With the certainty of gravity, the use of broadband wireless communication, high-speed data transmission and video imaging are currently available technologies that should be strongly considered by the Emergency Medical Service agencies of today for the applications of tomorrow. Rather than waiting for impending issues to overwhelm available resources, EMS entities must come to grips with how the pre-hospital industry will manage these newer technologies, putting them to use to improve service delivery in more cost-effective and efficient ways.

To illustrate this point, rather than discuss a broad range of technology-related topics, this article will restrict its focus to one important issue -- reducing the number of "unnecessary" or non-essential EMS transports. We will review the reasons why this is such an important issue, the obstacles and risks associated with remedying it, and a depiction of how technology may be used as part of the solution. Because we are exploring a new approach to an old problem, we will keep the focus more on the conceptual, rather than the details of actual implementation. We ask the reader to keep an open mind.

The State of EMS

The Institute of Medicine recently outlined the current state of hospital and pre-hospital services in the 2007 publications "Emergency Medical Services at the Crossroads" and "Hospital-Based Emergency Care - At the Breaking Point". This new "bible" for emergency care accurately reflects the growing crisis in the U.S. and provides a starting point for discussion of potential solutions. The "continuum of care" that exists to notify and disburse EMS workers, treat patients anywhere in a community, and provide safe travel to definitive care facilities, often involves unique partnerships between public and private entities. The assumption within this system is that each entity assumes responsibility to support the success of the next. As an essential component of the continuum therefore, it is incumbent upon pre-hospital providers to incorporate new methodologies whenever possible to reduce non-essential transports and other antiquated policies that adversely affect the emergency service system as a whole.

As is widely discussed, EMS agencies face a number of critical challenges in the contemporary world of emergency services. These include:

• High percentage of non- and under-insured patients
• ED overcrowding
• Reliance on 911 dispatch systems beyond the intended use
• High cost of service
• Inefficient use of existing resources
• Reduced morale resulting from increased call volumes and high stress
• Medical liability

The impact of these factors upon existing emergency response systems should be reviewed when evaluating the need for adapting change in the traditional EMS model. Solving the problems mentioned above must involve consideration of the entire interrelated system and cannot be separated by agency or role.

Unnecessary Transports

One of the glaring discrepancies noted in today's EMS environment is the large percentage of non-emergent and low acuity responses. This phenomenon is not new to emergency services, but has long been an overlooked aspect of a system that typically focuses on the care of critically ill or injured patients. As an example, in 2007 the Tucson Fire Department responded to over 12,000 "Alpha" or non-emergent EMS dispatches,- fully 16% of the department's total annual call volume of 75,000 calls. Looking at this phenomenon from the inception of 911-dispatch and fire-based EMS service to the present day, traditional dispatch of 4-person engine companies or 2-person paramedic ambulances had increasingly come to be viewed by fire department administrators and field personnel alike as extravagant and wasteful. As a result a new tier of service, the "Alpha Truck" program, was developed by Tucson Fire back in 2005 to increase effectiveness and reduce costs.

Before continuing with this discussion, we must define "non-emergent", "low acuity" and "non-essential transports". Clearly, patients with serious emergency medical or psychological needs should go the ED -- that's what EDs are for. With a reasonable degree of accuracy, we can define the above as:

• Medical conditions that can be safely and adequately treated without the need to be seen at an emergency facility;
• Conditions that can be cared for in the field by medics acting on standing orders or under the direct supervision of a licensed medical practitioner, and
• Patient's whose follow-up care is either unnecessary or can be accomplished by home-based outpatient mechanisms.

The currently employed protocols of most medical priority dispatch systems that identify minor injuries, general sickness, minor burns, allergic reactions, etc. provide a natural starting point for addressing this issue.

Treat and Release

One method to reduce the number of non-essential transports is by means of a treat-and-release program. Although this is a topic that has long been discussed in EMS, some of the principal reasons for it not being fully endorsed are:

• Liability issues associated with not transporting patients
• Liability issues related to treating patients in the field
• Lack of reimbursement for non-transported patients, and
• Public expectations

While there are many reasons to continue current transport practices, there are just as many reasons why the issue of non-essential transports and treat-and-release should be addressed by EMS agencies. Without question, a change of this magnitude requires political support and the public's understanding and acceptance of why this is necessary. It is reasonable to expect that a skillfully prepared public relations program can make this support attainable.

Reimbursement, while an infinitely more complex issue, is something that should be attainable because, at the risk of appearing naive, it simply makes good sense! After all, why treat a patient by a process that is not only more costly than necessary but also may be less convenient, less efficacious, introduce more risk, and actually be detrimental to other, more needy patients? Reimbursement may indeed be a thorny issue but, in the end, money talks!

A third related issue is the potential for integrating a human/social service referral process into the first response model, whereby medically related but non-emergent issues are turned directly from pre-hospital providers to appropriate agencies within the community. Tucson Fire formalized this process in 2007 to complement the Alpha Truck program. The idea behind this comprehensive approach is to channel the significant non-emergent EMS call volume toward a solution that alleviates growing pressures upon the overloaded 911-dispatch center and community hospitals. By addressing this niche of EMS activity with a slightly different response configuration, far more cost-effective results have been achieved for all parties in the care continuum. Utilization of modern video, audio and data communication technology will certainly play a large role in the continued success of these types of endeavors.

Lastly, and perhaps most challenging is the issue of pre-hospital provider liability.

Liability as a Primary Obstacle

The liability issues associated with treat and release are difficult to resolve because they are real. The cost of a judgment error by a medic is potentially high, and to many unacceptably high, both monetarily as well as professionally. To address these concerns, there is much EMS can do to insure the delivery of first quality care and "placing patients first" by means of training and sound treatment protocols. These are things that a highly professional, well organized EMS operation can manage -- particularly if the issues of public expectation and reimbursement are resolved. On the other hand, liability issues, in addition to being real, are also perceptual and frighteningly capricious. The fear and risk of a legal question arising either from a mishandled call or an unexpected or improbable outcome is not easily dismissed. The question is, how can a treat and release program reduce risk to the point where it becomes similar to the other risks the health care delivery system deals with? This is where technology may hold an answer.

A Technological Safety Net

A key concept in addressing the risks associated with treat and release may be to make it similar to already accepted forms of patient care. There are two things that will go a long way in doing this: 1) the ability to directly involve a licensed physician whenever necessary, and 2) complete documentation of the patient encounter. The question is how can this be accomplished in a mobile environment where a physician is not present? In truth, this technology already exists, and at a highly affordable price.

Through the use of telemedicine technology, a physician can now be virtually present in an ambulance. The equipment needed to do this is currently available and in use by some EMS agencies in the U.S. Similarly, the new wireless communications infrastructures, ranging from privately owned 3G Cellular (private systems) to more advanced broadband wireless system such as WiFi and mesh systems (which may be either privately or publicly owned) are sprouting up all across the country. While it is true that for some, EMS telemedicine may not be a viable option, for others, it is quite realizable.

Video recording equipment, ranging from stand-alone cameras to the built-in logging capabilities of a full telemedicine system provides the ability for EMS agencies to capture a complete patient/medic encounter. This technology can be used to provide a solid legal defense against false claims as well as provide evidence that care was delivered in accordance with accepted practices and is readily available in today's marketplace. EMS agencies concerned with directing scarce resources toward improving treatment, reducing non-essential transport, and alleviating health care system stress, should seriously consider adding this tool to their arsenal.

Rather than looking at either of these applications as "revolutionary" or "unique", it should be noted that both technologies are already well accepted outside of EMS. For example, the use of cameras by police is the perfect case-in-point for examining the value of video for legal protection. Initially opposed by the police, cameras are now routinely used whenever the possibility of legal action is identified. The parallel benefit to the EMS community is unmistakable. Use of telemedicine capabilities is well accepted in fixed-point location-to-location medical applications and is advancing to the point where telemedic care has already reached reimbursement potential. Similarly, legal and licensure aspects of telemedicine have also advanced to allow more widespread use of the technology.

One View of the Future

Consider the following: The PSAP receives a call from an elderly homebound person suffering minor burns caused by scalding water. The patient is frightened and somewhat confused and insists on being taken to the hospital. The call management protocol identifies this as an Alpha call, and instead of a BLS ambulance being dispatched, a light-duty truck with telemedicine capabilities staffed by two basic EMTs is dispatched. The team arrives on scene and assesses the patient's condition. They determine that the burn is not severe, easily treatable on-scene, and that the patient remains capable of providing for himself/herself at home. By using their telemedicine system, the EMTs are able to provide a "virtual" visit with an ED physician, who examines the patient and, after a face-to-face conversation, convinces the patient that everything needed has been done and that there is no reason to go to the emergency department. Furthermore, with the aid of follow-up telephonic care, the patient will be able to provide on-going self-care for the injury.

Consider what just happened - The patient was immediately provided direct physician contact along with definitive care -- no costly and unnecessary ambulance ride to a hospital followed by a long wait in a noisy, frightening ED and potential exposure to infection. A less costly light-duty truck was used instead of a 4-person fire truck. Follow-up care was directed at the level necessary to insure recovery and the entire event was recorded. In addition, cost effective care was provided promptly with minimum disruption to the patient and the EMTs were spared the "scorn" of the ED staff by not bringing in an unnecessary addition to the already overloaded triage area. The physician spent about the same time as would have been necessary had the patient been in the ED except that the issue of "protective medicine" was not introduced. Additionally, the physician received first-hand exposure to the world of EMS and gained a better perspective of the patient in their home environment. Best of all, reimbursement could be less than it would for a traditional call and still cover every aspect of the episode. Clearly, this was a straight win for all that were involved -- the ED, EMS, the physician, and most importantly, the taxpaying patient.

Moving Forward

Coming back to reality, that piece of not-so-science-fiction (the mostly fictional part was the reimbursement) should be something that EMS gives serious consideration. As stated in the recent report by the Joint Advisory Committee on Communications Capabilities of Emergency Medical and Public Healthcare Facilities that was delivered to Congress in February 2008, "By taking advantage of modern communications technologies, we can begin laying the foundation for a mobile, digitally connected health care system". The technology is here, the precedents are set, and the benefits both clear and considerable. The message is that EMS must give serious consideration to ways in which emerging technologies, particularly those that have such obvious implications, advanced communications and information management, may be put to use. Those that think that all of this is something that lies in some distant future should think again -- telemedicine is already here and advanced communications systems of all types, WiFi, WiMax, EVDO, Mesh, etc., are springing up all across the country. It must be remembered that, even though the bandwidth of these new communication infrastructures is very large, it is nonetheless finite. Unless directly involved in the planning and deployment of this infrastructure, EMS runs the risk of being at the end of a long line trying to get access to that bandwidth.

History will show us which direction EMS took at this critical time. The authors believe a close look at this technology now will serve an EMS agency well in planning for the anticipated challenges to be confronted by the demands of 21st century EMS services.