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Promoting Innovation in EMS: What We've Learned

Over the last year we’ve explored key recommendations of the Promoting Innovation in EMS (PIE) project. The PIE project utilized broad stakeholder involvement over four years to identify and develop guidance to overcome common barriers to innovation at the local and state levels and foster development of new, innovative models of healthcare delivery within EMS. Find earlier columns in the series under the monthly magazine issue archives at 

Over the last 11 months, we’ve brought you strategies to implement a few of the most significant recommendations of the Promoting Innovation in EMS (PIE) project. This final installment summarizes the strategies.

Project Summary

The PIE project evolved from the recognition by three federal agencies with oversight responsibility for EMS—the National Highway Traffic Safety Administration (NHTSA), the Health and Human Services Office of the Assistant Secretary for Preparedness and Response (ASPR), and the Department of Homeland Security (DHS)—that there are common regulatory, legislative, and financial barriers to EMS innovation faced in nearly every community. While there may be federal-level policy changes that could impact these, there are also many opportunities for local and state EMS leaders and partners to help overcome them. 

The project team interviewed internal and external stakeholders to get diverse perspectives on impediments to the desired state of EMS in our country. This group helped identify numerous common barriers across seven different domains and developed around 250 actionable recommendations aimed at local and state EMS leaders.

External stakeholder organizations represented included the Emergency Nurses Association, Visiting Nurse Associations of America, National Association of County and City Health Officials, Cigna HealthSpring, Kaiser Permanente, Geisinger Health System, Johns Hopkins Bloomberg School of Public Health, Mesa (Ariz.) City Council, and Institute for Healthcare Improvement. This broad representation provided keen insight into how to overcome barriers to innovation.

Members of the NAEMT EMS 3.0 Committee combed through the PIE recommendations and developed a triage/scoring methodology to help identify those that could be addressed first and then ranked them based on:

  • Feasibility—The likelihood of the recommendation being implemented, maintained, and sustained; 
  • Value—Does the recommendation position EMS to demonstrate enhanced value to our stakeholders?
  • Alignment—The extent to which the recommendation aligns with the EMS 3.0 mission.

This process helped focus on innovation strategies with the greatest potential to advance the EMS profession. For our final column in this series, we wanted to summarize the seven main themes of the series: the ingredients for successful innovation, quality measures and data, demonstrating value for EMS, decoupling payment from transport, EMS association alignment, education and medical oversight, and enhancing the business acumen of EMS providers. 

1. Ingredients for Successful Innovation

  • Visionary leadership—Innovation begins with a visionary leader—someone who can see something new and better than the status quo. It requires a telescopic view of the horizon, with a firm understanding of the realities of the local environment.
  • Risk tolerance—Innovation is messy. There’s a chance innovation could fail. It’s often said failure is only failure if you fail to learn. While risk can be mitigated by thorough planning, execution, and small-scale rapid-cycle testing and pilots, not everything will work perfectly. Develop a tolerance for risk you’re comfortable with.
  • Organizational readiness—Some organizations are known for being nimble and embracing change, others for being slow to innovate or adapt. Assessing organizational readiness for innovation is crucial for transformation. It requires an honest assessment of visionary leadership and risk tolerance of the organization’s internal and external stakeholders.

2. Quality Measures and EMS Data

The recommendation with the highest overall priority score focused on the need for EMS to determine ways to prove value. The EMS Compass project, highlighted in the PIE document, was an excellent first step toward developing quality measures that could demonstrate the value of effective EMS delivery.

While that project unfortunately sunsetted, a new initiative has been undertaken to continue the work. With seed funding from NHTSA, the new National EMS Quality Alliance (NEMSQA) has developed an organizational structure, steering committee representation, and a project plan to identify and adopt quality measures for EMS.

3. Demonstrating the Value of EMS Data

The second-highest-rated recommendation related to promoting EMS data as valuable to the rest of the healthcare system. In today’s healthcare environment data, especially outcomes data, is crucial. Strategies for implementing processes that bring value to EMS data may include:

  • Partnerships with organizations such as the American Heart Association, American Stroke Association, and American College of Surgeons to incorporate specific EMS data elements as a requirement for accreditation as a cardiac, stroke, or trauma center;
  • Development of a single data repository and reporting process for care of CPR, STEMI, stroke, and trauma;
  • Development of publicly accessible dashboards for comprehensive outcome reporting for care processes across the continuum (prehospital to hospital discharge) and patient outcomes;
  • Requiring EMS agencies and hospitals to report specific data elements as a condition of licensure, accreditation, and/or payment.

Now is the time to begin creating high-value partnerships with stakeholders to demonstrate the value EMS brings to the care continuum.

4. Decoupling Payment From Transport

Another top recommendation was that Medicaid and other health policy committees should allow EMS reimbursement for response and treatment independent from transportation. Many EMS responses could be safely mitigated without a trip to the ED, but if ambulance agencies are only paid to transport, there is little motivation to do anything different. 

State Medicaid offices can be more innovative with payment policy by either working to pass legislation or simply allowing ambulance response and treatment without transport as a covered benefit. As an example, the Arizona Health Care Cost Containment System (AHCCS) has paid for EMS treat-and-refer services since 2016.

A logical role for national EMS organizations would be to educate state Medicaid offices on the economic and patient-experience benefits of patient navigation and advocate for them to change payment policy. The same organizations could work with state payer associations or directly with large payers on the value of patient navigation vs. ambulance transport. 

5. One Voice

A key term contained in the PIE recommendations is that national EMS stakeholders should continue to advocate in a unified way. We often hear that the EMS community is fragmented when it comes to matters of legislation. The PIE authors recognized this.

The major associations that influence payment policy should agree on key tenets of decoupling payment from transport and all push in the same direction—perhaps even publish a statement on the components they agree on. 

6. Education and Oversight

EMS providers may lack the education and training to safely navigate 9-1-1 callers to alternative destinations. If we’re serious about decoupling payment from transport to enhance patient outcomes and reduce expenditures (i.e., demonstrate value), we need to prepare providers to do it safety and effectively. This will require new education, protocols, and quality improvement processes. The National Association of EMS Physicians and American College of Emergency Physicians should work with the National Association of EMS Educators and NAEMT to develop education and training standards to prepare EMTs and paramedics for alternative delivery models. 

7. Enhancing the Business Acumen of EMS Providers

A recurring theme throughout the PIE project was the challenge for EMS agencies to develop their business acumen. The reality is that healthcare, whether in a fixed or mobile setting and regardless of organization type, would generally benefit from being run more like a business. EMS leaders should understand things like fixed versus variable costs, depreciation of capital assets, and marginal cost analysis. Understanding the costs of service delivery helps determine the economic impact of implementing innovation in EMS agencies, but it’s only one side of the equation.

We hope you’ve enjoyed this series and can use the information to implement innovation in your agency. The authors of the PIE report stand ready to assist you in any way to enhance the value of your EMS agency. 

Matt Zavadsky, MS-HSA, NREMT, is chief strategic integration officer at MedStar Mobile Healthcare, the exclusive emergency and nonemergency EMS/MIH provider for Fort Worth and 14 other cities in North Texas. He is a member of the EMS World editorial advisory board.

Kevin G. Munjal,  MD, MPH, is an emergency physician who completed an EMS fellowship with the New York City Fire Department. He is founder and chair of the New York Mobile Integrated Healthcare Association, an organization seeking to empower EMS providers to play a larger, more integrated role within the healthcare system. 

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