EMS on the Hill: Vol.1 No.1, October 2007

When the group convened on July 10 to review the recommendations of the Institute of Medicine's 2006 Emergency Medical Services at the Crossroads report, certain guidelines had to be established to move the process forward. The group decided to approach this discussion accepting the validity and authority of the IOM report, not seeking to change any recommendations, but merely evaluating the urgency of each item and determining ways to begin realizing those with highest priority. Where possible, given the scope of the meeting and its participants, task lists were established for items considered. Below is a summary of these discussions.

Building a 21st Century Emergency and Trauma Care System

"3.1: The Department of Health and Human Services and National Highway Traffi c Safety Administration, in partnership with professional organizations, should convene a panel of individuals with multidisciplinary expertise to develop evidence-based categorization systems for EMS, EDs, and trauma centers based on adult and pediatric service capabilities."

The group was split on the urgency of this item: Pursuing it would likely pose signifi cant short-term challenges, but could serve as a springboard to realizing recommendation No. 3.4. The idea of a national all-encompassing categorization system is laudable, but in examining the feasibility of developing such a system, the majority felt NHTSA should take the lead. This was its conclusion for items 3.1--3.3. This would be a good project for the National EMS Advisory Council (NEMSAC).

"3.2: The National Highway Traffi c Safety Administration, in partnership with professional organizations, should convene a panel of individuals with multidisciplinary expertise to develop evidencebased model prehospital care protocols for the treatment, triage, and transport of patients."

As with recommendation No. 3.1, members were split on the urgency of this item. Again the majority felt NEMSAC and NHTSA should take the lead.

3.2 Action Item:
1. The group will draft a letter to NHTSA supporting continuation of the work group process for the evidence-based review of practice guidelines.

"3.3: The Department of Health and Human Services should convene a panel of individuals with emergency and trauma care expertise to develop evidence-based indicators of emergency and trauma care system performance."

Again, NEMSAC and NHTSA should take the lead.

"3.4: Congress should establish a demonstration program, administered by HRSA, to promote regionalized, coordinated, and accountable emergency and trauma care systems throughout the country, and appropriate $88 million over fi ve years to this program."

The group was split on the need to establish a demonstration program, but unanimous that any EMS funding is welcome. The group also agreed that this item must rely on items 3.1--3.3 to move forward.

"3.5: Congress should establish a lead agency for emergency and trauma care within two years of the publication of this report. This lead agency should be housed in the Department of Health and Human Services, and should have primary programmatic responsibility for the full continuum of EMS, emergency and trauma care for adults and children, including medical 9-1-1 and emergency medical dispatch, prehospital EMS (both ground and air), hospital- based emergency and trauma care, and medical-related disaster preparedness. Congress should establish a working group to make recommendations regarding the structure, funding, and responsibilities of the new agency, and develop and monitor the transition. The working group should have representation from federal and state agencies and professional disciplines involved in emergency and trauma care."

This item received the least support as a top near-term priority. The consensus supported continuing to operate through FICEMS (the Federal Interagency Committee on EMS).

"3.6: The Department of Health and Human Services should adopt rule changes to the Emergency Medical Treatment and Active Labor Act (EMTALA) and the Health Insurance Portability and Accountability Act (HIPAA) so that the original goals of the laws are preserved but integrated systems may further develop."

This item was the first of several to receive unanimous short-term toppriority support from the group.

Most members agreed that HIPAA and EMTALA need changes and that CMS (the Centers for Medicare and Medicaid Services) should clarify HIPAA and EMTALA as they relate to EMS care--specifically, how HIPAA relates to sharing information and the parameters surrounding it.

3.6 Action Items:
1. The group should send a letter to CMS supporting clarifi- cation of HIPAA and EMTALA as they relate to EMS care.

2. Advocates for EMS, Fire Service- Based EMS Advocates and the Department of Health and Human Services also need to apply pressure to achieve this recommendation.

3. ACEP and the Emergency Nurses Association will form a multidisciplinary work group to make recommendations for reducing ED overcrowding.

"3.7: The Centers for Medicare and Medicaid Services (CMS) should convene an ad hoc work group with expertise in emergency care, trauma, and EMS systems in order to evaluate the reimbursement of EMS, and make recommendations regarding inclusion of readiness costs and permitting payment without transport."

The was the second item to receive unanimous near-term top-priority support. The group agreed on its importance, but enthusiasm to move forward was limited because this is not just a CMS issue, but a Congressional issue. It was recommended that a multiplier be applied based on call volume to prepare for surges because, based on review of a recent GAO report on CMS EMS reimbursement, money is not available from general funds. The group felt NEMSAC should be the ad hoc work group and the American Ambulance Association should develop a reimbursement task force to assist.

3.7 Action Items:
1. The AAA will form a reimbursement task force.

2. Lobby the original requesters of the GAO report (Congress, not CMS) to continue the momentum of change and serve as a champion of the effort.

Supporting a High- Quality EMS Workforce

"4.1: State governments should adopt a common scope of practice for EMS personnel, with state licensing reciprocity."

This item was a unanimous top priority and is already moving forward, but should be facilitated through use of federal seed money. It was recommended that NASEMSO (the National Association of State EMS Officials) submit letters of advocacy to each state and the NCSL (National Conference of State Legislatures). These should be paid for by federal seed money.

4.1 Action Items:
1. NASEMSO will submit advocacy letters to each state and the NSCL.

2. Congress should approve seed money for this effort.

"4.2: States should accept national accreditation of paramedic education programs."

The vast majority of the group supported this as a near-term top priority and recommended using federal seed money for the implementation.

4.2 Action Item:
1. Congress should approve seed money for this effort.

"4.3: States should require national certi- fication as a prerequisite for state licensure and local credentialing of EMS providers."

The majority of the group indicated this should be a near-term top priority, although there was some concern over the language of the statement regarding licensure and credentialing.

Action Item:
1. NASEMSO will draft a letter to state governments supporting national certification as an alternative to state and local credentialing.

"4.4: The American Board of Emergency Medicine should create a subspecialty certification in EMS."

This item received unanimous support.

4.4 Action Item:
1. Through Advocates for EMS, the group will offer an industry letter of support.

Advancing System Infrastructure

"5.1: States should assume regulatory oversight of the medical aspects of air medical services, including communications, dispatch and transport protocols."

This was another item receiving unanimous near-term top-priority support. It was suggested that states adopt guidelines identified in the Foundation for Air-Medical Research and Education's white paper Air Medicine: Accessing the Future of Health Care, supported by NASEMSO, the National Association of EMS Physicians and the Association of Air Medical Services (AAMS).

5.1 Action Items:
1. Principal stakeholders NASEMSO, NAEMSP and AAMS will convene a summit with identified federal partners to review the Airline Deregulation Act.

2. The group will support exploring legislative amendment language to resolve federal/ state oversight conflicts.

"5.2: Hospitals, EMS agencies, public safety departments, emergency management offices, and public health agencies should develop integrated and interoperable communications and data systems."

This was overwhelmingly supported as a near-term top priority.

5.2 Action Items:
1. Everyone will encourage providers at all levels to stay engaged in state and local communications interoperability steering committees.

2. The group will support current NASEMSO and NHTSA efforts along these lines.

3. NASEMSO and NHTSA need to disseminate more updates to provider groups regarding communication issues.

4. This charge should be added to the agenda of the 9-1-1 and Medical Communications Committee of the FICEMS Technical Working Group (TWG).

5. Grants should have a "demonstrated level of operation" as a requirement.

"5.3: The National Coordinator for Health Information Technology should fully involve prehospital EMS leadership in discussions about design, deployment, and financing of the National Health Information Infrastructure (NHII)."

Another overwhelming near-term top priority.

5.3. Action Items
1. FICEMS/NEMSAC needs to address NEMSIS (the National EMS Information System).

2. The group will write a letter to Health and Human Services Secretary Mike Leavitt that reinforces the importance of EMS involvement in efforts to protect the health of all Americans.

Preparing for Disasters

"6.1: The Department of Health and Human Services (HHS), the Department of Transportation (DOT), the Department of Homeland Security (DHS), and the states should elevate emergency and trauma care to a position of parity with other public safety entities in disaster planning and operations."

A unanimous near-term top priority. Prehospital issues must be a priority in national preparedness, and all stakeholders should be raising awareness regarding the role of EMS in disasters.

6.1 Action Items:
1. FICEMS needs to seek funding.

2. Continue to support Advocates for EMS in this area.

3. HHS and DHS need to complete currently mandated reports and increase efforts to provide ongoing data regarding emergency medical and trauma care preparedness.

4. Group members will support the activities of the TWG's Preparedness Committee.

5. Invite FEMA and the Justice Department to join the TWG's Preparedness Committee.

6. NASEMSO will facilitate parallel integration at the state and local levels, including working with groups such as the National Emergency Management Association and the International Association of Emergency Managers.

"6.2: Congress should substantially increase funding for EMS-related disaster preparedness through dedicated funding streams."

A unanimous near-term top priority. There is a FY2009 line item request for EMS personal protective equipment and training funding in DHS grants.

6.2 Action Item:
1. A complete EMS needs assessment should be conducted by the FICEMS TWG.

"6.3: Professional training, continuing education, and credentialing and certification programs of all the relevant EMS professional categories should incorporate disaster preparedness training into their curricula, and require the maintenance of competency in these skills."

The Pandemic and All-Hazards Preparedness Act passed last year requires this. Group members had mixed views on its urgency because the National Association of EMS Educators is doing it now, and it should be supported through EMS standards.

Optimizing Prehospital Care Through Research

"7.1: Federal agencies that fund emergency and trauma care research should target an increased share of research funding at prehospital EMS research, with an emphasis on systems and outcomes research."

A unanimous near-term top priority.

7.1 Action Items:
1. Add the National EMS Re search Agenda to all national organizations' platforms.

2. Pursue federal matching of funding by private entities and foundations that support EMS research.

3. Bump up HRSA (Health Resources and Services Administration) funding for agencies that fund EMS projects.

4. FICEMS will identify a plan to create a single clearinghouse for EMS research grants.

"7.2: Congress should modify Federalwide Assurance (FWA) program regulations to allow the acquisition of limited, linked patient outcome data without the existence of an FWA."

A majority near-term top priority.

7.2 Action Item:
1. SAEM (the Society for Academic Emergency Medicine) should develop language to govern such a change.

"7.3: The Secretary of the Department of Health and Human Services should conduct a study to examine the research gaps and opportunities in emergency and trauma care research, and recommend a strategy for the optimal organization and funding of the research effort. This study should include consideration of: training of new investigators; development of multi-center research networks, involvement of emergency medical services researchers in the grant review and research advisory processes; and improved research coordination through a dedicated center or institute. Congress and federal agencies involved in emergency and trauma care research (including the Department of Transportation, the Department of Health and Human Services, and the Department of Defense) should implement the study's recommendations."

A majority near-term top priority.

7.3 Action Items:
1. The group will send a letter to FICEMS identifying current gaps and budget to fill those gaps, including future projections.

2. HHS should develop programs to train EMS researchers. Future issues of EMS on the Hill will track and report progress on these items.

People Planning: The EMS Workforce Project Looks Toward the Future
By John Erich, Associate Editor

Workforce studies are difficult by nature. People choose and change careers and take and leave jobs for different reasons--reasons that re- flect their unique circumstances and experiences and values. Generalizing about entire populations as they come and go is challenging to do and inherently imprecise.

So you can imagine what trying to do it for EMS is like.

But with demand for prehospital emergency medical services booming in coming years and chronic shortages of providers in so many American communities, it's imperative to try to get a handle on just what people are looking for in their EMS employment: why they pursue and accept positions or don't; why they like and stay in jobs or don't--the factors that are important to them and shape their career decisions. Figuring this out, as best we can, is vital to maintaining the right resources in the right places to protect the public's health and safety.

The considerable challenge of personality- profiling the country's amorphous EMS workforce belongs to the University of California, San Francisco's Center for the Health Professions, which is conducting the Emergency Medical Services Workforce for the 21st Century Project. The project is a three-stage effort to examine the future of the prehospital EMS workforce in the United States and find ways to make sure it's robust. The Center is working with the University of Washington under funding from the National Highway Traffic Safety Administration (NHTSA) and Health Resources and Services Administration (HRSA).

The work began in 2005 with a comprehensive look around. Investigators consulted with EMS experts and stakeholders and worked to identify sources of workforce data. Every major EMS organization took part. The goal was to develop basic policy and agree on fundamental questions to be addressed--to wit, what are the challenges facing the EMS workforce? What does existing data suggest affects supply and demand? What models predict workforce needs for EMS systems? And how can the data contribute to developing an agenda for the future?

The quick realization was that shaping the workforce of tomorrow requires a better understanding of the workforce of today: Where do shortages occur and why? What influences supply and demand? What impacts recruitment, retention and job satisfaction? What's with the lack of diversity? "Phase I was really a research phase: What is the current evidence about the workforce? What do we know about it?" explains project director Susan Chapman, PhD, RN. "It included things like how many of us there are and whether this profession is growing. What does EMS look like in terms of job projections for the future?"

WHERE WE'RE STARTING FROM But when you start trying to crunch numbers--at least the ones that are out there--things get hairy fast. To begin with, we can't even really tell something as basic as the size of the domestic EMS workforce.

"How many of us are there? We still don't know. And that's a very basic piece of workforce planning," says Chapman. "The data we used provides an estimate of around 200,000, but we know that's low. There have been some numbers tossed out as high as 900,000, but I don't know of any source to validate that. So we don't have very good ways of counting and tracking, on a national level for sure, and also in many states. To do workforce planning, one might want to know where we're starting from."

With the EMS workforce, even something this easy isn't easy. The Bureau of Labor Statistics (BLS)--the definitive source of workforce data from the federal government--only counts those who receive paychecks, which excludes volunteers. It categorizes firefighters, many of whom provide EMS, separately, so they're not counted as EMS. And it lumps EMTs and paramedics together into a single category.

That's three major flaws right out of the gate with the federal data. They don't recur with EMS' own primary data source, but even that has its limitations. The National Registry of EMTs' Longitudinal EMT Attributes and Demographics Study (LEADS), is, of course, limited to nationally registered providers.

Still, that's a lot of them, and LEADS has amassed a good amount of data over its nine years and counting. And while it doesn't, by itself, demonstrate any concrete conclusions about providers' job behaviors, it's valuable to understanding a lot about them.

"The first thing LEADS does is enable us to describe the EMS profession in a fairly representative way," says NREMT Associate Director Gregg Margolis, PhD, who coordinates LEADS and is part of the Workforce Project's steering committee. "Most people's perception of EMS is very localized. And if your view of EMS is that of a rural volunteer EMT, you'll have a very different perspective on the EMS workforce than if your view is of an urban dual-role firefighter. So the LEADS project enables us to get the best sense of the national community, realizing there are considerable and important variations at a local level."

Evaluating the EMS workforce really requires study on both levels: the micro of the individual provider and the macro of wider populations.

"LEADS lets us track changes in the larger EMS workforce over time," says Margolis. "Are we increasing the number of minorities recruited into EMS? Are we getting older as a profession? Those sorts of things. But the other thing we can do is track individuals over time. For example, does an individual's health decline over their time in EMS at a rate greater than we'd expect of the general population? What is the incidence of work-related injuries over time? What happens to people's satisfaction in the career fi eld over time?"

Firm answers as to why people stay and go? No. Directions for further study? Certainly.

CAN'T GET NO SATISFACTION

From LEADS, we learn things such as that at least 26% of compensated NREMT-Basics, per data published in 2003, have no health insurance. That 57% of nationally registered medics feel their retirement plans will be inadequate to meet their fi nancial needs. That more than 30% of NREMTs surveyed in 2004 reported problems sleeping. (For more LEADS fi ndings and provider background information, see the sidebar on page 8.)

Generally, LEADS data reveals, EMS professionals aren't satisfi ed with the levels of appreciation and recognition they get from their employers. employers.

A third are dissatisfi ed with their benefi ts. Third-year medics show declines in career satisfaction, especially in rural areas. And EMTs dissatisfi ed with their current assignments are more likely to report back problems.

Overall, the biggest sources of provider dissatisfaction involve pay and benefi ts, work schedule, and career ladder/opportunities for advancement. So logically, that's a good place to focus workforce studies, right?

Perhaps, but... "All else being equal, satisfaction does impact retention, but it's not the whole picture," says Margolis.

"The dilemma is that many people who are satisfi ed leave, for a variety of reasons, and many people who are dissatisfi ed stay. And this is an issue in all professions. Making an occupational change has to do with more than satisfaction."

A better correlation may be found in a concept called occupational commitment. Simplifi ed, this boils down to how much you love your career/ job/workplace and are willing to endure to maintain it. One popular model breaks down an employee's commitment into three areas: attachment, obligation and costs of leaving.

In nurses, for example, higher levels of commitment in these areas were linked to less intent to leave the profession.

Put in concrete terms, even if you're unsatisfi ed with your pay and bene- fi ts, you may really like your coworkers. You may feel a sense of duty to help your community. Changing jobs may entail uprooting the kids from school and the spouse from their job. In short, there's more to it than just you.

"Satisfaction is clearly a part of retention, but it's not the whole picture," says Margolis. "There are many other factors that go into an individual's decision about whether they're going to stay in a career fi eld."

SUPPLY AND DEMAND

Beyond individual workers' values and behaviors, there are other forces shaping the EMS workforce. Start with the fundamental economic bedrock of supply and demand.

"We know the population of the country is growing, faster in certain states than in others," says Chapman.

"We know we're not going to have enough healthcare workers overall as the population becomes older. So we expect a bigger demand for health services across the board, and of course a bigger demand for EMS services. Are we going to have enough people? And are we going to have enough people in the right places, with the right training and credentials, who will stay in the job?"

Assessing what we know about supply and future demand for EMS workers was the focus of a project presentation at the International Association of Fire Fighters' EMS Conference in June. There representatives related some of what they've found, including relevant BLS data, and unveiled a model illustrating the EMS worker supply process and what goes into it (see Figure 1). Such factors must, of course, be identifi ed before they can be addressed.

"Basically that looks at where we get EMTs and paramedics from, and what it takes to get from John Doe on the street to a practicing EMT or paramedic," explains Chapman. "There are all those steps to the supply, and they all have various things that impact impact infl ow into the system and out- fl ow from the system. For example, like any healthcare profession, we have educational requirements; we have licensure requirements; we have certifi cation requirements."

Demand is of course shaped by need, and both have been rising steadily. From 2000--05, per BLS data, employment of EMTs/paramedics grew by 19%, outstripping other allied health and public-safety occupations. During that period, employment of fi refi ghters grew by 12%, of law enforcement offi cers by 9%. And in the next 10 years, total employment of EMTs and paramedics is projected by the BLS to jump by more than 27%--a fi gure that does not include volunteers or cross-trained fi refi ghters and hence may be low. This surely illustrates the urgency of better understanding the U.S. EMS workforce.

"Demand for emergency services is only going to increase as the demographics of the United States begin to shift," warns Margolis. "More and more pressure will be placed on the emergency care system. And EMS will feel that pressure."

SETTING AN AGENDA

So a lot of areas warrant scrutiny as the Workforce Project progresses through its second phase. There remain signifi cant matters of compensation-- EMTs and paramedics remain underpaid in comparison to other allied health and public-safety occupations (see Figures 2 and 3)--training and education, volunteering, diversity and more.

"That's basically where we are right now," says Chapman. "We've fi nished an assessment report, which is in review at NHTSA. And that will hopefully be released in the next couple of months. Then our next step is to take that and fi gure out where we go from there. What's the next step for creating a policy agenda for the workforce of the future?"

Work on that agenda will proceed over the next year, informed by ongoing input from stakeholders and guidance from the project's expert steering committee. Opinions are also still being sought from providers through a blog established on the project's website, www.emswork force.com.

"We thought it would be nice to get some comments from the field--kind of an inexpensive way to do focus groups," says Chapman. "We pose the questions and moderate the responses. It's not meant to be necessarily representative or systematic or something you report in the research literature as data, but it gives a flavor to what providers in the field are thinking."

The third and final stage of the project will ultimately be policy implementation: recommendations and strategies for a hale and hearty future workforce.

Whether you're a street-level provider, supervisor, chief, decision-maker or just interested in the health of your fellow Americans, your input is needed and welcome. Participation on the blog is invited, and with things like LEADS and other datacollection efforts, bigger sample sizes are always better.

This is a broad, deep and complex issue, and investigators will benefit from collecting as much information as they can, on a range of relevant topics.

"The workforce issue does sort of touch on a lot of other EMS issues," says Chapman. "It cuts across every circle."

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