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EMS Leaders: It’s time for change & innovation


Editor’s Note: JEMS Editor-in-Chief A.J. Heightman, MPA, EMT-P reports from the American Ambulance Association (AAA) Annual Conference being held this week at Caesar’s Palace in Las Vegas.

During a three-hour preconference workshop on healthcare reform and ambulance service, EMS consultant and improvement advisor David Williams, PhD,  told American Ambulance Association (AAA) Annual Conference attendees that EMS agencies have to begin to fill the gaps in the healthcare system and be more fully integrated into the new healthcare movement.

Williams, improvement advisor with TrueSimple, based out of Austin, Texas, recommended that attendees read the work of the Institute for Healthcare Improvement (IHI), founded by Boston pediatrician and former Centers for Medicare and Medicaid Services (CMS) administrator Donald M. Berwick, MD, MPP, FRCP, (see below for bio) because of their strong grasp of healthcare reform. Prior to his work in the administration, Berwick was president and chief executive officer of the IHI, a not-for-profit organization helping to lead the improvement of healthcare throughout the world.

IHI has studied the management of healthcare systems, with emphasis on using improvement science and evidence-based medicine to improve the tradeoff among quality, safety and costs. Among IHI's projects are large, multi-hospital system improvement collaboratives, research and development, and online courses for healthcare professionals for reducing infections, lowering the number of readmissions, or managing advanced disease and palliative care.

Understanding the Opportunities
Williams said EMS can now have conversations with people who we previously never had access to because they know that EMS will be a part of the new healthcare system and approach. Insurance payers are increasingly interested in community paramedicine and where they can integrate EMS. The Dartmouth Atlas of Health Care website allows you to look at price-adjusted per-capita Medicare by Hospital region.

Williams cited the IHI Triple Aim Initiative, a new systems design approach that stresses:
1. Improvement of the quality of care;
2. Improvement of the patient experience (including quality and satisfaction); and
3. Reduction of the per capita cost of healthcare.

Williams said that EMS systems are now looking for opportunities to fill in open gaps, such as social services like hospice care and performance of immunizations. He noted that EMS is beginning to be seen as a cost efficient way to accomplish the healthcare goal.

In addition to filling in gaps, Williams says community paramedic is also a conduit to navigate patients through the healthcare system and "connect" them to the right service. Therefore, this new healthcare provider is not really a threat to other healthcare providers; thus it’s more likely to succeed and prosper.

Williams cited the work of Atul Gawande, MD, MPH, a general and endocrine surgeon at Brigham and Women's Hospital in Boston and noted journalist known in the public arena as an expert on reducing error, improving safety and increasing efficiency in surgery. Gawande also serves as associate director of the Brigham and Women's Hospital Center for Surgery and Public Health, an associate professor at the Harvard School of Public Health and an associate professor of surgery at Harvard Medical School.

Gawande has written extensively on medicine and public health for the New Yorker and is the author of the books Complications, Better, and The Checklist Manifesto.

Gawande speaks about things we should understand about healthcare. He cited an article that Gawande wrote in the New Yorker about “hot spotters,” whom he defined as patients with high per capita costs. Gawande has presented that we could lower medical costs by giving the neediest patients better care. Williams said that he feels that this will be a big opportunity for EMS.

Williams then presented some actual “high user” data to the attendees to illustrate the high cost of healthcare and how EMS can serve as a conduit to help reduce those costs:
• San Francisco: $32,000 per patient;
• San Diego: $33,459 per patient; and
• Seattle: $100,000 per patient.

He also told the attendees about innovative San Francisco paramedic Niels Tangherlini, who earned a degree in public health and found that high system uses were typically:
• Male;
• Homeless;
• Chronically inebriated;
• Had co-morbid mental illness;
• Had co-morbid medical conditions; and
• Aged 40–60.

The Cost Conundrum
Williams cited another Gawande article that appeared in the New Yorker that reflected on why the McCallum, Texas healthcare delivery system was so expensive. He pointed out that there was a lot of duplication of services and limited economies of scales.

Williams noted that EMS systems must begin to take a look at ways to make their systems more efficient and effective. He pointed out that inefficient systems do 40% of their time re-working to improve things that were not done right the first time.

He then referenced an article that appeared in the May 2006 issue of EMS Magazine. In "Taking EMS into Tomorrow,” EMS manager and educator, Mike Taigman says, "The time has come for us to fundamentally change the role of EMS systems.” Taigman states in that article that, “We [EMS] have the resources, competencies and relationships that no other part of healthcare has.”

The areas Taigman cited included:
• Facilitating the care of diabetics;
• Reducing frequency of asthma attacks;
• Reducing the incidents of elderly falls;
• Reconciling medication; and
• Assisting chronic congestive heat failure patients avoid triggers that result in hospitalization. EMS is not being seen as a way to reduce hospital readmissions.

Data can be retrieved from any community's hospital facility on the CMS website (at www.hospitalcompare.hhs.gov/), which shows community readmission incidence. For example, in one community, Williams pointed out that one in four patients were readmitted for heart failure.

Care Variation & Outcomes
Williams pointed out that we do not really have processes in place in EMS systems to track and determine variation in care. For example, EMS systems vary in how they run cardiac arrests versus using a standard way to run a code that is the most efficient and effective way.

Other innovative projects discussed by Dave Williams, PhD, include:

A Collaborative Project
Year #1 of the Coalition of Advanced Emergency Medical Systems project focus areas:
1. Multiple EMS agencies were involved in “Learning Sessions” on improvement science;
2. The agencies shared attention on a key operational issue with quality and cost implications;
3. There was participation in bi-weekly collaborative knowledge sharing;
4. A focus was put on the use of improvement tools.

Year #2 project focus area: This will be modeled after the IHI impacting cost and quality.

Caring for Maria
The American Medical Response Caring for Maria program, modeled after the Esther Project in Sweden, focuses on care around a standardized patient. There are 19 AMR operations around the U.S. involved in this innovative project. Their two main work streams are cardiac arrest and "other things that matter," such as ST-segment elevated myocardial infarction, stroke, pain, trauma and respiratory problems. Williams noted that the AMR program will also follow the IHI Breakthrough Collaborative Model.

An Organizational View
Mecklenburg (N.C.) EMS Agency views their organization as a system—a linkage of processes—and has decided to:
• Identify and map their processes;
• Develop organizational family of measures;
• Develop a portfolio of projects to improve those things; and
• Use these as a strategic pan for 2013.

Portfolio of Improvement Projects
AMR/Seattle is developing a portfolio of projects where improvement is directly ties to their core business. He added that AMR will also be developing a business case that includes estimated cost savings

EMS CMS Innovation
The Regional Emergency Medical Services Authority in Reno, Nev., received a $9.8 million CMS innovation grant that will focus on:
• Patient navigation;
• Chronic health;
• High users;
• Readmissions; and
• Use of a call center.

Dr. Donald Berwick
In 2010, President Barack Obama appointed Donald M. Berwick, MD, MPP, FRCP, to serve as the administrator of Centers for Medicare and Medicaid Services (CMS). However, Berwick was forced to resign in December 2011 because of heavy Republican opposition to his appointment and his potential inability to win a confirmation vote.

He has been quoted as saying that 20–30% of health spending is "waste" with no benefit to patients because of overtreatment, failure to coordinate care, administrative complexity and fraud. He also says part of this problem was because of CMS regulations.1

Critics of the Boston physician have cited his statements about the need for healthcare to redistribute resources thoughtfully vs. the existing rashining that occurs systemically between the rich and the poor and his favorable statements about the British health service. They quote Berwick as saying, "The decision is not whether or not we will ration care. The decision is whether we will ration with our eyes open."(1–2)

Berwick has said that Republicans had "distorted" his meaning: "My point is that someone, like your health insurance company, is going to limit what you can get. That's the way it's set up. The government, unlike many private health insurance plans, is working in the daylight. That's a strength."(2)

Critics point to such statements as, “Any healthcare funding plan that is just, equitable, civilized and humane must, must redistribute wealth from the richer among us to the poorer and the less fortunate. Excellent healthcare is by definition redistributional."(3–4)

Berwick announced in March that he would join the Center for American Progress as a senior fellow.

1. Pear R. (Dec. 3, 2011.) Health Official Takes Parting Shot at ‘Waste.’ In New York Times. Retrieved Nov. 26, from www.nytimes.com/2011/12/04/health/policy/parting-shot-at-waste-by-key-obama-health-official.html?_r=0.
2. Biotechnology Healthcare. (June 2009.) Rethinking Comparative Effectiveness Research. In U.S. National Library of Medicine National Institutes of Health. Retrieved Nov. 26, from www.ncbi.nlm.nih.gov/pmc/articles/PMC2799075/.
3. Dominech B. (May 12, 2010.) Obama Nominee Donald Berwick's Radical Agenda. In Red State. Retrieved Nov. 26, from www.redstate.com/ben_domenech/2010/05/12/obama-nominee-donald-berwick%E2%80%99s-radical-agenda/.
4. Tanner M. (May 27, 2010.) 'Death panels' were an overblown claim—until now. In The Daily Caller. Retrieved Nov. 26, from http://dailycaller.com/2010/05/27/death-panels-were-an-overblown-claim-until-now/.


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