In NYC, Emergency Services Are Going Wireless--But Imagine What They'd Be Like With Fast Fiber
BY Susan Crawford | Thursday, August 14 2014
Ten years ago, an emergency medical services technician in New York City responding to your 911 call took down information about you—your name, address, patient history, medications, allergies—on paper. That record of your pre-hospital care—your patient care record—was then handed to the nurse or healthcare practitioner when you got to the hospital, or faxed in from a central EMS office. It was possible for faxes and loose papers to be lost and the hospital had no chance to get ready for the patients coming in the door.
Today, thanks to years of sustained effort on the part of FDNY and the City of New York, pre-hospital paramedics can enter this crucial history on a secure tablet and transmit it across a dedicated wireless network to the hospital in digital form in advance of the patient's physical arrival. Result: hospitals in New York City are better prepared to treat patients, and pre-hospital records can be seamlessly combined with those maintained by the hospital.
Not only that, EMS now can store clean, reliable historical data from its 1.4 million yearly calls—more than 4,000 daily incidents during the busiest months of the year—and know much more about the effects of the protocols it follows during its provision of pre-hospital patient care services. How many units of different drugs stored in ambulances is it administering per year? How many kids of between five and seven did EMS treat yesterday? How many people were affected by a particular explosion or derailment?
This is a big deal: Chief of EMS Operations Abdo Nahmod says FDNY is "leveraging technology to improve patient outcomes." The FDNY EMS mobile electronic patient care record (ePCR) system—the first American system of its kind, being employed by the largest EMS system in the nation—marks an important evolutionary step in emergency medical services.
EMS patient care records were kept only on paper until 2004. Then EMS began scanning paper records that were brought back to the office, creating clumsy digital records that had to be extensively corrected before they could be saved or transmitted. Around 2010, FDNY leaders started the move from scanning to inputting data on tablet platforms and began testing hardware; they selected a rugged tablet manufactured to military specifications. They stayed with Sansio's Health EMS software to handle the electronic patient care records generated by FDNY EMS professionals (Sansio had been handling the scanning system) and adopted Sansio's xChange ER software to ensure that those records could be automatically integrated into hospital data systems.
Then former Deputy Mayor Cas Holloway urged the department to use NYC's dedicated public safety wireless network—NYCWin—to transmit the data across existing municipal infrastructure. Docking stations for the tablet were installed in the front of ambulances as well as in the back patient care area, and low-profile antennas and routers were added to the vehicles—turning all FDNY EMS ambulances into roaming secure NYCWin hotspots for the wireless transmission of electronic pre-hospital patient care records.
More than 3,500 emergency medical technicians, paramedics, and officers were trained on the system between March and November 2013; now that all employees in the field have been trained, the tablet system is part of the FDNY EMS Training Academy curriculum. Lieutenant Kathleen Knuth and other information technology experts within EMS undertook an extensive program of field training of officers and staff and continue to oversee 24/7 telephone support; Knuth says the number of support calls has gone down as field personnel get used to the system. The EMS has an internal, centralized repair station (they call it a "depot") that handles refurbishment and servicing of the tablets; FDNY succeeded in freeing itself from having to ship hardware units to the vendor, which allows the department to get things fixed more quickly and track for itself what software or hardware issues are causing problems.
To meet HIPAA requirements, FDNY had to make sure that the entire network was secure, that data was not accessible to anyone other than those authorized to see it, and that a thorough forensic ability—an audit trail for any and all access to or printing of any record—was in place. All of this coordination and training took sustained work with both FDNY's lawyers and its IT department. The system was adopted across New York City over a well-executed nine-month period (thanks to persistent leadership and project management, most recently by Chief Sophia Kwok). FDNY EMS patient care records are now entirely paperless.
All in all, the FDNY EMS "Mobile ePCR" system is already a success. Because EMS can remotely push upgrades to the tablet software, protocols and checklists for treatment can be changed when needed or required and drugs can be easily added, improving pre-hospital patient care while simultaneously making errors less likely; the tablet software requires workers to check off what they've done before they can proceed. (FDNY EMS knows all about employee ideation processes; many changes get made based on what field workers say would be useful.) FDNY EMS's historical databases, already enormous, are steadily becoming far more useful for predictive analytics and other purposes: EMS's improved ability to spot patterns and trends can have a major impact on pre-hospital care. For starters, EMS can now compare the call type assigned to a 911 contact (based on what a caller says under emotional pressure) to the disease or complaint EMS actually finds when it arrives on the scene; knowing how people tend to mis-describe what's going on can help EMS change what operators ask of callers. Better data, better call-center scripts, better patient outcomes.
Twenty-one hospitals across the city are now able to display to their staff basic information (and estimated time of arrival) for patients who are still en route, and those staff members now know what steps the EMS team has already taken; many more hospitals are steadily adopting the system. According to Chief Nahmod, hospital staff are ecstatic about this development: "This is the best thing you ever did," he says they tell him.
But Chief Nahmod knows that with better connectivity much more would be possible. Right now, the tablets send only data, and only from the (usually) street-level exterior locations where NYCWin's wireless signal reaches. In the future, an emergency medical technician—"I'm standing here alone and I need help," Chief Nahmod imagines the paramedic saying—should be able to stream video of the pre-hospital patient to experts and have the group come to a quick consensus about what treatment makes sense, right on the spot. That's telemedicine, and that will only be possible with ubiquitous fiber optic wires to which EMTs' devices transmit over closely spaced hot spots. Fiber policy is wireless policy, and New York City still has a way to go along these lines—particularly in the outer boroughs.
Nahmod is understandably proud of what his team has accomplished so far. "We're learning from what we know now," he says. When you're the patient, you don't know or care which city department is treating you, and you expect that everyone's in touch and acting based on the same accurate information. Now, with better and far more timely data, increasingly accurate and better targeted interventions, and coordination with the other medical systems that patients encounter, FDNY EMS is pushing the country towards a telemedicine future.
Susan Crawford is a visiting professor at Harvard Law School. She is author of Captive Audience and co-author of The Responsive City, out in Sept 2014 (with Stephen Goldsmith)