The keynote speaker was Ricardo Martinez, MD, former administrator for the National Highway Traffic Safety Admininstration and one of the authors of the 1996 EMS Agenda for the Future. To paraphrase his comments, he asserts that EMS is fragmented and suffers from the ill effects of isolation and insulation. He notes that EMS is deployed locally while fire is deployed nationally, that EMS should be declared an essential public service, and that we need the think exponentially not incrementally. He offered effective inspiration.
There were about 12 tables with seating for 6-8 at each table with one moderator per table. Each table would convene for 25-30 minutes to discuss the future of EMS based on a specific question related to the “guiding principles” identified by the subject matter experts (SME’s, who served as the moderators). The SME’s would then record any new ideas that seemed viable to them. I do not claim to have heard all the ideas or discussions, but I believe I was able to sit with nearly everyone that attended at some point. Most who attended where EMS chief officers, EMS industry writers, government officials both state and federal, VAOEMS, HHS, NHTSA, DHS, DOT, industry representatives from the IAFF, NAEMSE, consulting firms and EMS educators. It is notable who was not there: there were no representatives there from allied health professions, legislators, the hospital systems, insurers or Medicare/Medicaid.
The subject of social equity appeared in many of the early questions asked of the groups. While not initially concerning it became the predominant theme in the round of questions we worked through that morning. In its normal context that would imply that there was some concern about the equity of the treatment of patients; that was not the case. The concern was refined via feedback from the moderators which seemed to make it more of a concern about disparity among EMS systems affecting entire populations falling inside differing EMS systems that have developed locally.
We were repeatedly asked to think about how we would see the future of EMS if all the boundaries and restrictions did not exist. Some of us have a hard time with that, but after a few practice sessions even an old paramedic can become creative. Rather than describe each individual workgroup, the question and reaction, I will try to describe the ideas that seemed to bridge all the questions and which became better refined because of their resonance as the exercise progressed.
Integration - The vision includes the ability to treat more patients where they are found or to transport them to the most appropriate resource to improve care, reduce cost and improve resource utilization. EMS must have better integration with the rest of the healthcare system, public health, mental health and social services if it is to meet this agenda goal. It includes sharing access to patient records and treatment plans to guide care, removing artificial boundaries limiting where providers may practice and where patients may be treated. The most significant barrier appears to be communication and a willingness of the identified partners to engage in a meaningful way without some inducement.
Education - The vision involves placing paramedics and other providers with higher levels of education into the mix to assist in filling the gap between hospital and pre-hospital care. It suggests greater public involvement which will have a public education component. The integration component will require education of those we wish to integrate with as well as legislatures and insurers. It also addresses changes to the core material taught in paramedic level programs to include healthcare management, research, injury prevention, and the development of paramedic post-graduation programs. At every point in the discussions it became more evident that EMS will be used to fill a gap in the healthcare system left by the exit of the traditional family doctor. Paramedic education and practice would evolve to the level of the physician extender or nurse practitioner. Public education came up in almost all discussions as a way to improve public reaction and involvement in healthcare events.
Technology/Innovation - This was the most interesting and amusing of the topics covered, participants came up with ideas as frightening and wonderful as implantable chips to identify and hold patient healthcare data, monitor lab values, and provide other biometric data to healthcare providers. PSAP, dispatch, patient and hospital communications systems that could function as easily as a smart phone and provide real-time audio, video and biometric data to call takers, responders and receiving facilities to guide response, size-up, treatment and transport decisions in real time. Defibrillators that fit in your pocket. High-Tech lightweight bulletproof, puncture proof, thermally resistant PPE with built in biometrics. Drone technology dispatched with units to give advanced 360 scene size-ups & patient assessment. Use of AI to assist or autonomously respond to, assess, monitor, treat and transport patients more consistently and safely. Use of live universal standards of care based on the most current evidence.
Workforce retention and development - There was quite a bit of discussion surrounding the workforce, the various levels of care, the considerations for paid, volunteer and fire-based systems, and the effect of higher education standards on an already stressed system. Most acknowledge that burnout, long hours and low pay are factors in retaining people and preventing EMS from being a viable career path for most. To place EMS on par with other healthcare professions there must be transparency about the career, established career paths, progressive education programs from EMT-PhD, professional recognition and better wages, benefits, resources and working conditions.
System development /Sustainability - Understanding that EMS is a separate essential public service like the fire service, police or public education could be a pathway to resolve funding concerns and bring diverse systems across the nation into agreement on what minimum level of service and standard of care is acceptable without limiting the localities in their freedom to choose the design and make-up of the service. Encourage innovation, eliminate that which does not add value and self-inflicted obstacles like tradition. Understand your data and use it to find and demonstrate value, tie performance to requests for resources. Address top management stagnation with use of term limits, requalification or selection every few years instead of lifetime positions.
The parties with the largest influence on the outcome were not present. For any real integration to occur this must change.
Higher education, better technology, wages and deployment of all the suggested improvements will take investment. Most systems already struggle with funding, the first things to be cut are the very things the agenda seeks to implement. How can that be fixed? EMS will be asked to fill the gap left in healthcare with no means to achieve it if major legislative or economic pressure is not brought to bear to correct funding gaps. If EMS is identified as an essential public service with minimum standards of service and care defined, as with fire service or public education, or if EMS service can be scored like the fire service for insurance purposes it will create the political and economic pressure necessary.
This exercise appears to be driven by Federal agency concerns to encourage collaboration borne out of the ACA. The ACA encourages the development of Accountable Care Organizations (ACO’s) and ties reimbursement levels to performance of the system. It seems that this mechanism left out any collaboration with EMS or we would have seen the ACO’s (hospital systems) in the room ready to talk.
Public education programs such as those employed by the fire service have had a profound positive effect. Fire losses were once a grave concern for the nation prior to fire service public education programs and fire codes. With public education fire-related losses and deaths dramatically declined. This is a lesson EMS has been slow to learn, spending a fraction of the resources up front on public education can save big on the service delivery end. It is the best way to improve public health and be responsible with the resources we have.
I became concerned when I heard from several groups that volunteer systems were an obstacle to progress and promptly set them straight. EMS in the United States came into existance largely by volunteer systems that arose to address the need. The fact is that most of the United States is served by volunteer firefighters and EMS personnel. It is a great and valuable tradition in this nation and one I will not seek to discourage. Involving the public in the solution is also key to improving our situation whether encouraging volunteerism or simply providing the public education to allow the public to participate as a partner or better understand what we do.