The Computerworld Honors Program
Honoring those who use Information Technology to benefit society
LOCATION:
San Diego, CA, United States

YEAR:
2008

STATUS:
Laureate

CATEGORY:
Healthcare

NOMINATING COMPANY:
Palm

ORGANIZATION:
San Diego Medical Services Enterprise

PROJECT NAME:
“TapChart” Electronic patient documentation helping paramedics save lives on Smartphones in San Diego



Introductory Overview
TapChart is software designed for handheld mobile devices that San Diego’s Emergency Medical Services (EMS) responders use to collect 9-1-1 emergency patient information electronically on handheld Palm smartphones and PDA devices. TapChart’s development and implementation was funded and sponsored out of a vision to enhance patient care and documentation by SDMSE. San Diego Medical Services Enterprise (SDMSE) is a public/private partnership formed as a limited liability company between the city of San Diego Fire Rescue and Rural/Metro Ambulance. SDMSE is the largest 9-1-1 paramedic and non-emergency medical transportation provider in San Diego County.

The City of San Diego Emergency Medical Services (EMS) is responsible for the 911 medical care of 1.3 million citizens. Until 1997, (EMS) responders recorded all patient encounter information on paper Scantron “bubble” forms, which often were lost, incomplete, or illegible. This resulted in missing information and millions of dollars of uncollected revenue from billing. Additionally, hundreds of work hours were lost tracking down frustrated firefighters and paramedics who ultimately had to recreate lost paperwork. San Diego needed a more accurate, efficient and dependable method of collecting and transmitting patient information between emergency healthcare providers, hospitals and the billing office. By transferring documentation to handheld devices, reports became more accurate, legible, faster and easier to complete.

TapChart was developed to provide firefighters and paramedics with new documentation tools to foster better patient care and improve billing practices for services rendered. Called “TapChart” because of tapping the stylus on the device to create the patient’s medical chart, the software was developed in-house by a San Diego Fire-Rescue Department (SDFD) Captain/Paramedic. More than 70,000 of these patient encounter records are created annually and funds previously uncollected are now generating added revenue due to better business practices.

Above and beyond the fiscal benefits, however, are TapChart’s improvements to EMS that have made the City safer for its 1.3 million residents and visitors. The simple, direct interface of TapChart by its nature promotes thorough patient care. While taking a patient’s history and information, TapChart prompts emergency responders to ask detailed follow-up questions that might otherwise have been overlooked. TapChart also has a built-in database of medications and dosage indications that paramedics can reference to get a better understanding of patients’ conditions. Because the patient report is done by paramedics on a hand-held device at the patient’s side, they can chart everything in real-time and more accurately than trying to recreate the call on less mobile devices or paper later in the shift.

Implementing TapChart has also improved patient care in San Diego. Previously, firefighter paramedic first responders would document the patient assessment and vital signs and treatments on a handwritten sheet of paper and then hand it over to the arriving paramedic ambulance. Now, through intelligent design, TapChart builds a continuous record of patient information for the user. Each responder in the sequence of care can transfer the patient record via a secure infrared beam to the next responding party, typically from the “first responder” fire engine to the transporting ambulance, and then to the hospital E.R. This information is much more thorough and useful to E.R. doctors than the former handwritten notes scribbled in the back of a bouncing, lights-and-sirens ambulance. As well, it reduces redundancy, and also saves valuable time as the ambulance crew can continue the report instead of starting from scratch.

The Journal of Emergency Medical Services reported that of the 30 or so PDA EMS data systems they have seen, “TapChart is by far the most superior system by virtue of its depth, screen design, functionality, and easy, inexpensive implementation and modification.”

The Importance of Technology
How did the technology you used contribute to this project and why was it important?
“Introducing technology into a job that has that life-or-death risk, if it’s not done right, is a recipe for disaster”, said Roger Fisher, SDFD administrative manager, and the original flight paramedic who a decade ago wondered if these new-fangled Palm devices could have an application in EMS. “You don’t wave your hand and say ‘here’s this tool-use it.’ A lot of vendors come in and say this. Just because you have neat gadgets and toys doesn’t necessarily mean they have a place in public safety. TapChart was designed to be used as a tool to put in public safety’s hands that leads to better documentation and better patient care.”

All paramedics have an abundance of heavy equipment that must often be carried up many flights of stairs. Rugged computers are expensive and difficult to provide to many EMS systems. The development of inexpensive, affordable, mass market PDAs and smartphones made this project very viable.

Today, fire trucks and ambulances travel with Palm® Treo™ smartphones, in addition to their usual complement of firefighting and medical equipment. One Palm Treo resides in each fire truck while the ambulances each carry a pair—the extra as backup in case something happens to the first, which is always a concern considering the rigorous conditions they operate in, including, but not limited to, the being crunched by gurneys and run over by fire engines.

TapChart was written using a rapid software development tool. While the firefighter paramedic developer of TapChart had studied software design, it was the availability rapid development software that made the project possible. Third parties write software to add extra functionality. One such extension allows the PDA trouble-free infrared printing. This was vital as paramedics are required to leave a report at the hospital. Another software extension provided the ability to quickly and reliably transfer over 700 fields of information in only 15 seconds between PDAs. Spelling can also be a challenge for paramedics. Fortunately, an external spell check application keeps spelling errors to a minimum.

The firefighters, who typically arrive on scene first, start patient records on their handhelds, beaming them via the Palm Treo’s infrared port to the paramedics when they arrive in the ambulance. As hundreds of Palm devices were placed in service, it became vital to remotely manage the devices, accomplish secure data transfer, and manage the software files stored on each Palm device. SDMSE purchased a server based device management and data synchronization server. This addition made it possible for the program manager to know exactly when the Palm devices were being synced and to control precisely which files are added or deleted from each device.

Today’s mobile network functions have made mobility a truly valuable tool to the San Diego EMS workforce. For example, in San Diego when a heart patient or injured trauma patient is still in the field, paramedics can send doctors images from the accident scene or heart monitor readings, so that they can prepare for lifesaving treatment even before the patient arrives. This ability provides a far greater knowledge of the needs of the patient. Each minute saved in the process means a far greater quality of life for the future of every patient.

TapChart was written for Palm PDAs and Smartphones using Satellite Forms. Infrared beaming was made possible by a PalmDatapro beaming extension. Printing was made possible by Bachmann Printboy software. Spell checking is provided by LexSpell. Data synchronization and device management are provided by Nokia’s Intellisync server.

Benefits
Has your project helped those it was designed to help?   Yes

Has your project fundamentally changed how tasks are performed?   Yes

What new advantage or opportunity does your project provide to people?
TapChart benefits Public Safety and EMS as a whole. Records in TapChart have created an almost infinite bank of data that can be extrapolated and statistically analyzed to look for trends in patient care. TapChart is helping medicine respond to the needs of society by extending information from EMS to physicians and hospitals. EMS in San Diego and around the world has survived and scraped along with little useful documentation supporting the value that EMS provides. In the past, documentation practice using the old standard of field documentation and transfer of information to a patient’s medical record has been of little value to the permanent medical record or as a tool for reflective study and analysis. Today San Diego Medical Services Enterprise (SDMSE) is able to harness that deep well of data. For example, with a click, they can pull every cardiac arrest call crews responded to in a year and look for trends or review for Quality Improvement purposes. This helps SDMSE better serve the citizens and educate its EMS workforce.

TapChart provides many advantages over a paper based system. One important advantage is the easy availability of data. “I love the research potential and the benefit,” said Dr. James Dunford, city of San Diego Medical Director and Professor of Emergency Medicine, who oversees EMS in San Diego. For example, Dr. Dunford is currently submitting a proposal to an Internal Review Board to answer the basic question of how long it takes paramedics to monitor and transport patients having a heart attack. “The integrated system that links TapChart to CAD (Computer Aided Dispatch) will allow me to answer that question in one day. That is extraordinary,” said Dunford. The TapChart system is now providing the information to make data based decisions regarding pre-hospital patient care.

TapChart has also successfully increased the ability of SDMSE to serve the community in an efficient manner by decreasing out of service time due to report generation and returning ambulances back to service faster than in the past. With TapChart’s implementation, the City of San Diego has gained 16,500 extra hours of paramedic ambulance availability that were previously lost to more time consuming reporting methods. This allows the city to provide this valuable public service with its efficient resources.

TapChart improves the quality of each patient assessment. With each different chief complaint selected in TapChart, the firefighters and paramedics are prompted to ask very detailed questions to check for very specific physical findings on each patient. This intelligent assistant feature ensures a more thorough patient assessment which provides the E.R. doctors with better information. For example, when a patient is suspected of having a stroke, TapChart prompts the paramedic with the detailed questions of a standard stroke study protocol. This assistance in patient assessment and reporting did not happen with the old paper based system.

TapChart also gives the advantage of accurate, real-time data recording. Because emergency responders can fill out the paperwork at the patient’s side, they do not need to re-create calls later from memory. As well, the secure infrared beaming feature allows responders to share information easier and quicker between devices.

TapChart allows true data driven decisions and makes training and Quality Improvement easier, measurable and more efficient. SDMSE’s QI nurses can find and review calls with ease under the TapChart system. If they find that a trend is emerging, they can tailor continuing education and remediation programs accordingly.


If possible, include an example of how the project has benefited a specific individual, enterprise or organization. Please include personal quotes from individuals who have directly benefited from your work.
TapChart has positively impacted the lives and safety of more than 370,000 patients, and continues to create a safety net for the citizens and visitors of San Diego. The City of San Diego's 27 ambulances, 60 fire engines (with paramedics), and a workforce of more than 2000 rescuers work miracles each day to provide emergency services for 1.3 million residents scattered across the city's 330 sq. miles. With more than 200 emergency calls answered each day, these patient care providers produce about 70,000 patient records annually.

Dr. James Dunford-City of San Diego Medical Director:
“TapChart has a unique portability that allows more accurate data that provides me with the remarkable ability to retrieve accurate information within minutes of the medic’s turnover. It also has the capability to generate reports and answer important clinical questions in an afternoon. That’s a very special benefit.”

TapChart helps paramedics respond to emergencies in a more efficient manner.

Chuck Wood Paramedic/Engineer:
“From my perspective as a medic, before we had Tap Chart, we had to duplicate a lot of information on the bubble sheets. The Captain would be gathering all of the information until the ambulance gets there, and then you would have to re-enter it on the bubble forms. TapChart helps the paramedic transport crew spend less time at the hospital doing paperwork, and now we’re getting a legible copy. Whereas before, the doctors got a carbon copy of chicken scratches of no use to them, now they can get a laser print copy.


Ralph Carrasquillo, Jr. Captain, Paramedic:

“(TapChart) makes it easier to supervise people and make sure we documented what we needed to. It also creates more accountability….”

“(TapChart) makes patient care more thorough. It helps you complete fields, prompting you to capture all data fields.”

TapChart benefits the environment, helping San Diego’s EMS system go “green." California's second largest city was producing a mountain of paperwork. Seventy thousand patient transports annually meant 350,000 pages of paper forms. No longer will you see another wasted piece of paper on an ambulance or fire engine in San Diego. In the past, every patient report had to be retrieved by a “rounds driver” burning fuel just to collect paper records. San Diego has eliminated over 50% of the need for drivers to visit the stations resulting in significant reduction in fuel usage

John Pringle-Electronic Firefighter/Paramedic Documentation Coordinator:

“It allowed me as a paramedic to do much more accurate charting, and allowed my charting to be legible. If you can imagine, you’re sitting here taking notes, imagine taking that pad of paper you’re writing on and put it in the back of a pick-up going down a bumpy road, then trying to decipher that.”


With the use of TapChart, SDMSE has created a windfall increase in revenue exceeding on average $2.5 million annually.

Phil Forgione-CEO SDMSE:

“TapChart improves clinical care, from a risk management perspective, it reduces liability.”

Teri Crutchfield Director of Finance:

“It has virtually eliminated missing tickets. With TapChart, there can’t be a missing ticket. That’s huge. “

“It has also shortened days to bill. Instead of waiting for a rounds driver to pick up the records and have them processed, they are uploaded by the end of the week, reducing days to bill by about 3. Now we can bill in about 24 hours.”

“For the billing department, it has made the job much more productive and time sensitive, TapChart has helped immensely.”


Originality
Is it the first, the only, the best or the most effective application of its kind?   All of the above

What are the exceptional aspects of your project?
TapChart’s seamless adaptation into the EMS environment is unparalleled because it was created by a firefighter/paramedic, was among the very first to deploy extensive wireless patient record beaming, and is the largest single deployment of Smartphone based emergency medical services reporting in the United States.

TapChart is easy for emergency responders to use. It improves patient care and allows for more accurate charting. Because it is a homegrown solution, programming changes can be made immediately system wide. Patient information can be securely transferred from “first responder” fire engines to emergency responders arriving on scene via the device’s infrared beams, maintaining a comprehensive, continuous patient record. TapChart consistently results in a thoroughly-documented patient report protecting both victims and responders from future litigation.

TapChart creates a large bank of patient information that can be statistically analyzed to identify trends and improve patient care, and make improvements to protocol that on a meta-scale is saving thousands of lives.

Rod Ballard-President SDMSE, Deputy Chief EMS:

“It gives access to the custom reports I need on short notice. For example, during the fires, a drug company approached us wanting to make a donation. So I asked, how many dosages of Albuterol do we give each year? They looked up the info and gave it to me right then. I got back to the Mayor’s staff and they got an instantaneous answer.”

“It’s helped us financially. We are collecting better research and evaluating them for policy changes and treatments. We are getting accurate info that helps us with protocols and to give the right treatment.”

TapChart is less expensive to deploy on Palm smartphone devices than on laptops, and the extensive Palm warranty allows these to devices to be swapped out easily when they are damaged or defective, as the devices are designed for business applications, not life-or-death emergency services environments.

TapChart also saves millions of dollars in previously lost revenue from late and missing patient reports that can now be re-invested in the 9-1-1 public safety system.


Difficulty
What were the most important obstacles that had to be overcome in order for your work to be successful? Technical problems? Resources? Expertise? Organizational problems?
Fire fighting and EMS can be an environment resistant to change, and understandably so, because poor technology can result in life-or-death consequences. TapChart was a new way to do a job in a very tradition-oriented workforce. There was a bell curve of acceptance initially, but fortunately a large number of the workforce fell in the middle and were willing to give the program a try. As well, through attrition and expansion of the organization, a younger workforce more accustomed to using technology began working with TapChart.

This was not to say that there were no kinks to work out along the way. For example, emergency responders need “bullet proof” equipment. More than one Palm device fell victim to being crunched by a gurney or run over by a fire engine. This took efforts of educating the workforce. As well, writing narrative on a small screen proved to be challenging, so programmers added a folding, full-size keyboard, graffiti scribble system, and auto generation of narrative with more pull-down menus to select from.

Data synchronization over the internal city network began to fail and threatened the project in its early years. A commercially available device management and data synchronization server saved the project. Having in house developers made numerous revisions achievable. Being in a position to elicit continuous user feedback and then refine TapChart led to higher user satisfaction and a much stronger project.

SDFD Fire Captain Ralph Carrasquillo, Jr.

“The strength of TapChart is that there is always someone available to troubleshoot,” “They are available and return calls right away, and really help give answers. We’re really lucky to have the inventors of it and have access to them every day. It would be a lot more challenging if we didn’t have that resource.”

Greg George Captain, Paramedic, TapChart Programmer;
“This was done on a shoe string,” This was not your traditional I.T. project. It was about as grassroots as you could get.”

Finally, though SDMSE has reaped major benefits by having knowledgeable paramedic/programmers.

Often the most innovative projects encounter the greatest resistance when they are originally proposed. If you had to fight for approval or funding, please provide a summary of the objections you faced and how you overcame them.
This project was very entrepreneurial in nature for government personnel. This is not the type of endeavor often seen in the fire service. The SDMSE public private partnership for paramedic service in San Diego provided the proper environment for the development of TapChart to take place. No one was sure the effort would be successful, but the paper based system had to be replaced. Fortunately for TapChart, the program had champions early on who saw the potential of TapChart and helped make it a success. The TapChart advocates were willing to continue fighting for it even during the early stages when initial bugs needed to be worked out. “We didn’t meet with much resistance,” said Rod Ballard, the SDFD Fire Chief in charge of EMS, and an early champion of TapChart. “Because it was so far over (upper managements’) heads that they didn’t give any resistance because they didn’t think it would go anywhere. I had been talking about putting computers on the engines for a long time, but computers were about $4,000 each and the Palms were about $150. I was purely being a cheapskate.” These champions early on made provision to pay for a fire captain to purchase the software and to receive training to develop TapChart software. The Captain, Greg George, programmed at night at the fire stations and on his days off. Finally, TapChart was deployed on a small test group and eventually system-wide. TapChart currently has a full-time electronic documentation coordinator, a full-time programmer, and a clinical nurse educator that assists the program along with his regular duties, an amazing feat considering the volume of patient information being processed every day in the County of San Diego.

Success
Has your project achieved or exceeded its goals?   Exceeded

Is it fully operational?   Yes

How do you see your project's innovation benefiting other applications, organizations, or global communities?
The TapChart project has proven that SmartPhones and PDAs can be very effective cost saving tools for emergency workers. After witnessing SDMSE’s success, many other San Diego area agencies have gone the route of implementing PDA based patient reports. TapChart has been so vital to SDMSE’s financial success that it has proven to be a necessary business practice for any future paramedic ambulance service in San Diego.

The potential for TapChart’s continuous electronic patient documentation in emergency and medical services is virtually limitless given the resources to carry it out. As only one example, currently TapChart support is working with the University of California San Diego Medical Center to coordinate their respective data systems so that a paramedic patient record can be electronically integrated into a patient’s permanent hospital medical record. This allows vital information like EKG readings to be integrated into a physician’s record.

Electronic documentation is the first step in the efficient processing of patient data, the wave of the future. In the future, The Palm smartphone can also be used to process further forms that were previously on paper, for example, various check sheets at the fire stations. TapChart also now documents a form called an AMA (“against medical advice”) which is what a patient signs to release responders when they refuse a ride to the hospital. Before, if an AMA was not received, it had to be tracked down or the department was subject to liability, now the record must be captured in the Palm device or the record cannot be completed. This provides legal protection.

Large EMS systems currently searching for handheld paramedic patient report may benefit from TapChart in the future. A national vendor of emergency medical services data collection software is modeling their next paramedic patient reporting tool on TapChart.


How quickly has your targeted audience of users embraced your innovation? Or, how rapidly do you predict they will?
As with any new technology, there is a learning curve. We found that the majority of firefighters and paramedics were comfortable using TapChart within a few days of receiving training. However, the most vocal critics of TapChart at first are now its strongest advocates. New paramedic employees have reported that high tech tools like TapChart influenced their decision to seek employment with San Diego’s paramedic service SDMSE. Long-time paramedics say this has made their jobs so much easier and they would never want to go back to the bubble forms.

Carolyn Gain Paramedic:

“My story is atypical in that I truly feel the design of Tap Chart saved my paramedic job. Unfortunately, prior to its existence, I was very poor with paper pencil charting. My handwriting is borderline illegible. My frustration with the repetition of the county bubble forms led to omissions and errors. My timeliness with completion of documentation was questionable. The ability to organize multiple pieces of paperwork for each patient while running upwards of 15 calls a day was difficult. I was consistently staying an hour plus after my shift to try to complete the documentation. All this led to discipline and heartache.”

“From the time the Palm Pilot was unveiled with the TapChart technology I have not had one late submission, one returned form, or any errors noted.”

In conclusion, TapChart is not the only electronic patient documentation program on the market, but in San Diego, we can not imagine that a more successful product is available to accomplish our public safety mission and TapChart has stayed true to its original calling.

Digital/Visual Materials
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