Part One: Capturing Care in Real Time: Why Accurate On-Scene Documentation Matters

In recent years Mobile Integrated Health (MIH) has emerged as an innovative way to bridge gaps in healthcare coverage, reducing costly ambulance runs and hospital visits by proactively addressing the underlying needs of vulnerable populations. MIH providers have created multidisciplinary care networks, including home safety technicians, medication-assisted treatment (MAT) specialists, mental health counselors, and much more. In light of current efforts to standardize an MIH dataset, this two-part series will focus on the backbone of MIH: documentation.

It’s easy to see documentation as an afterthought, the work you do after the real work, but poor documentation will undermine patient care from the first visit to the last referral. Still, after a draining day, it can be hard to properly document – especially if you’re re-entering the same information you recorded on scene, you’re trying to remember which partner services to keep in the loop, and you’re still trying to fill in the blanks between the isolated incidents recorded by traditional EMS systems. That’s why HealthCall developed our longitudinal patient record, with imports to help you stitch together EMS incidents, support for tracking non-medical needs, and an expansive library of standardized & validated MIH assessments.

Documentation That’s Always At Hand

A patient’s medical history is one of the most valuable tools for most healthcare providers. However, community paramedics often have to collect puzzle pieces of information from multiple sources, and then circulate this information with various members of the patient’s care team. To avoid harmful allergic reactions, reconcile medications and understand the many pieces contributing to a patient’s condition, an MIH team needs up-to-date documentation – but on a home visit, they may have to rely on whatever information the patient has in their personal records. This sometimes means supplementing their records with patient-reported information risking incorrect, incomplete or biased documentation. Sometimes they have to work with even less – when supporting MAT in a prison, a team may have no information at all from the patient’s outside life.

A system that’s accessible on-scene is crucial for providing effective care in scenarios like these. HealthCall’s system is available via tablet and phone, with a responsive design that adapts to whatever device a paramedic has on hand. With real-time updates, a team on-scene can get immediate access to information entered by other teams and partner services. Plus, with HealthCall’s longitudinal patient record each MIH team’s encounters and notes are easy to reference for the teams that come after, including special notifications for high-priority notes and safety concerns, so that expertise is never lost and patterns are easy to identify.

Keeping Partners On The Same Page

Partnerships are the lifeblood of an MIH program, whether they’re with other healthcare systems or other community services. However, anyone who’s sent a group email knows it’s difficult to keep everyone on the same page. Different healthcare systems may refer the same patient with different details; different team members may not be aware of all the services a patient is connected to; different services may have conflicting schedules. Consider the real-life example of a homeless patient who missed their chance for a housing voucher: they had signed up, but when the time came they were in rehab with a separate recovery program.

HealthCall’s Care Network allows your team to document all the partner services you work with, and which patients you’ve connected to which services – but more than that, it allows you to securely share your patient record with those partner services, with customizable PHI permissions allowing each service to see only what they need to see. Partners can have access to a patient’s upcoming schedule, history, documents, and more. You can even directly collaborate with partner services to conduct assessments in HealthCall, making sure they collect all the information you need, in the format you need. HealthCall makes it simple to close the loop on what happens pertaining to patient care, without having to do any extra communication or chase down partners.

Avoiding Bookkeeping Burnout

While documentation is an invaluable tool, creating and updating it takes time and effort. Any community paramedic knows the work can already be exhausting, and if this stress leads to burnout your team loses valuable connections, expertise and manpower. That’s why it’s important to choose documentation tools that let you work with efficiency and accuracy, so you don’t document the same thing twice and you don’t spend time cleaning up mistakes.

Portability is important: if your team needs to make temporary notes because they can’t directly access your system on-scene, their documentation work is doubled. Recording information directly also reduces the chances of typos and and forgotten details. You receive the same benefits when a partner service can access your records directly, rather than relying on you to send them copies of the information they need. Plus, keeping your partners on the same page means spending less time dealing with the fallout of conflicting programs.

HealthCall provides all of these benefits, but we also go a step beyond, providing automatic support and quality of life features. HealthCall SMART Charts can automatically sum questionnaire results, calculate derived vitals and hide assessment questions that aren’t applicable to the patient. SMART Charts also feature touch-friendly controls, can collect electronic signatures, and can show a patient’s current answer to a question alongside their previous answers, so trends are readily apparent.

HealthCall clients may design custom SMART Charts, or choose from our library of standardized, validated MIH SMART Charts, including the Brief Assessment of Recovery Capital (BARC-10), the STEADI Fall Risk assessment, DSM-5-compliant assessments for Alcohol and Opioid Use Disorder, and dozens more – everything you need to document with ease.

We hope this illustrates the importance of documentation to an MIH program’s work on-scene – but there are also benefits behind the scenes, including regulatory compliance, directing program growth, and securing funding. Check out part 2 of this series to learn more about these benefits, and how HealthCall can bring them to your program.