U.S.
Department of Health and Human Services
Health Resources and Services Administration
Office of Rural Health Policy
This document was prepared under HRSA contract
# 250-03-0022, U.S. Department of Health and Human Services, Health
Resources and Services Administration, Office of Rural Health Policy.
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Acrobat Version (245 kb)
Contents
Foreword
Integrating Rural EMS into
the Healthcare Quality Debate
What About Rural?
So Where Doe EMS Fit into the "Quality Agenda?"
Organization of This Document
Quality Through Collaboration
Priority Strategies
Strategy I: An Integrated
Approach to Improving Health
Strategy II: Quality Improvement Activities
in Rural Areas
Strategy III: Strengthening Human Resources
Strategy IV: Finance
Strategy V: Building an Information and Communication
Technology (ICT) Infrastructure
Conclusion: Rural Health
and Emergency Medical Services: Shared Goals
APPENDIX A: References/List of
Key Documents
APPENDIX B: Acknowledgements
APPENDIX C: REMSTTAC Stakeholders'
Group
Foreword
The events of 9/11 and the hurricane
season of 2005 brought the need for improved emergency capabilities
and responses to the forefront of the American public and its policy
makers. Emergency Medical Services, or the prehospital phase of
the broader emergency care system, represents a key component of
a well-planned response to large scale emergencies. The same can
be said for the thousands of calls for medical assistance each and
every day.
Rural areas are not exempt from the need for EMS.
In fact, in many regards the need is greater. Injury rates are higher
in rural areas of America. Travel distances to acute care facilities
are longer. The resources and capacities to treat complex illnesses
or traumatic emergencies may not be available in rural and frontier
communities, resulting in secondary transfers to distant tertiary
care facilities.
Recognizing the critical nature of EMS, several
agencies, organizations, and institutions have addressed the issue
at the Federal level. Beginning in 2004, seven important documents
have emerged that address rural EMS in some fashion. The Institute
of Medicine has been responsible for the publication of four of
these documents. The first was released late in 2004 and is titled
Quality Through Collaboration: The Future of Rural Health, the latter
three volumes were released early in 2006 as specific subcomponents
of the future of emergency care series and are titled Hospital-Based
Emergency Care: At the Breaking Point, Emergency Medical Services:
At the Crossroads and Pediatric Emergency Care: Growing Pains.
The Rural and Frontier EMS Agenda for the Future
was released in 2005. The National Rural Health Association (NRHA),
the National Organization of State Offices of Rural Health (NOSORH),
and the National Association of State EMS Officials developed the
document with input from rural EMS providers across the country.
The Rural Hospital Flexibility Program Strategic Plan, again
issued in 2005, developed by the Technical Assistance and Service
Center and program grantees, addressed several EMS related themes.
Last, but not least, the HRSA Trauma and EMS Program published the
Model Trauma System Planning and Evaluation Guide in 2005.
Each of these documents is a landmark in its own
right. However, for policy makers at the Federal, State, and local
levels, the plethora of guiding documents can seem daunting, at
best. The purpose of this document is to create a translation between
and among the various guiding documents. In doing so, consistent
themes emerge from the various works, strengthening the rationale
and need to address key issues. The Office of Rural Health Policy
has used Quality through Collaboration: the Future of Rural Health
as a touchstone since its publication and administration approval.
The document you are currently reading supports the findings and
recommendations contained in Quality Through Collaboration
by cross-referencing them to the other documents. In doing so, a
clear picture of needs and priorities achieved by consensus emerges
across several different expert panels and processes. We hope that
you will also find it useful.
Marcia K. Brand, Ph.D. |
Nels D. Sanddal, Director |
Associate Administrator
for Rural Health, HRSA |
Rural EMS and Trauma
Technical Assistance Center |
INTEGRATING
RURAL EMS INTO THE HEALTH CARE QUALITY DEBATE
Improving the quality of health care services
has become a key focus of the health care industry, State and Federal
government payors, commercial insurers, employers, and increasingly,
patients and the general public. Federal agencies such as the Centers
for Medicare and Medicaid Services (CMS) are exploring ways to reimburse
health care providers for delivering effective, high quality services
(a strategy usually referred to as "pay for performance.")
Employer coalitions such as the Leapfrog Group are looking for ways
to reduce medical errors, encourage public reporting of clinical
outcomes, and reward doctors and hospitals for improving quality
and safety. Provider coalitions such as the Hospital Quality Alliance
(HQA), a joint effort of the American Hospital Association, the
Federation of American Hospitals, and the Association of American
Medical Colleges (along with CMS and the Joint Commission on the
Accreditation of Healthcare Organizations), are urging hospitals
to permit an array of clinical quality measures to be reported publicly
on the CMS-run Hospital Compare website
(www.hospitalcompare.hhs.gov).
What about rural?
Unfortunately, rural health care has been
only peripherally involved in these
Large areas of the United States (particularly
rural and frontier areas) continue to lack consistent access
to these services. |
discussions. Rural health care leaders and
advocates, however, are keenly interested in integrating rural issues
into the quality debate. With the November 2004 publication of Quality
through Collaboration: The Future of Rural Health, the Institute
of Medicine's Committee on the Future of Rural Health Care charted
an agenda for rural communities to fulfill the six aims set forth
in the Institute of Medicine's 2001 report Crossing the Quality
Chasm: A New Health System for the 21st Century to make health
care safe, effective, patient-centered, timely, efficient, and equitable.
The Institute of Medicine (IOM) committee on the Future of Rural
Health Care proposed a five-pronged strategy to address the quality
challenges in rural communities:
Strategy 1: Adopt an integrated, priority approach
to addressing both personal and population health needs at the
community level.
Strategy 2: Establish a stronger quality improvement
support structure to rural health systems and professionals in
acquiring knowledge and tools to improve quality.
Strategy 3: Enhance the human resource capacity
of rural communities, including the education, training, and deployment
of health care professionals, and the preparedness of rural residents
to engage actively in improving their health and health care.
Strategy 4: Monitor rural health care systems
to ensure that they are financially stable and provide assistance
in securing the necessary capital for system redesign.
Strategy 5: Invest in building an information
and communication technology (ICT) infrastructure, which has enormous
potential to enhance health and health care over the coming decade.
The Institute of Medicine believes that adoption
and implementation of this multi-faceted strategy is necessary to
enhance quality, to build focused rural community health systems,
and to bring rural providers fully into the national debate on improving
health care quality, safety, and performance.
So where does EMS fit in
the "Quality Agenda?"
In its 2004 report, the Committee on the Future
of Rural Health explicitly recognized EMS as part of the core
set of health care services that are of greatest need in rural
areas, while also noting concerns regarding insufficient access
to EMS because of constraints caused by long-standing shortages
of qualified EMS professionals in many rural areas. They also recognized
the importance of EMS in ensuring timely care in emergency situations,
and the unique aspects of rural EMS due to long distances to definitive
care. The committee further noted that because rural care processes
are different from those in urban areas, the data that are necessary
for quality improvement purposes are different. They pointed out
that data on emergency care, stabilization and transfer services
are of great importance in rural areas, and EMS involvement in quality
improvement efforts is, therefore, critical.
As noted in the Foreword, this paper was created
with the purpose of serving as a companion document to Quality
Through Collaboration. The focus is to encourage policy makers,
health care providers, and most importantly, EMS officials and providers,
to recognize the importance of including rural and frontier EMS
in the national discussion about health care quality. It is meant
to promote discussion regarding specific ways that rural and frontier
Emergency Medical Services (EMS) providers can engage in the rural
health care quality movement.
Specifically, the objectives of the paper are
to:
- Provide recommendations on building the best
possible emergency care "system" in rural America. These recommendations
will be presented in a framework based on the five strategies
outlined in Quality Through Collaboration, but other recent studies
and reports will also be examined in detail. Improving the quality
of emergency care has been an important (and in some cases primary)
focus of other influential publications in recent years including
the Rural Hospital Flexibility Program Strategic Plan, the Rural
and Frontier EMS Agenda for the Future, The HRSA Model Trauma
System Planning and Evaluation and the IOM Future of Emergency
Care series (which includes Hospital-Based Emergency Care: at
the Breaking Point, Emergency Medical Services at the Crossroads,
and Emergency Care for Children: Growing Pains).
- Propose new opportunities for collaboration
to further rural EMS quality of care among key stakeholders in
rural EMS including the National Association of State EMS Officials;
the National Organization of State Offices of Rural Health, the
National Rural Health Association and other rural health advocates;
EMS collaboratives such as the North Central EMS Institute, Critical
Illness and Trauma Foundation, rural health resource and technical
assistance centers including the Rural Emergency Medical Services
and Trauma Technical Assistance Center, Federally-funded rural
health research centers, and Federal agencies including the Office
of Rural Health Policy, NTHSA, CMS and others.
Organization
of This Document
The five priority strategies in Quality Through
Collaboration will be addressed in turn. In each section, following
a discussion of the IOM rural quality report, recommendations from
other key policy reports that related to the IOM recommendations
will be listed. Each bullet is followed by parentheses to show the
source of the recommendation (FSP = FLEX Program Strategic Plan,
RFEMS = Rural and Frontier EMS Agenda for the Future; MTSPE
= Model Trauma System Planning and Evaluation, IOM-FEC =
IOM Future of Emergency Care series). A brief description
of each of these documents is presented in Appendix A.
Particular attention will be given to key
themes that are shared in common among the reports mentioned above.
By bringing attention to key consistent themes in these recent reports,
the authors hope to create an active dialogue across the traditional
"silos" of rural health and Emergency Medical Services,
which could lead to the development of a well-funded, broad-based
model rural EMS system that would help ensure access to high quality
emergency care in America's rural and frontier areas.
QUALITY
THROUGH COLLABORATION: PRIORITY STRATEGIES
Strategy I: An Integrated
Approach to Improving Health
The first strategy proposed by the IOM Committee
on the Future of Rural Health was to formulate an integrated approach
to addressing the personal health care and population health needs
of rural communities. The report provides a broad range of actions
that could be adopted at both the personal health care system level
and the community level to improve health status. They suggested
an integrated framework that would lead to a more optimal allocation
of scarce financial resources devoted to improving the quality of
health in rural communities.
One specific point of discussion in Quality
Through Collaboration in this discussion related to EMS was:
Timely access to emergency care is a primary
concern for rural citizens. The IOM committee recognizes timely
care means something different in rural and urban areas, and in
rural communities', emergency care is the primary concern in regard
to timely care.
The report points out that residents who are far
from a source of definitive care depend on EMS to ensure that they
receive timely access to care. This means EMS must : 1) be adequately
equipped to care for patients who may have long travel distances
before reaching a hospital; 2) be able to communicate with Emergency
Department (ED) physicians and specialists to ensure appropriate,
timely medical direction, and 3) be able to transport patients as
quickly and as safely as possible. The key role EMS plays in ensuring
timely access to care also is reflected in numerous recommendations
of the Flex Program Strategic Plan, Rural and Frontier EMS Agenda
for the Future, the Model Trauma System Planning and Evaluation,
and the Future of Emergency Care series.
These recommendations include:
- Promote integration of rural EMS operations
into local networks and other activities designed to strengthen
rural EMS. [FSP]
- Plan, integrate and regulate, at the State
level, aero-medical, critical care transport, and other statewide
or region-wide systems of specialty care and transportation. Consider
the evolving role of telehealth resources and their application
to EMS patient management and medical oversight. …. [RFEMS, Clinical
Care & Transportation Decisions/Resources Chapter]
- Facilitate a State-level process, guided by
an appropriate multi-disciplinary committee, to ensure inclusive
systems of trauma care and other time critical emergency care
that define the roles of rural and frontier hospitals…. [RFEMS,
Clinical Care & Transportation Decisions/Resources Chapter]
- The emergency care system of the future should
be one in which all participants (from 9-1-1 to ambulances to
EDs) fully coordinate their activities and integrate communications
to ensure seamless emergency and trauma services for the patient.
[IOM-FEC]
- The Federal government should support the development
of national standards for emergency care performance measurement;
categorization of all emergency care facilities; and protocols
for the treatment, triage, and transport of prehospital patients.
[IOM-FEC]
In addition, the IOM Quality Through
Collaboration report notes the high death rate of unintentional
injury in rural areas, an issue of specific interest to EMS:
There are salient differences between
rural and urban communities in terms of health behaviors and environmental
threats that must be addressed to improve community health. One
threat to health highlighted in the IOM report is the age-adjusted
death rate for unintentional injury that is much higher in both
males and females in rural areas than in urban environments.
Addressing the issue of unintentional injury is
a natural fit for rural EMS providers. EMS is a critical part of
the trauma system that addresses the continuum of care: from prevention
to treatment to rehabilitation for unintentional injuries. In rural
areas, reducing rates of unintentional injuries will have a marked
impact on community health status. Reducing rates of unintentional
injury is one of the key objectives derived from Healthy People
2010, a document based on a broad consultation process, built
on the best scientific knowledge, and designed to measure programs
over time. Unintentional injury is one of ten leading health indicators
in Healthy People 2010, and the leading causes of unintentional
injury, motor vehicle crashes and homicides, are often predictable
and preventable. By becoming engaged in prevention of unintentional
injury, rural EMS can have a considerable impact on local communities.
Related recommendations from other policy documents
include:
- Make prevention one of the EMS-based community
health service roles of adequately staffed rural/frontier EMS
provider agencies. [RFEMSA, Prevention Chapter]
- Among local, State, Federal, and national EMS
and public health agencies (and other agencies with prevention
roles), cooperatively develop and fund community health advocacy
roles and prevention programs for rural/frontier EMS personnel
that are mutually beneficial. [RFEMSA, Prevention Chapter]
- Federal agencies and national organizations
with prevention roles should channel existing [injury prevention]
programs through State EMS agencies to local EMS provider agencies.
[RFEMSA, Prevention Chapter]
- Provider agency policy/procedures and innovative
incentives, EMS curricula, and accreditation, and other standards
target EMS provider health, safety and prevention. [RFEMSA, Prevention
Chapter]
- The trauma system should contribute to reducing
the entire burden of injury in a State, region, or community.
Therefore, it should integrate all three phases of injury prevention
into planning and practice. The trauma system should produce improved
health status outcomes, such as reduced injury occurrence and
better clinical outcomes for injured patients. [MTSPE, Three Phases
of Injury Prevention Chapter]
- Emergency care is broader than EMS and encompasses
the full continuum of services involved in emergency medical care,
including EMS, hospital-based ED and trauma care, specialty care,
bystander care, and injury prevention. [IOM - FEC EMS: At the
Crossroads]
Strategy II: Quality
Improvement Activities in Rural Areas
Chapter Two of Quality Through Collaboration
emphasizes the unique needs of rural health care providers in developing
infrastructure to support quality improvement activities. The chapter
emphasizes the use of practice guidelines and protocols, computer-aided
decision support, standardized performance measures, data feedback
capabilities, and QI processes and resources. They particularly
focused on systems quality improvement, which is critical for EMS
since EMS is involved in all phases of rural care, including triage,
stabilization and transfer, and is part of many "handoffs"
during patient encounters. The Committee on the Future of Rural
Health Care states:
An important role for rural providers is
triage, stabilization and transfer of emergency cases. This process
involves numerous "handoffs" that can negatively affect
the timeliness of service delivery and provides an opportunity
for miscommunication and medical errors. QI efforts need to focus
on the continuum of care with special emphasis on these handoffs.
However, for such a system to exist, much greater
collaboration will be necessary among and between medical providers.
True multidisciplinary workgroups must be employed to develop and
implement, through consensus, protocols for emergency care services.
Also, it must be recognized that in this new system, not all prehospital
patient encounters will result in transfers. Thus, it is important
that ambulance services be reimbursed for services rendered to patients
who are not transferred to a hospital. As such, in addition to recommendations
regarding QI systems, payment reform recommendations are also included
in this section. It is also important for the Federal government
to ensure that existing rules do not unnecessarily stifle discussions
among health care providers formally working on quality improvement
efforts. Rule changes should be implemented to enhance communication
among providers during emergencies as well as during discussions
about quality improvement.
Related recommendations from recent publications
that relate to this topic:
- Require performance improvement programs (including
clinical quality and patient safety) at the hospital and community
levels… [FPSP]
- Emphasize optimal interdisciplinary care of
the ill or injured patient, including complex event management
such as cardiac arrest and multiple casualty incidents. [ RFEMSA,
Education Systems Chapter]
- Link/integrate EMS data systems with other
relevant health information systems at all levels such as public
health surveillance, crash, medical examiner, hospital discharge,
and emergency department…. [RFEMSA, Information Systems Chapter]
- Encourage multi-system data collection for
specific research and performance improvement purposes. [RFEMSA,
Information Systems Chapter]
- Fund the availability of training and toolkits
to encourage effective local service/system quality improvement
processes. [RFEMSA, Evaluation Chapter]
- Ensure a mechanism for the on-going support
and review of the NHTSA "Guide to Performance Measures" and "Leadership
Guide to Quality Improvement for Emergency Medical Services Systems,"
and encourage their use in services and systems. [RFEMSA, Evaluation
Chapter]
- The Federal government should support the development
of national standards for the following: emergency care performance
measurement; categorization of all emergency care facilities;
and protocols for the treatment, triage, and transport of prehospital
patients. [IOM-FEC EMS: At the Crossroads]
- The lead agency should strive for inclusiveness
(all-facility and EMS system participation) by developing the
process improvement program statewide. This program should include
facilities in the most remote areas of the State, for example,
rural clinics and primary care centers in locations such as parks.
[MTSPE, Application of the Core Functions of Public Health to
Trauma Systems Chapter]
- Implement the following Federal reimbursement
reforms for emergency and interfacility EMS clinical care and
operations: call-components performed by first-response, ALS intercept,
ambulance, and other EMS response agencies that should be eligible
for reimbursement (not duplicated on any given call) should include
emergency response, assessment, treatment, triage, and transportation
or other disposition that may, or may not, involve traditional
transportation. [RFEMSA, System Finance Chapter]
- The National Highway Traffic Safety Administration,
in partnership with professional organizations, should convene
a panel of individuals with multidisciplinary expertise to develop
evidence-based model prehospital care protocols for the treatment,
triage, and transport of patients. [IOM-FEC EMS: At the Crossroads]
- The Centers for Medicare and Medicaid Services
(CMS) should convene an ad hoc work group with expertise in emergency
care, trauma, and EMS systems in order to evaluate the reimbursement
of EMS and make recommendations regarding inclusion of readiness
costs and permitting payment without transport. [IOM-FEC EMS:
At the Crossroads]
- The U.S. Department of Health and Human Services
should adopt rule changes to the Emergency Medical Treatment and
Active Labor Act (EMTALA) and the Health Insurance Portability
and Accountability Act (HIPAA) so that the original goals of the
laws are preserved, but integrated systems may further develop.
[IOM-FEC Hospital-Based: Emergency Care at the Breaking Point]
Strategy III: Strengthening
Human Resources
The IOM Committee on Rural Health recognized that
human resources are critical assets in every rural community's efforts
to enhance individual and population health and suggested that the
current health care workforce is poorly prepared to "address
the quality challenge."
The Committee recommended that:
Congress should provide appropriate resources
to
expand experientially based workforce training program in rural
areas to ensure that all health care professionals master the
core competencies
The Committee recognizes the following core competencies:
- Providing patient-centered care;
- Working in interdisciplinary teams;
- Employing evidence-based practice;
- Applying quality improvement methodologies;
and
- Utilizing informatics.
For all disciplines, the committee demanded
changes to continuing education as well as new provider training
programs and recommended increasing or enhancing experiential learning
programs in rural environments, recruiting rural faculty and students,
and expanding distance education.
The Committee on Rural Health, in discussing
EMS education specifically, noted that the volunteer nature of rural
EMS exacerbates the staffing challenges of rural ambulance services.
It is a challenge to offer training programs that meet the needs of
volunteers, who have limited time and may be reticent to drive long
distances for education. With increasing reliance on two incomes in
many rural households, volunteers may find it difficult to find the
time necessary to devote to continuing education. Recognizing this,
the Committee suggested that technology-based distance learning is
the key to the future of EMS education. The Committee also recognized
the importance of creative recruitment and retention strategies for
rural America, but the report focused on recruitment/retention strategies
of medical professionals and overlooked any specific recommendations
on EMS.
Other recently published policy documents have
included extensive series of recommendations focused on a number
of aspects of workforce development and enhancement. First, there
are a group of recommendations that suggest the creation of tools
and funding, to be deployed at the State and community level, to
enhance recruitment and retention programs, including volunteer
incentive programs which address the unique aspects of volunteer
ambulance services that are common to America's rural areas.
Specific recommendations include:
- Foster the development of a culture of volunteerism
and community service through local schools in partnership with
community agencies. [RFEMSA, Human Resources Chapter]
- Development of a national model to enhance
career mobility within EMS practice levels, and between EMS and
other health professions, to enhance the ability of rural/frontier
areas to retain health workers who wish to gain new skills or
advance or change health careers. [RFEMSA, Education Systems Chapter]
- Recognition of the need for flexible scheduling
to accommodate the lifestyle realities of rural volunteers. [RFEMSA,
Education Systems Chapter]
A second set of recommendations from these reports
focus specifically on ways the education system must be structured
to meet the needs of rural EMS professionals who need access to
continuing education:
- Fund at the State and national levels a Rural/Frontier
EMS Education and Training Initiative including:
- Funding to geographic areas which considers
progress in completing community EMS assessments and informed
self-determination processes;
- Funding through State EMS offices where needed,
to develop effective systems of training and education program/system
quality review and approval;
- Development of flexible models for the implementation
of a national model, including certificate and college-based
programs, for providing basic, intermediate, and advanced EMS
training and continuing education to rural/ frontier areas and
its implementation through State EMS offices. [RFEMSA, Education
Systems Chapter]
- Subsidization of training courses and continuing
education programs and the instructor, equipment supply, and technical
assistance infrastructure necessary to make them accessible to
rural/frontier areas. [RFEMSA, Education Systems Chapter]
- The use of interoperable systems of telemedicine
and distance learning to improve the accessibility of training
courses, effective quality improvement, and continuing education
programs. [RFEMSA, Education Systems Chapter]
- Incentives to increase the involvement of university
medical centers and area health education centers to provide outreach
educational programs to rural and frontier areas. [RFESMA, Education
Systems Chapter]
- Improved rural/frontier accessibility to training
programs in emergency medical dispatch, critical incident stress
management, and occupational safety training; as well as continuing
education programs with curriculum content geared to rural/frontier
application as appropriate. [RFEMSA, Education Systems Chapter]
- Encouraging the development of realistic, dynamic
patient simulators and mannequins for case-based and psychomotor
skill training and critical-decision making improvement. Support
for the development of patient simulator outreach programs. [RFEMSA,
Education Systems Chapter]
- The committee recommends that States link rural
hospitals with academic health centers to enhance opportunities
for professional consultation, telemedicine, patient referral
and transport, and continuing professional education. [IOM-FEC
Hospital-Based: Emergency Care at the Breaking Point]
- Development of State/regional stockpiling,
and sharing of expensive training devices such as mannequins and
patient simulators. [RFEMSA, Education Systems Chapter]
- Ongoing assessment by rural/frontier EMS agencies
and local hospitals of their resources and needs, and searching
for common educational opportunities. [RFEMSA, Education Systems
Chapter]
- The lead agency assists in ensuring a competent
workforce through evaluation, training, and education and monitors
the availability and effectiveness of trauma systems. [MTSPE,
Application of the Core Functions of Public Health to Trauma Systems
Chapter]
- States should strengthen the EMS workforce
by requiring national accreditation of paramedic education programs,
accepting national certification for State licensure, and adopting
common EMS certification levels. [IOM-FEC EMS: At the Crossroads]
A final group of recommendations specifically
highlight the need for leadership and management training for both
service chiefs and EMS medical directors. Ambulance service directors
often rise "through the ranks" and are not trained to
oversee the business of running an EMS service. Administrative aspects
of running a service may be overlooked and poorly administered.
Similarly, EMS medical directors very rarely receive training specific
to their role of overseeing an ambulance service[s].
These recommendations are:
- A national EMS service leadership and service
management training model should be developed and shared with
all State, territorial and tribal governments. This model should
include successful practices in EMS volunteer and paid human resources
management. [RFEMSA, Human Resources Chapter]
- Improved rural/frontier accessibility to a
training program for service managers which includes EMS leadership,
public and elected official advocacy, public education, grant-writing,
data collection, research, governing board management, and volunteer
management among other topics. [RFEMSA, Education Systems Chapter]
- Ensuring the delivery of quality emergency
medical services to rural populations is also complicated by the
make up and skill level of prehospital EMS personnel, and associated
issues of management, funding, and medical direction for rural
EMS systems. [IOM - FEC EMS: At the Crossroads]
- Prepare and protect rural/frontier emergency
and primary care physicians to serve as EMS medical directors
and assure adequate systems of performance improvement to support
their activities. [RFEMSA, Medical Oversight Chapter]
- Review all existing EMS medical oversight courses
and establish a Rural/Frontier EMS Medical Directors Course which
should be made available and distributed through multiple mechanisms
to allow maximum access by EMS Medical Directors. [RFEMSA, Medical
Oversight Chapter]
- EMS medical oversight must be introduced in
medical schools and included in the curriculums of primary care
residency programs. [RFEMSA, Medical Oversight Chapter]
- The committee believes that physicians who
provide medical direction for EMS systems should meet standardized
minimum requirements for training and certification that are reflective
of their responsibilities. [IOM-FEC EMS: At the Crossroads]
Strategy
IV: Finance
Quality Through Collaboration
stresses that payment systems must ensure the financial stability
of rural health care systems in order to ensure that these systems
can invest in human resources, information and communications technology,
and quality improvement efforts. The report demands that "pilot"
pay-for-performance systems must be tested with demonstration projects
in rural areas to ensure these systems do not harm the rural health
care delivery system.
Furthermore, they suggest that pay-for-performance
systems for rural areas may need to involve linkages of several
types of health care providers, which would most certainly include
EMS. They also encourage rural health care providers to work collaboratively
with other community leaders to develop community-wide initiatives
aimed at improving health behaviors, with the goal of examining
community health system effectiveness at addressing the quality
aims of the IOM "Quality Chasm" series (safety, effectiveness,
efficiency, patient-centeredness, timeliness, and equity).
Quality Through Collaboration discussed
current funding for various health system sectors. For EMS, they
noted that the majority of revenue is derived from transport fees,
while the remainder of revenue comes from State and local taxes.
The report notes that transport-based reimbursement is problematic
for low-volume rural EMS providers whose costs are not necessarily
linked to transport volume, but rather reflect the maintenance of
a state of readiness.
Funding recommendations appearing in other key
policy documents deal with several aspects of the financing of EMS.
Several promote enhanced funding of State EMS offices to help them
advance rural EMS issues. Others propose specific mechanisms through
which local ambulance services would be more equitably reimbursed
for the services they provide. These alternative payments systems
would alleviate the financial strain imposed by a system that reimburses
on the basis of transport and thus, does not reflect the cost of
preparedness for low-volume rural ambulance services. Other recommendations
encourage better access to grant funding, and specifically to preparedness
funding. The Rural and Frontier EMS Agenda for the Future
specifically implores CMS and other payors to reimburse rural EMS
providers for a broad range of prevention and primary care services
beyond emergency care. Authors of the Agenda recognize that
declining populations in some remote areas will also result in declining
numbers of health professionals. EMS is likely to be the last "link"
in the health care safety net for many of these areas; paying cross-trained
personnel with EMS training for preventive, primary care, and emergency
services may be the only way to ensure access to care in the remote
countryside.
Recommendations include:
- Adequately fund the State EMS lead agency to
enable it to carry out its designated responsibilities. [RFEMSA,
Legislation and Regulation Chapter]
- Create funding incentives and legislation models
to help State EMS lead agencies acquire sufficient legal basis,
authority, resources, and leadership to broadly develop and implement
EMS systems on an ongoing basis and to provide sufficient flexibility
to adapt to the unique needs of rural/frontier EMS. [RFEMSA, Legislation
and Regulation Chapter]
- Implement the following Federal reimbursement
reforms for emergency and interfacility EMS clinical care and
operations [RFEMSA, System Finance Chapter]:
- Call-components performed by first-response,
ALS intercept, ambulance and other EMS response agencies that
should be eligible for reimbursement (not duplicated on any
given call) should include emergency response, assessment, treatment,
triage, and transportation or other disposition that may, or
may not, involve traditional transportation.
- Retrospective review of medical necessity
should not be done for emergency response calls.
- Immediately implement the patient condition
codes model from the Negotiated Rule-Making process.
- Remove the "35 mile" restriction on cost-based
reimbursement for EMS agencies that are owned and operated by
Critical Access Hospitals.
- Employ definitions of "access" and "rural"
(and its degrees) in reimbursement, which will help to maintain
an adequate rural/frontier EMS infrastructure
- Consider a "critical access ambulance service"
definition or other means to ensure a minimal level of EMS infrastructure
in all geographic areas.
- Ensure that interfacility transports that
are "appropriate" from an EMTALA perspective are fairly reimbursed
and not subjected to retrospective medical necessity determinations.
- Adopt reimbursement practices that encourage
patient treatment and recovery at the facility closest to the
patient's home that is desired by the patient and capable of
providing the care required at the given stage of recovery.
- Facilitate the use of subscription services
as a part of the overall funding of the EMS safety net infrastructure,
in cooperation with State insurance authorities.
- Consider a single fiscal intermediary for
all EMS providers, and develop a "successful practice" guide
to assist EMS providers in maximizing billing efficiency and
accuracy.
- Form and fund through county, regional, State
or Federal tax dollars, rural/frontier EMS operational or service-contracting
networks in those areas where they provide economies of scale,
improved access to EMS care, improved quality and/or increased
tax payer value. [RFEMSA, System Finance Chapter]
- Make Federal and State domestic preparedness
and response funding programs such as those of the U.S. Department
of Homeland Security, CDC, HRSA, and the Office for Domestic Preparedness
(ODP) available explicitly and categorically to EMS systems and
providers including private and for-profit agencies. [RFEMSA,
System Finance Chapter]
- CMS, MCOs and other third-party payers should
fund EMS-based community health care pilot projects and define
EMS personnel as reimbursement-eligible care-providers under physician
medical oversight for primary care, prevention, and other services
they render. [RFEMSA, System Finance Chapter]
- The goal of trauma system financing is to provide
the public with a consistent, reliable, and readily available
health care safety net for injured patients. [MTSPE, System Finance
Chapter]
- Financial resources are needed to support the
EMS system response for trauma care. Funds are needed to train
EMS personnel to care for injured individuals. Although some EMS
providers volunteer their time to care for injured patients, in
many locations, salary support must be included in financial planning.
Financial support for a medical director to provide oversight,
protocols for care, and performance improvement guidance is required.
Local EMS agencies also must have the resources for ambulances,
as well as the equipment and supplies for patient care. [MTSPE,
System Finance Chapter]
- Funding should be increased for the emergency
medical component of preparedness - both EMS and hospital-based
- especially for personal protective equipment, training, and
planning. [IOM-FEC EMS: At the Crossroads]
- To determine whether incentives are properly
aligned, CMS should investigate whether Medicare and Medicaid
payment methodologies should be revised to support payment for
emergency care services in the most appropriate setting (including
treat and release). [IOM-FEC EMS: At the Crossroads]
Strategy V: Building an
Information and Communication Technology (ICT) Infrastructure
The IOM Committee on the Future of Rural Health
believes information and communication technology is a powerful
tool that has great potential to produce improvements in the quality
of patient care. The committee recognizes that there are key issues
and challenges for rural providers to develop the necessary infrastructure
to support a "paperless" health care system, and they
advance recommendations to help address these issues.
Where does EMS fit into this discussion? With
current discussions emphasizing the use of telemedicine, electronic
health records, electronic bedside physician order entry systems,
e-prescribing, etc. it may not be readily apparent how EMS providers
might benefit from this transition to a paperless system. The IOM
suggests several possibilities, however. For example, they discuss
studies of cardiac emergencies where data transfer capabilities
allowed physicians to monitor electrocardiograms during prehospital
care to assess the need for administration of thrombolytics. Another
recent study found benefits in the use of abdominal sonography for
prehospital care. A Vermont study found benefit in linking trauma
surgeons to rural emergency departments via videoconferencing in
the initial treatment of trauma patients. These studies suggest
important benefits for rural EMS in developing more advanced information
and communications technologies to support prehospital patient care.
In fact, the Rural and Frontier EMS Agenda for the Future
and the IOM Future of Emergency Care explored an even broader
range of information technology issues. One focus was the enhanced
use of telemedicine and interactive media for distance learning.
A second theme was technology to enhance emergency notification,
including systems such as 9-1-1, crash notification systems, and
home monitoring technologies. A third theme was enhanced interoperable
communication systems, and a fourth was the use of EMS information
systems for enhanced evaluation and performance improvement purposes,
as well as public health surveillance purposes.
Recommendations include:
- Recognition [within the education model] that
EMS education will be provider-need specific, conducted with varied
teaching techniques emphasizing hands-on training, and (where
appropriate) distance learning to assist the transfer of learning
and retention of essential skills and knowledge so as to provide
state-of-the-art rural emergency care. [RFEMSA, Education Systems
Chapter]
- The use of interoperable systems of telemedicine
and distance learning to improve the accessibility of training
courses, effective quality improvement, and continuing education
programs. [RFEMSA, Education Systems Chapter]
- A variety of learning methods should be used.
Web-based learning opportunities that can be later archived are
one cost-effective way to educate a large number of persons. [MTSPE,
Application of the Core Functions of Public Health to Trauma Systems
Chapter]
- Ensure telephonic or other access to completed
Enhanced 9-1-1 (i.e. including accurate physical addressing) and
Wireless Enhanced 9-1-1 (i.e. with geolocation of the calling
device) through effective Federal and State programs, mandates
and funding. [RFEMSA, Public Access Chapter]
- State EMS offices should consider a patient-centered,
medical leadership initiative to encourage E-9-1-1 and WE-9-1-1
system completion where other approaches have failed.
- Federal funding for State and local public
safety communications development should consider progress toward
E-9-1-1 and WE-9-1-1 systems completion.
- Integrate Automatic Crash Notification (and
other Intelligent Transportation System and Department of Defense
technology) and health event advice lines into the process of
EMS public access and EMS resource deployment. [RFEMSA, Public
Access Chapter]
- States should establish formal plans for roadside
call-box, satellite, and/or cellular networks to effectively cover
all rural/frontier primary roads. [RFEMSA, Public Access Chapter]
- As home health monitoring devices and automated
remote diagnostic technology develop, EMS leaders should pursue
roles for EMS in their use to further EMS-based community health
services. [RFEMSA, Public Access Chapter]
- Conduct comprehensive State EMS communications
needs assessments upon which to base Federal, State, and local
investment in communications infrastructure improvement. [RFEMSA,
Communication Systems Chapter]
- The Universal Service Program fund, Federal
Communications Commission, frequency allocation and other national
public safety communications organizations and agencies should
work to assure that rural/frontier EMS communications are enhanced.
[RFEMSA, Communication Systems Chapter]
- Rededicate radio spectrum to EMS and other
public safety use. [RFEMSA, Communication Systems Chapter]
- Explore EMS applications of innovative communications
and resource management technologies. Encourage Federal and State
agencies to provide pilot funding and access to their agencies'
technology developers and resources for this purpose. [RFEMSA,
Communication Systems Chapter]
- EMS leaders should continue to develop ongoing
paths of communication with State and Federal telecommunications
interoperability and Intelligent Transportation Systems industry
planning entities. [RFEMSA, Communication Systems Chapter]
- Implement and maintain a local EMS information
system at every local EMS service/agency. Maintain data on every
EMS event in a manner which is timely and able to drive the quality
of the EMS system service and patient care delivery. [RFEMSA,
Information Systems Chapter]
- Link/integrate EMS data systems with other
relevant health information systems at all levels such as public
health surveillance, crash, medical examiner, hospital discharge,
and emergency department, including CDC surveillance monitoring
systems. [RFEMSA, Information Systems Chapter]
- The following information technologies could
significantly enhance emergency care: (1) dashboard systems that
track and coordinate patient flow; (2) communications systems
that enable ED physicians to link to patients' records or providers;
(3) clinical decision-support programs that improve decision making;
(4) documentation systems for collecting and storing patient data;
(5) computerized training and information retrieval; and (6) systems
to facilitate public health surveillance. Given their demonstrated
effectiveness in the emergency care setting, the committee recommends
that hospitals adopt robust information and communications systems
to improve the safety and quality of emergency care and enhance
hospital efficiency. The committee recognizes that the appropriate
prioritization of and investment in these approaches will vary
based on each institution's resources and needs. [IOM-FEC Hospital-Based
Emergency Care: At the Breaking Point]
- The trauma management information system (MIS)
is used to facilitate ongoing assessment and assurance of system
performance and outcomes and provides a basis for continuously
improving the trauma system including a cost-benefit analysis.
[MTSPE, Application of the Core Functions of Public Health to
Trauma Systems Chapter]
- Communications among EMS, public safety, public
health, and other hospital providers is even more problematic
given the technical challenges associated with developing interoperable
networks. As a result of these challenges and the need for improved
coordination, the committee recommends that hospitals, trauma
centers, EMS agencies, public safety departments, emergency management
offices, and public health agencies develop integrated and interoperable
communications and data systems. [IOM FEC EMS: At the Crossroads]
- Nevertheless, the use of telemedicine and distance
learning allows previously inaccessible training to penetrate
remote areas and new, more realistic and dynamic patient simulators
to allow case-based honing of critical skills and decision making.
[IOM-FEC: EMS: At the Crossroads]
- The development of automatic crash notification
(ACN) technology, now becoming more widely available, has further
improved emergency response, providing immediate and increasingly
detailed crash information to dispatchers automatically, even
before anyone on scene places a call. [IOM-FEC EMS: At the
Crossroads]
CONCLUSION:
RURAL HEALTH AND EMERGENCY MEDICAL SERVICES: SHARED GOALS
The Institute of Medicine charged their Committee
on the Future of Rural Health with recommending priority objectives
and identifying changes in polices and programs to enhance the quality
of care in rural areas.
The IOM similarly charged their Committee on the
Future of Emergency Care in the U.S. Health System with developing
recommendations to improve the emergency care system in this country.
Developers of the Rural and Frontier EMS Agenda
for the Future specifically addressed the bridge between rural
health and EMS, noting that EMS must be integrated into the broader
rural health system.
The Model Trauma System Planning and Evaluation
Document explicitly linked the trauma system and public health.
The staff of the Office of Rural Health Policy's
Rural Hospital Flexibility Program has created a set of recommendations
designed to influence program development, primarily within States,
through the Rural Hospital Flexibility (FLEX) Program, which has
a focus on rural health issues including EMS.
It is likely that all of the stakeholders from
these various groups envisioned that their recommendations would
influence policy-making and funding allocations at local, State
and Federal levels. Indeed, many stakeholders are developing strategies
to implement recommendations outlined in these respective documents.
The intended value of the "crosswalk"
of these recent publications is to highlight how much common ground
exists among a broad-based and influential set of providers, policy
makers, and other stakeholders with interests in rural and frontier
EMS.
An incredibly diverse array of stakeholders participated
in the development of these key documents. Some groups that have
not been specifically highlighted earlier in this report are the
National Association of State EMS Officials (the key association
linking State EMS programs at a national level), the National Organization
of State Offices of Rural Health (the national organization representing
all 50 State rural health offices), the Rural EMS & Trauma Technical
Assistance Center, and the National Rural Health Association. Clearly,
a diverse and broad-based set of stakeholders is currently engaged
in policy discussions about the future of rural EMS and trauma care.
This synergy is exciting and suggests that the time is right for
advocates and policy-makers to pursue a common strategy to ensure
a bright future for rural and frontier EMS in this country.
APPENDIX A:
REFERENCES/LIST OF KEY DOCUMENTS
The following is a list of key documents published
in the last 3 years that formed the basis for this comparative report.
1) Institute of Medicine of the National Academies
(2005). Quality Through Collaboration: The Future of Rural Health.
Washington, DC: The National Academies Press. www.nap.edu.
As part of a Institute of Medicine quality initiative,
the IOM produced two reports, To Err is Human: Building a Safer
Health System and Crossing the Quality Chasm: A New Health
System for the 21st Century. These reports highlighted serious
problems with the overall quality of care delivered in the United
States. Quality Through Collaboration is part of a third
phase of the IOM's quality initiative focused on operationalizing
the vision of a future health system described in the Quality Chasm
report.
2) McGinnis, K.K. (2004). Rural and Frontier
EMS Agenda for the Future. Kansas City, MO: National Rural Health
Association.
Funded by the Office of Rural Health Policy, this
document was the result of a consensus-building process overseen
by the National Association of EMS Officials and the National Organization
of State Offices of Rural Health. Comments were accepted from around
the country through an interactive Web site and a national consensus
meeting in a process lasting a little over 1 year. The purpose was
to create a vision for rural EMS, building upon the seminal work
of the National Highway Traffic Safety Administration's 1996 EMS
Agenda for the Future.
3) Health Resources and Services Administration,
Office of Rural Health Policy. Rural Hospital Flexibility Program
Strategic Plan.
The Rural Hospital Flexibility Program is a Federal
initiative that provides funding to State governments to strengthen
rural health. The program allows small hospitals the flexibility
to reconfigure operations and be licensed as Critical Access Hospitals
(CAHs), offers cost-based reimbursement for Medicare acute inpatient
and outpatient services to CAHs, encourages the development of rural
health networks, and provides annual grants to State Offices of
Rural Health to help implement a CAH program in the context of broader
initiatives to strengthen the rural health care infrastructure.
The strategic objectives of the program are outlined in a strategic
plan. The plan can be found online at http://ruralhealth.hrsa.gov/funding/FlexStratPlan.asp.
4) Institute of Medicine of the National Academies
(2006). Future of Emergency Care: Hospital-Based Emergency Care.
Washington, DC: The National Academies Press. www.nap.edu.
The Institute of Medicine's Committee on the Future
of Emergency Care in the United States Health System was convened
in 2003 to examine the state of emergency care in the United States;
to create a vision for the future of emergency care, including trauma
care; and to make recommendations to help the Nation achieve that
vision. Their findings and recommendations are presented in three
reports. One report, Hospital-Based Emergency Care: At the Breaking
Point, explores the changing role of the hospital emergency
department and describes the national epidemic of overcrowded emergency
departments and trauma centers.
5) Institute of Medicine of the National Academies
(2006). Future of Emergency Care: Emergency Care for Children:
Growing Pains. Washington, DC: The National Academies Press.
www.nap.edu.
The Institute of Medicine's Committee on the Future
of Emergency Care in the United States Health System was convened
in 2003 to examine the state of emergency care in the U.S., to create
a vision for the future of emergency care, including trauma care,
and to make recommendations to help the Nation achieve that vision.
Their findings and recommendations are presented in three reports.
The second report, Emergency Care for Children: Growing Pains,
describes the unique challenges of emergency care for children.
6) Institute of Medicine of the National Academies
(2006). Future of Emergency Care: Emergency Medical Services
at the Crossroads. Washington, DC: The National Academies Press.
www.nap.edu.
The Institute of Medicine's Committee on the Future
of Emergency Care in the United States Health System was convened
in 2003 to examine the state of emergency care in the United States,
to create a vision for the future of emergency care, including trauma
care, and to make recommendations to help the Nation achieve that
vision. Their findings and recommendations are presented in three
reports. The third report, Emergency Medical Services At the
Crossroads, describes the development of EMS systems over the
last 40 years and the fragmented system that exists today.
7) U.S. Department of Health and Human Services,
Health Resources and Services Administration (2006). Model Trauma
System Planning and Evaluation.
This document was developed through a collaborative
process involving an incredible array of professional organizations
and Federal agencies. It is a guide to modern statewide trauma system
development. Its purpose is to provide trauma care professionals,
public health officials, and health care policy experts with the
direction to use the public health approach, a scientifically proven
method, when developing and evaluating trauma systems. Extensive
information on the model can be found online at http://www.hrsa.gov/trauma/model.htm.
APPENDIX B:
ACKNOWLEDGEMENTS
Data for the statistical analysis component of
this study was made available by the National Registry of EMTs (NREMT),
who approved the plan of analysis December 13, 2005. We would like
to extend a special thanks to the Longitudinal EMT Attributes and
Demographics Study (LEADS) committee. Without access to the LEADS
survey data, this study would not have been possible.
This compendium was made possible by funds provided
by ORHP and the Rural Emergency Medical Services and Trauma Technical
Assistance Center (REMSTTAC), and the Kansas Department of Health
& Environment (KDHE) - Office of Local & Rural Health. Special
thanks for producing this compendium go to KDHE-Office of Local
& Rural Health staff, Chris Tilden, Interim Director and to
REMSTTAC staff, Nels Sanddal, Director; Heather Soucy, Program Support
Specialist; Teri Sanddal, Associate Director and Joe Hansen, Assistant
Director and members of the Policy Document Workgroup at REMSTTAC.
Nels D. Sanddal, M.S., REMT-B, Co-chair
Director
Rural Emergency Medical Services and Trauma Technical Assistance
Center
Chris Tilden, Ph.D., Co-chair
Director
Kansas Department of Health & Environment
Office of Local & Rural Health
Contributors and Reviewers:
Thomas J. Esposito, MD,
MPH, FACS
Medical Director, REMSTTAC
Professor & Chief Section of Trauma Surgery
Department of Surgery
Loyola University Medical Center
Joe Hansen, Associate Director
Rural Emergency Medical Services and Trauma Technical Assistance
Center
Tami Lichtenberg, TASC Program Manager
Rural Health Resource Center
Technical Assistance and Services Center
Jerry Overton, Executive Director
Richmond Ambulance Authority
Jacob Rueda, Project Officer
U.S. Department of Health and Human Services
Health Resources and Services Administration
Office of Rural Health Policy
Gary Wingrove, Technical Consultant
Technical Assistance and Services Center
Rural Health Resource Center
APPENDIX C:
REMSTTAC STAKEHOLDERS GROUP
Katrina Altenhofen, MPH,
REMT-B
State Coordinator
Emergency Medical Services of for Children
Iowa Department of Public Health
Jane W. Ball, RN, DrPH
Executive Director (Retired)
EMSC National Resource Center
Trauma-EMS Technical Assistance Center
Bethany Cummings, DO
Rural Affairs Ad Hoc Committee
National Association of EMS Physicians
Drew Dawson, Chief, EMS Division
National Highway Traffic Safety Administration
Tom Esposito, MD
Medical Director
Rural EMS and Trauma Technical Assistance Center
Blanca Fuertes, Past Project Officer
U.S. Department of Health and Human Services
Health Resources and Services Administration
Office of Rural Health Policy
Christian L. Hanna, MPH
Michigan Public Health Institute
Child and Adolescent Health
Bob Heath, EMS Education Coordinator
Nevada State Health Division
Intermountain Regional EMS for Children Coordinating Council
Marilyn Jarvis
Assistant Director for Continuing Education
Extended University
Montana State University
Douglas F. Kupas, MD
Rural Affairs Ad Hoc Committee
National Association of EMS Physicians
Fergus Laughridge, Program Manager
Nevada State Health Division
EMS Bureau of Licensure & Certification
Tami Lichtenberg, Program Manager
Technical Assistance and Services Center
Rural Health Resource Center
Tommy Loyacono, MPA
National Association of Emergency Medical Technicians
Patrick Malone, Director
Initiative for Rural Emergency Medical Services
University of Vermont
N. Clay Mann, PhD, MS
Center Director of Research
Professor of Pediatrics
Intermountain Injury Control Research Center
University of Utah
Evan Mayfield, MS
U.S. Department of Health and Human Services
Center for Disease Control
Office of the Commissioner
Charity G. Moore, PhD
Research Assistant Professor
Cecil G. Sheps Center for Health Services Research
Univ. of North Carolina at Chapel Hill
Carol Miller, Executive Director
National Center for Frontier Communities
Kimberly K. Obbink, M.Ed, Director
Extended University
Montana State University
Jerry Overton, Executive Director
Richmond Amublance Authority
Daniel Patterson, PhD
AHRQ-NRSA Post-Doctoral Research Fellow
Cecil G. Sheps Center for Health Services Research
Univ. of North Carolina at Chapel Hill
Davis Patterson, PhD, Research Scientist
Battelle Centers for Public Health Research and Evaluation
Ana Maria Puente, Past Project Officer
U.S. Department of Health and Human Services
Health Resources and Services Administration
International Health / Office of Rural Health Policy
Jacob L. Rueda III, PhD, Project Officer
U.S. Department of Health and Human Services
Health Resources and Services Administration
Office of Rural Health Policy
Kristine Sande, Project Director
Rural Assistance Center
University of North Dakota Center for Rural Health
Mary Sheridan, Director
State Offices of Rural Health
Idaho Department of Health and Welfare
Dan Summers, RN, BSN, CEN, EMT-P
Director of Education
Center for Rural Emergency Medicine
West Virginia University
Chris Tilden, PhD, Director
Kansas Department of Health & Environment
Office of Local & Rural Health
Robert K. Waddell II
Secretary /Treasurer
National Association of EMS Educators
Bill White, President
National Native American EMS Association
Gary Wingrove, Technical Consultant
Technical Assistance and Services Center
Rural Health Resource Center
Jill Zabel Myers, Healthcare Consulting
Wipfli LLP
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