‘RAP’ IN ‘RAPPORT’
Amajor component of eRAP surveillance involves the application of programmatic algorithms to electronically identify frequent users and sort them by impact to the EMS system. By data mining
multiple repositories, eRAP recognizes a distinct person across multiple
incidents, uses a patient-association technique to collect all records connected to a unique patient and converts them into an auto-populated,
patient-centric case management system. The eRAP patient-association
mechanism matches patients in spite of errors or missing information.
Patients are then electronically ranked according to their number of 9-1-1
encounters and displayed on active dashboards.
Remarkably, during the process of developing this technology, eRAP
identified three individuals among the city’s 10 most affective patients who
had never been referred or previously identified, including the number one
EMS user in the city. We attribute the conventional method’s inability to
identify this patient to two principal factors: 1) the vast geographical range
from which this individual called 9-1-1, and 2) the aggressive rate at which he
calling the 9-1-1
previous frequent use.
>> Case 1: RAP
Client 1 is an energetic 60-year-old
male with underlying schizoaf-fective disorder.
A resident of a
he used to use a
senior citizen discount to enthusiastically tour San Diego via public transportation. When routes were inconvenient, he called 9-1-1 and strategically
requested a hospital close to his desired destination. On arrival at a hospital,
he typically eloped and reactivated 9-1-1 several blocks away.
By the time this patient’s behavior was identified and referred to RAP,
the client had accumulated 96 ambulance transports in three months. The
geographical spread of his calling location was so vast (see map above),
and his interactions with fire engine and paramedic crews so diverse that
he went unrecognized in the system. Based on eRAP’s electronic patient
ranking data, RAP was able to intervene and assist in developing a comprehensive case plan.
Unfortunately patients with this level of affect frequently have inadequately treated psychiatric disease and require a multitude of resources
to be stabilized. When Client 1 began exhibiting violent behavior toward
first responders and reached more than 200 calls in a brief period, he
was arrested and charged with 9-1-1 abuse, false reporting and assaults
on ambulance personnel. Once in custody, RAP advocated for the
patient’s redirection into the behavioral health court system, which typically results in supervised medication management and psychiatric care.
Unfortunately, the court therapeutic team determined the patient did not
have the ability to comply with treatment requirements, and the patient
received 90 days of custody plus three years of probation. After serving
90 days, the patient was released from jail. He promptly activated the 9-1-1
system from across the street in less than five minutes of his release. RAP
is still currently working to find appropriate resources for Client 1.
1: Electronic ranking to ID
most active callers
Perhaps the most groundbreaking function of eRAP is its ability to electronically identify vulnerable people in San Diego who have come in contact with EMS. All incoming ePCR and CAD incidents are put
through vulnerability filters, where eRAP searches the report for indications of
vulnerabilities, such as substance abuse, psychiatric and behavioral emergencies, in-home falls and hoarding behavior Individuals associated with these
incident types are identified, aggregated and ranked using custom recognition
algorithms. Vulnerability flags are automatically added to the patient’s profile
page; other data aggregated within the profile page include patterns in 9-1-1
activity, such as calling location, time of day and hospital destinations, to help
subsequent RAP case management strategies.
The eRAP “in-home vulnerability” algorithm identifies addresses where residents appear to be experiencing specific difficulties. The search algorithm is
2: Electronic discovery of
The eRAP program monitors and displays all incoming 9-1-1 calls on its iPad interface via a patient associative live “CAD View” screen. When engine or ambulance crews enter patient information into a handheld ePCR
device and click “save,” CAD View creates a link to that current patient data.
This allows RAP to identify patients within minutes of a 9-1-1 call, even while
crews are still on scene. Additionally, an icon indicates if the patient fulfills
vulnerability criteria or is a “top 50” client and tapping it will take the provider
to the patient-specific management page.
>> Case 3: RAP Client 3 is a 56-year-old homeless male who often called
9-1-1 up to three times per day from the same payphone. His chief complaints
were anxiety and shortness of breath after a bad dream; his symptoms
typically resolved after being awake for several minutes. All 9-1-1 calls would
occur during the daytime, with estimated costs to EMS and first responders of nearly $25,000 per month. RAP provided case management services
with its sister program, the San Diego Police Department (SDPD) Homeless
Outreach Team (HOT).
3: Patient associative CAD View
The eRAP program allows responders and assigned case managers to subscribe to time-sensitive 9-1-1 information alerts relevant to current case management workflow. Alerts can be delivered as e-mails, text messages and pages.
>> Case 4: RAP Client 4 is a 59-year-old chronically inebriated male who had
enrolled in the SDPD San Diego Serial Inebriate Program. In one year, the patient had
generated more than 70 alcohol-related ambulance transportsand four admissions to
the Level 1 trauma center. Three months after achieving sobriety, the patient relapsed
and was encountered again by EMS. The eRAP alerting system sent a text message