“Success is to be measured not so much by the position that one has reached in life… as by the obstacles which he has overcome while trying to succeed.”
- Booker T. Washington
With multiple premiers of The Chronicles 
of EMS and a wave of enthusiasm from the EMS Today conference in Baltimore, the future of EMS looks bright, blindingly-bright. I’m incredibly optimistic about where this crazy experiment in EMS is headed, but I also see some big hurdles in our path.
Put on your shades and let’s talk about what I feel are the five biggest challenges to EMS reform.
1.) We’ve been talking a lot about unity and standardization, but individual EMS systems are unique in every way. How do you influence standardization and still allow for the tremendous leeway required for EMS agencies to be optimized for the communities that they serve? Can EMS agencies be different in geography, financial resources, administrative structure, culture, call volume, compensation and certification/education level and still find enough unity to advance the profession together?
2.) Today’s EMS systems are run by local agencies. A collective of public, private and third party agencies, guided by medical directors who maintain autonomous control over the care given in their system. People in positions of power and influence are reluctant to sacrifice control to larger concerns. How do you convince local power brokers to relinquish control over standards that they currently establish and oversee as they see fit?
3.) How do you encourage unity without creating conformity and stifling creativity and innovation?
4.) Mother Teresa once said that she would never attend an anti-war rally, but if you ever organized a peace rally, she’d be there. Will we gain more by rallying against the things that are wrong with EMS or supporting and expanding on the things that are right?
5) Emergency room physicians and hospital administrators have a tremendous amount of influence over how EMS is conducted. They also profit from the current inefficiencies in the U.S. EMS system. How should we encourage hospitals and physicians to support the idea of alternate transport destinations when they are the ones who profit from patients being delivered to the E.R. Why would U.S. ER Physicians support paramedics making doctor’s appointments, transporting to urgent care facilities and leaving patients at home when it takes revenue from their pockets?
There are good answers to all these questions. Before EMS 2.0 can blossom these questions will need to be answered.
What are your answers? (Note: If I get a large enough response from the blogging community, I’ll create a follow up post to link them all together.)
More Insanely Good Stuff:
I started to write a comment, but it got too long.
Therefore it is now a blog post :
http://999medic.com/2010/03/09/in-response-to-5-hard-questions/
Thanks for making me think so much!
Great questions. I am not sure about the assumption that emergency department patients profit from many of their patients – regardless of arrival method: foot, POV, or ambulance.
I have heard emergency department rates of collection of 20% to 50% of fees.
Interestingly many EMS and hospital systems are already collaborating on regional care of major trauma, stroke, and STEMI patients. These steps for specific types of patients may be helpful for overall system issues.
Anyway you can’t solve the problem by not having the conversation.
@Medic999 great post Mark, I left some comments.
@Greg You’re so right about the conversation. I think the more we throw this stuff out there and all chew on it the more we’ll refine this idea of what we’re trying to promote and achieve.
I think hospital and ER revenue will be a major stumbling block to developing destination optimized systems. This comes from experience designing a CCT system where we staffed PA’s on medic rigs in Colorado and tried to do in home urgent care. (Suture removal, surgery follow up)
In focus groups the ER docs were very supportive of the idea but in practice, nobody called. The system went under a few years later after making a few dozen house calls. The CCT traffic was the only thing that kept the operation going as long as it did.
ER docs will be more than happy to design systems that divert non-paying indigent care and substance abuse patients elsewhere, but taking insured patient elsewhere for minor care issues or leaving them at home is going to be an uphill battle.
Hurdles to some, opportunities to others.
I draw a parallel to road construction. All roads have basic requirements, lane width, striping, base material, shoulder etc, but each area decides how many lanes and how many roads going how many different directions.
My EMS 2.0 doesn’t require the Greater Island Volunteer Fire Company to staff all ALS engines, but gives that community access to a higher trained applicant pool. Sure it’s hard to recruit and retain these days, but your community demands and expects help to walk through the door when they call for help.
Great tips Steve, keep ‘em coming.
Steve, I’ll take a shot at being the first naysayer to your questions. Your question 1-4 address the same issue that of a centralized organization or worse, government agency, dictating a uniform standard. Let us hope that never happens to a vital and growing profession such as ours. It would lead to cookie cutter medics and “cookbook” practices. Each area has it’s own needs and demands and each area must be able to determine what is best for itself. I will agree that a minimum standard of care and professional skills be expected but that regions should be able to greatly exceed the minimum as they see fit.
As to greedy hospital administrators not wanting to surrender the valuable trade we bring them, that is a canard. The 911 patients we bring in to ERs are typically the ones least able to pay. As a service, we lose money transporting those patients and as a hospital, they lose money treating and streeting them. I bet if you asked the ER staffs and administrators how thew would feel if we as EMS could defer patients to social services, urgent care clinics, etc. that they would be thrilled to allieviate the drain on their resources.
I would rather see the focus of EMS 2.0 on greater autonomy of the EMS providers, increase in skills and treatments allowed, concommitant increases in training and education.
Best wishes for your discussion!
@HM I like your road analogy.
@So Ill Medic Thanks for being a nay-sayr. We need those. I see a relationship between questions 1-3 but they are not the same question. They require different answers.
In saying they all speak to a centralized organization you’re suggesting an answer to the question (one possible answer) as if the question was the answer. I didn’t suggest any answers here. I merely asked the question.
I don’t see the relationship between question 4 and the others.
Again, I disagree with the idea that question 5 is based on a false assumption. You are correct that hospital ERs have a difficult time overcoming resource drains like uninsured patients. But once you suggest taking those few patients who have insurance somewhere else you’re going to meet with resistance. Tremendous resistance.
And I speak from experience. I tried to design and implement a system that did just that. It was a great idea. It didn’t work.
I think your list of things we should focus on is outstanding. Thanks for your comment and input.
[...] The EMT Spot
» 5 Hard Questions EMS 2.0 Will Need to Address [...]