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Findings and Results

The time-critical information services (TCIS) framework was developed, critiqued, refined, and validated by Advisory Committee members, multiple researchers at conferences, and through the peer-review publication process. It was also validated as an effective tool for analyzing EMS systems as it was used in a practical sense to guide both the San Mateo and Mayo Clinic case study investigations. A simplified TCIS model was also validated as a conceptual guide for IT managers and executives (Schooley et al., 2010a) (see below).

A General Framework for Multi-Organizational Collaboration for Time-Critical Services
(Adapted from TCIS Framework)

Time-Critical Service Process

Findings from the case studies indicate that for the current state of EMS, information systems are used in a partial manner to capture and analyze performance data across multiple organizations. Yet, there are numerous examples and indications that a management information system that acts as a "facilitator" to link information systems and organizations could be a valuable enabler of end-to-end performance analysis and improvement. A significant barrier to collaboration and end-to-end performance management is a prevalent technical, organizational, and governance gap between "pre-hospital" (i.e., dispatch, ambulance, fire) organizations and "hospital" (i.e., hospital emergency departments, trauma centers) organizations. This gap includes technological challenges (e.g., lack of data integration), organizational issues (e.g., institutional and cultural barriers to sharing information), and governance issues (e.g., lack of policy mechanisms to ensure information sharing). Furthermore, there is a pressing need to define, characterize, and implement end-to-end "quality of care" performance measures for EMS across the range of response and health care organizations.

Issues and challenges to inter-organizational information integration range across operational, organizational and governance dimensions. In this regard, these three dimensions influence to what degree information is shared or IT is deployed across organizations from end-to-end. In terms of the operational dimensions, the dynamic, complex, time-critical, and multi-variable nature of emergency and trauma care work creates a number of technology usability issues and challenges, which cause emergency professionals to take a conservative approach to new information and technologies to support EMS. For example, inputting data is the last thing on a paramedics mind in a life and death situation. To avoid the risk of service degradation, liability, and negative patient health consequences, emergency professionals explain the need to be cautious in the application of new IT to support emergency medical work processes. In terms of organizational dimensions, the case studies provide support for the thesis that inter-organizational alignment including a shared set of goals and cooperative agreements can facilitate information sharing. The San Mateo example illustrates the value of working cooperatively at monthly meetings to create a shared set of goals across organizations to enhancing information sharing. In contrast, issues of trust and cultural differences create inter-organizational information sharing and technology gaps. The apparent "pre-hospital" vs. "hospital" information sharing chasm illustrates this phenomenon. The San Mateo County re-design initiative directly addressed these issues by inviting any and all EMS personnel in the county across all EMS organizations to participate in defining the requirements and needs for the next generation EMS system. This process resulted in a consensus driven RFP that was recently released to the public. The initiative illustrates the value of facilitating inter-organizational consensus to drive an evidence based planning effort. In terms of governance dimensions, case study examples illustrate that clear lines of inter-organizational authority and accountability tend to enhance information sharing and technology. The San Mateo performance based contract defined clear authoritative boundaries and information sharing was enforced. In contrast, unclear lines of authority and accountability tend to limit information sharing and technology between pre-hospital and hospital organizations - such was the case between the EMS Agency and the 11 county hospitals. The Mayo Clinic case study provides an interesting contrast in that the EMS organizations are "connected" organizationally with the hospitals. Though information sharing is also a challenge for the Mayo Clinic, policies tend to come "top down" and are more easily enacted and enforced creating a more efficient mechanism for change.

The qualitative findings led to the development of a practical tool for assessing the level of technical, organizational, and governance integration that exists within an inter-organizational EMS system (see Figure below). This "High Performance Architecture" can be used to understand the high level components needed to significantly improve the IT-enabled performance capabilities of an end-to-end EMS system.

TCIS performance architecture

In terms of quantitative analysis of case study data, the research team linked pre-hospital EMS data with patient outcome data at the hospital (trauma center) to assemble an end-to-end representation of two years of traffic crash emergency response data. Analysis revealed important socio-geographic disparities in emergency care. For example, the analysis found positive correlations that indicate that elderly crash victims may be more likely to sustain serious injury and remain at a hospital for a longer period of time than younger individuals. In addition, correlations suggest the longer it takes for an elderly victim to arrive to a trauma center (e.g., because a crash took place in a rural or remote location), the longer those individuals stay at a hospital (as an indicator of time to recovery). While the sample size of this study was small, it supports prior findings from research. In addition, it provided evidence and a "proof of concept" as to the performance assessment value of linking data from end-to-end across multiple cooperating organizations. The proof of concept was particularly valuable considering the key findings from the National Symposium held in June 2008. National participants concluded that:
  1. There exists a paucity of information systems and tools that link, visualize, and allow for end-to-end performance analysis across the Country
  2. There is a need for clinical indicators to be included in a performance information model
  3. There is a need for test projects and proof of concept data systems to demonstrate the value of end-to-end information for EMS decision makers
Recommendations from the Symposium included the need for demonstration projects to illustrate the value of end-to-end information sharing with a focus on clinical performance indicators that can be pushed upstream and downstream to practitioners to allow for more timely and quality patient treatment. These findings led the project team to begin to develop a prototype application that could demonstrate the value of linking end-to-end data and visualizing such in a mobile, web based, geographic (Map) enabled platform in combination with performance and clinical indicators. While the prototype requires additional development moving forward, it has gained considerable attention from case study participants. The tool will continue to be developed in iterative fashion in collaboration with practitioners from case study organizations. In sum, research has encompassed completion of the conceptual framework and qualitative case study work. The case studies highlight how information integration holds the potential to significantly affect timeliness and quality of care performance for end-to-end e-government EMS services, especially where careful and deliberate IT enabled inter-organizational business process changes occur. From an applied perspective, the San Mateo County EMS Agency found the case study analysis and TCIS framework to be very useful and have used it to guide their strategic county-wide EMS system re-design initiative. Finally, findings have led to the development of a web based tool to support practitioner decision making across the time-critical, end-to-end, emergency medical continuum of care.
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