The Montgomery County (Texas) Hospital District (MCHD), one of the most clinically advanced and innovative EMS systems in the country, has made a bold decision to completely redesign its clinical department. In its place, MCHD has created an Office of the Medical Director role, a change the district believes will create a forward-thinking state-of-the-art system to support and enhance oversight for medical director, Jay Lance Kovar, MD, FACEP.
The redesign was undertaken as a response to projected shifts in the EMS industry, such as pay for performance, and also to take advantage of new opportunities like the Health Information Exchange.
JEMS Editor-in-Chief A.J. Heightman, MPA, EMT-P, asked MCHD EMS Director Allen Sims, EMT-P, to discuss the new direction for their EMS system and what precipitated these changes.
JEMS: Please give us a brief description of the Montgomery County Hospital District and the area you serve.
Sims: MCHD is a local governmental entity chartered by the Texas Legislature in 1977 to operate an indigent care program for the county. The program is analogous to a local Medicaid program. In addition, it has a long-standing tradition of operating the county’s EMS system.
In the past decade, the county’s population has grown from 300,000 to 450,000, making it among the fastest growing counties in the country. During that time, MCHD’s EMS call volume has grown from 22,000 a year to 45,000 a year. Our system is the second-largest, single-jurisdiction provider in the greater Houston area. Every day, we deploy 22 ALS ambulances.
JEMS: Tell us about your visionary move to reorganize your clinical operations program.
Sims: We made a decision to redesign the system we use to provide medical oversight to our crews. Our aim was to better reflect today’s healthcare environment and to validate and improve our quality of care. To do that, we chose to move away from the old model of a clinical operations department and establish an Office of the Medical Director (OMD).
JEMS: How does your new OMD differ from the clinical department model?
Sims: When we operated as a clinical practice division, we, like many EMS organizations, tended to focus on initial EMS training and continuing education. We were reactive to problem solving, seeking to understand the issues and address them through professional development. And although we’ve always been progressive with our protocols, our previous model wasn’t nearly robust enough to meet the changes we see coming.
With the OMD, we’ll be moving away from a purely reactive educational approach and providing a much more proactive type of medical oversight. It’s our desire to develop a total picture of the quality of care—from dispatch to discharge—integrating our efforts with EMS providers and hospital systems.
Our objective is to ensure we have the right people with the right skills doing the right tasks and working within the proper organizational structure. In doing so, we’ll provide accurate information about our performance to our staff and our medical director.
JEMS: What role did the anticipated national healthcare reform play in driving this change?
Sims: We were driven by several important considerations; healthcare reform was one. One of the major objectives of healthcare reform is the emphasis on value-based performance. Regardless of the current legislation’s fate, future health providers will be required to demonstrate the efficacy and performance quality to survive.
At a recent industry gathering, healthcare economist Uwe Reinhardt stated, “Healthcare providers will go under unless they have very robust managerial cost accounting and solid data about the quality of their care. For many providers, who still believe that they should be “reimbursed” for whatever their costs are, this may be a novel experience, but it’s fundamental.”
We want to be ahead of the curve in implementing programs that will help us manage such reform-driven changes as pay for performance.
JEMS: How do you think “pay for performance” will affect EMS, and how did it motivate your decision to move to your new medical oversight model?
Sims: We strongly believe that value-based purchasing (formally referred to as “pay for performance”) will move from a physician- and hospital-based model to encompass all elements of healthcare, including EMS. We’re not suggesting the model will reach down to the level of the individual paramedic, as it does with doctors, but certainly EMS agencies will be held accountable for their overall quality and cost of care.
All the elements are available for EMS to move toward this model. For instance, in the not-too-distant past, most EMS agencies used paper-based run records. Now, the predominant technology is electronic records. So, for the first time in our history, we have the capacity to easily track and measure our performance. And, equally important, we also have the capability to do large-scale system analysis to develop better standard measures of quality.
JEMS: Let’s talk about the details. Tell us how the OMD will function and what kinds of positions you will be filling.
Sims: We’ve designed the organization around eight primary positions divided into four primary areas:
Training, promotions, credentialing and regulatory compliance will be handled by two positions, the professional development coordinator and the medical staff service coordinator. Data integrity, measurement, analysis and reporting will be the purview of database administrator and a data analyst.
Quality, benchmarking, standards, best practices and protocols will be handled by a research associate and a performance improvement specialist.
Finally, healthcare integration, outcome determination and reporting and critical event review will be handled by two care specific coordinators; one for trauma and one for cardiac and stroke.
One important note is that although EMS experience would be a plus for the people in these positions, it won’t be a prerequisite. We’ll also be looking outside of EMS to staff them. The important criterion will be that they have legitimate experience and proven success doing the type of work they’ll be asked to do.
JEMS: It’s interesting that you’d bring up credentialing in the context of the new approach. Most EMS agencies already do credentialing, so how will it be different in your OMD model?
Sims: Some services have used the term “credentialing” for a while, but we don’t believe the majority of EMS systems have fully understood the “physician practice model.” I don’t think we’ve fully embraced the possibilities effective credentialing could provide as a quality service for an EMS medical director.
Through our medical staff services coordinator position, we intend to closely track all elements of our crews’ experience and their performance, including the number and types of patients, types of therapy rendered and the success of those therapies.
We also intend to track other elements of their patient interactions, such as childbirth situations. By doing so, we’ll be able to identify areas in which our paramedics need assistance and will be able to gauge those therapeutic areas in which they aren’t getting enough experience to stay current with protocols and skills.
For example, when we find a paramedic who hasn’t delivered a baby in a couple of years, we’ll bring them in for simulation training. Our goal is to move away from the old belief that it’s OK for a paramedic to go two or three years without using certain critical skills.
In the new world of EMS, we believe it will be important for medics to use their skills regularly, either in the “live” environment or with a simulator.
JEMS: You also mentioned “specific care coordinators.” Can you tell us more about these positions?
Sims: In our new OMD model, we’ll have two positions that are responsible for dispatch-to-discharge monitoring of patient outcomes. These specific care positions will follow patients as they enter the system through our Medical Priority Dispatch protocol. We’ll track their experience with our emergency medical responders and ambulance crews all the way through to the emergency department. But, the process won’t stop there. The specific care coordinators will follow patients through their hospital stay and beyond to see the longterm effect of EMS treatment.
One of the specific care coordinator positions will be a trauma care coordinator. Unfortunately, for many years, Montgomery County was fully dependent on the trauma system in Harris County (Houston). We didn’t have a trauma center of any level in our county, so we transported serious trauma patients, very often by helicopter, to trauma centers that were more than 40 miles away. Now, through the joint efforts of MCHD and the hospitals in our county, we have two Level III centers.
It’s up to us and our hospital partners to monitor our local trauma system to ensure it’s being used appropriately and efficiently. We need to ensure we’re taking the right patients to the appropriate level of trauma care. We also need to always be on the lookout for areas in which we can assist our trauma providers in maintaining their performance objectives.
Although those two items may sound routine, they’re important. In our region, we have had a long history of taking all, or most of, our trauma patients to Level I centers only.
In many cases, we had ambulances driving past and helicopters flying over perfectly appropriate Level III facilities to transport patients to Level I care. We have also had lower level trauma centers refusing to take appropriate patients and waving crews past. Neither of these elements represents effective use of a trauma system. The trauma system coordinator’s goal will be to help us get past—and stay past—these ingrained inefficiencies.
JEMS: Tell us about your cardiac and stroke care coordinators. What will those positions entail?
Sims: MCHD and our hospital partners have taken great strides in the care of cardiac and stroke patients. The list of innovative and early adopter treatments and protocols that we’ve successfully adopted is long.
In fact, as a medical community, we’ve purposely positioned ourselves as close to the state of the art as possible. But an aggressive system, such as ours, needs to be monitored and managed thoroughly. We need to know how we’re affecting our patients in the harsh and unpredictable environment of EMS. And we need to be able to identify trends and patterns that have the potential to reveal areas of improvement.
Also, although we always want to adopt new and innovative treatments as quickly as possible, we need to be able to prove their efficacy and ensure a positive benefit-to-cost ratio. We don’t want to adopt treatments, protocols and new technologies simply because they exist; we need to know and prove there’s a valid reason to do so. Close monitoring of the cardiac and stroke system’s performance will help us make those determinations.
JEMS: We know from the past that MCHD is a data centric system, collecting and interpreting patient-treatment data to help guide the way you deliver and improve your patient care. So how does the new model help you continue and expand the process?
Sims: Although we think we have done a good job in this area, there’s always room for improvement. Through new technologies and data collection and analysis techniques, EMS is more data-rich than ever. The problem is no longer “How do we get the data?” or “How do we analyze it?” Instead, it’s now, “How do we make the best use of it?” The restructure of our agency will enable us to best use the knowledge we know now.
For us, the OMD is the appropriate structure because of its “big picture” orientation and focus on analysis, research, effective feedback and constant performance monitoring is the appropriate structure.
JEMS: Have you learned anything thus far that will help others decide whether to pursue a similar clinical model?
Sims: It’s important to embrace the reality that our environment is evolving. No one can deny that our world is changing. We need to recognize that the momentum for change has been building for a decade or more.
We’ve reached a critical point in which technology and knowledge will allow us to adapt to social and economic pressures. As a service and an industry, EMS can either lead the change or be rolled over by it.
We’ve learned that once you accept the inevitability of, and need for, change, it becomes a matter of developing systems, structures and mechanisms to help you manage it.
One last point: Agencies shouldn’t be afraid to look beyond the old ways of doing things. Be bold enough to reach out to people, philosophies and best practices that exist outside the prehospital realm. The sooner we look to and adopt the best of what other medical fields have to offer, the sooner EMS will be recognized as a legitimate medical profession that can monitor itself and best improve its quality of care. JEMS
This article originally appeared in June 2011 JEMS as “New Directions: MCHD redesign takes a forward-thinking approach.”