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Forward-Looking EMS
This is the fifth in a series of articles from MONOC Mobile Health Services. MONOC is New Jersey's largest provider of EMS and medical transportation and first CAAS-accredited agency. The goal of this series is to provide insight and solutions for the different managerial and operational challenges facing the EMS leaders of tomorrow. For more, see www.monoc.org.
With the advent of national healthcare reform, there is no better time than right now to contemplate the future of EMS in this country. What is in store for prehospital emergency medicine for the next 10 years or so? Let's take this opportunity to examine the impact of ongoing advances in EMS, recent trends that have evolved and the likely effect of healthcare reform.
First, let's look at clinical advances in patient care. We've seen EMS agencies around the country continue to develop new and revised treatment for the patient population they serve. For example, hypothermia is actively being investigated and implemented as a new protocol for cardiac arrest patients. Early results seem to indicate this is an advantageous clinical care regimen and it promises to be expanded nationwide once it is generally accepted by the medical community. The pharmacological armamentarium carried by the nation's EMS providers continues to expand and advance. The skill sets our EMTs and paramedics, as well as our specialty care and air medical transport teams, are allowed to practice have become quite sophisticated.
However, we also see a collateral refinement of the medications and practices EMS staff is permitted to carry and perform. In some venues, lack of volume has caused proficiency degradation of certain skills, such as pediatric intubation, to levels judged unsafe, thus prompting medical oversight authorities to revise treatment protocols.
Expansion of "specialty care center" designations will also probably proliferate across the country. As the time-critical nature of treating strokes and myocardial infarctions becomes solidified into the EMS consciousness, demands will be placed on systems to deliver the right patient to the appropriate facility, quickly. We are already seeing state health departments in the U.S. set in place both specialty care hospital designation processes and patient destination protocols that will at least guide providers to specific facilities. In at least one state, the use of medevac is now part of the recommended protocol for scene response on STEMI patients when no appropriate receiving medical facility is close enough.
This growth in predetermined patient diversion will surely impact EMS by increasing transport time, and therefore turnaround time, of ambulances as they bypass the closest facilities in favor of specialty centers. There should also be an increase in the volume of interfacility ALS transports from community hospitals to tertiary care institutions for patients not appropriately transferred from the scene. EMS research is finally beginning to emerge as more providers complete and publish small investigative projects on subjects ranging from operational performance to educational methodologies to clinical outcomes. This long-awaited activity should result in more sound, evidence-based maturation of EMS systems and the way we deliver care to patients in the field. EMTs, paramedics and emergency physicians research and publish more, enhancing the literature on EMS. As this library expands, we can expect not only the number of advances to increase, but the pace of change to quicken.
RECENT TRENDS FORETELL THE FUTURE
Secondly, recent operational trends developing around the country portend the future of our industry. Case in point: Some agencies are testing the concept of "selective dispatch" and "selective transport" to improve efficiency and reduce operating costs. By identifying early on patients who do not warrant EMS intervention, or even transport to a hospital, scarce resources in some parts of the nation are being reserved. Although this is recognized as a medical-legal mine field, the lack of adequate funding from governmental fiscal constraints is forcing many agencies to design readiness and response processes that conserve costly assets. In some locales, the need to reduce staffing and curtail available resources is forcing the need to design ways to conserve personnel and assets for those who actually need, or would benefit from, EMS.
Real-time automatic notification of EMS needs, such as OnStar's vehicle collision announcement system, will likely improve both the speed of response and the efficient use of appropriate resources. This alone should reduce operating costs of emergency response organizations over the long term. In addition, if it is expanded across the country and utilized appropriately by dispatch agencies, patient outcomes should improve. Continuous, live situational awareness and syndromic surveillance has become of extreme importance to the public safety sector in the post-9/11 world, particularly for EMS.
There are examples of multiple 9-1-1 dispatch centers electronically linking their CADs across jurisdictional boundaries and utilizing new software to monitor regional case load and type in an effort to identify the outbreak of bioterrorism. A side effect of this new, real-time application of statistical analysis, beyond homeland security, is allowing EMS providers to quickly determine surges of demand and respond accordingly.
The ongoing trend toward improving operational efficiency and effectiveness continues to exist. Since the emergence of the public utility model in the 1980s, high-performance EMS systems have surfaced in the U.S. and their numbers, and those of hybrid and modified off-shoot models, have increased. Services and systems delivering prehospital emergency medical care have come under increasing demand to provide ever more sophisticated patient care, quicker, more reliably and productively, and at a significantly lower cost.
THE FUTURE OF HEALTHCARE REFORM
Lastly, what will healthcare reform mean to EMS in America? The most obvious effect should be to dramatically reduce the number of uninsured patients. For providers that bill for services for at least a portion of their revenue, this means less bad debt and more income. For providers that rely solely on tax subsidies, it means an even greater impetus for them, or their subsidizer, to begin charging for service. This may be an unintended consequence, or underestimated result, of healthcare reform. It may also mean a surge of activity, especially for fee-for-service providers, as patients seek care they've been avoiding, since they would now have financial means. This may be balanced by a similarly sudden increase in formerly uninsured patients attaining primary care not through EMS, but through the traditional doctor's office or convenient store-front medical practices.
Also, buried deep in healthcare reform legislation is language providing grant monies for the development, and implementation, of regionalized EMS systems that encompass multiple jurisdictions, counties and even cross state lines. Clearly, there is the intent at the federal level to move away from localized EMS operations, which tend to be more costly per unit-of-service than larger systems. It is easy to conjecture that this will spur some consolidation activity among many agencies, and perhaps establish new service entities either from, or replacing, several current local operations.
As usual, it is certainly an interesting time to be involved in the provision of EMS in America. There continues to be no single structure for design, delivery or financing that has evolved as the preferred model. It appears EMS systems will continue to advance and mature, perhaps at an accelerated rate, for the foreseeable future.
Since 1990, Vincent Robbins, FACHE, has served as MONOC's president and chief executive officer, responsible for the oversight, administration and management of three healthcare services companies. Formerly, he served in the administration of Temple University Hospital in Philadelphia, and with the New Jersey State Department of Health's Office of Emergency Medical Services. He holds a bachelor's degree in Medical Services Management and a Master's of Science in Healthcare Administration. He is also a Fellow with the American College of Health Care Executives. Mr. Robbins was also one of New Jersey's first certified paramedics. He has lectured and presented for the National Association of EMS Management, the New Jersey State First Aid Council, the New Jersey Medical Transportation Association, and University of Maryland at Baltimore County's EMS degree program, both the Ocean and Camden County Colleges' paramedic certification programs, as well as many other academic and professional bodies. He has authored numerous articles on the management and financing of complex healthcare delivery systems, including EMS and medical transportation systems.
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