Tag Archives: ems

Academia, Health Care, Technology

Using Intelligence in ePCR Database Design

The intelligence of a database design begins with the intelligent approach in which the developer focuses on the particular need the database is to fulfill. It is especially important to constrain, or specialize, a database used in health care, else the database can quickly grow beyond the bounds of efficiency. Efficiency can be found directly from table design, and it can be further achieved with business rules and logic. Designing a database for storing patients’ medical records also has some risk of increasing the likelihood of medical errors and statistical incongruities if done improperly; therefore, a qualified database administrator should be consulted (Campbell, 2004; McGlynn, Damberg, Kerr, & Brook, 1998). However, a preliminary needs assessment can be accomplished by asking a few simple questions: Who? What? Where? Why?

Who needs to use the database? For whom is the data useful? By identifying the scope, or domain, of each database user, the developer can gain a sense of which data points are important (McGlynn et al., 1998; Thede, 2002). For instance, in health care, a purely diagnostic database should efficiently offer comparative differential diagnoses to aid a physician in caring for patients; however, a database of this type will not offer much to the administrative arm of the practice. By understanding the relationship between physician diagnosis and billing, relational techniques can serve to ensure greater accuracy in billing procedures.

What data needs to be stored and retrieved? By listing the specific data to be stored, the developer has an opportunity to optimize the storage methods by creating an efficient and normal relational table foundation (Kent, 1983; Sen, 2009). A patient care reporting database, for instance, must be able to store patient identifying information, or demographics. Depending on the specific needs of the practice, demographic data can usually be stored in a single table. Other relational tables could be used to store references between the patient demographic record and pertinent medical information, thereby minimizing duplication (Thede, 2002).

From where does the data need to be accessed? Does this database require authentication for use on a local area network or a complex security policy for wide area network access (Campbell, 2004; McGlynn et al., 1998)? More importantly, however, is portability of the data. If the data is going to be replicated in a large composite database, the data needs to meet the specifications of the repository. This is often achieved by the publication of a template, or a clear set of directives on how data is to be formatted before transmitting data to the repository. An example of this is the Medicare electronic records requirements set forth in the Health Insurance Portability and Accountability Act (HIPAA) of 1996. By accounting for common templates in the design phase, the developer can avoid having to parse data prior to transmitting the data over the network.

Why are we storing the data? Today, it is very common to store data if merely for purposes of recording an interaction, such as a patient contact. However, it is important to understand how the data will be used in the future. Will the data need to be immediately accessible, such as in emergency or critical care areas, or could the data be compiled and batch processed during times of off-peak network load, such as in billing or logistics. Could paper reporting fulfill the immediate need better? If so, should the data on the paper report be entered in a database later? Regarding transcription, it is important to be knowledgeable about the available technology for creating scanned images, portable electronic documents, and the use of optical character recognition in order to properly prepare for the storage of each.

By answering the who, what, where, and why of the database needs assessment, we ultimately answer the question of how to design and implement the database. As an example, in order to design an ambulance run form, we must take into consideration demographics, the history of present illness (or, the reason for the ambulance request), past and pertinent medical history, including, but not limited to: medications, past medical problems and surgeries, and allergies to medications and environment. It is also important to store the assessment, care, and outcome, as well as the disposition of the incident and the destination facility. Additionally, medical standards, such as diagnostic codes, medications, protocols, and algorithms, could be stored in reference tables for preventing redundancy within the data model (Kent, 1983; McGlynn et al., 1988; Sen, 2009, Thede, 2002). Ambulances are mobile; therefore, network access is an important consideration when designing an electronic ambulance patient care reporting database. For this type of database schema, I would recommend using a small, efficient database locally with a mechanism in place to replicate the data to the larger repository when the network is accessible.

Another challenge in creating a database is learning how not to store information. Information is made of of data, but only data should be stored (Collins, 2009). Programming logic can be used to synthesize data into information and, further, into knowledge. Many database designers mistakenly store information, or even knowledge, quickly inflating the size of the database and decreasing its efficiency and normalcy (Kent, 1983; Sen, 2009).

In conclusion, developing an electronic patient care reporting database for a physician practice has some inherent risk if done poorly; however, a knowledgeable member of the office team can highlight the project requirements by performing the needs analysis.

References

Campbell, R. J. (2004). Database design: What HIM professionals need to know. Perspectives in Health Information Management, 1(6), 1-15. Retrieved from http://www.ncbi.nlm.nih.gov/

Collins, K. (2009). Managing information technology. Exploring Business (pp. 122-130). Retrieved from http://www.web-books.com/

Health Insurance Portability and Accountability Act (HIPAA) of 1996, P.L.104-191. (1996).

Kent, W. (1983). A simple guide to five normal forms in relational database theory. Communications of the ACM, 26(2), 120-125. Retrieved from http://www.bkent.net/Doc/ simple5.htm

McGlynn, E. A., Damberg, C. L., Kerr, E. A., & Brook, R. H. (1998). Health information systems: design issues and analytical applications. Retrieved from http://www.rand.org/pubs/monograph_reports/2007/MR967.pdf

Sen, A. (2009, May 7). Facts and fallacies about first normal form. Retrieved from http://www.simple-talk.com/sql/learn-sql-server/facts-and-fallacies-about-first-normal-form/

Thede, L. Q. (2002). Understanding databases. In S. P. Englebardt & R. Nelson, Health care informatics: an interdisciplinary approach (pp. 55-80). St. Louis, MO: Mosby.

Academia, Health Care, Technology

Implementing an EMR system

Electronic records streamline the flow of many of the components of patient care. EMRs and ePCRs are very useful in lowering costs, simplifying business processes, and increasing patient safety, as well as overall efficiency, if implemented correctly (Smith, 2003).

Currently, I work as a critical care paramedic providing patient care in acute settings, whether prehospital of interfacility. Within this capacity, I also teach classes to other health care providers, including first responders, emergency medical technicians, paramedics, nurses, physicians, and allied health personnel. I am familiar with the concepts of electronic patient care reporting (ePCR) and the importance and utility of electronic medical records (EMR); however, the only means of electronic reporting available in my capacity as a paramedic is poorly developed ePCR software coupled with intermittent network connectivity, so I still choose to utilize paper reporting. My part-time job with a local municipal ambulance provider relies on a widely available third-party ePCR system that seems to work well. I do utilize this ePCR system when working for this provider.

I have also gained experience with information technology and object-oriented programming concepts while developing platform-independent, client-server distributive applications designed for the internet and intranets. I also have experience with Windows and Unix/Linux platforms.

References

Smith, P. D. (2003). Implementing an EMR system: One clinic’s experience. Family Practice Management, 10(5), 37-42. Retrieved from http://www.aafp.org/fpm/2003/0500/p37.html

Academia, Clinical, Culture, Emergency Medical Services, Health Care, Politics, Public Health, Society

Physician-assisted Suicide

I have always maintained that the best thing that I have ever done for a patient was to hold their hand as they died; however, there are few scenarios that I can posit where I would ever cause the death of another, and I would never do it in my capacity as a medical professional. In the State of Connecticut, assisting a patient in their suicide is illegal (Kasprak, 2003; Saunders & Smith, 2010). Saunders and Smith (2010) describe the use of “semantic ploys” (para. 3) in arguing for physician-assisted suicide and how the court deemed the “issue rests with the legislature, not with the court” (para 4).

Two states have laws permitting physician-assisted suicide, Oregon and Washington (Death with Dignity Act, 1997; Death with Dignity Act, 2008). The other 48 states either have laws forbidding assisted suicide, such as Connecticut, rely on common law, or have no laws permitting or forbidding the practice (Kasprak, 2003). Personally, my thoughts on the matter are clearly reflected in my opening statement. More compelling, however, is a recent discussion on the discontinuation of implanted cardiac devices in patients with a desire to “refuse continued life-sustaining therapy” (Kapa, Mueller, Hayes, & Asirvatham, 2010, p. 989). Many of the respondants to this study viewed the discontinuation of pacemakers akin to physician-assisted suicide, whereas less felt the termination of cardioverter-defibrillator therapy was an ethical issue. Oddly, lawyers indicated less problems discontinuing therapy than did physicians.

There are conditions that are so intractably painful and wrought with suffering that I would not even consider thinking less of a person suffering such a malady who took their own life. Death, for many people, is a fear beyond fear, and for a person (of considerable sound mind) to choose death as a viable alternative to such suffering, I commend their bravery and choose not to judge them negatively. No physician or other health care provider should cause the death of a person directly, but acknowledging the patient’s will to die is another matter. In lieu of providing a chemical means of ending life, a physician could, in my mind, counsel a patient on the means and methods that might be viewed as more effective and humane than other means which might result in unwanted suffering. I do believe that a person has the right to choose an alternative to a surely painful and agonizing death, regardless of the presence of depression. If a person is suffering from depression because of a terminal illness that is causing physical suffering, it is hard to imagine this person will resolve the depression before succumbing to the causal disease process. In these cases, the person has the right to choose a more dignified death. For those cases where the person is incapacitated and cannot make health care decisions, I feel that any friend or family member, or a consensus of available friends and family members, should be able to make the decision to continue or discontinue life-sustaining measures. Even if the decision is wrong for the patient, most of the time the decision is for the benefit of the family and friends and lacks medical relevance aside from resource management, though there are spiritual, emotional, and moral considerations that the next of kin may face which are no less relevant.

Personally, I grant any person permission to end my life if they see me engulfed in flame or if taken on the battlefield by an enemy known for public torture. Beyond these two circumstances, I will always choose to live so long as I have my thoughts. I have heard some people intimate that they would wish to die if they were conscious but perpetually paralyzed (i.e. locked-in syndrome); however, I am not so sure that I would want to die just for lacking the ability to communicate with others. I would want to view the world, though, perhaps by television or radio. I am too curious as to what comes next for the world. As we interfere with the dying process, it does make sense that we address the morality in which we do this. It does not seem right to have brain dead patients connected to ventilators and feeding tubes forever. It’s Orwellian.

References

Death with Dignity Act of 1997, O.R.S. 127.800 et seq. (1997).

Death with Dignity Act of 2009, R.C.W. 70.245 (2008).

Kapa, S., Mueller, P. S., Hayes, D. L., & Asirvatham, S. J. (2010). Perspectives on withdrawing pacemaker and implantable cardioverter-defibrillator therapies at end of life: Results of a survey of medical and legal professionals and patients. Mayo Clinic Proceedings, 85(11), 981-990. doi:10.4065/mcp.2010.0431

Kasprak, J. (2003, July 9). Assisted suicide (OLR Research Report No. 2003-R-0515). Retrieved from http://www.cga.ct.gov/2003/olrdata/ph/rpt/2003-R-0515.htm

Saunders, W. L. & Smith, M. R. (2010, June 21). Assisted-suicide advocates fail in Connecticut. National Review Online. Retrieved from http://www.nationalreview.com

Emergency Medical Services, Public Health

A Tertiary Care Transfer

On December 18, 2009, “Simon Jones” called 9-1-1 and summoned emergency medical services (EMS) to his residence after developing a significant difficulty in breathing over the last few days. Mr. Jones is an elderly male who lives alone after his wife passed away three years ago. His two adult children live out of state. As EMS arrived, they found Mr. Jones to be in moderate distress with difficulty breathing, a low-grade fever, pale and cool skin, and general complaints of weakness. Mr. Jones stated a significant past medical history, including coronary artery disease, diabetes, hypertension, angina pectoris, myocardial infarction, congestive heart failure, and chronic obstructive pulmonary disease. Mr. Jones was treated by EMS with intravenous fluids, provided a breathing treatment, and transported to the local community hospital’s emergency department (ED).

Upon arrival at the local hospital, Mr. Jones was registered as a patient during turn-over from EMS to the nurse and attending physician who initially prescribed antibiotics and continual oxygen by nasal cannula. Within an hour, Mr. Jones spiked a high fever, became severely short of breath, and his blood pressure dropped precipitously indicating systemic inflammatory response syndrome (SIRS), or sepsis. The attending physician quickly ordered IV fluids run wide open with vasoactive medications added to support the patient’s blood pressure. Mr. Jones was unable to breathe effectively, however, and required intubation and was subsequently placed on a ventilator. The attending physician consulted with the University Hospital “One Call” physician who recommended transferring Mr. Jones to the intensive care unit (ICU) at University Hospital. A critical care transport (CCT) unit, staffed by two critical care paramedics and an emergency medical technician driver, was called for the transfer.

Mr. Jones was transferred to University Hospital without issue. Upon arrival, the intensivist accepted patient care from the CCT crew and began formulating a team to care for Mr. Jones, specifically mindful of his complicating medical history. Mr. Jones still had a low blood pressure and required ventilatory support, but his core temperature began dropping below normal. After a few days of using medication to attempt to correct the infection and hemodynamics (blood pressure, et al.), the patient developed acute renal failure (ARF). Mr. Jones, however, did not develop acute respiratory distress syndrome (ARDS), which was a concern from being on the ventilator with SIRS. Mr. Jones received continuous bedside hemodialysis for added kidney support.

After eight more days in the ICU, Mr. Jones’s hemodynamics began to self-regulate, and he seemed to be improving quite well. After three more days, Mr. Jones’ kidney function began to improve and hemodialysis was discontinued. Four days later, Mr. Jones was extubated, removed from the ventilator, and transferred to a medical/surgical bed. After a short stay, Mr. Jones was discharged to a skilled nursing rehabilitation center for improvement of his activities of daily living (ADLs). Mr. Jones soon returned home with no lasting effects from the medical confinement. He continues to follow up with his primary care physician.

Academia, Culture, Emergency Medical Services, Health Care, Society

Codes of Ethics

Of the three ethical codes presented by Lewis and Tamparo (2007), I align myself most with the Principles of Medical Ethics: American Medical Association (AMA). The AMA promotes honesty, integrity, compassion, respect, and most importantly, responsibility. In all manners of occupation, it is virtuous to remain honest; this is paramount in medicine. Physicians, nurses, paramedics, and other health professionals may make mistakes during their career, and it is important that these mistakes be corrected as soon as possible and understood to promote practices that may minimize the same mistake from happening. Honesty leads to integrity. Integrity is a hallmark of professionalism and, in conjunction with honesty, promotes trust. Having compassion and respect for patients regardless of political, societal, economic, or other divisions allows a provider to actually care for his or her patients rather than just deal with them. As a paramedic, I try to be as trustworthy and caring as possible to each and every patient I see. Ultimately, I understand my responsibility to my community, to fellow clinicians and technicians, to patients, and to myself. I hold ultimate responsibility for my actions and inactions, and I take care to not let these adversely effect the perception others hold of me as a professional. The AMA expects this of all physicians, and as an extension of the physicians I work for, I must strive to meet the same demands.

The Hippocratic Oath is dated in its language and demands. Though the oath can be approached as symbolism, the metaphor can be lost on some. I appreciate the Hippocratic Oath for what it is (a foundation for the ethical practice of medicine), but contemporary words, meanings, and application serve me better.

I find the Code of Ethics of the American Association of Medical Assistants lacking in context, applicability, and substance when adopted for paramedicine, my chosen occupation; therefore, I do not align as well with this code as I do with the previously mentioned codes of ethics.

Codes of ethics provide baseline philosophies that serve to direct the actions of groups. By ascribing to such, the professional belonging to such a group allows the code to guide moral judgments when the answer is unclear. In medicine, this is especially true. Medical professionals deal with life and death decisions which stretch the boundaries of personal moral beliefs. By ascribing to a notion of a slightly higher directive than one’s self, the professional can remove his- or herself from the situation with more clarity and less bias.

My personal ethics are bound by a sense of personal liberty and the responsibility of that liberty. Without responsibility, there are no consequences. Without consequence, there is no learning. I like to learn so that I may be the best paramedic that I can to the next patient in my care. For me, it is always about the next patient; they deserve the best that I can offer.

References

Lewis, M. A. & Tamparo, C. D. (2007). Codes of ethics. In Medical law, ethics, and bioethics for the health professional (6th ed.; pp. 241-243). Philadelphia, P.A.: F. A. Davis.

Academia, Society

Occupational Social Responsibility

According to Barendsen (2007), my profession is a caring one. I am a paramedic and I serve my community. I am also a firefighter who serves his community without compensation. It could be said that I blur the lines between my professional and personal life, but I enjoy great satisfaction doing so. I am by nature a very socially responsible person, but I extoll the virtues of taking personal responsibility. As a paramedic, I have a mantra: we combat stupidity.

As Barendsen (2007) points out, “workers in caring professions typically describe themselves as filling in or taking over a responsibility that others have abandoned” (p. 173). Everyone at some point in their lives makes stupid decisions. This is part of human learning, but some of these mistakes can unfortunately be lethal. This is where I feel that I make a difference in the lives of others. Driving too fast, smoking, eating too many fatty foods, or incidences of drunken abilities (in Texas, we had a saying that no good can from the statement: hey, hold my beer; watch this!). We all make these mistakes, thus we are all prone to stupidity from time to time. I enjoy the fact that many times I can help to allow others to learn from these mis-steps and reduce the lethality of their decision matrix.

There are times, however, that I have to get away from my occupation for my own sanity. I enjoy a number of hobbies and friends with varying interests that I can rely on to take my mind off of the worries of work. Also, attending school gives me added balance in the personal development side of life. Though attaining my degree will certainly better my professional outlook, I am seeking a degree solely for personal achievement. The prevalence of burnout in my profession is extremely high (Felton, 1998; Neale, 1991), so I make great efforts to balance and separate my personal life from my professional life. Admittedly, this is difficult at times because I am almost always on call.

References

Barendsen, L. (2007). Service at work. In H. Gardner (Ed.), Responsibility at work: How leading professionals act (or don’t act) responsibly (pp. 172-195). San Fancisco, CA: Josse-Bass.

Felton, J. S. (1998) Burnout as a clinical entity — its importance in health care workers. Occupational Medicine, 48(4), 237-250. doi:10.1093/occmed/48.4.237

Neale, A. V. (1991). Work stress in emergency medical technicians. Journal of Occupational and Environmental Medicine, 33(9), 991-997.

Academia, Clinical, Emergency Medical Services, Health Care

Flawed Conclusions in Literature Review

For this week’s discussion, I have chosen to analyze an article (Sakr et al., 2006) that attempts to outline the efficacy and potential dangers of certain drugs used to treat shock. As a critical care paramedic, the discussion surrounding this article can provide insight to choosing alternative therapies when caring for my patients, but it is important for me to understand the potential biases and limitations of such a study that could lead to flawed conclusions (Gluud, 2006).

Sakr et al. (2006) collected data on ICU admissions over a two week period to further understand how dopamine effects mortality and morbidity when administered in response to hemodynamic compromise. Also, other administered vasoactive drugs were included in the analysis whether administered concomitantly with dopamine or instead of dopamine. The researchers did not distinguish between etiologies except to delineate between septic shock and non-septic shock. Patients who presented with shock or suffered a shock state within the first 24 hours of admission were included in the analysis. Patients admitted to the ICU mainly for 24 hour surgical observation where not included.

Shock is defined as “a state of inadequate cellular sustenance associated with inadequate or inappropriate tissue perfusion resulting in abnormal cellular metabolism” (Hillman & Bishop, 2004, p. 121). There are many etiologies of shock, including sepsis, anaphylactic, neurogenic, hypovolemic, cardiogenic, and others, which respond differently to various therapies. This confounder creates an information bias, as this variable is not identified in the data collection and cannot be scrutinized. Simply identifying the etiology of each shock state would limit this bias. The researchers, however, acknowledge this limitation and others.

Another confounding variables is the time constraint of the data. In regards to septic shock, this variable becomes evident. Many pathogens spread predictively during certain times of the year. The concomitant treatment of these infections could predispose patients to suffer a prolonged state of shock (in cases where the pathogen might not be immediately recognized) or provide for an ideal treatment pathway when the pathogen and the antibiotic regimen are fully understood and effective. This selection bias could be controlled by choosing patients who present throughout the year.

As Gluud (2006) points out:

When intervention effects are moderate or small, the human processing of data, unsystematic data collection, and the human capacity to overcome illnesses spontaneously limit the value of uncontrolled observations. Experimental models are essential for estimation of toxicity and pathophysiology.
(p. 494)

References

Gluud, L. L. (2006). Bias in Clinical Intervention Research. American Journal of Epidemiology, 163(6), 493–501. doi:10.1093/aje/kwj069

Hillman, K. & Bishop, G. (2004). Clinical Intensive Care and Acute Medicine. West Nyack, N.Y.: Cambridge University Press.

Sakr, Y., Reinhart, K., Vincent, J., Sprung, C. L., Moreno, R., Ranieri, V. M., De Backer, D., & Payen, D. (2006). Does Dopamine Administration in Shock Influence Outcome? Results of the Sepsis Occurrence in Acutely Ill Patients (SOAP) Study. Critical Care Medicine, 34(3), 589-597. doi:10.1097/01.CCM.0000201896.45809.E3

Academia, Clinical, Culture, Emergency Management, Emergency Medical Services, Health Care, Public Health, Technology

Patient Safety Considerations for EMS

 In the out-of-hospital emergency care setting, patient safety is paramount. Initially, victims of trauma or illness are already suffering in an uncontrolled environment. It is this same environment where first responders, emergency medical technicians, and paramedics must operate to stabilize and transport the victim to the hospital, a more controlled environment. Unfortunately, there is little research in the area of patient safety in this setting (Meisel, Hargarten, & Vernick, 2008; Paris & O’Conner, 2008).

Importance

Focusing on patient safety and developing processes to ensure optimal safety would allow the study of inherently dangerous, yet potentially beneficial therapies, such as rapid sequence intubation where the clinician uses a series of medications to rapidly sedate and paralyze a critical patient for ease of inserting a breathing tube. Focusing on safety, an EMS department in Maryland successfully instituted such a program (Sullivan, King, Rosenbaum, & Smith, 2010).

With more research in this area, the Emergency Medical Services (EMS) can improve the care they seek to deliver to their patients.

Challenges

There are many challenges facing EMS as they seek to deliver safe and effective care to their patients. Motor vehicle accidents (including air transportation accidents), dropped patients, medication and dosage errors, other inappropriate care, and assessment errors all contribute to the number of adverse events in the EMS out-of-hospital care setting (Meisel et al., 2008). Unfortunately, it has proved difficult to identify both the existence and the cause of each event (Meisel et al., 2008; Paris et al., 2008). Additionally, there are adverse events that are impossible to track, such as the iatrogenic exposure to a pathogen. It would be very difficult to distinguish how and when a patient was first exposed to the infecting pathogen without considering community-acquired infections and hospital-acquired infections, which are both equally difficult to ascertain (Taigman, 2007).

Strategies for improvement

As EMS seeks to increase the professionalism among its ranks, the stakeholders must acknowledge responsibility for providing evidence-based processes to ensure patient safety.

References

Meisel, Z. F., Hargarten, S., & Vernick, J. (2008, October). Addressing prehospital patient safety using the science of injury prevention and control.Prehospital Emergency Care, 12(4), 4-14.

Paris, P. M. & O’Connor, R. E. (2008, January). A national center for EMS provider and patient safety: helping EMS providers help us. Prehospital Emergency Care, 12(1), 92-94.

Sullivan, R. J., King, B. D., Rosenbaum, R. A., & Shiuh, T. (2010, January). RSI: the first two years. One agency’s experience implementing an RSI protocol. EMS Magazine, 39(1), 34-51.

Taigman, M. (2007, July). We don’t mean to hurt patients. EMS Magazine, 52(4), 36-42.

Academia, Clinical, Emergency Medical Services, Health Care, Politics, Public Health, Society

Pay-for-performance in EMS?

There has been much discussion regarding reimbursement models for health services, and two main themes have emerged, the historical fee-for-service model and a quality-driven pay-for-performance model (Institute of Medicine, Committee on Redesigning Health Insurance Performance Measures, Payments and Performance Improvements Staff, 2007). While many providers argue that the reimbursement level is currently too low to sustain operations (Institute of Medicine, Committee on Redesigning Health Insurance Performance Measures, Payments and Performance Improvements Staff, 2007), patient advocates cite an overwhelming number of medical mistakes allowing providers to benefit from poorer outcomes leading to increased needs of critical care services which lengthen hospital stays dramatically (Committee on Quality of Health Care in America & Institute of Medicine Staff, 2001; Institute of Medicine, Committee on Redesigning Health Insurance Performance Measures, Payments and Performance Improvements Staff, 2007). While considering more effective designs within our health care system, treatment efficacy, reimbursement paradigms, and patient safety could possibly be used as a foundation upon which to rebuild our health care infrastructure. The Committee on Quality of Health Care in American and the Institute of Medicine Staff (2001) offer “six aims [safe, effective, patient-centered, timely, efficient, and equitable] for improvement that can raise the quality of care to unprecedented levels” (p. 5).

Fee-for-service models, the traditional norm in health care reimbursement, seek to itemize care expenditures based on particular procedures or services rendered to the patient. Though fee-for-service models reward providers for timely, and possibly effective and efficient, delivery of care, it does little to address safe, patient-centered, and equitable considerations.

Financial barriers embodied in current payment methods can create significant obstacles to higher-quality health care. Even among health professionals motivated to provide the best care possible, the structure of payment incentives may not facilitate the actions needed to systematically improve the quality of care, and may even prevent such actions.
(Committee on Quality of Health Care in America et al., 2001, p. 181)

As a paramedic, I am bound to a Medicare reimbursement model that focuses solely on the transportation of the patient and not on the care rendered. For a patient experiencing cardiac chest pain, merely placing them on a continuous ECG monitor and providing transportation to the hospital allows my employer to be paid the same as if I initiated an intravenous line, administered oxygen, aspirin, nitroglycerin, and morphine, and performed serial diagnostic 15-lead ECG readings during the transport. In any case, though, payment is withheld if the patient is not transported. I have to assume that this inequitable reimbursement scheme is replicated across the health care spectrum.

Pay-for-performance models, however, seek to reward the provider for improving the quality of care delivered and “represents an attempt to align incentives in the payment system so that rewards are given to providers who foster the six quality aims set forth in the Quality Chasm report” (Institute of Medicine, Committee on Redesigning Health Insurance Performance Measures, Payments and Performance Improvements Staff, 2007, p. 36; Committee on Quality of Health Care in America et al., 2001). Some detractors of pay-for-performance worry that providers serving poor and ethnic communities that have typically poor health and preventative compliance will not benefit from such performance measures. The worry is that the numbers of providers will be lacking in these communities, worsening the communities health outcomes (Nafziger, 2010). Though, “pay for performance is not simply a mechanism to reward those who perform well; rather, its purpose is to encourage redesign and transformation of the health care system to ensure high-quality care for all” (Institute of Medicine, Committee on Redesigning Health Insurance Performance Measures, Payments and Performance Improvements Staff, 2007, p. 44). Pay-for-performance focuses on safety, and a search of the literature does not reveal any complicating risk to patients under a pay-for-performance system so long as the system is patient-centric, taking into account the patient population serviced by each provider.

For instance, regarding a certain type of heart attack called a “STEMI”, or ST-segment elevation myocardial infarction, it is beneficial for the paramedic ambulance to bypass the local community hospital and transport the patient to a primary coronary intervention (PCI) facility for a cardiac catheterization. In this instance, the local community hospital is losing potential revenue. Perhaps if the reimbursement model reflected this evidence-based and patient-centered decision and provided a small monetary reward to the local community hospital for allowing the directed care at the PCI center, then mortality and morbidity from STEMI in the community would be reduced and the local hospital would be rewarded for their involvement in the process even if they did not provide any direct care. This is just one instance in the realm of emergency care where pay-for-performance can help to ensure safe, effective, patient-centered, timely, efficient, and equitable delivery of care to the patient.

As both a health care provider and consumer, I would prefer the pay-for-performance model of reimbursement. As a provider, I am a patient advocate, and as a patient, I will, of course, advocate for myself. Pay-for-performance enables provider growth, evidence-based practice, better patient safety mechanisms, and an overall efficient and a more complete and holistic delivery of care.

References

Committee on Quality of Health Care in America (Author), & Institute of Medicine Staff (Author). (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press.

Institute of Medicine, Committee on Redesigning Health Insurance Performance Measures, Payments and Performance Improvements Staff (Author). (2007). Rewarding provider performance: Aligning incentives in Medicare. Washington, DC: National Academies Press.

Nafziger, B. (2010, May 6). Pay for performance could hurt docs who serve poor, blacks and hispanics. DOTMed News. Retrieved from http://www.dotmed.com/fr/news/story/12570/

Academia, Clinical, Emergency Management, Emergency Medical Services, Health Care, Public Health

Botulism: A Measurement of Occurrence

 Botulism, caused by the Clostridium botulinum bacterium, is typically caused by poorly prepared, home-canned foods and can cause symptoms as simple as blurred or double vision to full body paralysis, sometimes causing death (Centers for Disease Control and Prevention [CDC], 1996). The incidence of botulism is said to be extremely low with only 126 reported cases in the United States in 2003; with only eight attributable to foodborne vectors, the predominant cause is accidental contamination (CDC, 2004).

One of the concerns regarding botulism is its toxicity. Botulinum toxin is the most potent toxin known to man (CDC, 2006). This potency lends to botulinum’s ability to be used as an agent of bioterrorism, though most of the known cases have been shown to be accidental in nature (CDC, 1996; CDC, 2006). Another concern is the accidental or negligent contamination of any food prepared for wide distribution, such as canned vegetables from a large manufacturer.

Surveillance is important to identify each and every case in order to have the most accuracy possible when considering increasing or decreasing trends of incidence and prevalence of the disease. The cause of any increase or decrease in incidence of botulism should always be investigated.

Any increase of incidence could identify a possible problem while a decreased incidence could foretell efficacy in the efforts of mitigation. More appropriately, though, as Friis and Sellers (2009) show, further identification should be made in order to focus on specific descriptive factors, such as affected populations, the geography of these populations, known vectors, and factors of time. This process will ensure that more accurate trends are observed.

For instance, the CDC (2004) has stated that in a typical year, such as 2004, the incidence of botulism is less than 200. With incidence reporting covering the entire United States, increases or decreases in this crude number serve only to identify general changes in frequency; whereas, further identification of certain characteristics of the disease pattern will help to further isolate affected individuals and etiologies (Friis et al., 2009). Within the CDC’s (2004) data, infant occurrence of botulism is identified as the major contributor to incidence, thereby isolating the remaining occurrences to adults. The CDC has gone further to separate the incidences of botulism into three groups, infant occurrence, foodborne infection, and wound infection. A separate group is reserved for other occurrences relating to the use of pharmacological botulin.

Using descriptive factoring of the 2003 CDC data (2004), further geographic isolation of occurrences show that infant occurring botulism is fairly wide-spread with a small number of incidences in each of twenty-two States, though California and Pennsylvania account for about half of the reported infant occurrences. Foodborne and wound occurrences of botulism were isolated to Alaska, California, Colorado, Oregon, Utah, and Washington. Texas had the only two reportable cases classified as “Other”. Theoretical assumptions can now be used to show that the problem in Texas is resolved but should continue to be monitored, and food safety education projects should focus on home-canning in the western regions of the United States.

In conclusion, epidemiology is an important means of understanding and identifying causation and etiology, as well as preparing for mitigation and outbreak response. In this example of botulism, I have identified localization of the disease, common pathways of infection, or vectors, and means of helping to mitigate future occurrences of the disease. Botulism numbers are quite low, but dealing with other diseases of larger scale, grouping the data into useful subsets will assist in following the progression of the disease from outbreak to outbreak and in consideration of mitigation techniques employed.

References

Centers for Disease Control and Prevention, U. S. Department of Health and Human Services. (1996). Botulism (Clostridium botulinum): 1996 case definition [CSTE Position Statement No. 09-ID-29]. Retrieved from http://www.cdc.gov/ncphi/disss/nndss/casedef/botulism_current.htm

Centers for Disease Control and Prevention, U. S. Department of Health and Human Services. (2004). Surveillance for Outbreaks of Botulism [Summary of 2003 Data]. Retrieved from the Centers for Disease Control and Prevention website: http://www.cdc.gov/ncidod/dbmd/diseaseinfo/files/Botulism_CSTE_2003.pdf

Centers for Disease Control and Prevention, U. S. Department of Health and Human Services. (2006). History of Bioterrorism: Botulism. CDC Emergency Preparedness and You [Podcast]. Washington, DC: CDC Bioterrorism Preparedness and Response Program.

Friis, R. H., & Sellers, T. A. (2009). Epidemiology for public health practice (4th ed.). Sudbury, MA: Jones & Bartlett.