Title: ERA – Electronic Records in Ambulances to support the shift to out of hospital care: challenges, opportunities and workforce implications
Funder: Health and Care Research Wales (Welsh Government)

Abstract: Ambulance services have a vital role in the shift towards the delivery of health care out of hospitals, when this is better for patients, by offering alternatives to transfer to the emergency department (ED). For this to happen safely and effectively, ambulance clinicians must be able to decide which patients will benefit from being treated at scene or left at home, and ensure that patient information, including details of 999 assessment and care, is passed to community based care providers. The introduction of information technology (IT) in ambulance services, to electronically capture and store patient data, can support out of hospital care, and has been encouraged by national policy across the UK, but roll-out has proved complex, with major workforce implications. There is considerable variation across services in terms of implementation and the degree to which electronic records are integrated with other IT. We aim to examine how electronic records in ambulance services can support community-based care in a number of ways: by acting as a base to which other electronic resources (e.g. decision support software, referral tools or ‘apps’) are attached; by facilitating transfer of patient information to or from other providers; by allowing services to identify and manage repeat service users; and by making data readily available for research and evaluation. We aim to investigate and describe the opportunities and challenges of implementing electronic records and associated technology in ambulances to support a safe and effective shift to out of hospital care, including the implications for workforce in terms of training, role and clinical decision making skills. Lessons learned from the experience of implementing electronic records so far should inform future development of IT in ambulance services, and help service providers to understand how best to maximise the opportunities offered by electronic records to redesign care. Our study will include a baseline assessment of progress in all UK ambulance services in implementing electronic records and other technologies to support care delivery and decision-making. We will review and build on what is already known about implementation of technology in health care to inform four in-depth case studies of services at different stages of implementation. Across the case studies, we will assess current usage, and examine the role of context and time in shaping implementation and service change. We will take a whole systems approach, looking at the recursive relationship between technology and the ambulance workforce. Our working methods are participatory, built on a close relationship between the research team, ambulance services and other stakeholders, and using research paramedics as field researchers. In the final phase of our research, we will work with all UK ambulance services and other stakeholders to assess the potential for further development of electronic records, electronic decision support and referral tools to maximise their potential to support the shift of care from hospital to community based services. We will develop and build on existing theory about the implementation of IT in health care, developing the research base in the field of pre-hospital care and across care settings, and examining how implementation of electronic records takes place in relation to the implementation of other IT developments to support alternative care pathways.

Lay abstract: Increasingly, ambulance services have a role to play in keeping people out of hospital. Instead of transporting people to the emergency department, they might provide them with care in their own home, or refer them to a community-based provider such as a falls service. For this to happen safely and effectively, paramedics need to be able to make the right decision for patients, for which they need the right information; they need to be able easily and accurately to pass on the patient's details; and they need to make a record of their contact with their patient. Technology can have a role in helping paramedics with all of these, and so help to keep people out of hospital. Electronic records are not just useful in their own right, but can be linked to other technology which helps paramedics to make the correct decision and put people in touch with services to help them. Some ambulance services are recording patient information electronically, but some are not. We know that switching to new technology is not always straightforward and it can make a change to people's jobs - sometimes in ways which aren't expected. Our research aims to find out how ambulance services can make the best use of information technology to support people with good quality care out of hospital. We will look at what happens day to day, when paramedics use technology in practice; at how the ambulance service as an organisation starts to use new technology and adapts to the changing landscape of care; and at what happens in between, as paramedics respond to this changing environment, learn new skills and change their role and practice. We will talk to all the ambulance services in the UK to find out what they are doing in terms of introducing electronic records and other IT to support care delivery and decision making. We will then do a detailed study of four ambulance services - one service which has used electronic records for a few years, one which does not use them, and two which are part way through bringing them into use. In each area we will have a research paramedic who will find out about how decisions are made about using electronic records and technology, whether and how they are used, what people feel about them, and what difference they have made (or could make) to how paramedics and the service work. We will analyse data about current levels and patterns of usage of electronic records. We will talk to paramedics, managers, and people running other relevant health services, read reports and documents and spend time on ambulances looking at how records and other technology are used. We will compare what has gone on across the four sites. We will look in detail at care for people with three particular conditions (falls, diabetic hypoglycaemia, mental health crisis) which have potential for increased non-conveyance, to see what difference electronic records in ambulances are making - or could make - to people with those conditions. We will then bring together all the ambulance services in the UK to talk about what we have found and discuss what they think will be the best way to make use of technology to help paramedics keep people out of hospital. All ambulance services are looking for ways to keep people safely away from hospital, and the Department of Health and the devolved governments are keen for them to do this. Our study will help ambulance services to get a better understanding of the best way to to do this with the help of technology

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE