Episode 21: Interoperability & Emergency Services: Shifting Perspectives
Jonathon Feit, co-founder and CEO of Beyond Lucid Technologies & Consulting joins The Dish on Health IT hosts, Ken Kleinberg, Pooja Babbrah and special guest host Ed Daniels to talk about the role of emergency services (EMS) in the healthcare ecosystem now and in the future and how EMS fits into healthcare’s interoperability journey.
The hosts, Ken Kleinberg and Pooja Babbrah briefly introduced themselves. Guest host, Ed Daniels introduced himself by saying that the majority of his career has been spent on interoperability, data exchange and HIEs. Ed was a volunteer firefighter for 14 years and is currently working on the development of a multi-stakeholder collaborative on eConsent which is why this discussion was of particular interest to him.
Jonathon then introduced himself explaining that he is not a field practitioner or first responder. He shared that he joined the military after September 11, 2001 but discovered that his Tourette’s syndrome disqualified him from service, which led him to find another way to serve. He decided to leverage his skills as a technologist to solve problems related to data exchange to support EMS and first responders.
Beyond Lucid, the company Jonathon co-founded is focused on solving these issues. Right now, Beyond Lucid spends half of their day in the world of Fast Healthcare Interoperability Resources (FHIR), EMS, critical care both ground and air, the other half of the day is in the world of electronic health records (EHRs) focusing on things like patient matching. Beyond Lucid is currently running the Oregon Portable Orders for Life Sustaining Treatment (POLST) registry from a technology standpoint and are branching into pediatrics and medical complexities. What Jonathon finds interesting about this work is identifying what field providers do and what they need. Using end of life medical orders as an example, Jonathon pointed out that there is really a 0% margin of error. If someone has indicated in their records that they don’t want to be resuscitated but first responders are unaware of these records, the patient’s wishes may not be followed.
Another aspect of data exchange from the field to health systems so that data captured in the field can be incorporated into the patient’s record fast enough for it to be useful in how the patient is cared for in the emergency room (ER). The future of Beyond Lucid is focused on car crashes, winning a patent on a system to gather crash intelligence about the passengers such as number of passengers, whether children are in the car, or special medical needs of passengers such as hemophilia. There are mission critical pieces of data that need to be exchanged in real-time.
What prompted Jonathon to reach out to Point-of-Care Partners initially was the episode of the Dish on Health IT about social determinants of health (SDOH) because it highlighted patient data that helped look at patients as people. SDOH is important to providing holistic care.
Host, Ken Kleinberg asked for a little more context of how EMS fits in the overall healthcare ecosystem, asking specifically about how EMS has historically been billed separately from other healthcare services as transport.
Mr Feit explained that yes, it’s true that EMS is billed as transport is many places but it’s a yes with an asterisk because things are changing due to COVID. He explained that you really have to look more broadly to federal laws and how EMS is regarded. For example, up until the last 18 months, CMS regarded EMS as a supplier to healthcare, not a provider. This impacts not only how services are billed but related to interoperability rules as well. Meaningful use doesn’t apply to EMS which is a big problem because EMS uses a different data set that falls under the department of transportation and not Health and Human Services (HHS). He added that EMS is the most expensive taxi ride you’ll ever take. With the exception of one value-based care experiment happening now, EMS services are generally billed on a per mile basis and the rate is cost adjusted based on the experience level of the driver and the severity of the patient. EMS is emerging as a central part of safety net care in rural spaces where there aren’t enough doctors to serve the population and the fact that it’s a service available 24/7. Viewing EMS as a provider is a critical distinction that’s starting to change.
Ed agreed with how Jonathon characterized the current view of EMS in healthcare generally and in regulation. Ed explained that historically, ambulances were intended to just get the patient into the hospital as soon as possible but it’s changed drastically over the years with life-saving services being performed on site and in transit. Ambulances are no longer just transport but definitely a provider situation. It’s time for a change in how this type of care is provided and being billed and reimbursed.
Ken observed that it would be a real problem if the patient was charged in hospital for how far they were pushed in a wheelchair from their room to get a test. Ken then asked Pooja if there was a parallel between how pharmacists have transitioned to be part of the care team as opposed to an adjunct service. Pooja responded that she does see some parallels and mentioned reading a CMS blog post by Chiquita Brooks-LaSure and other CMS leaders that discussed the Center for Medicare and Medicaid Innovation (Innovation Center) which explored 50 alternative payment models to fee for service. While only a handful were considered successful, the ones that had some success had mandates to back them up. Pooja added that she thinks that just as the payment model in pharmacy is being revisited, the payment and reimbursement model for EMS should be re-examined as well.
Ed added that another scenario where the pay for transport model for EMS just doesn’t make sense is when a patient maybe just needs to get emergency care at home but doesn’t need to be transported to the hospital. The current reimbursement structure doesn’t allow for this.
Jonathon pointed out that there is currently an “allergy” in the mobile medical arena to good data. He went on to clarify that when you mention CMS, where they have extremely wonky geeks who are truly good at their job, people forget they need fuel for their work, they need data. Jonathon went onto explain that when creating mandates versus voluntary guidance, you really need not just data but good data to back that up and see what is working and what’s not. Right now, entering in information about a patient encounter by EMS staff isn’t a priority because there isn’t an understanding of how good data could transform things for the better. EMS has so much catching-up to do. Jonathon added that this lack of good data problem isn’t unique to EMS by any means but it’s an issue that needs to be tackled for us to see real change.
Jonathon explained that part of the reason he reached out to Point-of-Care Partners was because he felt we provide a breadth of perspective to these issues in healthcare that reflects the bigger picture. He added that when docs talk to other docs or nurses and EMS techs to talk to Fire fighters, they aren’t hearing from outside their environment to gain that broader perspective and close the gaps in understanding about their role in the ecosystem. He continued to say that we need to make the case why it’s so important to get good data into the system and for that data to be fluid across environments.
Ken interjected and said that now that the now we’re getting into the interoperability part of the conversation, he wanted to ask about the system that’s generally used by EMS called The National Emergency Medical Services Information System (NEMSIS) and asked if it was connected to EHRs.
Jonathon responded that NEMSIS is separate and therefore and unequal data set maintained through the National Highway Safety Administration. It has a rich history of tracking data for car crashes and heart attacks while driving which Jonathon admitted was a gross over-simplification. There is a way for NEMSIS to connect to EHRs but there hasn’t been education and discussion from the federal level down to the state, county and regional level on why the data and connecting to EHRs matters.
Beyond Lucid was awarded a project in California back in 2015 to build the bridge between NEMSIS using HL7 standards like CCD. Beyond Lucid completed a gap analysis to understand what it would take to go from one to the other. What they found was an 85% overlap between what was required in the EMS system and the HL7 CCD. The 15% gap fell largely in 3 buckets including family history, past encounters and mental health which is very similar to SDOH. There are efforts to plug this hole with real-time data. Jonathon added that there are other efforts giving an example the largest fire service in Southern Denver, Colorado which was the first to send real-time data to Sentara health system in 2018 which shows it can be done, however, Jonathon added that health systems and EMS aren’t doing a good job of talking with each other about their respective needs.
Ken asked Jonathon to talk about Beyond Lucid being one, if not the first EMS IT vendor to join the Commonwell Health Alliance and whether they are now getting some SDOH data from HIEs.
Jonathon explained that about 2 years ago at the National Association of State EMS officials, there was an outcry for SDOH and contextual data. Up until then this demand was mostly at the local level. Beyond Lucid volunteered to be the vendor to make this possible and develop a superset of data and has announced this capability to populate SDOH data for 911 calls. This project made a lightbulb go off for those involved on why this data should be a separate data set when it really should be integrated in the overall record.
Jonathon explained that strong ID is really important because especially when you’re looking at end of life orders, you want to make sure you’re looking at the right patient. Unfortunately, a lot of initiatives required affirmative permission from he patient to look them up but the problem is that this doesn’t work in the back of an ambulance. Ultimately the trust framework is critical but right now there is so much dirty data. Jonathon went on to say that now that FHIR V4 has been balloted and approved and Carequality/Sequoia was awarded the trust framework project, it seems progress is being made and EMS is finally at the table.
Ken asked Pooja to provide her perspective on how EMS might use SDOH and eConsent and advanced care directives. Pooja shared that when you think about the knowledge first responders gain about a patient’s living situation and environmental challenges, it makes sense that they could contribute valuable SDOH data that could be used downstream. It’s about time the industry start looking at how the data going into EMS systems can be shared along the care continuum.
Jonathon interjected that it’s also important for police to have access to some of this information and that Beyond Lucid has helped create a database of medically complex children so police know if they are interacting with someone that perhaps is non-verbal so can’t explain their situation or who can’t follow verbal commands. Without this information Police encounters can end tragically. Encounter data really needs to flow throughout healthcare and also community services.
Ken re-focused the conversation on eConsent. Ed shared that he is working on an initiative now on how to get electronic informed consent and advanced directives. It’s a very complicated question and there isn’t one answer.
Ken began to close out the podcast by asking Jonathon if there was any last topic he’d like to cover suggesting perhaps something about COVID and vaccines since Jonathon had mentioned this in conversations prior to the podcast.
Jonathon responded that he knows vaccines can be controversial and really he isn’t talking about vaccinations per se but it’s important to talk about interoperability and data quality and that for many years vaccination registries didn’t talk to each other or couldn’t be accessed by providers. This is important in the context of when you’re planning to hold someone to account on getting vaccinated and proving they’ve been vaccinated. Jonathon posed the question that shouldn’t there be a single source of truth rather than asking people to hold onto a little card? If we get the smart people in the room to solve these problems, we can make so much progress.
Pooja added that in her role on the NCPDP board, they’ve had many conversations about how to use existing standards to create a central source of truth. Pooja explained that she’s glad we were able to have this important discussion.
