National EMS Information System
Michael Schnyder&
Massachusetts Office ofEmergency Medical Services
Introductions
Overview• History of EMS Data Collection
• Overview of the Original NEMSIS Program
• Overview of the NHTSA Data Element Standard
• Results from the Original Pilot Project
Overview• What’s Next for NEMSIS
• WIIFY (What’s in it for you)
• Use of Massachusetts’ Data
History of EMS Data• We can date it back to the “modern age of
EMS” – 1966: Accidental Death and Disability
“A review of ambulance services in the United States indicates a paucity of information and a limited framework for the collection of data on and the evaluation of current ambulance services.” (Page 13)
More Recent History?– 2003:The EMS Outcomes Evaluation Project:
“No local, state, or federal databases were suitable for use due to inconsistent data definitions, inconsistent data formatting, and variation in inclusion criteria.” (Page 8)
http://www.nhtsa.dot.gov/people/injury/ems/emsoutcomes03/
Status: United States
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District of Columbia
KEY:
Active Data System
No Active Data System
Did Not Respond to Survey Source: NEMSIS TACCapability Survey, 2006
So What Happened In Between?
• Largest event happened in 1992-1993– The NHTSA EMS Data Elements Version 1
• Great try, the spirit was there
• Too loose of a standard
• EMS relatively uneducated to the potential of computer technology
Enter the NEMSIS Project• Late 90’s, the National Association of
State EMS Directors decided there was a NEED for uniform data collection
The Need• EMS Education
– Curriculums– Local Education
• EMS Outcomes– Something other than death– System evaluation
• EMS Research– Generate hypothesis– Evaluate cost-effectiveness– Identify problems and target issues
• EMS Reimbursement– National fee schedule and reimbursement rates
The Original Team• NASEMSD
– Project Management– Regional Meetings– Operational Support
• Greg Mears, MD– Principle Investigator
• NEDARC– Clay Mann, PhD, Co-Investigator– Mike Dean, MD, Co-Investigator– Technical Assistance
• State Data-Managers
The Money• NHTSA
– EMS Division (Primary)
• HRSA– EMS-C, Trauma, and EMS
• American Heart Association– Support for EMS Software Development
The ConsensusProfessional Organizations
• AAA• AAMS• ACEP• ACS-COT (NTDB)• AHA (NRCPR)• EMSOP• IAFC• IAFF• NAEMD• NAEMSP• NASEMSD• NENA
Federal Partners
• CDC• FEMA• HRSA-EMSC• HRSA-EMSC/NEDARC• HRSA-EMSC/NRC• HRSA-ORHP• HRSA-Trauma/EMS• NHTSA
This Desire…• Turned into the revision of the National
EMS Dataset
• More than just a dictionary– Why each element exists– What each element’s purpose and use– How to store and send the data– How they interact with each other
Overview of the NEMSIS Standard
Where We Need to Be• EMS is one piece of
a health care puzzle
EMSSystem
EmergencyDepartment
Hospital
Rehabilitation
Prevention
911System
The Data Sources
Linkage
MedicalDevice
DomesticTerrorism
Outcomes
QualityManage-
ment
Personnel
System
CardiacArrest
Trauma
Patient
Incident
Dispatch
NHTSA2.2
NEMSIS Overview• Composed of two components:
– Demographic dataset: • Standardized set of data fields that
describe an EMS system
– EMS dataset:• Standardized set of definitions describing
an EMS event
NEMSIS Overview• Both have the following:
– XML (eXtensible Markup Language ) formats – XSD (XML Schema Definition)
• Provides the capability of moving data from one system to another
• XML provides the method on which data is stored
• XSD provides the definition and rules for a field
NEMSIS Overview• Date of Birth
– You don’t want to have people enter any data into the field.
• You need them to:– Complete the field– Format: MM/DD/YYYY– Range: Today’s date to 125 years ago
NEMSIS OverviewNumber of fields to be collected:
Nat’l
State
Local
List in current dictionary
Mass’ List is Being Developed
States/Regions set the minimum number of fields
Why?• Portability means:
– Ease of movement of the data
– Commonality of the elements to be moved
– Software vendors developing applications that can be used across the country
Portability!
Patient Care Report Software
Agency C’s Software
911Center
Patient Care
Report
Agency A’s Software
Patient Care
Report
Patient Care
Report
Agency B’s Software
What Happened With The
Original NEMSISProject?
Success!• The Standard was adopted
• A pilot “national” EMS database was created
• Software Vendors are moving to the new standard
• National Effort
The Standard• Over 400 different elements to choose
from– No, you don’t have to enter all for each run– Choices, choices, choices– A State’s data dictionary will be smaller
• A standard that will be seen throughout the country– No other healthcare provider is even close
Pilot National Database• One of the final deliverables for the
NEMSIS Pilot Project
• Four states with an existing data system were to provide 30k reports to Dr. Mears– Delaware– Minnesota– Mississippi– North Carolina
Pilot National Database• Three out of four states provided data
• The data were combined into a common database and a query engine was built – First time that EMS data was combined from
multiple states– If this could be done, then there should be
limited issues with scaling to accept the entire nation
Software Vendors• Estimated to be over 70 EMS software
vendors in the nation
• As of March 24, twenty vendors have entered the compliance certification process– Certifications will be awarded in early June– An number of vendors are going for the Gold
standard
States Using the NHTSA Standard
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Puerto Rico
Marianas Islands
Guam
American Samoa
District of Columbia
U.S . VirginIslands
KEY
100% of the EMS Data Dictionary Uses Using the NHTSA 2.2 Standard
Not 100% of the EMS Data Dictionary Using the NHTSA 2.2 Standard or No Answer
Did Not Respond to Survey
HI
National EMS Database
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District of Columbia
U.S . VirginIslands
KEY
Submitting in 2006
Reporting as Capable of Submitting in 2007
Reporting a Date After 2007 or Unknown
Did Not Respond to Survey
Part Two • The Next Steps:
– Federal Support– NEMSIS TAC– Software Compliancy– NEMSIS Freeware, etc.– National EMS Database
Federal Support• Already discussed about the Federal
commitment to the new process
• NHTSA, HRSA, CDC have all made a financial and political commitment to the cause
• Here’s how…
Federal Support• Provided money to establish a NEMSIS
Technical Assistance Center – $600k year one– Possibly $1 million for Year Two– Talk about providing more money
• NHTSA has established a funding source for states who are making a NEMSIS system
Other Funding Source• The Federal Register published that 34.5
million will be offered each year over the next 4 years to States– Non-competitive– $300,000 - $500,000 per application
• The “catch” is tying NEMSIS in with traffic crash data
NEMSIS TAC• The TAC picked up the work at the end of
the Pilot phase of NEMSIS (Sept 2005)– University of Utah received the grant– Utah contracted with University of North
Carolina to continue their efforts
• The Goal is to collect data from States and Territories to create the National EMS Database
NEMSIS TAC• Simple goal, complicated objectives
• This means that the TAC will be offering assistance to:– States– Local EMS agencies– Software developers
NEMSIS TAC Resources• www.nemsis.org • Reference Documents• Communication and Public Education• Maintain Dataset and XSD• Development Tools• Direct Technical Assistance• National Database Development• Other
www.NEMSIS.org
Software Compliancy• On March 1, 2006, the TAC began testing
software developers for compliance
• At the end of March there were over 15 applicants (multiple software packages too)
• There are two levels of compliance:– Gold– Silver
Silver and Gold Compliance
Silver
• Must have the National elements
• Any additional elements must comply with the standard
• Must create the right XML/XSD files
Gold
• Must be able to offer all of the elements found in the NHTSA dataset
• Must create the right XML/XSD files
Compliance• Upon successful completion of the
compliance certification, the developer and application will be posted on the NEMSIS site
• Always remember to be an informed customer (There is the possibility of cheating the certification process)
Compliance• At this time, no one has been certified in
either the Silver or Gold level
• The first ones will be posted in early June– The website can be (and is) updated on a
frequently basis (i.e. daily)
National EMS Database• 2006- Five states will be submitting data
– North Carolina– Minnesota– New Hampshire– Mississippi– Nebraska, North Dakota, or Tennessee
• The TAC will collect the data for the NCSA
• The TAC will also design the reporting system to extract data
• This reporting section will analyze data from a national, state, and local level
• The TAC is creating 10 report sections for the National EMS Database
National EMS Database
The Ten Categories• Data Quality Section
• Overall Section
• Times Section
• Medical & Trauma Section
• Disposition Section
• Agency Section
• Cardiac Arrest Section
• Delay Info Section
• Financial Aspects Section
• “Other” Section
The Reporting System• Plans call for:
– Canned Reports
– User-defined Reports
– Logic built into the reporting section
– A quality score for each report
– Multiple output formats• Screen, PDF, etc.
Let’s Go Over the Fields
What is in it for You?• Performance Improvement Initiatives
• National Trauma Registry, etc.
• Data Element Recommendations
• Massachusetts' needs
Performance Improvement• More Money Parts 1 & 2
• Changing the Business Logic– Protocol Development (Evidence-based)– Time Related Analysis & Interventions– Capability & Consistency– Dynamic Unit Deployment
More Money, Part 1• Situation:
– Volunteer EMS need money to survive– Saw data system as an unfunded mandate
• Truth:– Cost of computer, printer, internet: $1,400– Yearly cost: About $250– Time to complete reports: Unknown cost
More Money• Results:
– EMS entered agreement with billing company– Virtually eliminated the “EMS secretary”
position– It did take longer to write a patient care report– Revenue increased for the agencies– Turnaround time for $$ was faster
Advantages of Electronic• Completeness check (edit check)
– Can’t bill unless to have the information
• Not applicable data is hidden
• Electronic means closer to invoicing– Invoices should be mailed within 72 hours
from the time of service*
*Prehospital Care Administration, pg 386
More Money Pt. 2• University of North Carolina is combining
their system with money from a Duke Endowment
• The Performance Improvement Center will analyze EMS data to determine:– What resources are needed– How much $$ an agency could use
Paramedics review anddetermine protocol
changes
Paramedics revise theprotocols and back it up
with evidence
Paramedics meet withthe Medical Directors and
review the proposal
The Medical Directorsdiscuss and vote on
changes
The changes then followthe standard bureaucratic
path
Most changes are madestatewide
Protocol Development
• The “Total Airway Package” was the paramedics reviewing every aspect of respiratory distress and how the Delaware EMS system operated
Total Airway Package
Intubation Asthma Congestive Heart FailureSurgical Airway
Nasal ETT
Oral ETT
Oxygen
Albuterol
Peak Flow
“Needle Cric” Oxygen
Lasix
Nitro
Morphine
Rescue Airway
Drug-facilitated Atrovent
Steroids
Dilatation Cric
CPAP
Total Airway Package
• CPAP: Changed the respiratory emergency world in Delaware– How would you like to turn a CHF patient
around in 5 minutes?– Decreased Nasal ETT attempts = More
patients successfully intubated
Total Airway Package
NEMSIS = Improved Services
• Mainly because:– We will have more data
– We will have consistent data
– We will be able to put computers to work
– The local efforts will turn into national ones
ResponseTime
On-SceneTime
TransportTime
RestockTime
What the PublicCares About
911Answer Call
ProcessingAffects Response Times
Time Related Analysis
Time Analysis• Averages are “old school”
• “Fractiles” only tell you so much
Our Average Response Time is:
7.5 Minutes
Time GraphsReponse Time Percentile Graph
8.3%
20.9%
81.1%
90.3%
99.2% 100.0%
32.7%
95.7%
61.8%
55.9%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
110%
EMS Agency
Average90% Mark
Interventions• The same can be said about EMS
interventions– We have inconsistent definitions– We have inconsistent protocols– We have inconsistent equipment– We have inconsistent way to measure
Example: Intubations• We are interested in
monitoring the percent of successful intubations completed in the field
90% 86% 94%
89% 86% 93%
88% 92% 91%
93% 84% 88%
87% 91% 90%
95% 89% 92%
91% 90% 84%
83% 85% 97%
88% 87% 87%
91% 90% 91%
Our Data:
Capable and Consistent• The argument has been:
– “Who should say what is good for one location is good for another?”
• The logic has been that each EMS agency is different– Service area– Types of organization and providers– Patients, hospitals, equipment, etc.
Start by graphing the data:
Intubations
65%
70%
75%
80%
85%
90%
95%
100%
105%
110%
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Time Intervals
Ob
serv
atio
ns
Does this tell us anything?
Add the Mean and Control Limits:
Intubations
65%
70%
75%
80%
85%
90%
95%
100%
105%
110%
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Time Intervals
Ob
serv
atio
ns
Events
Mean
UCL
LCL
The control limits are three standard deviations above and below the mean.
Deployment of UnitsUnit Distribution-
Let the computer do the thinking
-Red dots are posting locations
-Polygons are response areas for each unit
Software: MARVLIS
Track district coverage on a real time basis
DeploymentSoftware: MARVLIS
National Trauma Registry• Currently being re-written and in the final
stages
• Great news: About 40% of the TR dataset’s elements come from the NEMSIS dataset– Electronic highway (two-way) for data to be
submitted to hospitals and back
Data Element Recommendation
• This is not an “official” list
• Some of the potential elements you can use from the NEMSIS dataset
• Let’s go over it
What are Massachusetts’ Needs?
Any Other Questions?
T
H
A
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YOU