The Future of Service Delivery, Reimbursement, Education, Dispatch, Medical Direction,

Technology and Regulation

EMS 3.0

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A merica’s healthcare system is undergoing one of the most significant transformations

in history. Fee-for-service payment models that financially reward providers for activities instead of outcomes are rapidly transitioning to payments based on patient outcomes and the quality performance of healthcare providers. Economic models such as accountable care organizations (ACOs), value-based payments, shared savings and bundled-payment methodologies are rapidly being implemented by the Centers for Medicare & Medicaid Services (CMS) and other payers. CMS has announced its desire to have 90% of Medicare payments tied to quality-based measures by 2018 and is rapidly moving toward that goal by implementing programs such as the Hospital Readmissions Reduction Program and Bundled Payments for Care Improvement initiative.1–3

Additionally, the frenetic merger and acquisition activity on both the payer and provider sides of the healthcare equation demonstrates the race to gain negotiating leverage by increasing the patient populations covered by payer groups and the provider populations included in delivery networks.

While we may never have a true single-payer system like most economically developed countries in the world, it appears we may be headed toward an oligopolistic system with a few payers and a few providers who will negotiate healthcare delivery to the majority of the U.S. population.

This healthcare transformation has been referred to by many industry

experts as “Healthcare 3.0” because it represents the third major evolution

of healthcare finance and delivery, and hints that there will be more

evolutions to come.

EMS 3.0 ExplainedModern emergency medical services essentially began soon after the National Highway Transportation

Safety Administration published its landmark paper

Accidental Death and Disability: The Neglected Disease of Modern

Society, which among other things detailed the inability of EMS systems to effectively respond to vehicle crashes and other trauma incidents.4

Largely as a result of the deficiencies highlighted in the report, Congress passed the EMS Systems Act of 1973.5 The act essentially made federal grants available for the development and evaluation of enhanced and coordinated EMS systems.

Prior to its passage, ambulance service was delivered largely by a patchwork of untrained and uncoordinated providers who were not integrated into the overall healthcare system. In fact, nearly half of ambulance services were provided by funeral homes. We can call this period EMS 1.0.

Transformation: Showing the Value of EMS Top national associations are coming together to drive the industry’s next evolution

By Matt Zavadsky, MS-HSA, EMT, National Association of Emergency Medical Technicians

This infographic, produced by the National Association of Emergency Medical Technicians, outlines key considerations as our healthcare system transforms. Download at EMSWorld.com/12196811.

4 EMS 3.0

Since then advances in EMS delivery systems, provider training and clinical processes of care have largely improved the reliability and coordination of EMS delivery. However, payment for transport has been essentially unchanged as the primary reimbursement model. EMS is generally paid to transport patients to the hospital—we are a transportation supplier, not a healthcare provider system. This model rewards EMS for and incentivizes us to drive up healthcare system costs by using the highest-cost transportation resource (an ambulance) to transport patients to the highest-cost healthcare provider (an emergency department) without any real proof of the value of that model for most patients. Consider this EMS 2.0.

While we were improving the delivery of EMS, we spent very little time studying the effects of what we were doing. While there is a robust library

of published research on the process of care delivery, there is a dearth that shows better patient outcomes as a result of these enhancements. As an example, even after investing billions of dollars to reduce the time from sudden cardiac arrest to the initiation of CPR, the national survival rate for out-of-hospital cardiac arrest has barely changed.

Proving ValueWith the changing focus of payers and providers to reward outcomes and value, the EMS profession needs to transform how we integrate our services into the healthcare system. And that goes way beyond the concepts of community paramedicine. We need to prove the value we bring to patients, healthcare providers and healthcare payers if we are going to not only survive but thrive in the healthcare 3.0 environment—hence the need to transform to EMS 3.0.

Figure 1: Areas of Leadership Attributes Association Lead

Industry education and legislative advocacy National Association of EMTs

Payment reform and legislative advocacy American Ambulance Association

Regulatory oversight National Association of State EMS Officials

Medical oversight and clinical practice National Association of EMS Physicians

Education reform National Association of EMS Educators

Leadership development and management National EMS Management Association

Technology and information systems The Paramedic Foundation

Call-taking and resource allocation International Academies of Emergency Dispatch

The EMS 3.0 transformation is envisioned by leaders from eight national associations who have come together to drive the initiative—each leading within their specific area of expertise and influence but with the true alignment we all need to move in the same direction together. For the associations participating and areas they’ll lead, see Figure 1.

Advocacy GoalsA criticism of EMS during legislative initiatives has been the lack of a unified voice speaking for the industry. The process of developing this shared vision of the future and EMS’ role in it has brought these associations together. All agree on a general direction for our industry. In fact, several participants have invited other association representatives to join committees of their associations to share ideas and collaborate.

We hope this initiative, and the education afforded to the industry through forums such as this supplement, will help inform our internal and external EMS stakeholders on the changing overall direction of EMS from a simple mechanism for patient conveyance to a fully integrated, patient-centered provider of medical care that demonstrates value to the patient and the rest of the healthcare system.

REFERENCES1. Rau J. HHS Pledges to Quicken Pace Toward Quality-Based Medicare Payments. Kaiser Health News, kaiserhealthnews.org/news/hhs-pledges-to-quicken-pace-toward-quality-based-medicare-payments/.2. Centers for Medicare & Medicaid Services. Readmissions Reduction Program (HRRP), www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/readmissions-reduction-program.html.3. Centers for Medicare & Medicaid Services. Bundled Payments for Care Improvement (BPCI) Initiative: General Information, https://innovation.cms.gov/initiatives/bundled-payments/.4. National Academy of Sciences, National Research Council. Accidental Death and Disability: The Neglected Disease of Modern Society. EMS.gov, ems.gov/pdf/1997-Reproduction-AccidentalDeathDissability.pdf.5. Cengage Learning. EMS Systems Act of 1973, cengage.com/resource_uploads/downloads/1435480279_241560.pdf.

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6 EMS 3.0

T he evolution of EMS has continued since the above was published in 2006, but the payment system,

especially in the Medicare program, has remained stagnant. Ambulance services have been virtually ignored as federal and state policy-makers seek to drive healthcare providers toward more innovative models. Overall, ambulance services account for a tiny amount of Medicare’s expenditures, but they offer the promise of improved care transitions and patient outcomes. Before this promise can be achieved, however, it is necessary to address three immediate barriers in the current Medicare payment system: 1) economic instability; 2) a focus on medical transportation rather than the provision of healthcare services; and 3) the designation of ambulance services as suppliers rather than providers of healthcare.

This concept was reinforced by the National Academy of Sciences in its June 2016 report A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury.1 The report contains a significant recommendation for enhancing the economic model for EMS. The authors of the report, chaired by Donald Berwick, MD, recommend: Congress, in consultation with the U.S. Department of Health and Human Services, should identify, evaluate and implement mechanisms that ensure the inclusion of prehospital care (e.g., emergency medical services) as a seamless component of healthcare delivery rather than merely a transport mechanism.

Possible mechanisms that might be considered in this process include, but are not limited to amendment of the Social

Security Act such that emergency medical services is identified as a provider type, enabling the establishment of conditions of participation and health and safety standards.

Additionally, modifying the Social Security Act to define EMS as a provider type could prompt CMS to develop a trauma- or emergency care-based shared savings model with relevant metrics that could be used to measure the value of prehospital care delivered, including patient outcomes and the appropriateness of the facilities receiving patients.

The American Ambulance Association (AAA) continues to lead the effort to develop forward-thinking yet practical payment reform efforts nationally. As part of this effort and in coordination with the National Association of EMS Physicians (NAEMSP), National Association of EMTs (NAEMT) and National Association of State EMS Officials (NASEMSO), the AAA has identified three short-term policy reforms that would set the stage for future innovative payment models.

The immediate priority is to obtain federal reimbursement levels for EMS that are more closely aligned to the costs of delivering the service. The short-term reform includes:

➤➤ Building the temporary ambulance add-ons into the base rate, consistent with findings from the Governmental Accountability Office that current

A Road Map to Payment ReformHow we can achieve an updated reimbursement structure

By Kathy Lester, American Ambulance Association

“Emergency care has made important advances in recent decades: emergency 9-1-1 service now links virtually all ill and injured Americans to immediate medical response; organized trauma systems transport patients to advanced, lifesaving care within minutes; and advances in resuscitation and lifesaving procedures yield outcomes unheard of just two decades ago.”

—Emergency Medical Services at the Crossroads

EMSWORLD.com 7

Medicare rates are below the cost of providing services;

➤➤ Establishing a cost data collection system, tailored to the unique nature of ambulance services, consistent with the report issued by CMS under the American Taxpayer Relief Act; and

➤➤ Designating ambulance services as providers of service so that the healthcare services they deliver as outlined in a 2006 report by the then-Institute of Medicine (now the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine) are eligible for reimbursement based on the services they provide (healthcare) as opposed to a supplier of transportation.

These policies would not only create the economic stability to innovate, but also establish the foundation necessary to reform the payment system by providing meaningful and reliable cost information to promote improving reimbursements and paying for services apart from transportation as a way for EMS to deliver high-value services. If the policies are not implemented, then the industry risks being relegated to harsh competitive bidding rates, such as those imposed on durable medical equipment, and/or becoming subcontractors to larger provider systems and subject to an ever-shrinking pie.

While some agencies have been able to work with local non-Medicare payers to develop and test new economic models for EMS delivery, federal government support and reimbursement for such models will depend on achieving comprehensive, accurate and reliable cost data and having ambulance services designated as healthcare providers. These intermediate-term reform policies would allow Medicare to leverage the unique aspects of ambulance services, reduce unnecessary emergency room visits and eliminate fraud and abuse in the area of nonemergency services. These policies include:

➤➤ Coverage and payment for transport

to alternative destinations;➤➤ Establishing coverage and payment

for response, assessment and referral at the scene without transport; and

➤➤ More specifically defining nonemergency services.

As these new payment models are developed and implemented, the AAA, NAEMT, NAEMSP and NASEMSO urge the industry to continue efforts to build consensus and support for longer-term reform efforts that will allow for even greater innovation. Such models could include:

➤➤ Seeking coverage and reimbursement for triage services;

➤➤ Seeking coverage and reimbursement for community paramedicine (including efforts to better manage and coordinate individual and population care); and

➤➤ Seeking more comprehensive payment reform related to the ambulance fee schedule, including refining payment categories, addressing high-cost items and considering patient characteristic and/or ambulance provider adjusters.

The challenge with any of these longer-term reforms is how to establish

a sustainable payment rate for providing the services, especially if these services are not related to traditional EMS care provided at a scene. While demonstration projects have shown progress, the federal government has yet to agree to reimburse for these services directly. If these services are to help increase the federal funding for ambulance services, it will be imperative to have valid and reliable cost data for providing such services, as well as valid and reliable outcomes data showing the value of these services in reducing overall Medicare costs.

Finally, the AAA has long acknowledged the importance of establishing a data-driven paradigm for EMS. However, the first step is not to implement a value-based purchasing (VBP) program. CMS does not believe VBP is necessary to drive quality in EMS. However, valid and reliable quality metrics are important for internal quality assessment and quality improvement activities, as well as research. Thus, while not a component of payment reform, developing a core set of measures for QA/QI and evidence-based practices will be an important part of the future of EMS.

REFERENCE1. National Academies of Sciences, Engineering, and Medicine. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press, 2016.

The immediate priority is to obtain federal reimbursement levels for EMS that are more closely aligned to the costs of delivering the service.

8 EMS 3.0

T he vision of the National Association of State EMS Officials (NASEMSO) includes “a seamless

nationwide network of coordinated and accountable state, regional and local EMS and emergency care systems. The systems use public health principles, data and evidence as a basis for safe and effective care.”

A majority of state EMS agencies embrace this encouragement to take a broad leadership, planning and facilitating approach to system development and oversight. These agencies, as exemplified in California,

Maine and South Carolina, have proactively developed pilot programs to enable mobile integrated healthcare (MIH)- and community paramedicine (CP)-type programs, one component of the EMS 3.0 transformation. Others, such as Colorado, Wyoming and North Dakota, have recently changed laws and/or regulations to accommodate MIH-CP. According to NASEMSO surveys conducted over the last three years, 46 states or territories have, or will have in 2016, laws and regulations that enable (or do not prevent) MIH-CP.

The EMS 3.0 initiative encourages

EMS systems and agencies to become integral components of transforming community health systems. This means providing a well-organized and -equipped response to medical emergencies as a fundamental service and building on that foundation the ability to target other unmet and unscheduled nonemergency health needs of the community. Our challenge is also to analyze and update the components and attributes of the EMS system so they are

consistent with this integration within the overall healthcare system.

Beyond enabling CP pilot programs and changing laws or regulations, some state EMS agencies have taken leadership roles in engaging potential stakeholders at informational and planning forums as MIH-CP services are contemplated, bringing MIH-CP services and potential funders (e.g., Medicaid) together, and planning for ways to establish regulations that protect the public while enabling services to be delivered under the EMS 3.0 conception of EMS.

State Leadership and LawState offices must help pave the way for MIH-CP and other aspects of change

Consensus has been that CP does not involve a change in scope of practice, but rather a change in its role or setting.

By Kevin McGinnis, MPS, & Paul Patrick, National Association of State EMS Officials

Photo: Dan Swayze, Center for Emergency Medicine

EMSWORLD.com 9

Regulatory ChallengesSome system features contemplated in the EMS 3.0 approach, such as the involvement of nurse triage in the 9-1-1 call process, have evolved over time and have well-defined standards of care and operation that can serve as proxies within regulations. Some other 9-1-1-initiated features of EMS 3.0, such as alternative transport destinations, treat and release, and compliance with POLST, all predate CP but have been managed through existing rules or protocols. Yet other system features, such as MIH, are more difficult because they involve organizational partners and operational arrangements that vary with local needs, and a mix of providers (e.g., doctors, nurses, physician assistants, EMS personnel) licensed by potentially different agencies.

Community paramedicine is an important component of EMS 3.0 but falls in the middle of the range of regulatory difficulty. The traditional definition of CP is utilizing EMS resources to address community healthcare gaps. In most states this keeps CP in the jurisdiction of the state EMS agency. Consensus has been that CP does not involve a change in scope of practice, but rather a change in its role or setting. Many state EMS agencies have said that if there is no change in scope of practice presented by CP activities, then CP may be practiced. Some states, such as Texas, have no statewide EMS scope of practice. As long as there are no other exclusions in law or rule to CP, then it may exist with the blessing of, and a scope defined by, the local medical director.

The setting in which CP is practiced may often be the patient’s home. One regulatory complication that has never arisen in emergency calls in patients’ homes is whether nonemergency CP services constitute home healthcare and are subject to regulation under the state agency responsible for regulating such care. This was found to be the case

with one EMS agency in Colorado that was required to license as a home health provider (Colorado’s recent law change fixed this). This discussion is occurring in other states as well, with no generally applicable consensus yet.

When the EMS Systems Act of 1973 was enacted, planners of the time discussed the EMS system as extending from primary prevention (preventing emergency illnesses and injury) to secondary prevention (mitigating the impact of an emergency illness or injury when it occurs through fast and appropriate response) to tertiary prevention (rehabilitative care to prevent recurrent emergency illness or injury or other untoward conditions arising). These concepts reemerged in the 1996 EMS Agenda for the Future but were largely forgotten as state EMS

enabling laws were written in the 1970s to 1990s. The resulting language often narrowed the application of emergency medical services and the practice of EMS providers to emergency response and care during patient transport. Law changes to enable CP have often addressed this limitation.

Another area of regulatory focus is the training and certification of CP practitioners. From a clinical practice perspective, the scope of practice issues discussed above may make this a moot point. Some states and local agencies are developing training programs limited to the role and setting of the CP practices to be employed. Some states are requiring a college-based CP training program (a national consensus course is in its fourth

edition and widely used) and/or a national certification (a national certification examination for CP is now available).

Responsibility to MeasureMuch of state EMS regulation involves a responsibility to protect the public, and that is largely what is discussed above. But in returning to the notion of the state EMS agency as system leader, it has a responsibility to measure whether the system is performing as it is supposed to.

State EMS officials have long cringed at newspaper requests for data comparing the response times of EMS agencies as largely irrelevant to the quality of the services provided. Such process measures are relied upon as proxies for slippery-to-implement outcome measures. So too are some structural measures those regulatory agencies use as stand-ins to assure performance quality, such as minimum numbers of certain supplies and equipment carried on ambulances.

The National EMS Information System (NEMSIS) has become a valuable tool with great potential to help monitor the success of EMS 3.0 services. Some ePCR vendors are adapting their products to accommodate MIH-CP use. At least one major effort to define performance measures for MIH-CP has produced useful results and will hopefully become partner to the EMS Compass performance measures initiative.

These types of measures need to be implemented widely to gauge EMS 3.0’s productivity in helping measure the healthcare system’s success in achieving the goals of the Institute for Healthcare Improvement’s Triple Aim:

➤➤ Improving the patient experience of care, including quality and satisfaction;

➤➤ Improving the health of populations; ➤➤ Reducing the per capita cost of

healthcare.

Consensus has been that CP does not involve a change in scope of practice, but rather a change in its role or setting.

10 EMS 3.0

T raditional EMS has been considered to a large extent an extension of the emergency

department—hence the reason we refer to it as “prehospital” care. In the prehospital arena, the traditional role of EMS medical directors, EMS fellowships and the EMS board exam has focused on ensuring optimal emergency care for the population with special emphasis on patients with acute time-sensitive conditions. As EMS and the rest of the healthcare system move toward a greater emphasis on population health, EMS medical direction will need to expand beyond traditional emergency care.

Under the concept of EMS 3.0, prehospital patients may be navigated to locations other than an ED, and services provided by EMS may include post-acute care follow-up or management of patients who are part of plans of care, such as home health and hospice. As such, a collaborative, multidisciplinary approach to medical control and direction may be beneficial.

Consider the following scenario: Your transformed EMS agency has enrolled an adult diabetic patient into its high-utilizer program at the request of a partner hospital. The patient has a primary care physician and an endocrinologist as part of her care team.

One of the goals of your program is to enhance the relationship between the patient and her primary care team to help achieve better long-term outcomes. When you interact with the patient on a scheduled home visit, you find her blood glucose is 70 mg/dL and note in her log that her level has varied significantly pre- and post-meals for the past several days. She is compliant with her short-term and long-term insulin dose and meals, but you would like to know if her current BGL should be treated and how. You also suspect the patient may need a dose adjustment or other evaluation by the endocrinologist.

In this scenario it is logical for you to contact the patient’s endocrinologist for care coordination for a few patient-centered reasons:

➤➤ The endocrinologist likely knows this patient and is familiar with her history and medical issues;

➤➤ The endocrinologist will be the one following up with the patient in his office, preferably in the next day or so, so the medical and environmental history should be provided to him, and the instructions for intermediate care are appropriate to come from him;

➤➤ You want to reinforce with the patient that it is permissible to contact the doctor when issues like this arise and how to ask pertinent questions.

Transforming RolesA transformed EMS agency will still need strong physician medical oversight from an EMS physician. Responses to 9-1-1 calls and prehospital care are still at the core of EMS 3.0 service delivery. However, in the scenario above, it is also logical for primary care or other specialty physicians to be involved in medical oversight as well.

An additional role for the EMS 3.0 medical director is to facilitate navigation and coordinate enhanced protocols in collaboration with those other physicians who may be required for care delivery in the mobile healthcare environment. In some transformed agencies, the EMS medical director may develop care protocols in which EMS-based MIH providers contact other types of physicians who may have an established relationship with the patient for online medical direction.

For example, in the community paramedicine program at New York's Mount Sinai Hospital, primary physicians have obtained a new form of regional certification—the “telemedicine physician”—that allows them to give orders to paramedics if the patient is cared for by the primary care practice. Similarly, in the MedStar system in Fort Worth, the medical director develops MIH protocols in collaboration with other

The Role of the Medical DirectorA more collaborative, multidisciplinary oversight is called for in the future

By Kevin G. Munjal, MD, MPH, National Association of EMS Physicians

EMSWORLD.com 11

physicians involved in the MIH programs. These physicians have specialties such as cardiology, endocrinology, nephrology, family medicine, critical care and even hospice physicians. Part of the protocol is a specific authorization for the EMS MIH providers to contact and receive medical direction from the patient’s physician team.

For program-specific protocols implemented with identified partners such as home health or hospice agencies, the EMS medical director and partner agency’s medical director cosign the protocols for enrolled patients.

Part of the reason for this shared collaborative approach is that on occasion, when the patient’s PCP can’t be reached, the EMS medical director may be consulted for patient care. Knowing the shared treatment protocols will help keep the clinical focus patient centered, even for patients who won’t necessarily be transported to an ED.

9-1-1 Nurse Triage Medical DirectionFor some agencies, part of their MIH approach may include a 9-1-1 nurse triage program. Essentially, this model is an update of the EMS 2.0 version of Emergency Medical Dispatch (EMD). Just as there is a significant role for the EMS medical director in EMD, there is a significant, if not greater role for the medical director in 9-1-1 nurse triage.

The first role will be assisting with the selection of the nursing algorithms and decision support system to be used by the public safety answering point (PSAP) or EMS agency. There are several available and the medical director should have an essential role on choosing which program the agency will use. Next, the medical director should be the final authority on which 9-1-1 call types (response determinants) are eligible to be referred from the 9-1-1 call-taking process to the nurse triage program. In some cases the organization

providing the nurse triage algorithms may require adherence to their own list of call types that are eligible, but the local EMS medical director may choose to exclude some call types from that list or apply to the board of medical advisors to modify that list or otherwise customize those sets of call types depending on the community resources that the nurse may have access to in

support of lower-acuity patients.As an example, MedStar uses the

Priority Dispatch Advanced Medical Priority Dispatch System (AMPDS) for its emergency medical dispatch system and the same provider for its Emergency Communication Nurse System (ECNS). The Board of Medical Advisors for the International Academies of Emergency Dispatch (IAED) approves the response determinant 26-A-06 (sick person complaining of nausea) as eligible for transfer from a 9-1-1 call to the triage nurse. MedStar’s local medical director does not approve this response determinant as eligible. As a result, patients with this response determinant do not get transferred to the triage nurse.

It’s important to note however, that the converse is not true: Even if the MedStar medical director approves of the 26-A-10 (sick person feeling ill) response determinant going to the triage nurse, the IAED Board of Medical Advisors does not authorize a caller with that response determinant to be transferred, so the determinant is ineligible.

SummaryBecause of the expanded role EMS providers may play in the community, medical direction in EMS 3.0 should appropriately be a collaborative effort led by EMS subspecialty-certified physicians specially trained in emergency medicine, but also physicians who specialize in disciplines such as internal/family medicine, critical care, cardiology, nephrology, endocrinology and pulmonary medicine. The EMS 3.0 medical director should be able to build patient-centered coalitions of physicians to help meet the care coordination goals of the patient, their physicians and the EMS system.

Under the concept of EMS 3.0, services provided by EMS may include post-acute care follow-up or management of patients who are part of plans of care, such as home health and hospice. Photo: United Ambulance Service

12 EMS 3.0

Earlier in this supplement we discussed the changing role of the EMS system. A core element of this

transformation is adequately preparing providers in the field to operate in this new environment. For the past 40 years, the key components of training and certification have not changed much, essentially because the role definitions of EMTs and paramedics have not changed much. The National Highway Transportation Safety Administration’s National EMS Education Standards define the roles of EMTs and paramedics as:1

➤➤ Emergency Medical Technician—The primary focus of the emergency medical technician is to provide basic emergency medical care and transportation for critical and emergent patients who access the emergency medical system. This individual possesses the basic knowledge and skills necessary to provide patient care and transportation. Emergency medical technicians function as part of a comprehensive EMS response, under medical oversight. Emergency medical technicians perform interventions with the basic equipment typically found on an ambulance. The Emergency Medical Technician is a link from the scene to the emergency healthcare system.

➤➤ Paramedic—The paramedic is an allied health professional whose primary

focus is to provide advanced emergency medical care for critical and emergent patients who access the emergency medical system. This individual possesses the complex knowledge and skills necessary to provide patient care and transportation. Paramedics function as part of a comprehensive EMS response, under medical oversight. Paramedics perform interventions with the basic and advanced equipment typically found on an ambulance. The paramedic is a link from the scene into the healthcare system.

The role definitions in the NHTSA statement center on three main concepts: emergency, response and transportation. These definitions are appropriate for EMS 2.0, and a large portion of the EMT and paramedic roles even in EMS 3.0. However, most EMS practitioners will tell you that a very small portion of the calls they answer are really emergencies—that is, patients who are hemodynamically unstable, requiring immediate medical intervention.

Skill Sets for Current TrendsIn fact, a recent analysis of 9-1-1 dispatch data in Fort Worth, Tex., revealed that using the Advanced Medical Priority Dispatch Systems (AMPDS), 36% of 9-1-1 EMS call response determinants required neither a lights-and-siren

response nor first responders. Further, a 10-year review of call types in Fort Worth revealed the following trends:

Call Types That Went Up Interfacility ...........................11.32% Sick person ...........................10.37% Falls .........................................5.87% Unconscious person ..............5.20% Assault .................................... 4.21% Convulsions ............................ 4.16% Psychiatric .............................. 3.76%

Call Types That Went Down Breathing problems .............10.48% MVA .......................................10.38% Chest pain............................... 7.97% Traumatic injury ..................... 3.71% Abdominal pain ......................2.83%

Note the lower-acuity call types (interfacility and general sick person) are generally the calls that are increasing as a percentage of call volume, and the traditional high-acuity calls (chest pain, MVC and breathing problems) are actually decreasing. This shift in call volume over time provides a glimpse into the core training requirements that may need additional focus in EMS 3.0.

New Training ElementsThe growing desire of the nation’s healthcare system to move toward value and patient navigation (right patient, right time, right care, right setting) will

The Transformation of EducationHow should we prepare new providers to fill their new, larger roles?

By John Todaro, BA, REMT-P, RN, TNS, NCEE, National Association of EMS Educators

KNOWLEDGE BASE ON SPECIFIC HEALTH ISSUES• Broad knowledge about community• Knowledge about specific health

issues• Knowledge of health and social

services systems• Ability to find information

ORGANIZATIONAL SKILLS• Setting goals and planning• Juggling priorities and managing time

EMSWORLD.com 13

necessitate additional training and education for our EMS providers.

The role of EMS providers in EMS 3.0 is substantially different than simply responding to a 9-1-1 calls, assessing and treating immediate medical conditions and transporting patients to emergency departments. In addition to being able to effectively manage a compromised airway, treat lethal dysrhythmias, apply a traction splint, control external hemorrhage and perform all the other treatments called for in EMS responses, practitioners of EMS 3.0 will need additional core training to effectively assess patient acuity and determine if immediate transport to an ED is appropriate or if the patient’s medical needs can be better managed by an alternative care provider such as an urgent care center, clinic or follow-up appointment with the patient’s physician. With more focus on prevention, EMS practitioners will need training for post-acute follow-up care and disease management, social determinants of health and in-home environmental factors.

Perhaps adding the core training elements for community paramedicine or even community health worker educational elements should be part

Community Health Worker Educational Curriculum2

typically 1,500 hours. By comparison, the training requirement for a barber in Texas is 1,500 hours, and a radiology technician training program is a two-year course of study.3,4 In the United Kingdom and Australia, where paramedics provide a much more substantial role in the healthcare system, eligibility for licensure requires a three-year university degree.5,6

If EMS providers truly want the responsibility and respect enjoyed by providers in other countries, it will likely require a more significant investment in training and licensure and the movement away from certification to an actual license.

REFERENCES1. National Highway Traffic Safety Administration. National EMS Education Standards, www.ems.gov/pdf/811077a.pdf. 2. Texas Department of State Health Services. Community Health Workers—Promotor(a) or Community Health Worker Training and Certification Program, www.dshs.texas.gov/mch/chw.shtm. 3. Texas Department of Licensing and Regulation. Barber Frequently Asked Questions, www.tdlr.texas.gov/barbers/barberfaq.htm#education. 4. InnerBody.com. Becoming a Radiology Technician, www.innerbody.com/careers-in-health/becoming-radiology-technician.html. 5. University of Surrey. Paramedic Practice BSc (Hons)—2017 Entry, www.surrey.ac.uk/undergraduate/paramedic-practice.6. Ambulance Victoria. Become a Paramedic, ambulance.vic.gov.au/paramedics/become-a-paramedic/.

TEACHING SKILLS• Sharing information one-on-one• Mastering information, planning and

leading classes, collecting and using information from community

ADVOCACY SKILLS• Ability to speak up for individuals or

communities and withstand intimidation• Using language appropriately• Overcoming barriers

COMMUNICATION SKILLS • Listening• Using language confidently and

appropriately• Reading and writing well enough to

document activities

SERVICE-COORDINATION SKILLS• Identifying and

accessing resources• Networking and building

coalitions• Providing follow-up

CAPACITY-BUILDING SKILLS• Empowerment:

Identifying problems and resources to help clients solve problems themselves

• Leadership• Strategizing• Motivating

of the core curriculum for EMTs and paramedics?

Technician vs. ClinicianMany in EMS share concern about the way EMTs and paramedics are viewed by the rest of the healthcare industry, as well as the pay afforded them. There are two main reasons the pay and respect for EMS providers are lower than those of other healthcare practitioners: the education required for the position and the perceived value of the role. EMS providers in the United States are certified technicians. The training requirements to be eligible for certification as an EMT consist of 150 hours; for a paramedic the training is

INTERPERSONAL SKILLS• Counseling• Relationship building• Working as a team member• Working appropriately with diverse groups

of people

14 EMS 3.0

It is difficult to balance the call for evidence-based care with emerging technology, because an evidence base

has to be created. This is the situation facing community paramedicine in the United States. Information on its performance (primarily financial) has come far enough that the number of agencies beginning programs is growing exponentially. The big hurdle in community paramedicine was first identifying data elements and then turning data into information.

As the biggest overhaul of the U.S. EMS system since it began in the 1970s, community paramedicine will also be a contender in leading and spreading technology in the industry. Early adopters of MIH-CP have already brought a number of technologies into their systems and are trying hard to integrate technology into bidirectional information flows.

NEMSIS is one of our greatest allies in information and technology adoption. Some early adopters have embraced the HL7 certification of NEMSIS and begun exchanging data with clinics and hospitals using health information exchanges. This trend will continue and grow. EMS is still light years ahead of the other parts of healthcare in relation to NEMSIS and care data, and part of our struggle will be with hospitals, clinics and payers catching up.

Connected DevicesThe community paramedicine early adopter programs are also experimenting with connected devices

and turning their data into information. The CP program in Renfrew County, Ontario, is using devices such as scales and blood glucose machines that can transmit data over the Internet to automate the dispatch of community paramedics to patients who don’t even know they’re in trouble. Over the next decade algorithms will be perfected and software designed to monitor Internet-fed device data so that when a patient’s data falls out of an assigned set of parameters, the CP will be notified to respond and complete a full assessment.

To take advantage of connected devices for emergency and MIH-CP purposes, it will be necessary to have robust and reliable “pipes” for patient/mission-critical data exchange. The commercial wireless-dependent modems and other communications tools now employed are not adequate for these communications. They are not reliable when calls and data packets are dropped or transmission rates fail or are throttled down by commercial providers. At the scene of a major car crash, for instance, the cell tower serving that area will quickly become inundated with texters, callers and video uploaders, potentially leaving no room for EMS data exchange needs (public safety personnel have no priority over other users).

Fortunately, organized public safety interests, including EMS, sought and received from Congress our own nationwide broadband network. It is called the First Responder Network Authority, or FirstNet, and is now under construction. Early adopters are already

using it in a limited fashion in five locales in the country.

FirstNet and the devices and applications it will enable will change how EMS is practiced because of the availability of information at the practitioner’s fingertips. From diagnostic information to nearly perfect real-time awareness of the resources available to the provider at the scene, FirstNet will provide the EMS professional with tremendous decision-making power. Because of this, EMS is likely to be the most prolific user of FirstNet among all public safety disciplines.

ConclusionEMS agencies need to start watching technology and attending programs being established in other parts of healthcare, such as by home health agencies. Much of what community paramedics do is done by home health where it exists, but their industry is more developed than community paramedicine.

While data is nice, information is the key to identifying evidence-based technology. We need EMS agencies that are willing to be on the front end in creating the evidence base, and we should not all take the position that we only do those things proven by evidence. If we do that, we will never be part of the solution. Take “evidence-based practice” with a grain of salt and stick your neck out to be one of the evidence creators. Do it, though, with your practice rooted in research. That will make you and your agency a contributor to science.

By Gary Wingrove & Kevin McGinnis, The Paramedic Foundation

Integration of TechnologyData is nice but must be turned into useful information

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16 EMS 3.0

EMTs and paramedics often scratch their heads when dispatched to “emergency” calls such as

toothaches, minor injuries and low-acuity medical complaints. A field provider with one month of experience quickly realizes that many of the calls he’s dispatched to are not really emergencies at all. What if there were a reliably proven way to quickly gather information from a caller to determine whether a lights-and-siren EMS response is truly necessary? What if the 9-1-1 call-taker had a cadre of resources they could allocate, from a full-on hot response to a referral to a nurse in the call center who could walk a caller through determining the best resource for their complaint?

Panacea? No, it’s reality. EMS systems in other parts of the world that are truly integrated into healthcare delivery networks have been doing exactly this for years. The result is a dramatically different expectation on the part of the caller, much better patient outcomes and significantly lower costs.

Look to the United Kingdom. The U.K.’s National Health Service (NHS) has been doing exactly this for decades. Callers to its 9-9-9 are initially processed using the Medical Priority Dispatch System to quickly allocate the traditional emergency resources if clinically necessary, such as for car wrecks, heart attacks, strokes and major trauma. If a patient needs something else, such

as a solo advanced care practitioner to respond, assess and treat a laceration with sutures and antibiotics, that resource is sent.

Callers who meet physician-approved criteria for low-acuity medical calls are transferred to specially trained NHS nurses in the call center. These nurses use a robust computer-assisted decision-support tool to guide the caller through a series of clinical assessment algorithms that lead to recommendations for locus-of-care resources tailored to meet their clinical need. Perhaps an appointment at a medical clinic or their primary care practitioner? Maybe self-care at home for flu-related symptoms or a relentless bout of the hiccups? It’s not just the U.K.

Dispatch and Resource Allocation There are smarter ways to handle calls than a full lights-and-siren response

There are a few high-performance, high-value EMS systems that use the MPDS fully for what it was designed to do: allocate resources based on the clinical description of the patient.

By Jerry Overton, International Academies of Emergency Dispatch

EMSWORLD.com 17

handling calls this way—it’s the majority of Europe and Australia. These countries have figured out the most effective way to integrate the dispatch and resource allocation function into their call centers.

So what’s different in the U.S. that has prevented a similar model? Why do we send an ambulance, and in some cases a fire truck, to nearly every EMS call and do our darnedest to convince the patient that unless they go by ambulance to the ED, they could die?

It’s About the Money!If EMS agencies don’t transport patients to an ED, the system does not get paid. If EMS and fire agencies reduce their response volume, they won’t require as many people, and resources and jobs could be lost. The perverse incentives of our healthcare system force the payers to pay us to do things that often are clinically unnecessary just to be eligible for payment. However, places like the U.K., Denmark and Australia have single-payer systems. That incentivizes payers to allocate the right resource to the right patient in the right setting at the right time. An ambulance trip to the ED costs the payer money, and if it’s not necessary, it’s wasted money. If the EMS system is able to safely and effectively meet the patient’s medical need over the phone or by using an ACP without needing an expensive ambulance trip to an ED, then the EMS provider is very valuable to the payer and paid well for that service.

Even the pure response allocation concept is money-driven. Despite the dearth of research that demonstrates the clinical outcome value of first response for conditions other than a handful that are time- and life-sensitive, EMS systems across the country include a very expensive first-response component, one that often responds lights-and-siren to every EMS request. First-response leaders who are honest about why they send these expensive resources hot to every call offer three reasons:

REFERENCE1. International City/County Management Association. Public Safety, http://icma.org/en/icma/knowledge_network/topics/kn/Topic/216/Public_Safety.

➤➤ It’s what the public expects;➤➤ If we don’t respond to calls, we’ll lose

funding;➤➤ You never know if the ingrown toenail

is a real emergency and callers are unaware of the risks.

Seriously? First, we gave the public the expectation that we need to have someone to them in five minutes or less on every call. The public in the U.K. does not have that expectation and is therefore not disappointed when seven people don’t show up for their cut finger. In places like Fort Worth, Reno and Louisville that have implemented 9-1-1 nurse triage systems, the patient experience scores are very high—often with patients saying the process was much better than going to the ED, but they never knew they had another option.

Second, we need to find the value equation for first-response agencies and, honestly, the price point communities are willing to fund. Many places across the country are already calling into question the value of having four people on fire engines and a fire engine on every corner, especially in tough economic times. The International City/County Management Association’s Center for Public Safety has published several studies recommending the downsizing of fire departments.1 Finally, call triage systems across the globe have processed millions of calls through priority dispatch and nurse triage systems and have implemented evidence-based guidelines to make these systems safe and effective.

The other side of the money equation is the hospital side. Under Healthcare 2.0, hospitals had the potential to earn more revenue when more patients come to the ED, so they had little incentive to participate in systems that reduced EMS transports to the ED. Today, under Healthcare 3.0, as hospitals and health

systems move toward shared savings models that financially reward reduction of unnecessary expenditures for things like ED visits, they are more interested in exploring opportunities to enhance patient care while reducing costs.

Expansion of 9-1-1 Nurse Triage There are a few high-performance, high-value EMS systems that use the MPDS fully for what it was designed to do: allocate resources based on the clinical description of the patient. First response, BLS and ALS resources are sent based on the patient’s need, not the political agenda of provider agencies. Some systems—Fort Worth, TX; Syosset, NY; Reno, NV; Mesa, AZ; King County, WA; and Salt Lake City, UT—are now using the full scope of the program and have incorporated nurses into their triage systems. These systems have demonstrated the value of this approach to care delivery, and consequently payers are funding these programs and patients are loving them. These programs have reduced EMS response volumes by referring patients with low-acuity medical complaints to resources matched to better meet their needs.

As these systems continue to publish research that proves the safety and effectiveness of this care delivery model, healthcare system participants will take further notice. Now is the time for EMS system leaders to start evaluating the dispatch component of the EMS 3.0 value-driven healthcare delivery system. Prove (or not) the value of the two extremes of our response models: everyone to every call, preferably all with lights and sirens, or using the “four rights” model, where patients in cardiac arrest get everything and patients with the hiccups get nurse advice over the phone.

18 EMS 3.0

Emergency medical services, like most of healthcare, is in the process of transition from fee-

for-service models to patient-centered, value-driven and outcomes-based delivery systems. The old model was based upon a sequence of events: a person calling for help, an ambulance arriving, EMS providers intervening in some manner and then transporting the person to an emergency department for “definitive care.” This model has become, in many ways, obsolete. The transformation of EMS to a new model—from EMS 2.0 to EMS 3.0—will be based upon the changes happening in the larger healthcare arena. EMS 3.0 will help realize the Institute of Healthcare Improvement’s Triple Aim: improving the individual experience of care; improving the health of populations; and reducing the per-capita costs of care.

To achieve the Triple Aim in EMS and realize the transformation to EMS 3.0, organizations must develop a new array of service lines that expand beyond emergency response. To succeed, EMS systems and providers will need strong, prepared and capable critical thinkers in leadership positions.

Historically there has been a large gap between leadership and

management needs and the preparation of individuals to fill positions that can meet those needs. Highly skilled and experienced EMS practitioners have often been the candidates of choice for leadership and management positions. Unfortunately, patient care experience and clinical expertise are not reliable predictors of success in those roles.

Rather than expecting individuals will become successful leaders and managers by learning on the job, we should be preparing tomorrow’s EMS leaders for their roles. Leadership preparation should begin during primary EMS provider education, as we expect providers to demonstrate team leadership before sitting for initial certification exams. As EMS careers progress, further leadership development must be guided by established competencies, enhanced through education, training and professional development activities, and validated through a recognized credentialing process.

There are many domains within EMS and EMS 3.0 that will benefit from a proactive approach to professional development. All the attributes discussed in this supplement need leaders—people with vision who

clearly articulate goals and objectives, who collaboratively create plans and inspire people to execute them. We will need a cadre of well-prepared leaders to ensure we successfully make the transformation to EMS 3.0.

The diversity of EMS models, concepts and systems is due to what may be labeled “divergent evolution.” Systems grew and evolved in relative isolation, developing to meet the needs of the communities they served. EMS 3.0 provides the potential for a more focused evolution with a set of agreed-upon performance metrics that can be adapted to meet community needs guided by the Triple Aim.

We must collaborate to ensure diverse stakeholders are represented to create the EMS systems and programs needed to serve our communities and close gaps in local healthcare and community services. EMS will need leaders to serve in every phase of this transformation. As we proceed with a revision of the EMS Agenda, we must remember to consider the critical role leadership will play in moving our domain forward. We must be prepared to educate and train current and future EMS leaders to ensure the success of this transformation.

Aspects of LeadershipMany domains of EMS and EMS 3.0 can benefit from a proactive approach to professional development

By Michael Touchstone, BS, EMT-P, National EMS Management Association

Publisher Scott CravensEditorial Director Nancy PerrySupplement Editor Matt Zavadsky, MS-HSA, EMTArt Director Barbara Pineiro

EMS 3.0 is an editorial supplement produced in partnership with the National Association of Emergency Medical Technicians, sponsored by Emergency Reporting, ESO Solutions, GD, ImageTrend and Nonin Medical, and published by EMS World and SouthComm, 1233 Janesville Ave., Fort Atkinson, WI 53538, 800/547-7377, EMSWorld.com. © Copyright 2016. All rights reserved. No part of this publication may be reproduced without written permission from EMS World.

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