctor when you graduate medical school,’ said David Lehrfeld, Oregon’s EMS and trauma systems medical director. Refusing to allow EMS providers access to case reviews and real-time data stands in almost unfathomable contrast to the practice of medicine, which relies on constant iteration and the integration of advanced technology to improve. ‘You can’t learn, you can’t get better,’ Lehrfeld said.
In this information vacuum — and especially if a patient is alone or unable to answer questions — medics depend on subtle and experienced sleuthing.
A bunched-up blanket near someone who has collapsed suggests they were gripping it in pain until they passed out. Medicine bottles reveal preexisting conditions or ongoing antibiotic treatments for pneumonia or a UTI, for example. Whether they are untouched can say even more. In winter, a freshly shoveled driveway might be a precursor for a heart attack. In summer, a nonfunctioning air conditioner unit might point to heat stroke.
‘The clues you can pick out in a cursory glance can be the thing that saves their life,’ Ogden said. ‘All those things factor into the care we give.’
But some critical information can be hard to discern from surroundings alone. Serious allergies are almost impossible to infer. A medic may misinterpret the symptoms of certain conditions, including MS or diabetes, as a head injury or intoxication. If they know a patient was just discharged, they might choose to bring them back to the same hospital for continuity — even if it takes a few extra minutes to get there. ‘Our number one goal is to find and treat something that can kill you,’ said Jessica Krause, who worked for 16 years, up until the Covid-19 pandemic, as a paramedic in North Carolina and in the Midwest. ‘But some of those things look like nothing at all.’
Or, conversely, the most obvious symptoms — devoid of context — can become a red herring for the true threat. If someone has a heart attack and crashes their car, should a medic treat it as a trauma incident or a cardiac case? Patients or bystanders can also misremember critical facts, forgetting to flag serious allergies, old injuries, or rare diseases.
‘If I don’t have a whole picture,’ Krause said, ‘I might miss something.’
And then there’s everything that medics like Krause do pick up on that could offer important insights for recovery, rehabilitation and future treatment. Did the person who broke her hip have a railing on her staircase or rugs on slick floor surfaces? Does the person with diabetes have fresh food in their fridge? Is the elderly patient really taking all the medications they’re sent home with?
As Tyler Newcomb, an EMT in New Jersey, cautioned: ‘That lack of flow of information can only hold back care.’
Today, the field’s complex landscape and rapid evolution has made it hard to find the will and funding necessary to close the information gulf between emergency medics and the health care systems where they drop off patients.
In many places, no entities are willing to pay for feasible software and hardware updates that could open a portal for EMS providers to peer into EHRs. ‘It costs a lot to create these technical connections,’ Abbey said.
‘The hospitals see no reason to invest in a technology that’s not going to make them money, that’s the bottom line,’ Lehrfeld said. ‘It’s not a priority for them.’
And EMS providers themselves may not be able to afford it. Many agencies operate under financial strain, and their medics may make runs to a half-dozen hospitals, each of which may run on a unique EHR. (Epic, one of the country’s largest EHR providers, doesn’t offer EMS-specific products but has helped health care providers connect their EHRs to EMS agencies on a more case-by-case basis.)
‘It would be ridiculous to ask the EMS agency to foot the bill,’ Lehrfeld said.
In recent years, health information exchanges, or HIEs, have allowed several health care providers, including EMS agencies, to access and exchange laboratory results, radiology reports, clinical care summaries, and medication histories. Still, Cash said, HIEs remain ‘pretty rare,’ and many were only made possible as federally funded pilot programs.
CRISP, a multistate HIE in the Maryland region, for example, connects 60-plus hospitals and outpatient facilities and received at least $16.5 million in grants to get off the ground. For EMS providers in the state, its impact has been invaluable, said paramedic Erich Goetz. Whereas before he faced the same concrete wall as most medics, now Goetz can request and receive patient updates in hours.
‘There’s been a paradigm shift,’ he said. ‘If I’m wrong, I want to and need to know that I was wrong.’ Through CRISP, for example, Goetz has learned of at least one occasion where what he was certain was cardiac arrest turned out to be a huge spike in blood sugar that was missed by an uncalibrated glucose monitor.
‘That was an eye-opening moment for me,’ he said. ‘It’s changed a lot of how I think about my patient care.’
Elsewhere, repeated and traumatizing cliffhangers are one of many reasons the EMS field suffers from elevated rates of PTSD, burnout, turnover, suicide and suicidal thoughts. Spending your career showing up for the worst day of everyone else’s life and endlessly wondering whether you’re hurting or helping can lead medics down a dark path.
‘It cheese-graters your soul,’ Ogden said.
But the opposite can be true, too. A recent patient of Goetz’s seemed bound for death — or, at a minimum, major brain damage — after she was in cardiac arrest for over half an hour. After a few days, he asked for an update and found out she’d made a miraculous recovery. ‘It gave me a much needed morale boost,’ he said.
https://www.statnews.com/2022/01/04/emergency-medics-electronic-health-records/
