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Introducing the PIE Project

Kevin Munjal

Over the next year EMS World, in conjunction with the National Association of Emergency Medical Technicians, will provide detailed implementation strategies for some of the key recommendations of the Promoting Innovation in EMS (PIE) project, a national framework document funded and supported by the United States National Highway Traffic Safety Administration (NHTSA) Office of Health Affairs, the Department of Homeland Security, and the Department of Health and Human Services.

The PIE project utilized broad stakeholder involvement over four years to 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. Each month we will focus on one recommendation and highlight the document’s actionable strategies to continue the EMS transformation.

In this kickoff to the PIE series, we interview one of the principal investigators for the project, Kevin Munjal, MD. Munjal is an assistant professor of emergency medicine and associate medical director of prehospital care for New York’s Mount Sinai Health System.

Tell us about the PIE project.

The PIE project evolved out of recognition by the three federal agencies that have oversight roles for EMS—NHTSA, the Health and Human Services Office of the Assistant Secretary for Preparedness and Response (ASPR), and the Department of Homeland Security—that there are common regulatory, legislative, and financial barriers to EMS innovation faced in nearly every community that the federal government can’t specifically resolve. However, they felt that a collaborative group of EMS and healthcare stakeholders would be able to articulate the barriers and, more important, develop strategies to help the EMS and healthcare community overcome them. These federal agencies requested proposals to develop the document, and the collaborative proposal submission of Mount Sinai and the University of California–San Diego, under the leadership of Dr. James Dunford and me, was awarded the project.

What were the project’s goals?

First and foremost our goal was to develop actionable recommendations for overcoming barriers to EMS innovation. We did not want to get lost in abstract notions, but rather identify, with specificity, what the barriers are and what can be done locally and at the state level to innovate. Next, we knew the value of the convening process. The people and organizations that participated were chosen very specifically. We thought having EMS providers, payers, regulators, medical directors, institutes of higher education, and partner associations (and those who may perceive EMS innovations as competition) all together would yield very fruitful dialogue. And that’s exactly what happened: Through the convening process, relationships were built between people and organizations that have promoted innovation in EMS, even before the final document could be released. Finally we wanted this collection of key leaders in healthcare and EMS to hear from EMS agencies directly. We accomplished that by convening regional listening sessions. We also used a very open, transparent process. All meetings were accompanied by telephone conference calls, and we released several versions of the documents for public review.

What were the key steps in the process?

First we created the national steering committee. We knew one of the keys to success would be having the right stakeholder organizations represented. We invited the usual EMS organizations, such as NAEMSP, NAEMT, AAA, ACEP, NASEMSO, IAFC, and IAFF. However, we also invited key organizations such as the Emergency Nurses Association, the Visiting Nurses Association of America, and the National Association of County and City Health Officials. Then we reached out to specific people from organizations that were either driving EMS innovation or would be exceptionally insightful while helping articulate barriers to innovation and how to overcome them. These invited perspectives included representatives from Cigna-HealthSpring, Kaiser Permanente, Geisinger Health System, Johns Hopkins Bloomberg School of Public Health, Mesa (Ariz.) City Council, Institute for Healthcare Improvement, Regional EMS Authority (REMSA), and MedStar Mobile Healthcare. We also used a very transparent and iterative process, which started with two regional forums, one in New York and one in California, and one national meeting. We also hosted several sessions at large national conferences such as the NAEMSP annual meeting and Pinnacle EMS Leadership & Management Conference. Section drafts were shared for comment to both the internal EMS industry and external stakeholders. We also worked to attain full consensus on all recommendations. As you might imagine, that turned out to be a heavy lift. It’s one of the reasons the process has taken so long and why there have been so many versions of the document. One example was state medical directors: A core group of participants felt state medical directors were a key component for advancing EMS, while others felt they actually impeded innovation. Through significant dialogue we arrived at recommendations focused not on whether there should be state medical directors, but rather on what both parties could agree were the types of roles a good state medical director could play to promote innovation.

Tell us about the format of the document.

The document is organized into what the steering committee identified as seven themes: legal and regulatory; financial sustainability; education; regional coordination; interdisciplinary collaboration; medical direction and oversight; and data and telecommunications. Each section has a description of the challenge, followed by strategic approach to overcome the barriers. Each section then ends with a list of recommendations aimed at various levels for each strategy to be applied in a specific way: local agencies or authorities, state associations and authorities, or national associations. In all there are more than 250 recommendations.

What are the next steps?

The document was made publicly available for comment for over a year and is now closed. The core team is finalizing the document for dissemination. We plan to roll it out at national conferences and through publications to serve as a platform for action. Then it’s up to the EMS community to begin implementing the recommendations. NAEMT’s EMS 3.0 Committee has initiated a process of cataloging all the recommendations and ranking them based on value, feasibility, and alignment. The committee will then select the top 3–5 recommendations for each section and assist with implementing them.

Any closing comments? 

This project has been a huge undertaking, and we’d like to thank all who have and continue to participate. Special thanks to West Health, the Greater New York Hospital Association, Kaiser Family Foundation, and many others who have been instrumental. We encourage everyone to access the document, become familiar with the recommendations, and work to enact those most applicable to their circumstance. 

To download the current version of the document visit

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.  

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