This document discusses ambulance services in New Zealand and a new electronic patient report form (ePRF) system called CareMonX that is being implemented. It notes that there are about 600 ambulances nationally that respond to over 400,000 emergency calls per year. The current paper-based ambulance records are obsolete, illegible, and incomplete. CareMonX ePRF is an electronic clinical record system that will replace the paper forms and integrate with other healthcare providers using clinical standards. It will allow ambulance crews to capture patient assessment findings, vital signs, medications, and interventions using coded clinical terms like SNOMED CT which will improve data sharing and analysis.

1. Fire and Ice 24 July 2015
SNOMED
…makes a good first clinical impression

2. • 2 partially publicly-funded ambulance operators (~70% MoH and ACC - opex only)
• About 600 ambulances nationally
• More than 400,000 emergency calls per year (more than 1,000 a day)
• 80% transported
• About 70% medical / 30% trauma
• St John covers 90% of the NZ population
• Shared control/communications centres (111) in Auckland, Wellington and Christchurch
Ambulance in
New Zealand

3. • MDT system in ambulances obsolete
• Hand-written patient report forms often illegible and incomplete
• NHI Number not always collected
• Little patient information available at point of care
• GPs not advised of ambulance contacts
• Hospitals not always aware of incoming ED patients
• Ambulance clinical record not available electronically to the hospital, A&M or GP
• Hospitals do not advise ambulance of patient outcomes
• Difficult to extract data for education, clinical audit, research, performance improvement
The Problem

4. • CareMonX MDT and ePRF
• Valentia Technologies - Irish-based
• Purpose-built ambulance clinical record system
• Configured for NZ requirements
• Implemented in UK, Europe, Middle East
• Modern layered architecture
• Platform independent
• Part of an integrated suite of products
CareMonX
MDT
CareMonX
ePRF
The Solution

5. On the Road
Defibrillator
Wireless hub
CareMonX ePRF
CareMonX MDT

6. Standards
based system
• Standards allow us to easily share data with
other healthcare providers
Clinical Document
Architecture
HISO 10052
Ambulance
Care
HISO 10043
CDA templates
HISO 10011
eDischarge
HISO 10040.4
Metadata
HISO 10046
Consumer
Identity
HISO 10005
HPI
HISO 10041.1
Medications

7. Code systems
and term sets
• Code systems and term sets allow us to
describe an episode of care
SNOMED CT
Ministry of
Health
Ambulance
specific
UCUMStatistics NZ
LOINC NZMT

8. Use of
SNOMED CT
• We use SNOMED to help describe:
What we
thought
What we saw
What we did
Vital observations; e.g. GCS, HR, BP, SPO2
• Observation name recorded using LOINC Code; e.g. 8867-4
Heart Rate
• Simple observations recorded using UCUM; e.g. mmHg
• More complex concepts recorded using SNOMED; e.g.
Heart Rhythm:
426285000 Electrocardiogram: normal sinus rhythm (finding)
164889003 Electrocardiogram: atrial fibrillation (finding)
164890007 Electrocardiogram: atrial flutter (finding)
164887001 Electrocardiogram: supraventricular arrhythmia (finding)
164896001 Electrocardiogram: ventricular fibrillation (finding)
164895002 Electrocardiogram: ventricular tachycardia (finding)
427084000 Electrocardiogram: sinus tachycardia (finding)
426177001 Electrocardiogram: sinus bradycardia (finding)
426307007 Electrocardiogram: junctional rhythm (finding)
164909002 Electrocardiogram: left bundle branch block (finding)
164907000 Electrocardiogram: right bundle branch block (finding)
164898000 Electrocardiogram: heart block (finding)

9. Use of
SNOMED CT
• We use SNOMED to help describe:
What we
thought
What we saw
What we did
Medications administered
• Medication name recorded using NZMT Code; e.g.
• Dose recorded using UCUM; e.g. mL
• Route of administration represented by a SNOMED
concept; e.g.
10370021000116107 Midazolam
10446531000116106 Morphine
24308091000116101 Naloxone
417255000 Intraosseous route (qualifier value)
47625008 Intravenous route (qualifier value)
46713006 Nasal route (qualifier value)

10. Use of
SNOMED CT
• We use SNOMED to help describe:
What we
thought
What we saw
What we did
Interventions performed fully coded using SNOMED concepts
• Procedure; e.g.
• Body structure; e.g.
• Laterality; e.g.
• Anatomical relationship; e.g.
• Intervention success; e.g.
173067007 Airway Management Cricothyroidotomy
250980009 Cardioversion
392231009 IV insertion
181373000 EJV
362741001 Forearm
243941009 Fourth intercostal
7771000 Left
24028007 Right
49370004 Lateral
261132002 Midclavicular
385669000 Successful
385671000 Unsuccessful

11. Use of
SNOMED CT
• We use SNOMED to help describe:
What we
thought
What we saw
What we did
NZ Emergency Care Reference Set
• Developed by Tom Morton & Andrew Munro from NMDHB
• Based on work done by NEHTA in Australia
• SNOMED concepts describing 23,240 reasons why people
turn up in ED
NZ Ambulance Clinical Impression Reference Set
• Developed by St John and WFA researchers
• A subset of NZECRS
• SNOMED concepts describing 465 reasons why ambulances
take people to ED
• Medical and trauma – map to Read codes
• As close to a diagnosis as a non-doctor can get
• NOT presenting complaint, symptom or observation

12. • Transfer of Care at hospital or Medical Centre – CWS integration
• Patients left at home – delayed transfer of care
• Ambulance officer as an ad-hoc member of a shared care team
• GP advice – initially via HL7 2.4 messaging; later via HIE
• Ambulance Care Summary becomes part of the patient’s clinical record
• Close the loop with hospitals and ACC – clinical impression vs diagnosis;
treatments vs outcomes
• Research – ambulance planning; wider population and public health research
So what?

13. About the
project
• Upgrade communications technology in ambulances 
• Replace MDT 
• Introduce electronic clinical record to replace paper form
(not WFA)
IT Health Board involvement
Significant MoH and ACC funding
TransitionStart-up Initiate Design Build

14. Timing
• Now – UAT of ePRF
• August 10 – Trial implementations “pilot”
• October 5 onwards – Staged national roll-out
• Next year – version 2:
 Access from 3rd party CWS
 GP advice
 Enhanced clinical audit
 Modifications and enhancements