EMERGENCY MEDICAL SERVICES INFORMATION SYSTEMS

Transcription

1 EMERGENCY MEDICAL SERVICES INFORMATION SYSTEMS AND A FUTURE EMS NATIONAL DATABASE Gregory Mears, MD, Joseph P. Ornato, MD, Drew E. Dawson, BA ABSTRACT Since the early 1970s, various publications and legislation have contributed to the development of emergency medical services (EMS) information systems and databases. Yet, even today, EMS systems vary in their ability to collect patient and systems data and to put these data to use. In addition, no means currently exists to easily link disparate EMS databases to allow analysis at local, state, and national levels. For this reason, the National Association of State EMS Directors is working with its federal partners at the National Highway Traffic Safety Administration (NHTSA) and the Trauma and EMS program of the Health Resources and Services Administration s (HRSA s) Maternal and Child Health Bureau to develop a national EMS database. Such a database would be useful in developing nationwide EMS training curricula, evaluating patient and EMS system outcomes, facilitating research efforts, determining national fee schedules and reimbursement rates, and providing valuable information on other issues related to EMS care. Key words: data Received June 29, 2001, from the Department of Emergency Medicine, University of North Carolina (GM), Chapel Hill, North Carolina; Department of Emergency Medicine, Virginia Commonwealth University s Medical College of Virginia (JPO), Richmond, Virginia; and Health Systems Bureau, Montana Department of Public Health & Human Services (DED), Helena, Montana. Revision received September 4, 2001; accepted for publication September 17, Presented at the Turtle Creek Conference III, Dallas, Texas, April 29 May 1, Supported by an unrestricted educational grant from Wyeth-Ayerst Laboratories. Address correspondence and reprint requests to: Gregory Mears, MD, Associate Professor, Department of Emergency Medicine, CB7594, University of North Carolina, Chapel Hill, NC <gdm@med. unc.edu>. collection; data registry; emergency medical services; information system. PREHOSPITAL EMERGENCY CARE 2002;6: Prehospital emergency medical services (EMS) is a system that ensures that patients with acute traumatic and medical conditions are provided medical care outside the hospital and, when necessary, are transported to an appropriate medical facility. Emergency medical services providers are no longer considered just an expensive source of transportation but are now held accountable for their response times, quality of service, and medical care provided and for their cost or value to the patient and community. As with other medical specialties, EMS providers also are being required to prove their effect on patient outcome as a justification for their existence. As part of the health care system, EMS personnel must interact at the local hospital, regional, state, and federal levels through the exchange of information. To facilitate this exchange, EMS systems must have methods of collecting and analyzing data and sharing the data with others. The development of local and state EMS information systems is an ongoing process that should facilitate improved EMS systems and improved patient care and should culminate in the establishment of a national EMS database. DEFINING EVENTS IN DEVELOPMENT OF EMS INFORMATION SYSTEMS Any discussion of EMS information systems must draw heavily from historic documents and events that have shaped the current EMS system. The following 123 events are helpful in understanding the evolution of EMS information systems Emergency Medical Services Systems Act In 1973, the Department of Health, Education and Welfare identified 15 essential components of an EMS system (Table 1). 1 Although an information system was not listed as one of the 15 components, the review and evaluation component was predicated on good data from a variety of sources. Even more important, federal funding was provided to state and regional EMS systems that modeled their system after the 15 components. For the first time, EMS was considered a system, not just an aggregation of ambulance services. This legislation also was the first to require data or documentation of EMS services through a coordinated patient record and a formal review and evaluation process (now referred to as quality management ). TABLE 1. Fifteen Essential Components of an Emergency Medical Services System (1973)* 1. Manpower 2. Training 3. Communications 4. Transportation 5. Facilities 6. Critical care units 7. Public safety agencies 8. Consumer participation 9. Access to care 10. Patient transfer 11. Coordinated patient record keeping 12. Public information and education 13. Review and evaluation 14. Disaster plan 15. Mutual aid *Source: Emergency Medical Services Systems Act of Public Law , Title XII of the Public Health Services Act. Washington, DC, 1973.

2 124 PREHOSPITAL EMERGENCY CARE JANUARY / MARCH 2002 VOLUME 6 / NUMBER 1 TABLE 2. Utstein Criteria Cardiac Arrest Core Data Set (1991)* Template Data for Survival Measurement 1991 Utstein Style for Uniform Reporting of Data In 1991, the American Heart Association published Recommended Guidelines for Uniform Reporting of Data from Out-of-Hospital Cardiac Arrest: The Utstein Style. 2 This publication was the first major document to specifically address EMS systems and their impact on patient outcome. Other documents had addressed patient outcome as an endpoint, but the Utstein criteria were a standard data set with standard definitions for measuring cardiac arrest survival across systems. The Utstein criteria required the exchange of information among the dispatch center, the EMS system, and the hospital. The recommended Utstein data set is listed in Table Uniform Prehospital Data Set In 1993, the National Highway Traffic Safety Administration (NHTSA) developed a national consensus document that defined 81 elements important to an EMS Time Event Data Population served Time of collapse/time of recognition Confirmed cardiac arrests considered for Time of call receipt resuscitation Time first emergency response vehicle is Resuscitations not attempted mobile Resuscitations attempted Time vehicle stops Cardiac etiology Time of arrival at patient s side Non-cardiac etiology Time of first CPR attempts Arrest witnessed Time of first defibrillatory shock Arrest not witnessed Time of return of spontaneous circulation Arrests after arrival of emergency medical Time intubation achieved services personnel Time intravenous access achieved Initial rhythm ventricular fibrillation Time medications administered Initial rhythm asystole Time CPR abandoned/death Initial rhythm ventricular tachycardia Time departure from scene Other initial rhythm Time arrival at emergency department Determine presence of bystander CPR Any return of spontaneous circulation Efforts ceased in field or emergency department Admission to intensive care unit Patient died in hospital and within 24 hours Discharged alive Death within one year of discharge Alive at one year *Based on information obtained from: Cummins RO. The Utstein style for uniform reporting of data from out-of-hospital cardiac arrest. Ann Emerg Med. 1993;22: CPR = cardiopulmonary resuscitation. information system. Of the 81 elements, 49 were considered essential and 32 desirable (Table 3). 3 These elements were created to allow an EMS system to benchmark itself with respect to the service, patient care, personnel performance, patient outcome, and data linkage with other organizations or larger data sets. Perhaps even more important was the creation of a standard definition for each element, which is the critical backbone for any information system EMS Agenda for the Future In 1996, after widespread national input, NHTSA published the EMS Agenda for the Future A Vision for the Nation s EMS System. 5 This publication describes EMS as a community-based health management system, fully integrated with the overall health care system. The goal of the document was to improve the quality of community health, resulting in more appropriate use of acute health care resources, while allowing EMS to remain as the public s emergency medical safety net. The EMS Agenda for the Future identified 14 distinct attributes of EMS, one of which was information systems (Table 4). 5 The EMS Agenda for the Future made five recommendations for EMS information systems: 1) EMS must adopt a uniform set of data elements and definitions to facilitate multisystem evaluations and collaborative research; 2) EMS must develop mechanisms to generate and transmit data that are valid, reliable, and accurate; 3) EMS must develop and refine information systems that describe the entire EMS event so that patient outcomes and cost effectiveness issues can be determined; 4) EMS should collaborate with other health care providers and community resources to develop integrated information systems; and 5) EMS information system users must provide feedback to those who generate data in the form of research results, quality improvement programs, and evaluations Data Elements for Emergency Department Systems In 1997, the National Center for Injury Prevention and Control published Data Elements for Emergency Department Systems (DEEDS). 6 Similar in concept to the NHTSA EMS data set, DEEDS targeted the hospital emergency department. Publication of DEEDS extended the concept of an information system to the emergency department by providing standards for data collection and linkages back to EMS and forward to hospital discharge EMS Agenda Implementation Guide In 1998, NHTSA produced a follow-up document to the 1996 EMS Agenda for the Future called the EMS Agenda for the Future: Implementation Guide. 7 This document

3 Mears et al. FUTURE EMS NATIONAL DATABASE 125 outlined suggestions or approaches to the development of the 14 components of the EMS Agenda for the Future. This implementation guide reinforced the need for a standardized EMS information system. Clearly, a comprehensive EMS information system is the backbone for future EMS system development. EXISTING REGISTRIES AND HEALTH CARE DATABASES Trauma Registries At the local, state, and national levels, trauma registries have served as a valuable descriptive and quality management tool for trauma centers and trauma systems. These TABLE 3. National Highway Traffic Safety Administration Uniform Emergency Medical Services (EMS) Data Set (1993)* Essential Desirable Incident address Complaint onset date Incident city Complaint onset time Incident county Date unit notified Incident state Time of arrival at patient Location type Patient care record number Date incident reported Crew member identification number (3) Time incident reported Crew member type/level (3) Time dispatch notified Patient street address Time unit notified City of residence Time unit responding County of residence Time unit arrives at scene State of residence Time unit left scene Telephone number Time unit arrives at destination Social security number Time back in service Age Lights and siren to scene Chief complaint Service type Injury intent Incident number Factors affecting EMS delivery of care Response number Time of first CPR Agency/unit number Provider of first CPR Vehicle type Time CPR discontinued Crew member identification number (1)Time of witnessed cardiac arrest Crew member identification number (2)Witness of cardiac arrest Crew member type/level (1)Time of first defibrillatory shock Crew member type/level (2)Return of spontaneous circulation Patient name Initial cardiac rhythm Zip code of residence Cardiac rhythm at destination Date of birth Respiratory effort Gender Skin perfusion Race/ethnicity Glasgow Coma Score (total) Destination/transferred to Revised trauma score Destination determination Procedure attempts Lights and siren scene Treatment authorization Incident/patient disposition Cause of injury Provider impression Pre-existing condition Signs and symptoms present Injury description Safety equipment Alcohol/drug use Pulse rate Respiratory rate Systolic blood pressure Diastolic blood pressure Glasgow eye-opening component Glasgow verbal component Glasgow motor component Procedure or treatment name Medication name *Source: National Highway Traffic Safety Administration. Uniform Pre-Hospital Emergency Medical Services (EMS) Data Conference: Final Report. Washington, DC: National Highway Traffic Safety Administration, CPR = cardiopulmonary resuscitation. TABLE 4. EMS Agenda for the Future: Emergency Medical Services Attributes* Integration of health services Emergency medical services research Legislation and regulation System finance Human resources Medical direction Education systems Public education Prevention Public access Communication systems Clinical care Information systems Evaluation *Source: National Highway Traffic Safety Administration. Agenda for the Future (DOT HS ). Washington, DC: U.S. Department of Transportation, Aug registries contain detailed information regarding the management of patients as they progress through the trauma system. Although trauma registries capture limited EMS data, an electronic link with EMS data is extremely important to complete the description of trauma care from initial event through hospital discharge or rehabilitation. Several trauma registry vendors provide software to trauma centers and systems at the local or state level. Currently, two national trauma registries group aggregate data from participating trauma centers and states the National Trauma Databank maintained by the American College of Surgeons, 8 and the National Pediatric Trauma Registry maintained by Tufts University. 9 Motor Vehicle Crash Database Motor vehicle crash data are collected and maintained through either the state departments of transportation or state law enforcement agencies. State departments of motor vehicles or their equivalents also maintain additional driver and motor vehicle databases. Each of these data sources can potentially be linked to EMS information systems, thereby significantly enhancing the utility of the

4 126 PREHOSPITAL EMERGENCY CARE JANUARY / MARCH 2002 VOLUME 6 / NUMBER 1 information from each contributing source. The NHTSA s Crash Outcomes Data Evaluation System (CODES) 10 uses probabilistic linkage to match state data from law enforcement, EMS, and the emergency department or hospital. Federal financial assistance is available to states that have the ability to capture data from these three venues. CODES is a collaborative approach to generating medical and financial outcome information relating to motor vehicle crashes and using these outcome-based data to guide highway traffic safety program decisions. CODES was initiated in 1992 and is currently used by 25 states. 10 Cardiac Arrest Registry Since 1995, when the U.S. Food and Drug Administration approved the use of intravenous (IV) amiodarone for life-threatening ventricular arrhythmias, EMS systems have had the option of using this agent for patients in cardiac arrest. The purpose of the Advanced Resuscitation of Refractory VT/VF (ventricular tachycardia/ventricular fibrillation) IV Amiodarone Evaluation (ARRIVE) registry is to create a prototype of a national database of patients with out-ofhospital cardiac arrest, with the focus on determining how EMS systems transition to using amiodarone. Additionally, the data could be used for quality improvement in systems that have recently added IV amiodarone to their cardiac arrest protocols. The data collection and analysis is being sponsored by Wyeth- Ayerst Laboratories, but an independent group has been contracted to monitor the data collection and analyze the results. The principal investigators at each EMS site also will function as an independent monitoring committee. Some participating EMS systems began collecting ARRIVE data in June and July 2000, with more systems signing on in early To date, retrospective data have been collected on approximately 3,000 patients and prospective data on approximately 750 patients. Other Databases and Information Systems Several other health care related databases and information systems exist at the local, state, and national levels. Most states have some form of a hospital insurance or admission discharge database. These databases may or may not capture information about patients who are not admitted to the hospital, such as those seen in the emergency department and released. Each state maintains a medical examiner s database, in which information on all deaths, including the cause of death, is recorded. Many states have some form of public health or injury surveillance database. However, the amount of information and the usefulness of these databases vary greatly from state to state. DESIGNING EMS INFORMATION SYSTEMS Information systems are used to translate raw data into information that is useful in EMS system development and management and in medical direction. As outlined in the EMS Agenda for the Future, uniform data elements with uniform definitions, which can describe an entire EMS event, are the goal in designing an EMS information system. An EMS event begins with layperson or patient recognition of a medical problem and activation of the EMS system through the or communications center. An EMS event ends with transfer of care to another health care provider, release of the patient from EMS care, refusal of EMS care by the patient, or death. To measure and draw conclusions through research, patient outcomes, quality management, or evaluation, the end of an EMS event must include some information regarding emergency department care, hospital care, and final patient disposition. Information systems must also provide a mechanism for storing and retrieving data about EMS events in the form of historic medical records. Knowledge of previous medical care or EMS use can be crucial to patient management in the true acute care situation when little information about the patient is available. The design of the information system must ensure that pertinent patient information is readily accessible before or during the care of an individual patient. An EMS information system must include data from several sources. For example, the communications center can provide timerelated data, such as dispatch and arrival times, dispatch complaint information, vehicle response information, and emergency medical dispatch data. Emergency medical dispatch protocols identify general patient demographics, chief complaint, protocol used for the response, and prearrival instructions. A patient or event identifier should be established to ensure that the communications data are linked with the EMS patient care record. The Utstein criteria (Table 2) 2 and NHTSA Uniform Data Set (Table 3) 3 provide important standard definitions for prehospital data points. Information system designers should work within these standards to create an environment in which information can be linked with other databases, systems, and registries. By using uniform data, standardized evaluation, research, and outcome measures can be obtained. However, information systems designers should note that the Utstein criteria and NHTSA Uniform Data Set provide recommendations for only a minimal data set. For complete documentation of an EMS event, other data elements must be created, including standards of medical care documentation, such as cur-

5 Mears et al. FUTURE EMS NATIONAL DATABASE 127 rent medications taken by the patient, drug allergies, medicaland injury-related risk factors, examination results, narrative interactions or treatment exceptions, and disposition details or instructions. As EMS progresses beyond its traditional treatment and transport modalities, the need for documentation of treatment and referral or treatment and release must be considered. Data collection during an EMS event can be facilitated through the use of medical devices. Information collected by a medical device that is stored and later downloaded into the information system is essential to the future of EMS databases. Direct data collection from medical devices removes many inherent data entry errors, improves the completeness of the medical record, and frees personnel to provide patient care. Currently, prehospital medical devices do not have a universal capability to transfer all the numeric and waveform data to information systems outside their proprietary software. Thus, a single EMS system might have multiple devices from multiple manufacturers that perform the same function. Consequently, to download and archive data, the EMS system must have the proprietary software from each manufacturer. Because of the multiple proprietary systems, the ability to combine and use the data is limited, especially if waveforms such as 3-, 5-, or 12-lead electrocardiographic information from a monitor or defibrillator is included. Likewise, the incongruity of data from proprietary systems makes it impossible to create an electronic medical record in a timely manner for use immediately after patient care. The retrieval of previous EMS events for comparison is therefore extremely difficult. Manufacturers must create an open architecture whereby device data, both numeric and waveforms, can be moved from database to database within an information system to allow electronic record retrieval or generation. Information systems must include interactions with other health care providers who participate in any EMS event, such as emergency department and hospital personnel. The DEEDS data set is the current recommended standard for emergency department data. It provides definitions for each recommended data point and includes coding and documentation that can yield information on patient outcome. Although DEEDS was published in 1997, emergency departments are only now beginning to follow its recommendations. Communication with hospitals is critical in identifying data points that will allow linkage between EMS and hospital databases. However, in many states, patient care confidentiality rules limit an EMS system s ability to obtain hospital patient care and outcome data. States should revise regulations and statutes so that information can flow in both directions while being sensitive to patient confidentiality issues. Obtaining consistent and uniform patient outcome information is essential to the future of EMS. Also, there must be an enhanced capability to link EMS event data with a variety of data sources at the local, regional, state, or national level. Examples of potentially linkable data sets include trauma registries, state EMS databases, injury prevention databases, law enforcement databases, medical examiner databases, and CODES. More than ever before, EMS systems are being held accountable for their finances, quality of service, and patient care. All EMS information systems should incorporate billing and reimbursement data in a format that permits easy interaction with billing software, fulfills government regulations for Medicare reimbursement, and is compatible with other third-party payment requirements. Effect of EMS Systems Diversity Emergency medical services are by their very nature extremely variable. Boundaries, jurisdictions, geography, politics, equipment, personnel, and training are never the same for any two systems. Some system design concepts have universal implications, such as response times for cardiac arrest survival or decreased scene times in multisystem trauma, but few concepts have been proved through research. No current guidelines or literature have proposed a standard EMS delivery plan for rural or wilderness populations. Emergency medical services information systems mirror this diversity and lack of standards. Urban EMS systems have different data and communication needs than do rural systems. In an urban environment, resources often are constrained, call volumes are high, and issues such as trauma center use and hospital diversions are important. In a rural environment, response times and resources are important but for different reasons. In rural systems, limited patient contact makes it more difficult to maintain education and skills. In addition, rural systems are often staffed by volunteer providers, and funding or resources might not be available for paramedic-level care. When implementing an information system, each and every system attribute must be considered. Compared with rural systems, urban systems require data more to improve their efficiency in day-today operations. In rural systems, data may be more important for monitoring and improving the system through patient outcome measures and quality management, for maintaining service in the community, and for documenting activities to improve fund-raising. Volunteer (nonprofit), private service (for profit), and third-party (government-based) EMS systems

6 128 PREHOSPITAL EMERGENCY CARE JANUARY / MARCH 2002 VOLUME 6 / NUMBER 1 also may have unique EMS system information needs. For instance, a private EMS service will be more interested in capturing the billing information on each EMS encounter, while a volunteer service might not be interested in gathering billing data. Consequently, the amount, method, and mechanism for data documentation, computer data entry, and data analysis vary among EMS service types; this variation must be considered in the development of any EMS information system. Other Considerations The time perspective is an important data collection consideration. Because complete documentation should include information regarding the entire EMS event from dispatch through patient transfer to a medical care facility, pre-event information, the EMS patient encounter, and post-event disposition are all important. Emergency medical services data should be defined and analyzed based on sound business principles. For example, documentation should permit analysis of performance based on the EMS service, technician or caregiver, and patient. Finally, EMS data collection and use must be based on the EMS system design and its workflow. Inadequate consideration of these two factors will result in incomplete data, useless information, and information system failure. Data definitions must be clear and understandable, collection must be as automated as possible, and the information system should have a positive effect on performance by improving the provider s time with each patient, improving patient treatment and care, and providing real-time (or near-realtime) feedback to the system and providers. Many potentially good EMS data collection systems have failed for a lack of understanding and consideration of the end user and EMS workflow. NATIONAL EMS INFORMATION SYSTEM State EMS agencies, charged with developing and implementing state EMS systems, often do not have sufficient data to evaluate statewide EMS priorities, monitor the systems, identify trends, plan prevention programs, or justify funds to support infrastructure development. As national decision makers testify before Congress or present data to the Health Care Financing Administration, there is often insufficient information to drive requests for enhanced local EMS reimbursement, development of national EMS educational standards, and myriad other activities in support of EMS system development. Embarrassingly, data at all levels are typically inadequate even to describe EMS as a profession. Data lacking in this area include the number of EMS providers, the cost and value of EMS, safety data (e.g., number of ambulance crashes), and patient outcomes. The EMS Agenda for the Future clearly described the absence of a coordinated national EMS information system: There is no central database, at a national level for example, that relates to the current practice of EMS. The data required to completely describe an EMS event exist in separate disparate locations. These include EMS agencies, emergency departments, hospital medical records, other public safety agencies and vital statistics offices. In most cases, meaningful linkages between such sites are nonexistent. The lack of organized information systems that produce data which are valid, reliable and accurate is a significant barrier to coordinating EMS system evaluation including outcomes analyses. Lack of information systems that are integrated with EMS and other health care providers and community resources severely limits the ability to share useful data. Research efforts are hindered by underdeveloped information systems. In general, the data derived from an information system may be inadequate for research purposes. However, it is extremely useful for hypothesis generation and may require only minimal supplementation. Integrated information systems serve as multisource databases which have been developed as useful tools for conducting EMS cardiac arrest research. 5 Why a National EMS Database Is Needed The absence of good EMS information has thwarted development of data-driven national standard EMS training curricula and provided enormous challenges for an EMS outcomes project that was intended to develop tools to help standardize measurement of EMS outcomes. The dearth of reliable and valid EMS data also continues to plague researchers. Thus, a national EMS database is needed for several reasons. With data being gathered by various agencies and in various forms, they cannot be linked in a way that would prove useful to EMS systems and to the patients they treat. A national EMS data registry would prove invaluable for EMS education, outcomes, research, and reimbursement. Education The absence of a national EMS database has been a significant impediment to the structuring of a coherent national EMS education system. When the EMS National Standard Curricula were developed in the 1990s, only limited data were available on which to base decisions regarding training of EMS personnel. Despite a commitment to a data-driven curriculum development process, decisions were made based on the limited data available and, consequently, on expert opinion. The National EMS Education Agenda for the Future proposes the

7 Mears et al. FUTURE EMS NATIONAL DATABASE 129 development of a national EMS education system consisting of national EMS core content, national EMS scope-of-practice model, national EMS educational standards, national EMS program accreditation, and national certification. 11 The development of an ongoing mechanism for sharing information from a national EMS database with the committees working on implementing a national EMS education system will provide invaluable support to data-driven decision making. Outcomes At present, limited information is available on outcomes, both patient outcomes and EMS system outcomes. The establishment of reliable outcome measures will help with monitoring EMS systems, determining which treatments are effective, assessing which EMS system configurations are useful, improving reimbursement, and modifying a national EMS education system. A national EMS database, combined with records linkage, would also facilitate research on EMS outcomes that would culminate in a set of outcome measures other than mortality. Research Having access to a national EMS database could facilitate research efforts considerably, providing a large sample of standardized data from which to draw. Such a database would be invaluable in the generation of research hypotheses, evaluation of cost effectiveness, and standardization of data used by researchers. Reimbursement Although reimbursement for EMS services is typically a local issue, decisions regarding EMS reimbursement, such as that for Medicaid and Medicare patients, are made at the state and federal levels. Consistent data at the local level would facilitate reimbursement, while a national EMS database could provide useful information for determining national fee schedules and reimbursement rates. A national EMS database could also be used to facilitate cost benefit analyses, assist with issues regarding non-transport of patients, and help ensure links with patient outcomes. Future of a National EMS Database 12 The National Association of State EMS Directors (NASEMSD), an organization of state EMS directors from each of the 50 states and the territories, has recognized that the absence of a comprehensive national EMS information system has had a significant detrimental impact on the EMS community s ability to describe itself, to influence policy and funding, and to chart its future direction in an increasingly data-driven environment. In 1999, in a collaborative project with the Emergency Medical Services for Children (EMSC) program, NASEMSD obtained funding to explore the feasibility of establishing a national EMS database. In 2000, NASEMSD convened a multidisciplinary group of local, state, and federal partners to discuss the establishment of a national EMS database. Although the project was initiated by NASEMSD, development of a national EMS information system will be based on a national consensus-driven process and must have the commitment of individual EMS providers, EMS agencies, state and federal agencies, and others. In 2001, NASEMSD received funding from NHTSA and the Health Resources and Services Administration s (HRSA s) Maternal and Child Health Bureau s (MCHB s) Trauma and EMS Program for a two-year project to develop a national EMS information system. This information system will be based on a version of the NHTSA prehospital data set that will be revised concurrently as a part of the national database project. It is understood that a national EMS database can only be as good as the local EMS data on which it is based. The local data collected from patient encounters will be passed on to state EMS offices, which must then be able to use the data in a beneficial way at the state level before sending a subset of the data to the national database. This project will require considerable collaboration among the EMS community at the local, state, and national levels to develop, promote, implement, and integrate data at every EMS level. Once implemented, a national EMS database will serve many purposes: help public officials and the general public better understand EMS; drive policy and make funding decisions; identify national trends in patient care and policy; facilitate national benchmarking while recognizing individual state and local variations; assist in identifying and decreasing errors in clinical management; provide data to assist with business structure and management; promote research, including hypotheses generation; help establish national EMS outcome measures; clarify how EMS fits into the total public health care system; drive implementation and facilitate monitoring of the EMS Education Agenda for the Future; identify unmet needs and priorities from federal partners; and determine the effectiveness of EMS systems and EMS patient care. CONCLUSION Emergency medical services systems need data for system and resource management, quality improvement, injury or population surveillance, and reimbursement. The dilemma is that as more time is needed for hands-on patient care, more information must be documented. To overcome this barrier

8 130 PREHOSPITAL EMERGENCY CARE JANUARY / MARCH 2002 VOLUME 6 / NUMBER 1 to data collection, EMS systems must adopt information systems that streamline the recording, storage, retrieval, and application of quality information. A system to collect, monitor, and report the activities of an EMS system in a efficient manner makes the medical director s job easier. Large sets of unqualified data that have been collected for traditional reasons with little feedback will lead to failure of the data system and decreased cooperation among agencies. A modern EMS system relies on access to data to manage the health of the system and make informed decisions. Nationally, EMS must be able to describe its patient population and services and to describe objectively its problems and needs. Development of a national EMS database in collaboration with the EMS federal partners at the NHTSA and the HRSA/MCHB will allow EMS to take a giant step forward as a key component in the health care system. References 1. Emergency Medical Services Systems Act of Public Law , Title XII of the Public Health Services Act. Washington, DC, Cummins RO. The Utstein style for uniform reporting of data from out-of-hospital cardiac arrest. Ann Emerg Med. 1993;22: National Highway Traffic Safety Administration. Uniform Pre-Hospital Emergency Medical Services (EMS) Data Conference: Final Report. Washington, DC: National Highway Traffic Safety Administration, Spaite D, Benoit R, Brown D, et al. Uniform prehospital data elements and definitions: a report from the uniform prehospital emergency medical services data conference. Ann Emerg Med. 1995;25: National Highway Traffic Safety Administration. Agenda for the Future (DOT HS ). Washington, DC: U.S. Department of Transportation, Aug National Center for Injury Prevention and Control. Data Elements for Emergency Department Systems: Release 1.0. Atlanta, GA: Centers for Disease Control and Prevention, National Highway Traffic Safety Administration. Agenda for the Future. Implementation Guide. (DOT HS ). Washington, DC: U.S. Department of Transportation, National Trauma Data Bank (NTDB). Website: 9. National Pediatric Trauma Registry. Website: Johnson SW, Walker J. NHTSA Technical Report: The Crash Outcomes Data Evaluation System (CODES). DOT HS Washington, DC: Department of Transportation, National Highway Traffic Safety Administration, Jan National Highway Traffic Safety Administration. EMS Education for the Future: A Systems Approach. Washington, DC: NHTSA, National EMS Information System. Website: Suggested Reading 13. Braun O. EMS system performance: the use of cardiac arrest timelines. Ann Emerg Med. 1993;22: Cone DC, Jaslow DS, Brabson TA. Now that we have the Utstein style, are we using it? Acad Emerg Med. 1999;6: Cummins R. Why are researchers and emergency medical services managers not using the Utstein guidelines? Acad Emerg Med. 1999;6: Durch JS, Lohr KN (eds). Emergency Medical Services for Children. Washington, DC: National Academy Press, Garrison HG, Foltin G, Becker L, et al. Consensus Statement: The Role of Outof-Hospital Emergency Medical Services in Primary Injury Prevention. Final Report. Consensus Workshop on the Role of EMS in Injury Prevention; Arlington, VA, Aug 25-26, National Academy of Sciences, National Research Council. Accidental Death and Disability: The Neglected Disease of Modern Society. Washington, DC: National Academy Press, National Highway Traffic Safety Administration. EMS Outcomes Evaluation: Key Issues and Future Directions. Proceedings from the NHTSA Workshop on Methodologies for Measuring Morbidity Outcomes in EMS. Washington, DC: U.S. Department of Transportation, Apr 11-12, North Carolina Prehospital Medical Information System. Website: www. premis.net. 21. Siscovick DS. Challenges in cardiac arrest research: data collection to assess outcomes. Ann Emerg Med. 1993;22: Spaite DW, Criss EA, Valenzuela TD, Guisto J. Emergency medical services systems research: problems of the past, challenges of the future. Ann Emerg Med. 1995;26: Spaite DW, Valenzuela TD, Meislin HW. Barriers to EMS system evaluation problems associated with field data collection. Prehosp Disaster Med. 1993;8:S35-S Svenson JE, Spurlock CW, Calhoun R. The Kentucky emergency medical services information system: current progress and future goals. Kentucky Med Assoc J. 1997;95: Swor RA. Out-of-hospital cardiac arrest and the Utstein style: meeting the customer s needs? Acad Emerg Med. 1999; 6:875-7.