American EMS: 2027

The photo shows the back of a yellow Fairfax County (VA) ambulance.
Photo/National Highway Safety Traffic Administration

Andrew Bober, NRP, looks at the future of EMS by examining the past.

Emergency medical services (EMS) is an essential service in today’s society as it is unimaginable to picture a country without a system to respond to the sick and wounded. Despite its critical importance to American safety infrastructure, EMS is the youngest form of public safety to have developed in the U.S. Modern EMS finds its birth in 1966 with the “White Paper,” which is a publication by the National Research Council officially titled Accidental Death and Disability: The Neglected Disease of Modern Society, which highlighted the gaps in prehospital care that existed in the U.S.1

With the creation of the national highway system, a new surge in trauma and an inability to provide emergent medical care to the public became a new priority. The National Highway Transportation Safety Agency was created in 1970 with the  Highway Safety Act, which adopted the responsibility of standardizing EMS care. In 1973, the Emergency Medical Services Act provided 15 guidelines for states to develop more effective EMS systems. By 1996, the EMS Agenda for the Future revised and improved upon the previous components with “14 attributes.” This brief reflection into the past is necessary when looking into the future of EMS. Since 1996, federal agencies have published papers investigating this subject area, however progression in virtual technologies, EMS-based research, and a global pandemic has altered the medical field within the past few years. These recent developments have led to a gap in previously published papers regarding the future of EMS. Based on a review of literature and statistics, this paper will predict the changes and innovations that affect the future of community paramedicine, funding for EMS, and education standards, which will transform patient care in the next 5 years.

Related

Since 1973, EMS has been an ever changing entity transforming to me the increasingly complex needs of society. The nature of treatment EMS professionals provide needs to continue to expand yearly. In 2022, the state of EMS finds itself as an established and even an over-utilized branch of public safety. As EMS grew, it became the arm of public safety that has become responsible for roles beyond caring for acutely sick and injured patients, which is what it was originally designed to handle. Current duties that go beyond the scope of traditional EMS care include, the care and transport for mental health and substance abuse patients, high-frequency transports for chronically ill patients, primary care providers for underserved communities, etc. Specifically, the amount of high-frequency utilizers of the 911 system, who do not have an acute condition, has been an obstacle for EMS services to tackle. “It is estimated that nationally 5% of emergency department (ED) patients account for 25% of all the visits, and 62% of all ED visits are for avoidable conditions … with approximately 21,760,000 arriving by EMS.”2

The inability to treat this population adequately, in the prehospital setting, has generated a need for definitive change to EMS services that will occur within the next five years. This paramount change very well could be a widespread incorporation of community paramedicine. Community paramedicine is defined by the U.S Department of Health and Human Services as an emerging field where EMS providers operate in an expanded role to “connect underutilized services to underserved populations.”3. A shift toward community-oriented medicine has the potential to help the EMS profession advance its utility in society, effectiveness as a prehospital source of medical care, and aid with prevention and care of both acute and chronic illnesses and conditions. In 2027, it is this author’s prediction that states will have guidelines to encourage EMS systems to include a community-oriented care aspect.

Services will be encouraged to utilize local community needs assessments (CNAs), provided by hospitals, to create initiatives to further care for the public beyond 911 response. Services can choose to utilize harm reduction programs or other mobile integrated health programs. Some examples of public health programs include: public education for chronic illness or substance use disorders, at-home vitals assessments, a referral program to help patients find local resources, etc. COVID-19 has also demonstrated that tele-medicine can effectively be employed within a population to bring primary care, as well as specialty services into a patient’s home. Throughout the pandemic, telemedicine was proved to be a reliable means of visiting physicians without needing to travel to an office. During the pandemic this provided means for patients to remain in isolation and quarantine, however in a post-pandemic era, this technology can be utilized to improve the accessibility of health care.

In 2027, community paramedicine programs could either educate patients on how to utilize technology to attend telemedicine visits, or even provide the patient with a computer/laptop/tablet to conduct an online visit with their doctor. Undoubtedly, the use of community paramedicine programs via EMS in 2027 would expand the utility of EMS, expand the means for citizens to obtain quality healthcare, and decrease the over-utilization of 911 resources.

Adequate funding remains a central issue in EMS in 2022, necessitating a change in how funding is obtained and prioritized for EMS systems. Currently, EMS funding can occur in a variety of modes. Largely, EMS is either public or private. Public funded EMS is funded by a tax-base, such as municipal EMS or Fire/EMS departments. Private services are funded solely by insurance revenue. Many EMS systems operate with some contributions from the municipalities that they serve, supplemented by insurance payouts. Additional avenues of funding include grants, subscription based services and donations by the community.

Despite the number of avenues that EMS systems can utilize, most services are inefficient at generating optimal profit. Many struggle to create competitive provider salaries and optimal equipment/training, among other items. A passage from EMS Agenda 2050 states, “One of EMS’s biggest challenges today is making systems sustainable and efficient despite outdated funding and reimbursement models … EMS systems struggle to stay afloat, unable to pay for infrastructure, education and other necessary investments in the future.” Definitively, EMS funding is a prime concern with the status quo, which should be addressed in 2027. EMS Agenda 2050 proposes a “people-centered EMS system,” where the costs and values of various services are integrated with community partners and stakeholders, and made transparent to individual patients.4

In 2027, this idea could be actualized with the creation of more “mobile integrated health” programs. These programs can generate additional revenue because they benefit hospital systems, existing 911 infrastructure, and benefit payers because of reduced hospitalization costs. With the aforementioned stakeholders benefiting from mobile integrated health programs they can expect a return of investment. This is an incentive for these stakeholders to fund the EMS systems that create mobile integrated health programs. In 2027, EMS systems will receive additional funding and revenue streams by expanding into the field of community paramedicine, which will allow for the overall betterment of EMS as an industry.

Since the birth of modern EMS, education has frequently changed to accommodate new findings, best practices, evolving equipment, and technological advances. In 2022, the providers at every level of EMS are among the most educated in terms of didactic and clinical hours requirements. Nevertheless, there is still improvement that can be made in the realm of EMS education. In 1996, a document was drafted and supported by NHTSA, titled Education Agenda for the Future‘, which described a series of limitations within EMS education and proposed solutions. The document highlighted one specific limitation being, “ EMS education is based on perceived needs rather than practice analysis and research.”5

In other words, EMS education does not focus on patient-based outcomes to create their teaching standards. This item is important in the age of evidence-based medicine, because it underscores the importance of creating a curriculum that leads to the best possible patient outcomes, as opposed to following arbitrary education objectives. An example of this concept would be the introduction of glucometers in Pennsylvania for Basic Life Support providers in 2017.6 This change created a new standard of education and curriculum adjustments in the state of Pennsylvania. However the necessity of teaching this new skill to emergency medical technicians (EMT) has not yet been clinically proven to have benefited patient outcomes. Does teaching this new skill and expanding the scope of a Pennsylvania EMT take away from the education of other topics that are proven to save lives?

These questions must be asked and answered when creating a curriculum to ensure that education standards are consistent with the therapies/tools that save lives in the field. This important concept will be addressed in the year 2027, because at this time there will be a national curriculum that is patient-outcome oriented. The education curriculum will prioritize educational standards that are proven to have associated beneficial patient outcomes. The curriculum will also focus on ensuring that the most covered topics will be the type of patients that EMS encounters most. The benefit of this adjustment in EMS education will be a more prepared clinician who is armed with the appropriate skills and knowledge to make the greatest impact on their patients.

EMS has progressed exponentially since the 1960s, and has been improved by passionate, driven leaders of the industry in a relatively short amount of time. In the next five years, there will continue to be improvements in a variety of aspects of EMS to improve upon the status quo and correct current limitations. As demonstrated, there is a high amount of frequent-utilizers of the EMS system which tax 911 resources. This creates a need for mobile integrated health and community paramedicine programs to be developed within EMS services, which will start to become widely accomplished by 2027.

Additionally, these programs will provide more revenue streams for EMS agencies to benefit from, because of an existing lack in EMS funding across the nation. Finally, education is a targeted area for future improvements. By 2027, EMS education will shift to patch existing problems because curriculums will be developed based on patient-based outcomes. The coming years will undoubtedly produce further advancement in research and technology and impact the course of EMS in the future. However, armed with the knowledge of today, this paper demonstrates predictions on how current challenges in the field of EMS will be improved upon in the next five years.

References

1. “Accidental Death and Disability: The Neglected Disease of Modern Society.” EMS.gov, National Academy of Sciences, https://www.ems.gov/pdf/1997-reproduction-accidentaldeathdissability.pdf.

2. Albright, Bridget. Vpsi High Utilizers – King County, Washington – King County. https://kingcounty.gov/depts/health/emergency-medical-services/~/media/depts/health/em ergency-medical-services/documents/vulnerable-populations/VPSI-high-utilizers.ashx.

3. “Health Resources and Services Administration.” Community Paramedicine: Assessment Tool, https://akastage-www.hrsa.gov/sites/default/files/hrsa/opa/publicuserguide.pdf.

4. “EMS Agenda 2050.” Office of EMS: EMS Agenda 2050, https://www.ems.gov/projects/ems-agenda-2050.html.

Education Agenda for the Future – EMS. EMS.Gov, https://www.ems.gov/pdf/education/EMS-Education-for-the-Future-A-Systems-Approach/EMS_Education_Agenda.pdf.

5. Pennsylvania Statewide Basic Life Support Protocols. Pennsylvania Department of Health Bureau of Emergency Medical Services, 1 July 2019, https://www.health.pa.gov/topics/Documents/EMS/2019%20PA%20BLS%20Protocols% 20Final.pdf.

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