Prehospital data gaps: When the chart misses the story

Suppose a woman over 65 arrives by ambulance to a busy ED with a chief complaint of weakness. Her vitals are stable and the next morning, she is discharged. Her chart didn’t reflect that she was hypotensive and tachycardic when EMS arrived and her pressure normalized en route thanks to an IV and a fluid bolus. Her vitals look reassuring because of what EMS had already done and her field presentation and EMS intervention, which were documented in the prehospital care report, never reached her care team.

Now suppose a man in his late 60s also arrives complaining of weakness. His vitals are stable, and he is discharged within hours. What his chart doesn’t show, however, is that this is his 10th encounter of the year and that he was treated for a similar complaint ten days prior. Nor does it show that he has no primary care physician, and that calling 911 is his only accessible option. Neither patient’s chart details their full medical story. This isn’t a clinical failure, but a systematic gap: the vital information necessary to provide them evidence-based care exists; it just never reached the teams that needed it. 

Two articles by the ESO team that were recently published in the Emergency Medicine News look at that gap from different angles, one at the bedside and one across the whole system.

Bringing evidence-based care bedside

In We built the chart around everything except what happened first, Nicholas Cozzi, MD, MBA, and Eric Beck, DO, MPH, both of ESO, describe how prehospital data rarely reach the hospital team in time to inform care, especially when many agencies still fax patient reports. Details often go missing, including vital information such as unsafe home environments, neighbors’ account of baseline function, prehospital interventions, or the presentation of hypotension and hypoxia in the field.  

A few of the key findings they cite:  

• In a video-based study of pediatric ED handoffs, fewer than one-third included vital signs. 

• In a trauma handoff study, receiving staff documented only 72.9% of key data points. 

• Longer ED boarding tracks with higher mortality. 

• The current system is fragmented and key patient information is getting lost in translation.  

Access alone isn’t the answer. A physician doesn’t have hours to spend scrolling through hundreds of documents to get the information they need. Ambient Artificial Intelligence (AI) already drafts bedside physician-patient conversations into notes in real time. The same approach can be used to sift through prehospital findings to create easy-to-digest records that the ED care team can access instantly. The information loop can also run both ways. EMS clinicians, who frequently walk away not knowing what happens to their patients after hand off, can access patient outcomes and learn from them for future patient interactions.  

Seeing the care patterns the system missed

EMS documentation is built to reflect individual encounters, which is why agencies can report their call volumes precisely and still not know how many people that call volume represents.  In When the emergency department is the only open door, Antonio R. Fernandez, PhD, NRP, and J. Brent Myers, MD, MPH, both of ESO, explain why the lack of longitudinal care documentation matters and the impact that linking encounters to individual patients can have.

Their study, A national description of emergency medical services patient utilization patterns, retroactively analyzed 9.5 million encounters from more than 3,000 agencies in the 2024 ESO Data Collaborative.  

Some key findings:  

• Patients that utilize EMS five or more times made up 3% of patients but 16% of encounters. 

• Patients that utilize EMS 12 or more times made up 0.4% of patients but 5% of encounters. 

• The highest-utilization group had a repeat encounter at a median of 10 days, versus 44 days for those with two to four encounters. 

• Patients with 12 or more encounters were transported more often than single encounter patients (83% versus 75%). 

• Admission odds rose through moderate and high utilization, at 1.57 and 1.37, then inverted to 0.58 at 12 or more, where ED discharge reached 75%, compared with 64% for single-encounter patients. 

• Incidents in the most socioeconomically vulnerable quartile showed threefold higher odds of very-high utilization against the least vulnerable (OR, 2.96) 

• Medicaid coverage carried threefold higher odds of very-high utilization versus commercial insurance among encounters with linked payer data 

For many patients, calling 911 is their only accessible option.  There’s opportunity for alternative response models, such as community paramedicine, mobile integrated healthcare, nurse navigation, and chronic disease management programs, to fill that gap in the system. Providing these alternatives would also ease the strain on the EMS agencies and emergency departments (EDs) who treat them, many of which are overcrowded and limited in resources. The authors also encouraged payment models to reward patient-centered care over volume. 

It all boils down to data

“Our patients have been telling their stories to EMS clinicians all along—in their homes, in the backs of ambulances, in the details no monitor captures. It is time the system let the rest of us hear them.” – Nicholas Cozzi, MD, MBA and Eric Beck, DO, MPH

The data necessary to improve the outcomes of these patients is already there. They just need to get it to the right teams at the right time. At the ED, that means ensuring a physician can note the interventions made by their prehospital partners. On a system-wide level, it means EMS agencies can see which patients keep returning and provide them with the alternative care that moves the needle on their outcomes. By connecting the entire care ecosystem, these patients’ needs will no longer slip through the cracks.

At ESO, our mission is to improve community health and safety outcomes through the power of data. Research powered by the ESO Data Collaborative and the dedication of our research teams and ESO community is one of the ways we work towards that mission.   

To read more on the work being done by the ESO team on prehospital intelligence and longitudinal record keeping, check out both We built the chart around everything except what happened first and When the emergency department is the only open door in the October issue of Emergency Medicine News.