Welcome to the second issue of EMS on the Hill, a newsletter representing the work of a broad group of EMS organizations dedicated to achieving positive change and recognition for emergency medical services at the state and federal levels. In July 2007, this group of organizations met to review the recommendations of the 2006 IOM Crossroads report and develop priorities and action items to help make these recommendations reality. This newsletter will provide updates on those action items, plus discuss other critical industry issues.

MOVING FORWARD IN 2008

With the new year come new opportunities for the betterment of emergency medical care in the U.S. One of the biggest is the chance to make progress in implementing recommendations made in the Institute of Medicine's 2006 Emergency Medical Services at the Crossroads report.

As reported in the last issue of EMS On the Hill, top EMS leaders gathered in Washington, DC, last summer to discuss ways to advance the IOM's comprehensive agenda for improving America's EMS systems. Participants from the nation's leading EMS organizations agreed on priority areas and general steps to take, then took them home for assessment by their groups and integration into their agendas. They'll be goals for 2008 and beyond. No one is expecting landmark leaps forward overnight, of course, but there's now a consensus effort among the major players for moving these ideas forward.

One initial challenge lies in an uncertain electoral landscape. Much of what needs to happen needs to happen legislatively, and with the 2008 elections approaching, EMS concerns--especially ones that would cost money-- are generally not priorities for lawmakers. (Note to EMS readers: Anyone want to work to change that?) But there is a potentially major federal resource coming on the administrative side: a 26-member National EMS Advisory Council that will make recommendations to NHTSA's Offi ce of EMS (OEMS). Its membership, expected to be announced soon, will include a wide range of EMS stakeholders who will help inform the OEMS' work. "The NEMSAC establishes a formal method for obtaining input and advice from the nation's EMS community," NHTSA of- fi cials said in announcing the panel's creation in 2006.

Other progress is occurring through OEMS and FICEMS (the Federal Interagency Committee on EMS) as well. NHTSA is working with federal partners to produce an evidence-based practice guidelines process, and FICEMS' Technical Working Group (TWG) is developing short- and long-term EMS needs assessments. Work also continues on the national EMS education standards.

Among the leading emergency medical care advocacy organizations, the American College of Emergency Physicians is planning to use the annual EMS Week celebration in May to promote causes important to EMS. This year's event is May 18--24. For more, see www.acep.org/ emsweek.

NATIONAL NEWS

EMS EXPO ROUNDTABLE BRINGS TOGETHER THE BIG GUNS

A common lament in EMS is that the federal government's involvement in the fi eld is so fragmented. The cabinet-level departments of Transportation, Homeland Security and Health and Human Services all have irons in the prehospital fi re, sometimes more than one. If you need to pose questions to federal sources about workforce issues, Medicare reimbursement and disaster response, you could be looking at three lengthy phone-tree ordeals. Unless you were at EMS EXPO last October in Orlando, where show architects assembled a groundbreaking panel of top federal offi cials to discuss their efforts on behalf of EMS and take questions from attendees.

Panelists represented the range of federal involvement in the prehospital fi eld:

• John Brasko, EMS/Safety and Health training specialist with the U.S. Fire Administration;
• Drew Dawson, director of NHTSA's Offi ce of EMS;
• Richard Hunt, MD, FACEP, director of the Division of Injury Response in the CDC's National Center for Injury Prevention and Control;
• Jon Krohmer, MD, FACEP, deputy assistant secretary and deputy chief medical offi cer for the Department of Homeland Security;
• Sally Phillips, RN, PhD, director of the Agency for Healthcare Research and Quality's Public Health Emergency Preparedness Research Program;
• Charlotte Yeh, MD, FACEP, regional administrator for the Centers for Medicare and Medicaid Services (CMS);
• Kevin Yeskey, MD, director of the Offi ce of Preparedness and Emergency Operations (OPEO) and deputy assistant secretary under the Department of Health and Human Services' Assistant Secretary for Preparedness and Response (ASPR).

Opening remarks were delivered by David Marcozzi, MD, FACEP, director of the new Emergency Care Coordination Center under ASPR/OPEO.

The discussion was moderated by Kurt Krumperman, senior vice president of federal affairs and strategic initiatives for Rural/Metro and chair of the American Ambulance Association's Emergency Preparedness Workgroup.

Each of the panelists delivered brief remarks outlining their entity's work. Dawson cited a range of priorities for his offi ce, the offi cial lead body for EMS within the federal government, including NEMSIS, 9-1-1 pandemic infl uenza guidelines (now available), education standards, the EMS Workforce Project, a surveillance system for provider injury and illness, preparedness assessments and data standardization.

Noting that all disasters have health implications, Krohmer outlined a number of DHS preparedness efforts, including the creation last year of an Offi ce of Health Affairs, headed by acting Assistant Secretary/Chief Medical Offi cer Jeff Runge, MD, FACEP. Among its duties, this offi ce oversees the Bioshield and BioWatch programs and National Biosurveillance Integration System. A Medical Readiness Division will coordinate contingency planning, fi rst-responder readiness, WMD incident management support and coordination of medical-preparedness grants.

Yeskey also had a new offi ce to promote, HHS's Offi ce of the Assistant Secretary for Preparedness and Response, of which OPEO is part. The ASPR's offi ce was formerly the Offi ce of Public Health Emergency Preparedness. Its other components include a biomedical research and development arm, an offi ce of public health and a policy/planning offi ce. These advise the assistant secretary on bioterrorism and other publichealth matters.

Yeh, citing the statutory basis for the Medicare reimbursement fee schedule, told attendees it wasn't something CMS could change, but that some services weren't availing themselves of all possible reimbursement options. For instance, she noted, Section 1011 of the Medicare Modernization Act authorizes payments for emergency care of undocumented aliens, yet only 450 services have registered to receive them.

Yeh also promoted the periodic "open-door forums" that let constituents pose questions to CMS personnel. Among these are forums for the ambulance industry, which cover issues concerning payment, billing, coverage and delivery of services. For more, see www.cms.hhs. gov/OpenDoorForums.

Hunt discussed the CDC's efforts in injury prevention and response and noted the integral role of EMS in injury research. The Centers' emphasis on the area is highlighted in its Acute Injury Care Research Agenda, revised in 2005.

In collaboration with NHTSA, the CDC last year completed a revision of fi eld triage criteria initially published by the American College of Surgeons in 1999. The 2006 update guides providers in choosing transport destinations for severely injured patients (i.e., specialized trauma centers vs. other nonspecialized facilities). For the badly hurt, care at a Level 1 trauma center can reduce the risk of death by up to 25%. For more, see www.cdc.gov/ncipc.

Q&A

Following the presentations, the fl oor was opened to questions. The most intriguing came from Michael Parker, president of California's Priority One Medical Transport.

Parker described a service under extreme duress: No profi t since the new fee schedule. Cessation of service in almost a dozen counties. Trouble making payroll. Tens of thousands of dollars in federal reimbursements still due from a response to Texas after Hurricane Rita, and certain major expenses incurred therein not covered at all. Priority One, he concluded, was in desperate straits and dire need of help.

At once, Parker's question illustrated both the breadth of problems facing many EMS services today and the diffi culty in fi nding solutions among the various realms of control. There were no magic-bullet answers anyone could offer him, just open ears.

"I think they were sympathetic," Parker said in November, "but I don't think, individually, there's much they can do."

Reimbursements under the fee schedule, Parker says, don't cover costs of operation. FEMA has lagged in making repayments, state payments under MediCal were interrupted by budget wrangling, and even CMS, Parker says, held up payments for two months while performing audits.

The cumulative result is a prolonged cash crunch that now threatens his company's existence.

"The banks are no longer our friends," Parker says. "It's a terrible thing. Small business can't fl ourish if the government doesn't pay them."

In the end, Congress and state legislatures are the avenues for changing this, and lobbying them on behalf of EMS remains an imperative. In the meantime, though, there's always value in bending the ears of those in authority.

HOT TOPICS: OPINIONATED POSTERS SOUGHT BY EMS WORKFORCE RESEARCHERS

As the EMS Workforce Project progresses, its leaders continue to seek comments from those involved with the profession by way of a blog they've set up at http://futurehealth. blogs.com/emsworkforce.

The blog poses workforce-related questions and solicits input to help guide researchers' work. The project--officially the EMS Workforce for the 21st Century Project--is an effort to examine the future EMS workforce in the U.S. and help ensure its health and viability. Primarily conducted by the University of California, San Francisco's Center for the Health Professions, it is currently in the second of three stages.

The first entailed a comprehensive assessment of the country's EMS workforce; this resulted in an assessment report, which should be published soon, but basically left researchers seeking a better understanding of worker demographics and supply/demand issues. The second phase, ongoing, involves studying these areas and developing a policy agenda. This will include recommendations that will ultimately, if all goes as planned, be implemented to help ensure a robust EMS workforce in coming years.

Current blog discussions in late 2007 focused on provider burnout and the effect of shift length on patient care. But by far the most-discussed topic was a general one: What are the key challenges regarding the EMT/paramedic workforce at your worksite? That question drew an intriguing potpourri of answers:

• "EMS is the bastard child nobody wants. We are the lowest paid, we have no retirement, and we have the most requirements to maintain our certification. Seems kind of backwards."
• "Education... We are constantly being asked to reduce hours of training, reduce the number and level of personnel needed to accomplish a medical protocol, curriculum 'dumbing-down.' Is this what our country wants during a time when we need to be our best?"
• "Back injuries. The average weight of our patients over the years has greatly increased. It is not uncommon to have several patients in one 24-hour shift be 300 to 400 pounds."
• "As our city continues to grow, the pool of paramedics to hire becomes smaller and smaller."
• "Until EMS can present a united front to the public and to legislators, starting first with a federal administration free of the the oppression of the fire service, we are destined to watch as some of America's best paramedics are forced to go over to the 'dark side' or become RNs."
• "Society has changed. We have more and more people who want 9-1-1 to solve all their problems, medical or otherwise. We are no longer a society that 'takes care of ourselves and then helps others.'"

Other hot discussion topics include the public perception of EMS providers, what keeps you in the field, provider shortages and the growth of workforce diversity. Additional questions will be posted as the project progresses. Learn more at www.emsworkforce.com.

IN THE SPOTLIGHT

BUILDING A MODEL EMS SYSTEM: THE MARYLAND EXPERIENCE

For all of EMS' problems, there are, inarguably, many excellent providers out there plying the craft. And there are, across the U.S., a lot of good services. But when it comes to EMS systems, there aren't that many that truly resemble what we believe good, comprehensive EMS systems should look like.

In its 2006 Emergency Medical Services at the Crossroads report, the Institute of Medicine described its ideal: well-planned and highly coordinated emergency/trauma care systems that deliver evidence-based interventions, are accountable for their performance and meet the needs of patients of all ages. Under such systems, the IOM's expert team postulated, each sequential and overlapping component of emergency medical services--dispatchers, providers, allied healthcare professionals, public safety and public health--would be fully interconnected and work in concert to ensure patients get "the most appropriate care, at the optimal location, with the minimum delay."

The IOM report cited four "model systems" to which designers might look for such approaches:

• Austin/Travis Co., Tex.
• Palm Beach Co., Fla.
• San Diego Co., Cal.
• The Maryland state EMS and trauma system.

This story examines Maryland's, the only statewide system of the group.

MAIN THRUSTS

The three main thrusts of the IOM system vision are regionalization, coordination and accountability. The Maryland Institute for Emergency Medical Services Systems (MIEMSS), which governs EMS in the state, emphasizes all three.

Regionalization

In this context, regionalization means delivering patients to specialized facilities best suited to give them the most appropriate care. The classic model for this is the U.S.' tiered trauma system, in which facilities are categorized by their capabilities and patients are delivered to those best suited to help them--the most severely injured, for example, to Level 1 centers.

"Regionalization is the right patient to the right hospital at the right time," says MIEMSS executive director Bob Bass, MD, FACEP, who was part of the IOM subcommit subcommittee that developed the Crossroads report. "It means having specialty centers or centers of excellence designated and making sure, from an EMS systems standpoint, that transported patients meeting certain criteria make it to the right hospital."

With trauma, there's ample evidence that this kind of system structure can improve outcomes and reduce costs, as well as help measure performance and enable research. So why not, the thinking goes, employ it across a range of care: neurotrauma, pediatric trauma, perinatal, hyperbaric, burns, eye problems?

Maryland has all of the above, and in 2007 designated stroke centers as well. A supporting protocol for neurological emergencies directs that patients with acute stroke be taken, upon meeting certain criteria, to primary stroke centers for specialized treatment. STEMI (ST segmentelevation myocardial infarction, a kind of heart attack) centers are coming next.

"It's all about making sure patients who have a particular condition get to the hospital that can apply the best care in a timely way," says Bass. "And states need to play a key role [in projects like this] to make sure the regions are interoperable, and that we don't end up with worse fragmentation than we already had."

That is to say, regions have to be able to work together--common technologies and languages and procedures, doing and measuring the same things the same way. As a statewide system, Maryland's can ensure that they do.

Coordination

All providers in the state work under the same protocols, with a centralized communication system and licensing/certifi cation/designation processes. The state is carved into defi ned jurisdictions (primarily counties and the city of Baltimore), each with its own medical oversight and quality improvement. Five regional councils help the jurisdictions work together.

"The jurisdictions work on intrajurisdictional coordination, and the regions address interjurisdictional coordination," explains Bass. "Then we also have the Atlantic EMS Council, which deals with interstate coordination. All the Atlantic states meet together and work on common issues, such as reciprocity."

There's a medical director at the state level, and each council and each jurisdiction has one as well. They gather annually to exchange ideas, crunch data and revise protocols. A separate, parallel system of medical oversight exists for pediatrics. The state also coordinates at the operational level. A 24/7 central communications center dispatches and coordinates air-medical resources from bases around the state and monitors variables like weather and traffi c. Beyond that is a medical communications hub that links hospitals and ambulances across the state. It also connects EMS to its brethren in public safety (fi re, law enforcement) and public health.

"No matter where you are in the state, you get a tower, and we can patch you," says Bass. "If you're in a rural area at a far end of the state and need a pediatric specialist, we can plug you in. If you need a trauma specialist, we can plug you in. If you need a hyperbaric specialist, we can plug you in."

In its communication and coordination endeavors, the state has made good use of modern information technologies. In a catastrophic or multicasualty incident, a Webbased tool called FRED (for Facility Resource Emergency Database) connects to hospitals to help keep state offi cials apprised of their surge resources (staffi ng, meds, local EMS resources, etc.). In more mundane times, CHATS (the County Hospital Alert Tracking System) monitors hospital operations--things like diversion status and whether the ED or ICU or trauma department is full. This allows ambulances to be sent directly to alternative facilities, preventing delays in care.

Accountability

Accountability involves measuring performance, which entails collecting data. A statewide offi ce is uniquely situated to do this. "We're one of the few states," notes Chris Handley, MIEMSS' director of data and research, "that actually has the ability to look at statewide data under a complete set of the same prehospital care protocols."

Most state providers now use an interactive Web-based patient care report form, EMAIS (Electronic Maryland Ambulance Information System), that allows system participants at all levels to track numbers and generate reports. The state is also fi ve years into a cardiac arrest database, and maintains a number of other databases (trauma, etc.) as well.

Data, of course, is only as good as what you do with it. And data sets only provide a useful comparison if you have something similar to compare them to. For a state, benchmarking against anything can be a challenge--"What other state would we benchmark with? I think we're the only one that has a statewide cardiac registry," says Bass--but the jurisdictional setup of Maryland lends itself well to intrastate comparisons, again so long as like things are compared. "To make sure we're comparing apples to apples, we have to benchmark rural areas to rural areas, and urban areas to urban areas," Bass adds. "That's the kind of stuff we hope will evolve out of the IOM recommendations."

The emphasis on data is thoroughgoing. Collected at the state level, it's sifted through, sussed out and passed back to jurisdictions for their edifi cation and further use. "With all the data coming in at the state level," notes Handley, "we provide data information analysis back." Jurisdictions are encouraged to utilize it as much as possible.

"The quality assurance groups in each jurisdiction need that data," says Bass. "Now, particularly through EMAIS, they have it. They can generate all these standard reports, and we push the data back to them and let them do their own thing. We just want them using the data." "We're actually doing quite a lot with our data," Handley adds, "and we're looking to do more."

REDUCING FRAGMENTATION

An overarching goal of all these efforts is to reduce what the IOM identifi ed as a major bugbear of modern EMS: the dreaded fragmentation.

"The fragmentation the IOM talks about is multifaceted," says Bass.

"There's fragmentation between EMS services, which, from an operational standpoint, we address in communications. There's fragmentation from a patient-care standpoint, which we address in protocols. There's fragmentation from an overall standpoint, which we address by jurisdiction and region. So reducing fragmentation and improving coordination and integration takes a multifaceted approach. And I think it really does go to the heart of some of the IOM recommendations for integrated, regionalized systems of care."

Unfortunately, some aspects of the Maryland system may not be easily replicable elsewhere. Its cornerstone trauma system dates to the pioneering efforts of R.A. Cowley in the 1960s, and its work has generally been well supported by governors and legislators. And system participants recognize the value of integration and working together. MIEMSS' policies are set by a board that includes not only EMS representation, but emergency and trauma docs, nurses, hospital and med-school administrators, etc.

"It's all about building consensus and working cooperatively," Bass says. "Our regulations rarely get challenged when we publish them, because we generally build that consensus fi rst. We do the work on the front end."

Future plans include expansion of the state communications system and work with cardiac arrest data that will help guide public access defi brillation efforts.

As we strive to improve America's emergency medical care systems, it's important to note that no system has it all fi gured out. Maryland's successes should, as the IOM says, "provide insights" for initiatives elsewhere. Leaders of emergency medicine must keep searching for ways to innovate and improve (easier, of course, if they're legislatively supported in doing so).

"Model doesn't mean we're perfect," Bass emphasizes. "NHTSA came in a couple of years ago and gave us a very complimentary evaluation, but on the other hand, they left us with 59 recommendations. And that's a good thing. We recognize that while we may be one of the better statewide systems, at the same time, we're still evolving. We still have lots we want to do. And we're in the process of that every day." For more: http://www.miemss.org.

Coalition Offers a Voice for Providers in Oklahoma

EMS advocates often lament the profession's lack of political presence and clout at the various levels of government. But a new effort in Oklahoma is demonstrating that EMS need not be confi ned to the sidelines while its future is determined by others. The fl edgling Oklahoma EMS Coalition has already shown an ability to impact the legislative process in its state.

The effort grew out of recommendations made in 2006 by a gubernatorial task force that would have focused state funds and support on tech schools that train EMS providers. Left out, as these recommendations began the translation to legislation, were the institutions of higher education that produce around a third of the state's providers. Predictably, this sat poorly with folks on the higher-ed side.

"We were interested in getting higher ed into the legislation," recalls Russ Calhoun, EMS program director at Oklahoma State University's Oklahoma City campus. "We felt like we should be playing a major role, along with the career techs, in the areas of tuition reimbursement and development and maintenance of distancelearning programs."

What followed was a quickly arranged trip to the statehouse, wherein the author of the bill was convinced to add language covering the highered programs. The bill was eventually tabled, but the stage was set. "That," says Leaugeay Barnes, director of the EMS program at Oklahoma City Community College, "is pretty much what started the whole thing."

That initial taste of success led to greater involvement in the workings of government for EMS folks within the state's colleges. Paramedic students were taken to the statehouse to meet their legislators and be exposed to the processes of lawmaking. This was tied in with lobbying efforts by EMS stakeholders. It also helped educate lawmakers to the needs of EMS. Communication was enhanced, to the benefi t of both sides.

By the time the 2006 fall semester started, interest among the state EMS community was fully piqued. Its consensus: Let's form a group to keep ad- dressing these issues on an ongoing basis. The coalition was born.

"EMS isn't always a priority for [lawmakers and administrators], and they're not aware of our needs," says Calhoun. "There's a tremendous need to educate them, but we're at a disadvantage because we're not well organized. EMS in Oklahoma, like other states, does not have a strong advocacy group and an understanding of how to lobby properly. So this coalition is much needed, not just to advance this one piece of legislation, but to continue on and address issues in the future that are going to need unifi ed support."

With the legislation in question dormant but not dead, the current focus is on further lobbying this year. Meanwhile, the coalition is taking formal shape. A mission statement has been produced, and bylaws are in the works. Initial participants are expected to include the state ambulance and EMT associations, EMS for Children, the state EMS educator, air-medical and geriatric advocacy groups, and the fi re service. Others may be incorporated down the road.

There's plenty to work on. Oklahoma has seen nearly four dozen services go belly-up in the last fi ve years, with numerous others reducing their levels of service due to paramedic shortages. The goal is not just to shape legislation, though that's certainly an important component, but also to be an ongoing voice when rules and policies are promulgated by the state health department, which oversees EMS in Oklahoma.

"The legislation up right now is important, but to me there's a bigger picture," says Barnes. "We need to do everything correctly, because it's really about the future. So if it takes a little bit longer to do things right and get it well organized and well supported, we'll take that time to do that." A website will be forthcoming. For more on the Oklahoma EMS Coalition, e-mail Barnes at ljwebre@yahoo. com or Calhoun at calhoun@osuokc. Edu.

Original content by John Erich and Susan Nicol Kyle, staff writers.

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