what’s in it for us? using data for success in patient care!

paramedicfoundation.org twitter.com/paramedicfound

facebook.com/ParamedicFoundation

What’s In It for us? Using Data for Success in Patient Care!

Nick Nudell, MS, NRP, FACPE

National Rural EMS and Care Conference

April 2017

Fargo, ND



Nick Nudell, MS, NRP, FACPE

• BA in IT Management, MS in Information Security, studying D.Sci. in Information Systems – Analytics & Decision Science

• Paid/volunteer & urban/rural 18+yrs Paramedic, 25yrs technology

• Former EMS Compass Project Manager

• Rural health & healthcare information systems consultant

• Board Member – Paramedic Foundation & National EMS Management Association



Life is about the journey

49 States2 Provinces8 months44,250 mi truck27,500 mi trailer9.3mpg4,720 gallons diesel1,162 hours1 fish



It is not a Magic School Bus



Tell me about you!



Perspectives



Tok Area, Alaska: 41st Largest State• Pop est: 7,023 or 0.25 per sq/mi (0.01/km²)

• 25,059 sq/mi (64,900 km²)

• AlCan Border Crossing into USA:• 114,996 private passengers

• 1,307 pedestrians

• 3,762 bus passengers

• 6,219 trucks

• 62,277 crossed in to Canada

• 2 doctors, 3 clinic rooms, 60 EMS

Source: https://transborder.bts.govhttp://www.tc.gov.yk.ca/



Adapt, Overcome, & Advance!

Nearest hospital is 203mi =4hrs ground or 90 minutes by airFurthest road point is border @322mi = 6 hours to hospitalTrauma center is 3.5 hr flight after getting to Fairbanks



EMS systems are complex

Managing without information is crazy!

Supply Management

Vehicles Purchase & Repair

Medications

Dispatch

CPR Classes

Human Resources

Professional Development

Narcotic Tracking

Defibrillator Upkeep

Community Involvement

Scheduling

State Licensing



Environment Dictates Conditions!



Start with where you wanna go!



• Precision medicine based algorithm development• Prevents injury or disease from occurring

• Relies on Personal Molecular Profile (PMP)

• Adapts/evolves for dynamic systems

Paramedicine Vision - Of The Future



• Ability to access and update their health record anywhere anytime

• Provide all care providers appropriate access anywhere anytime

• Accountability by all providers for the ultimate continuity of care

• optimal specific PRECISE advice based on genetics, history, research, current trends, cell phone data, demographics, & outcome studies• Better than Google

Paramedic Patient Centric Ideals



• Required symptom based “protocols” to protect physicians providing “delegated practice” to subordinates:• Designed for lowest common denominator

• Some states still rely heavily and some do not

Paramedicine - Of The Past

a.k.a. Deductive-Nomothetic Reasoning



Paramedicine - Of Today• Evidence Based Guidelines (problem based protocols)

• Relies on cohorts – studies of similar conditions

• Pattern recognition (similar to facial recognition)

• Reactionary and works best when situations are static

a.k.a. Inductive-Idiographic Reasoning



What is the key to advancing our future?



Good Data Is Important!



A lot of data moved in 2016…

• Moved a zettabyte of data - one trillion gigabytes or 667 trillion Netflix movies

• 4.5 BILLION websites

• Every day:• 500 Million Tweets

• 4 Million Hours of content uploaded to YouTube

• 4.3 BILLION Facebook messages / 5.75 BILLION Facebook likes

• 6 BILLION daily Google Searches

• Nearly 250 BILLION emails



We have a lot of healthcare data!• 2011: 150 exabytes (150 billion gigabytes) =1.5M miles

• Stack of paper to Uranus

• Space shuttle takes 7.3 years to get there!

• 2014: 420 million wearable, wireless health monitors

• 137+ million records since 2006 in National EMS Information System national database (as of April 2017)



We can share it too!

• Sharing health information means sharing more than just data

• Supports knowledge building across organizations silos by sharing interesting patterns/findings

• Patient centered – doesn’t care who the organization is



Other paramedic data sources!



It is time to rethink things!

Define data elements?

Define expectations?



Wisdom

Knowledge

Information

Data

It is not about the data!

Paramedics have provided “data” to hospitals for 50+ years!



It is about decisions!• Decisions are dependent on knowledge of

all the relevant factors

• Information about patients is used to drive care planning

• Personal, professional, organizational learning results in knowledge

• Quality measures & clinical studies inform the process



Simple Decision Aids



Clinical Decision Support

• Increases quality of care

• Enhanced health outcomes

• Avoidance of errors and adverse events

• Improved efficiency, cost-benefit, and provider and patient satisfaction



Empowers visual analysis & reporting



Empowers paramedic self-improvement



Empowers paramedic benchmarking



Adaptable for any

audience & purpose

0

20

40

60

80

100

Pro

toco

l Co

mp

lian

ce P

erc

en

tage

Month

Compliance with Cardiac Arrest Bundle

Protocol Compliance % Median

CL 0.4120.5273

UCL0.946

1.1315

0.0000.000

0.200

0.400

0.600

0.800

1.000

1.200

1.400

1.600

5/1

46

/14

7/1

48

/14

9/1

41

0/1

41

1/1

41

2/1

41

/15

2/1

53

/15

4/1

55

/15

6/1

57

/15

8/1

59

/15

10

/15

11

/15

12

/15

1/1

62

/16

3/1

64

/16

5/1

6

Pe

rce

nta

ge -

RO

SC a

t A

ny

Tim

e

Month

ROSC at Any Time During Cardiac Arrest

CL 0.6125

UCL1.2636

0.000

0.500

1.000

1.500

2.000

5/1

46

/14

7/1

48

/14

9/1

41

0/1

41

1/1

41

2/1

41

/15

2/1

53

/15

4/1

55

/15

6/1

57

/15

8/1

59

/15

10

/15

11

/15

12

/15

1/1

62

/16

3/1

64

/16

5/1

6

Pe

rce

nta

ge -

Cap

no

grap

hy

Aft

er

Air

way

Month

Capnography Used After Airway Placed

CL 0.8380.838 0.9939

UCL1.5251.600

1.8235

LCL 0.1520.076 0.16440.000

0.500

1.000

1.500

2.000

2.500

5/1

46

/14

7/1

48

/14

9/1

41

0/1

41

1/1

41

2/1

41

/15

2/1

53

/15

4/1

55

/15

6/1

57

/15

8/1

59

/15

10

/15

11

/15

12

/15

1/1

62

/16

3/1

64

/16

5/1

6

Pe

rce

nta

ge -

Mo

nit

or

dat

a u

plo

ade

d

Month

Percentage of Cardiac Arrests Where Monitor Data Was Uploaded



Even dreaded QA/compliance monitoring



Automated daily management reports



Overall performance monitoring



Real time monitoring for trends & outliers

0

5

10

15

20

25

30

5/1

4

6/1

4

7/1

4

8/1

4

9/1

4

10

/14

11

/14

12

/14

1/1

5

2/1

5

3/1

5

4/1

5

5/1

5

6/1

5

7/1

5

8/1

5

9/1

5

10

/15

11

/15

12

/15

1/1

6

2/1

6

3/1

6

4/1

6

5/1

6

Tota

l In

cid

en

ts

Month

Number of Cardiac Arrests Per Month

Total Incidents

Median



Gives ability to reduce variability



But, must still use meaningful measures



• Bigger is NOT better!• 578 nationally defined EMS elements

• 10,000+ ICD10 codes

• Thousands more in RxNorm, SnoMed, etc

What Is Not Needed? More data definitions.



• 30 minutes per ePCR x 40 million calls = 20 million hours• 20M x $100 = $2,000,000,000 spent on writing ePCRs

• $50 per call!

• What can be improved? Let’s:• Better use the data to show our value to our communities

• Ask data vendors to show us the value of their services

What Is Not Needed? More data definitions.



• National EMS Management Association jumpstarting an Information and Technology Committee seeking broad participation• Develop a standard and credential for Paramedic Information Practitioners

• To manage the data collection, sensemaking, knowledge building, decision support of paramedic agencies of the future!

What Is Needed? Information Specialists!



What Is Needed? Complementary Perspectives!

Information Systems

Evidence / Operational Knowledge

Performance Improvement



What is Needed? Performance Measures!

• EMS Compass 1.0 got us started in defining what should be measured• Also developed a process (being submitted for peer review) to develop

evidence based performance measures in the future

• EMS Compass 2.0 is now getting started as the EMS Quality Alliance with broad based participation. More to come!



What is a performance measure?

Measurement Domain

Clinical Area

Topic

Family of Measures

Structure

Process

Outcome

Balancing

Measure Formula

Denominator Numerator =Score



Structure

Process

Outcome Stroke Bundle of Care

For positive stroke assessment,

average time from LKW to arrival at

stroke center

Documentation of LKW

Positive stroke Assessments

transported to Stroke Center

Blood Glucose for Positive

Prehospital Stroke Assessment

Notification of stroke team

Suspected Stroke Receiving

Prehospital Stroke Assessment

Performance Measure Example: Stroke-7 Bundle of Care*

Stroke-1 Stroke-2 Stroke-3 Stroke-4

Stroke-7

Stroke-5

Stroke-6

*For illustration only. This does not represent a final measure and may change significantly before it becomes finalized.



What is Needed? Evidence!

• Prehospital Guidelines Consortium working to identify evidence base for new guidelines

• Need to understand implications of evidence in rural vs urban areas and ensure the perspectives are incorporated

• Disseminating new guidelines for rapid widespread adoption is critical



• “Previvors” will become common in rural and remote areas as a direct result of strong EMS and healthcare systems supported by information AND technology!

Paramedicine Vision - Of The Future



ContactNick Nudell, MS, NRP, FACPE

Chief Data Officer & Board Member of The Paramedic Foundation, a (501c3) non-profit charity

Board Member of the National EMS Management Association

[email protected]

(760) 405-6869

emsnerd.com

twitter.com/runmedic

KK6TYY

what’s in it for us? using data for success in patient care!

Data & Analytics