Precision emergency medicine in health care delivery and access: Framework development and research priorities

Abstract

Background:

The integration of precision emergency medicine (EM) into our conceptualization of the health care system affords the opportunity to improve health care access, delivery, and outcomes for patients. As part of the Society for Academic Emergency Medicine (SAEM) Consensus Conference, we conducted a rapid literature review to characterize the current state of knowledge pertaining to the intersection of precision EM (defined as the use of big data and technology to deliver acute care for individual patients and their communities) with health care delivery and access. We then used our findings to develop a proposed conceptual model and research agenda.

Methods:

We completed a rapid review of the existing literature on the utilization of big data and technology to ensure and enhance access to acute/unscheduled care for individual patients and their communities. Literature searches were conducted using Ovid MEDLINE, Embase.com, Cochrane CENTRAL via Ovid, and ClinicalTrials.gov in January 2023. Using the identified articles, we determined core domains, developed a framework to guide the conceptualization of precision EM in health care delivery and access, and used these to identify a research agenda.

Results:

Of the 815 studies identified for initial screening, 60 underwent full-text review by our technical expert panel and 21 were included in the evaluation. Core domains identified included expedited/personalized prehospital care, delivery to the right level of care, personalized ED care, alternatives to ED care/post-ED care, prediction tools for system readiness, and creation of equitable systems of care. A research agenda with four priority research questions was defined following identification of the core domains.

Conclusions:

Precision EM includes consideration of the health care delivery system as a mechanism for improving access to emergency care using data-driven strategies. This provides a unique opportunity to use data and technology to advance systems of care while also centering patients, communities, and equity in these advances.

INTRODUCTION

Regionalization of emergency care, particularly for time-critical conditions, has long been an important focus in emergency medicine (EM).¹ At the core of regionalization efforts is the goal of delivering the “right care to the right patient in the right place at the right time.”² In working toward this goal, precision medicine principles can be applied to population-level considerations. As delivery system innovations supported by newly developing technologies continue to emerge, the premise of regionalization—connecting patients to the appropriate care for their medical condition and for their needs more broadly—may alternatively be thought of as precision medicine at the population level. As such, one can consider several levels when conceptualizing its application, including at the level of the patient (e.g., bedside treatment), community (e.g., social support, food access, environmental exposures), or health system (e.g., prehospital resources, care delivery spaces; Figure 1).

FIGURE 1.

Manifestations of precision medicine across levels of care.

Initially, precision medicine was defined in the context of genomics. Since that time, definitions of personalized medicine and precision medicine have rapidly evolved to reflect the broader process by which data are collected, interpreted, and translated into personalized medical care at the patient level.³ However, there previously has not been a collective understanding of how precision medicine intersects with EM. To address this gap, in May 2023, the Society for Academic Emergency Medicine (SAEM) convened the first-ever EM consensus conference on the topic “Precision Emergency Medicine: How Data Science, -Omics, and Technology Will Transform Emergency Medicine.” The conference created a shared definition that precision EM is the purposeful use of big data and technology to safely, efficiently, and authentically deliver acute care for individual patients and their communities.⁴

Using this definition, precision EM may be incorporated into the conceptualization of the health care delivery system by considering strategies that harness big data and technology (either separately or in conjunction) for improving the organization of emergency care systems. This affords the opportunity to continue to improve health care access, delivery, and outcomes for patients in personalized, data-driven ways. In fact, this direction was anticipated when experts in emergency care delivery convened in 2010 to envision the next phases of innovation in emergency care delivery; the group identified the integration of emerging technologies as a key theme.⁵

To address the application of precision EM to regionalization and emergency care access, the Healthcare Delivery and Access Workgroup was formed. The workgroup sought to develop a shared understanding and guide future research and system design in the application of precision EM to the organization of emergency care delivery. To achieve this, we conducted a rapid review of the literature to characterize the current state of knowledge pertaining to big data and technology as used to ensure and enhance access to acute/unscheduled care for individual patients and their communities. We then used our findings to develop a proposed conceptual model that serves as the foundation to propose a research agenda.

METHODS

We completed a rapid review of the literature as it pertained to precision EM to ensure and enhance access to acute unscheduled care for individuals and their communities. As defined by the Cochrane Rapid Review Methods Group, a rapid review is “a type of evidence synthesis that brings together and summarizes information from different research studies to produce evidence for people such as the public, health care providers, researchers, policy makers, and funders in a systematic, resource efficient manner. This is done by speeding up the ways we plan, do, and/or share the results of conventional structured (systematic) reviews, by simplifying or omitting a variety of methods that should be clearly defined by the authors.” Our approach to the literature review was developed under the guidance of a research librarian (ML) using the PRISMA 2020 statement⁶ and followed the guidelines outlined in Cochrane Rapid Reviews Method Group updated recommendations.⁷

Our study topic was defined a priori in accordance with the consensus conference definition of precision EM and our particular consensus conference technical expert panel’s focus on health care delivery and access. Specifically, the goal was to ascertain how precision EM applies to health care delivery and access. This objective informed the specified goal of the literature review: to characterize the current state of knowledge pertaining to big data and technology as used to ensure and enhance access to acute/unscheduled care for individual patients and their communities. Electronic searches for published literature were conducted by a medical librarian (ML) using Ovid MEDLINE (1946 to present), Embase.com (1947 to present), Cochrane Central Register of Controlled Trials (CENTRAL) via Ovid (1991 to present), and ClinicalTrials.gov (1999 to present). The searches were run in January 2023.

The search strategy incorporated controlled vocabulary and free-text synonyms for the concepts of EM, health care delivery or health care access, and precision medicine. The full database search strategies are documented in Supplements S1–S4. No restrictions on language or any other search filters were applied. All identified studies were combined and deduplicated in a single reference manager (EndNote⁸) then uploaded into Covidence systematic review software.⁹

Our technical expert panel was inclusive of EM health services experts, topical experts in precision medicine, a medical librarian, and patient representative. Title and abstract reviews were completed independently by two reviewers (RAS, KSZ), with meetings to resolve any disagreements. The resultant 60 studies were divided between five team members (MGE, KEK, RK, RAS, KSZ) who were responsible for full-text review and data abstraction. To be eligible for inclusion, studies were required to fulfill the following criteria:

1. Includes content specific to, or does it include, the acute care setting (prehospital, emergency departments [EDs], urgent care).

2. Is related to health system’s role either in delivery or access to care.

3. Can be described as personalized/precision medicine (as defined above, by consensus conference leadership).

4. Is not a better fit for a different workgroup in the consensus conference (e.g., genomics research; Supplement S5).

If questions arose during the initial full-text review or if the application of any criteria to an identified study was unclear, the entry underwent a second full-text review to adjudicate inclusion. Following inclusion, data were abstracted by one of the workgroup members (RAS, MGE, KEK, RK, KSZ) using a standardized data abstraction tool (Supplement S6). This included the primary topic areas of each paper, potential research questions/gaps, and relevant themes identified. The identified topics, research gaps, and themes were then presented to the technical expert panel in a subsequent meeting where they were further discussed and refined. Our technical expert panel used these themes to develop a draft framework to address the use of precision EM in health care delivery and access and propose immediate and long-term research questions in the field of precision emergency care delivery (Objective 1).

From the identified research gaps, a proposed evidence-based research agenda was developed (Objective 2). Utilizing a modified Delphi process, both products were then presented and refined in an iterative fashion over the course of three sessions. The participants included a group of topic experts (including the technical expert panel) in attendance during the SAEM 2023 Consensus Conference (Supplement S7). The final four research questions were selected by consensus at the end of the final session.

RESULTS

Objective 1: Creation of a framework for the integration of precision medicine and health systems science

Our search strategy produced 815 studies for initial screening. After title and abstract review, 60 studies were identified from this list and underwent full-text review by the full technical expert panel. One additional article was identified through citation review of included studies. In total, 21 studies met our inclusion criteria and were abstracted (Figure 2; Table 1). Reasons for exclusion included lack of reference to acute care setting (n = 15) or not specific to health care delivery or access (n = 13) or they did not fit precision medicine definition (n = 12). Using the studies identified, six topical areas were identified (Figure 3). Summaries of the included articles were aggregated and outlined as the current state of the literature as captured by our review (“What We Know”) and identified research question are outlined opposite to those summaries (“Knowledge Gaps and Research Questions”). The level of each summary or research question correlates directly to each of the identified themes, which are represented in the central figure.

FIGURE 2.

PRISMA 2020 flow diagram.

TABLE 1.

Summary of included articles.

Title	Author	Year	Article Type	Summary
“Learning health care” for patients and populations	Abernathy	2011	Editorial	Advocacy toward “learning health care” in which data are used to personalize care for patients with continuous monitoring and outcomes.
Pilot Project: Community Health Assessment Program Through Emergency Medical Services	Agarwal et al.	2013	Clinical trial	Evaluating a weekly 8-h EMS program in the implementation of potential preventative interventions, potentially impacting decrease in EMS calls.
Health care hotspotting: a scoping review	Alderman and Conklin	2022	Review article	Scoping review of hotspotting as a mechanism to improve medical care for “super-utilizers.”
A new tool to measure acuity in the community: a case study	Baker et al.	2021	Original research	Report of hospital-at-home program and the development of risk stratification tools for measuring patient acuity/trajectory.
Special Needs Tracking and Awareness Response System (STARS): improving pre-hospital care for complex medical needs patients	Casey et al.	2019	Meeting abstract	Report of a hospital-based program developed to implement individualized prehospital emergency care plans for medically complex children.
Telemedicine fighting acute coronary syndromes	Clemmensen et al.	2010	Summary article	Brief history of teletransmitted ECG and recent results obtained when used in routine practice for acute triage and referral.
Patient perceptions of the EDITH (Emergency Department in the Home) Service	Davis et al.	2022	Meeting abstract	Evaluation of older adults' perspectives on alternatives to ED locations of care.
Impact of an individual plan of care for frequent and high utilizers in a large healthcare system	Fertel et al.	2019	Original research	Study of the implementation of individualized care plans on costs, inpatient length of stay, and ED visits.
Models of care for frail older persons who present to the emergency department: a scoping review protocol	Huang et al.	2020	Review protocol	Scoping review protocol examining models of care for frail older persons who present to the ED.
Automated external defibrillator delivery by drones: are we ready for prime time?	Karam	2022	Editorial	Discussion of the potential of AED drone delivery for out-of-hospital cardiac arrest.
The role of the Internet of Things in Healthcare in supporting clinicians and patients: A narrative review	Lederman et al.	2021	Review Article	Survey of literature on the Internet of Things (IoT) in health care with instructive examples of how it can be used.
Answering the alarm: a system of care for Black youth at risk for suicide (WeCare)	Lindsey et al.	2022	Clinical trial	Study utilizing tailored, technological interventions as a systems-level strategy to respond to suicide risk among Black adolescents who present to EDs.
Effectiveness of a transitional home care program in reducing acute hospital utilization: a quasi-experimental study	Low et al.	2015	Original research	Evaluation of individualized care plans for transitional home care on ED visits and hospital readmissions for medically complex patients.
Predictive tracking of patient flow in the emergency services during the virus winter epidemics	Mory et al.	2016	Clinical trial	Development of a predictive tool to alert to anticipated influx of people to EDs during winter epidemics.
Implementing myocardial infarction systems of care in low/middle-income countries	Nascimento et al.	2019	Review article	Description of access barriers to standard of care for myocardial infraction in low-income countries and potential strategies to overcome barriers at both the individual and the community levels.
Developing a digital handover application for paramedics to provide a personalized approach to pre-hospital stratification for out of hospital cardiac arrest	Pareek et al.	2022	Clinical trial	Evaluation of the impact of point-of-care labs in the prehospital setting on clinical outcomes after out-of-hospital cardiac arrest.
Evaluation of a patient-centered integrated care program for individuals with frequent hospital readmissions and multimorbidity	Pineiro-Fernandez et al.	2022	Original research	Evaluation of a program designed to reduce readmissions among multimorbid patients and patients with frequent readmissions.
Measuring health equity for ambulatory care sensitive conditions in a large integrated health care system: the development of an index	Pressman et al.	2019	Original research	Development of an index to measure ambulatory care sensitive visits as an indicator of health system inequities.
Acute PAncreatitis and Home Care vs. Hospital Admission Study	Ramirez-Maldonado et al.	2022	Clinical Trial	A study of patients with pancreatitis who may be appropriate for home treatment rather than in-hospital.
Personalized prehospital triage in acute ischemic stroke	Venema et al.	2019	Original research	Simulation modeling to determine the optimal personalized prehospital transportation strategy (primary stroke center vs. intervention center) for stroke patients.
Utilizing a health information exchange to improve care transitions after an emergency department visit	Vrablik et al.	2019	Meeting abstract	Report of the implementation of a tailored care plan in the Emergency Department Information Exchange (EDIE).

FIGURE 3.

Framework for the integration of precision medicine and health systems science.

Expedited/personalized prehospital care

Among the studies designated for inclusion, three studies directly addressed transport or care delivered in the prehospital setting.^10–12 These studies identified personalized prehospital protocols intended to streamline care of complex pediatric patients and evaluated point-of-care testing that allowed for patient stratification in out-of-hospital cardiac arrest patients. Also, when considering prehospital care for cardiac arrest, one article discussed the use of drones to deliver automated external defibrillators. Overall, these articles reflect ways in which personalized prehospital emergency care may be operationalized. They highlight opportunities to expedite definitive care through the delivery of information or resources to emergency medical services (EMS) clinicians while also ensuring that this care can be tailored to the patients and communities being served.

Transport to right level of care

Adjacent to the process of delivering appropriate care in the pre-hospital setting is transporting patients to an appropriate level of care. Here we find examples related to two well-developed systems of care—for myocardial infarction and stroke. The studies identified consider patient transport to the appropriate level of care (e.g., interventional stroke center for suspected large-vessel occlusions)¹³ and with prehospital data transfer to ensure mobilization of resources (e.g., prehospital ECG transmission for myocardial infarction).^14,15 The proposed interventions leverage the existing systems of care to address a patient’s acute care needs efficiently.

Personalized acute care

The largest group of studies in the space of personalized acute care delivery dealt with either personalized care plans or multidisciplinary care teams for complex or marginalized patients.^16–21 Topics addressed were broad and included ED care for frail older patients, recently discharged patients, high utilizers, and mental health care for Black adolescents, among others. These findings reflect the importance of considering specific patient needs within the ED, such as patients with high health care utilization as well as the needs of communities, as reflected in studies considering culturally tailored approaches to mental health treatment for Black youth.¹⁹

Transitions of care and alternative care space

In addition to the provision of high-quality care in the ED, consideration of alternative care spaces also arose in our review of the literature. Several articles evaluated the potential use of EMS clinicians to extend care to the home either before ED presentation or after.^22–27 Access to acute/unscheduled care may be expanded through the inclusion of care by different providers and use of technology expanding the traditional view of care spaces.

Creation/maintenance of equitable systems of care

Leveraging our systems of care to prevent or address disparities in access, care delivery, and outcomes remains a critical component toward advancing health equity. Two articles address how precision EM may be used to this end, evaluating the role of hotspotting, or population-targeted interventions to improve access and developing equity-focused care measures to track health system inequities.^30,31

Prediction tools for system readiness

A key component of emergency care is the ability to respond rapidly to shifts in strains on the health care system, either due to predictable patterns (e.g., seasonal patterns in viral transmission) or to unanticipated events (e.g., mass casualty events). Two reviewed studies considered utilization of either predictive modeling or real-time monitoring to improve system responsiveness.^28,29 Utilizing health, geospatial, and public safety information allows for improvements in precision of the health system to care for their communities. Together, these themes create a foundation to inform our understanding of the current state of how precision EM is currently used and understood for improving emergency care delivery.

Objective 2: Defining the research agenda for precision emergency care delivery

Through an iterative process, our technical expert panel used the identified themes to guide the development of broad research questions that address potential gaps in the literature. The complete list of drafted questions that were brought to the larger consensus group is presented in Supplement S8.

Following three rounds of revision and prioritization to achieve consensus, the final priority research questions included:

1. How should EDs and health systems integrate into the communities they serve (e.g., use of health information exchanges, expansion of virtual and at-home care modalities) and use prediction tools to deliver care better and optimize care transitions across care delivery spaces?

2. What are best practices for identifying and engaging key parties and conducting research on and implementation of personalized medicine within emergency care delivery systems?

3. How do we integrate other care providers and use bidirectional data transfer to optimize this system (e.g., EMS clinicians, primary care offices, rehab facilities)?

4. What measures can be used to evaluate equity in the implementation of precision medicine within systems of emergency care?

DISCUSSION

This work provides a definition for the intersection of precision EM and health care delivery and access based on a rapid review of the literature with a goal of guiding future work and research in this topic area. Our proposed definition for the application of precision EM to health care delivery and access is “the study of big data and technology as used to ensure and enhance access to acute/unscheduled care for individual patients and their communities.”

Using this definition, we identified six key themes based on a review of the literature and ongoing research studies: (1) expedited/personalized prehospital care, (2) transport to right level of care, (3) personalized ED care, (4) transitions of care and alternative care spaces, (5) prediction tools for system readiness, and (6) creation of equitable systems of care. This framework developed from these themes will be valuable to facilitate the creation of a robust foundation of knowledge. To guide next steps, four questions were identified as priority research areas which are reviewed below in detail.

1. How should EDs and health systems integrate into the communities they serve (e.g., use of health information exchanges, expansion of virtual and at-home care modalities) and use prediction tools to deliver care better and optimize care transitions across care delivery spaces?

   Our first question focused on the integration of EDs and health systems into the communities that they serve. Broadly, this research question addresses the selection and dissemination of newly developed technology at the systems level to improve care delivery and match system resources to patient needs. This includes disaster-preparedness and planning, e.g., technology to coordinate resource distribution and the exchange of information prior to patients presenting to the hospital.²⁸ Technologies to augment prehospital medical control calls (such as the integration of video³²) facilitate rapid disease recognition in the prehospital setting,^11,13 initiate treatment prior to ED arrival,¹² or deliver virtual/at-home care illustrate the ways in which health systems can be leveraged to deliver precision medicine to patients and communities.^22,23,27 By building infrastructure for information sharing, we facilitate coordination of care systems as well as research into the application of these systems to serve the specific needs of their communities.

2. What measures can be used to evaluate equity in the implementation of precision medicine within systems of emergency care?

   This question entails both individual and societal measures of equity, spanning from the delivery of individual patient care to equitable access and utilization by communities. While historically, the approach to building and growing systems has not necessarily been centered around health equity, ongoing data advances and new technology provide an increased opportunity to detect and intervene upon ongoing health inequities. By adapting our existing systems with attention to gaps in care, we may be able to more rapidly and efficiently address population-level questions such as: (1) transfer systems, including which communities have access to appropriate levels of care and how this may impact transfer patterns; and (2) reconsideration of the role or definition of catchment areas to clearly define the responsibilities of the health care systems to the communities they serve.

   Additionally, it is important to acknowledge the dependence of such efforts on the data and definitions used. For example, the definition of “community” may be related to geography, disease process, identity, or a combination thereof. Further, current data are often limited by poor data quality³³ or inconsistent collection and reporting.³⁴ Finally, as data advances and technology are disseminated, particular attention to their role in the mitigation or exacerbation of disparities, such as those seen in rural or critical access hospitals, is crucial. In developing equitable systems of care, we must also center on improved, representative, and transparent methods as part of advancing research to address the systems and structures that may serve as the root cause of existing inequities.^35,36

3. How do we integrate other care providers and use bidirectional data transfer to optimize this system (e.g., EMS clinicians, primary care offices, rehab facilities)?

   At present, patient clinical information tends to exist almost exclusively in a “forward flow” model. In this model, for example, EMS clinicians provide data to receiving EDs; however, there are limited mechanisms to retrieve relevant clinical data prior to arrival. Though the development of rapid information transfer forward is critical to emergency care, feedback in a bidirectional or closed-loop pattern is similarly important in improving patient-specific, coordinated care. This research question broadly addresses care transitions as an opportunity to improve the health system’s ability to implement patient and community-specific care plans. Examples include rapid care coordination to better interface with PCP’s office (e.g., in goals of sending to ED or ED avoidance, ED follow-up, systems resources); minimizing loss to follow-up by determining levels of care, coordinating discharges, safety planning; prioritizing feedback systems to EMS clinicians for ongoing quality management; and using real-time data to improve care delivery in hospital system. As an important component of these advances, questions around maintaining data security while simultaneously improving bidirectional flow will be critical for long-term viability. In these ways, precision EM can help refine workups, improve longitudinal patient care, and rapidly respond to fluctuations in system pressures.

4. What are best practices for identifying and engaging key parties and conducting research on and implementation of personalized medicine within emergency care delivery systems?

   Several of the studies identified involve a broad spectrum of key parties both across the health system and within communities. As appropriately identifying and engaging with invested communities are critical to the success of any precision EM advances, guidelines on such methods become similarly important. Depending on the question, this may include community members, various job families, patients, and community organizations. As research is designed to apply health systems sciences to the delivery of precision EM, approaches to engaging key parties may be snowball sampling methodology to reach communities, including those that may experience barriers to participation; engagement of qualitative/community-based participatory research experts as part of the central research team; and increased utilization of existing recommendations for patient-centered care and research, such as those developed by the Patient-Centered Outcomes Research Institute and the Lown Institute’s Right Care Alliance.^37,38 Through representative engagement of those impacted by the research questions at hand we enhance the ability to develop precision EM systems of care to communities.

LIMITATIONS

It is important to note the potential limitations of our approach. In particular, given the expansive nature of precision medicine and the nature of a rapid review, certain articles may have been missed by our approach. For example, due to our focus on prehospital and hospital search terms, alternative care destinations that did not occur after a 9-1-1 encounter or ED visit may have been missed. Additionally, as the concept of precision in delivering care to communities is still emerging in the literature, work that did not specifically use terminology related to precision medicine would not have been captured by our search results. While we attempted to augment these gaps via feedback from topic experts, future work in the space of precision EM and health care delivery may lead to subsequent revisions to our presented framework.

CONCLUSIONS

Precision emergency medicine has tremendous potential to advance emergency medicine and health care delivery systems. Just as regionalization and the growth of specialized care centers (e.g., trauma centers) have improved population access to high-quality time-sensitive care, the next steps in advancing emergency care systems can incorporate big data and technological innovations in the next phase of development. These strategies may enable personalized care, community-specific care options, and enhanced system organization and preparedness. Approaches must simultaneously consider priorities of patients, communities and key parties to ensure that advances are patient-centered and enhance equity in emergency care access and delivery.