A Look Back at the Future

What will emergency medical services look like in 20 years? 

Think about it for a while. Make some predictions, write them down. Then publish them and forget about them. We’ll check back in 2040 and see how you did. 

That’s the challenge EMS World posed to some sage industry veterans who contributed to our first issue of the new millennium back in January 2000. That issue—assembled in late 1999 when EMS World was just Emergency Medical Services Magazine and now surviving only in rare print archives—previewed 21st-century EMS and the changes it might hold. We found 20 contributors and put ’em on the record. It wasn’t in the plans then, but after reviewing that issue in 2020, it seemed fun and illuminating to circle back with some and evaluate their expectations vs. reality. 

You can find that 2000 article in a special download at www.emsworld.com/1224716/january-2000-cover-report. It featured some pretty insightful folks. We don’t have levitating stretchers yet, but they foresaw a whole lot else. 

Mobile Medicine 

Turns out you didn’t have to be Nostradamus in Y2K to see some permutation of community paramedicine/mobile integrated healthcare coming. The need was already manifest, the solution apparent to many. 

• The time grows near when EMS providers will partner with hospitals and healthcare insurance companies to provide in-home services, wrote Dennis Rubin, then fire chief in Dothan, Ala. These may include vaccinations, immunization, suture removal, and other simple procedures.
• EMS will perform more home evaluation and treatment services, agreed emergency physician James Augustine, MD, FACEP. The EMS field is contained within the arena of “unscheduled care.” This field will change in the next century to feature more chronically ill patients living at home, who have in-dwelling medical devices, catheters, ventilators, nebulizers, vital signs monitors, and medication-dispensing systems. 
• EMS agencies will increasingly provide “mobile medicine,” wrote Gordon Sachs, then director of IOCAD Emergency Services, going beyond the E in EMS to treat minor injuries at the scene, distribute prescriptions, and refer patients to clinics, rather than transport them to the ED.

Obviously some details have differed as today’s integrated programs have developed. They’re less broad-based services across communities than targeted interventions for identified populations. Care parameters have grown in a piecemeal way reflective of local needs. Payment has followed in fits and starts. Not a wholesale change to be sure, but generally the direction our experts expected. 

“We were ahead of our time with use of the term unscheduled care, but it really is where we are headed,” says Augustine, now chair of the National Clinical Governance Board of U.S. Acute Care Solutions and a longtime EMS medical director in multiple states. “We used to refer to EMS as the transition zone between in-hospital care and out-of-hospital care. Now, really, EMS is the basis for effectively transitioning people between inpatient needs and outpatient needs. It’s a way for moving people toward better outcomes by having great people take care of their needs before they have to go inpatient.”

Rubin and Augustine worked together in Washington, D.C., in the late aughts when D.C. Fire and EMS launched its Street Calls program to connect high-volume users with solutions to their nonemergency needs. The program had some early success, and “we learned intervening earlier just made a lot of sense,” says Rubin, now fire chief in Upper Merion, Pa. “Communities that want to start bending the tremendous cost curve of delivering emergency medical care simply have to look at it.” 

While streamlining costs and improving experiences are sufficient goals in their own right, the growth of CP-MIH programs also lets EMS demonstrate value. The Affordable Care Act was a decade off in 1999, but the imperative of proving EMS’s worth was becoming plain. Wrote Rick Patrick, then an emergency services education specialist with insurer VFIS, now director of national fire programs at the USFA: EMS will be challenged to justify its existence. Does what we do make a difference? Added Mark Meijer, president of the American Ambulance Association and Life EMS in Michigan: There could be opportunities for providers to demonstrate maximum efficiencies to the communities they serve through alternative delivery models and exploration of alternative patient destinations, as an example.

Meijer still leads the company he cofounded, and Life has expanded into the CP-MIH realm with integrated care paramedics, but for Meijer they’ve come with an important difference from what he imagined. 

“There was always a thought that we had to have an ‘expanded scope’ for paramedics involved in that kind of arena,” he says. “But that scared our brethren professionals, and we realized training medics in additional procedures and medications may not necessarily result in those skills being utilized. So what we’re pleased to see is basically use of the skill set paramedics have developed through their training and experience to keep people safely in their homes and provide a level of ongoing care we never anticipated being involved in.” 

Some of that is now quite contrary to traditional EMS work—for instance, helping elderly patients with advance directives and end-of-life wishes…and generally just trying to keep them away from hospitals. 

“The hospital can no longer be the funnel,” says Hank Christen, EdD, MPA, in 2000 director of EMS in Okaloosa County, Fla., now semiretired and a consultant for Active Shooter 360 in Shalimar, Fla. “And they don’t want to be the funnel! They did at one time. They don’t want that now. That’s been a very pleasant surprise, because no matter what, we’ve always transported to the hospital. That’s just not sustainable anymore.” 

Technology and Data 

It’s not exactly bold to say technology and data systems will advance in the future. But if they did, they were right. 

• Sachs: Just like defibrillators have made their way from the ED to ALS units to first responder units, other equipment commonly associated with hospitals will be found on EMS vehicles. He cited ultrasound and the capability of sharing images with hospital teams. 
• Augustine: Advanced communication systems will offer the individual more ways of assessing and treating unscheduled medical events. Video links will allow a patient to be directly linked to EMS, their primary physician, the ED physician, or their subspecialist. 
• William McClincy, then regional training coordinator for EMMCO West in Meadville, Pa., now its executive director: The use of computers, multimedia projectors, multimedia programming, and advanced communication systems (e.g., satellite, Internet) will be as common as the slide projector or TV/VCR in today’s classroom. Traditional “four-walled classrooms” will be replaced with interactive online training programs. Students, while at work or in their homes, will be able to access multisensory interactive online courses… Patient treatments and procedures will also become high-tech… EMS personnel will use a palm-sized computer to record patient data and make inquiries into specific treatment procedures. (The most popular cell phone of 2000, recall, was the Nokia 3310.) 

Capabilities have advanced wildly and continue. Some systems have taken great advantage. Education and aspects of patient care have been revolutionized. But gaps persist. Regulation and reimbursement have lagged for innovations like telemedicine. And free and easy universal patient data flow still eludes us. 

“As a hospital-based provider, I routinely cannot get the EMS records of the patients I see, because they’re locked up in a system somewhere and not available,” says Augustine. “In our old days working with three-copy EMS PCRs, they were always available, always with the right information, right there in the ED record and carrying through the hospital. Now it’s lost. And when I send the person home, their record—which could help the next EMS person decide whether they’re having an MI or not, or what a blood clot means—isn’t available to EMS. 

“I think it’ll really require an entity with the mammoth size and silo-busting capabilities of a Google or an Apple to break down those silos and to begin to really apply technology in the way patients need it.”

People Hurting People

Overall violent crime is still far less than the 1990s, but your mileage may vary. Only Christen really mentioned violence in 2000, but it’s always influential to EMS debate. Much of the last 20 years was occupied by a focus on terrorism, compounded in recent years by active shooters and in 2020 widespread civil unrest. EMS has adapted with each: 9/11 led to the universalization of ICS, expansion of mass-casualty capabilities, and preparation for WMD/CBRNE threats; mass shootings galvanized rescue task forces and Stop the Bleed training; demonstrations have forced honing of mass-gathering care and riot response. 

“Now we have hot and warm zones for medic responses,” Christen says. “Those used to be hazmat terms; now we apply them to mass shootings or any type of crime scene. EMS has ballistic helmets and vests, sometimes with plates—I didn’t anticipate that. But EMS is always going to be right in the middle when there’s violence.”

The last two decades have seen multiple combined and even some EMS-only departments adopt ballistic protection and other heightened defenses. Don’t bet against more following. “If folks let their guard down,” warns Rubin, “they’re getting ready for a sucker punch.”

Payment Reform

Everyone in 2000 was very concerned.

• Jon Krohmer, MD, then president of NAEMSP, now director of NHTSA’s Office of EMS: We have to identify a reimbursement structure that will support [all our] activities and maintain EMS as the public’s “medical safety net.” 
• Tim Wiedrich, then president of the National Association of State EMS Directors (now Officials), now chief of the North Dakota Department of Health’s Emergency Preparedness and Response Section: Funding will continue to be a major issue in the 21st century, since EMS is a hybrid of public safety and traditional medical services, neither of which consistently address the responsibility of providing stable funding.
• At the time Medicare was revamping its ambulance fee schedule. Meijer and the AAA were immersed in the negotiated rulemaking process behind it. As Medicare often accounts for 35%–40% of a full-service ambulance operation’s fee-for-service revenue, he wrote, this could in some ways reshape system design and local funding requirements. 

They were right about it remaining an issue. Ambulance operations still rely enormously on Medicare, and while we’re gradually developing some new revenue streams, the search for definitive funding solutions continues. 

“Would I have thought 20 years ago we’d still be in the same payment format today as we were then? No,” says Meijer. “When we did the negotiated rulemaking process, one of the biggest challenges was that there were no new dollars. So it was a matter of allocating existing dollars. And in the two decades since, a lot of great people with great ideas have tried to initiate some level of changing how ambulance and EMS services are reimbursed, to no avail. There have been some cost studies—ironically we have one in the offing that’s been delayed due to the pandemic. But I’d have lost a bet on that one—I’d have thought that 20 years following negotiated rulemaking, we would had some revamped way to reimburse EMS.”

“I’d imagined in 1999 we would have had much greater payer support for the development of in-home technologies and the emergency care system being able to serve people at home,” says Augustine. “Frankly, the laggard has been the federal government in all the CMS programs. They were very deliberate in implementation of ET3 programs, and then when we really had a crisis, they had to release the regulations fairly quickly. Now we’re at the point of approving payment for treatment in place. So I believe the next 20 years will really significantly expand our opportunities to do more in-home care and management of patients who don’t benefit from hospitals.” 

COVID-19 should help goose things along. It’s driven an explosion in telehealth, with new adopters, new processes, and even some reimbursement beginning to follow. It’s plausible to see some of those efficiencies outliving the pandemic. 

“Any big event that occurs in humanity should be a point where we make dramatic improvements in the way we do things,” adds Augustine. “We apply new technologies. We implement new processes. So this is our opportunity as an inflection point for the entire health system.”

A Few More Hits and Misses

“Of course it would have been suspicious if I’d said ‘In 2019 or 2020 there will be a major pandemic.’ So I didn’t get that one,” joked Christen. No one else specifically called one either, though most in healthcare likely knew one was possible. 

EMS infection-control expert Kathy West, RN, BSN, MSEd, looked for better access to better information on infection control. That’s available and largely embraced in EMS, but misinformation and mistrust of healthcare authority has abounded among the general public during the COVID-19 outbreak. Healthcare education has grown imperative. 

Krohmer wrote of a need for the specialization of the EMS physician, which came to pass with the 2010 recognition of EMS as a physician subspecialty. He and Patrick echoed Matt Streger’s call to bolster our evidence base. McClincy saw specialized treatment centers (e.g., STEMI, stroke) supplanting traditional hospitals for certain patients. Alexander Kuehl, MD, medical director for New York City EMS in the ’80s, foresaw requirements for structure in call receiving, caller interrogation, and bystander instruction. Only Meijer mentioned diversity, but in 2020 it’s more important than ever. 

Here and there were scattered a few way-off predictions we won’t recount here but you can tease the authors about when your paths next cross. 

The Next 20 Years 

We could all make some more predictions here. Let’s talk instead about one background factor that’s likely to shape developments in EMS and healthcare for the better in a way people might miss. 

For 50 years now, EMS has served as an entry point for people who have made healthcare their careers. Many people now have begun as EMTs and gone on to become not only nurses and physicians and department chiefs but influencers, policymakers, and executives. Paramedics have become medical directors, hospital administrators, elected officials, and a surgeon general. 

In short, people who understand the importance of EMS are gradually trickling upward into positions to make more and more of a difference about it. 

“We now have EMS people who serve in hospitals,” says Augustine. “They serve nonemergency transport needs. They serve emergency transport needs. They’ve become all-hazards experts, and many of the departments I work with have only people who are EMS-trained—all the way up to the chief, everybody is a paramedic. 

“What a great success that is! We’re at that point now where a lot of people who were in it early on are now decision-makers and can say, ‘We need to commit more money and responsibility to those people!’”

Whatever the next 20 years hold, that’s gotta help.  

Sidebar—How I Did: Erik Gaull  

MIH is a big step forward, but otherwise EMS hasn’t changed much in 20 years

• Then: Senior emergency services analyst, Tri-Data Corp. 
• Now: Master firefighter/paramedic III, Cabin John Park (Md.) VFD

In January 2000 I wrote a brief article for what was then EMS Magazine that began, I don’t believe there will be a fundamental difference in the way the EMS is delivered in the next century. Twenty years on my prediction has proven to have been largely correct. The biggest change I foresaw was the development of “alternative pathways” for delivering care—what we now call mobile integrated healthcare (MIH)—that would allow EMS providers to deliver services more comprehensive than just taking someone to the hospital. MIH has been an important step forward for the EMS profession. By focusing holistically on a patient’s needs, rather than simply their medical presentation, MIH personnel can better address root causes of illness, including psychosocial issues. It has been extremely pleasing to watch as progressive EMS systems have morphed from providing emergency response to a community health service. As more and more is asked of EMS agencies (of all types), the MIH role will continue to grow and gain greater significance within the healthcare system.

While all this represents a notable and much-needed expansion of the role of EMS agencies, the second premise of my original prediction sadly holds true: In most areas of the country, EMS has not advanced much from where it was 20 years ago. The dominant EMS model is still one of providing rapid response to emergencies and transporting patients to the hospital. (My EMS system only added a non-lights-and-siren response for low-acuity calls to the computer-assisted dispatch system a few months ago, and destinations other than a hospital or authorized freestanding emergency clinic are unheard of.) Outside of large cities and exurban counties, the realities of the labor pool and economics of EMS argue for using volunteer personnel who are trained as medical first responders or EMTs. It is too expensive to train, equip, and deploy paramedics in many parts of the country, so localities either make do only with basic life support or have some advanced life support units, the effectiveness of which is hampered by time and distance.

This problem is almost intractable. Competent care is a function of education and call volume. Training paramedics takes both time and money—and even when well-trained paramedics can be hired, retaining them and keeping them motivated, knowledgeable, and skilled can prove extremely difficult (near-impossible) in low-volume rural/frontier EMS settings.

I’d love to be wrong about my final prognostication—EMS in the 21st century is unlikely to be radically different from what it is now—but for this not to be the case, we’re going to have to abandon our previously held beliefs about what we do, how we do it, and why. Only then will we be able to move more fully in the direction of MIH—something that will be better for patients and the EMS system that exists to serve them.

Sidebar—How I Did: Matt Streger 

So far so good—but with COVID-19 and beyond, major change is still imminent

• Then: Paramedic, Greenville County (S.C.) EMS
• Now: Partner, Keavney & Streger, Princeton, N.J.

It’s hard to look back at what you wrote 20 years ago with a critical eye. Between the fact that I don’t want to be overly self-critical (or self-aggrandizing) and the fact that I’m a very different person than I was back then, evaluating my predictions from 2000 on the future of EMS was quite a challenge.

That being said, I think my predictions have stood up pretty well to the test of time. We’ve spent 20 years studying EMS and making changes to our practice based on that science (e.g., backboards), but we still have such a long way to go with other evidence-based changes (e.g., response times). We still struggle with how we want to be evaluated regarding outcomes and still struggle with how to get some of that data. At least 13 years have passed since we talked about EMR interoperability, and we spent a pretty penny on those systems, and yet we still struggle with information sharing. The healthcare system in general needs to do a much better job in this area, including EMS.

But evaluating my predictions through the lens of COVID-19, my earlier comments about the tension in EMS between public health and public safety seem to be pretty on the nose. We continue to struggle with our identity between these two domains and for acknowledgement and respect overall. The pandemic has illustrated just how important it is to have our feet firmly grounded in healthcare, lest we risk missing out on resources for infection control, evolving protocols, occupational medicine, access to healthcare PPE, and more. We do need to change our reimbursement structure to combine the healthcare, wellness, and quality metrics associated with being healthcare providers with the preparedness, surge capacity, and specialty response capabilities usually funded through public safety. 

EMS is about to undergo a rapid mutation as a result of COVID-19. The efforts to restructure our basic operations (ET3), reimbursement structure (cost data collection), workforce changes, responder mental health issues, preparedness funding, and more are going to burst forth much faster than we previously anticipated. Even calls to defund law enforcement (which I interpret as a call to restructure public safety responses) provide opportunity and risk to EMS agencies as those roles are reimagined. If we stick to the old ways and refuse to evolve, we run the risk of losing control over our destiny—or potentially becoming extinct.

Sidebar—How I Did: Gordon Sachs

A look back from the outside

• Then: Director, IOCAD Emergency Services
• Now: Chief of All Hazard and International Fire Support, USDA Forest Service Fire & Aviation Management

Looking back at the prognostications made in the year 2000 about EMS in the future was both entertaining and heartening. It was entertaining because it brought back (mostly) fond memories of when I was directly involved in the delivery of prehospital EMS, not just at the local level but on many national-level groups and projects. It was heartening because of the accuracy of so many of the predictions. It also saddened me to recall we’ve lost some of the great EMS leaders and change agents (such as Jim Page) but made me proud that some of my former colleagues in the world of EMS rose to positions of prominence (including a couple becoming presidents of the International Association of Fire Chiefs).

Even though many of the destinations have not yet been fully reached, the changes in EMS certainly have moved significantly in the direction predicted 20 years ago. One thing hasn’t changed, and in fact was exemplified during the 2020 COVID-19 pandemic: EMS is a critical service at the intersection of public health and public safety. EMS providers are more recognized as “frontline heroes” by the public now, not just “ambulance drivers,” and EMS agencies are much more than “first aid crews.” 

Just as the 1970s television show Emergency! drove public perception regarding the advancement from BLS to ALS care, so some of today’s shows drive public perception about the current state of EMS. While nearly all depict EMS delivered at the ALS level, some show physician response teams (PRTs), where MDs are trained as EMS responders and dispatched just as today’s ALS units are. These PRTs routinely perform interventions in the field that would have been unimaginable to the medical community or public 20 years ago. Are PRTs the standard of care across the nation? No, but thanks to television, the public may think so, and this may lead to an expectation that agencies need to fill, just as Emergency! led to the widespread acceptance of paramedics.

While my career choices drew me away from the delivery of EMS, I am still heavily involved in emergency response and incident management. This has given me the opportunity to see EMS through a different lens. I have seen EMS embracing the Incident Command System (mandatory now for compliance under the National Incident Management System, but one of the battles I fought back in the day, when many EMS agencies refused to consider it). I have seen competent national-level EMS coordination for disaster response. And I’ve seen excellent, expanded federal-level interest and involvement in EMS, including a significant escalation of the stature of the Federal Interagency Committee on EMS (which I once chaired when it was just another federal committee).

I had the opportunity a few years ago to activate and observe my local EMS providers (for a family member) on more than one occasion over a few weeks’ span. The fire-based ALS and BLS responders who responded were professional, empathetic, humble, and skilled during each patient encounter—much better than some of the emergency physicians we encountered! I found firsthand there have been many advances since I was an EMS provider—from “text to 9-1-1” to response protocols to patient care capabilities. The responders can do more interventions without checking with physicians (IVs, pain meds, etc.), and if they needed to, they could send photos or even real-time video to the emergency department from the scene. 

Surprisingly (or perhaps not), the biggest “wow” for me was the automatic loading stretcher. It may not be a big deal to today’s provider, but for those of us who have permanent back problems because of years of lifting loaded stretchers, it is an amazing feature! 

I’m glad I don’t have to predict what EMS will look like in the next 20 years. There are so many uncertainties—funding is always an issue, but budgets will be extremely tight due to the impacts of COVID-19 on local, state, and federal economies. Volunteerism is down so much in both fire and EMS that local and state governments will be forced to act. The health insurance industry always has a big impact on EMS, and it is not clear what direction healthcare laws, regulations, rules, and guidelines may take. And there’s technology advancing at a rapid pace—who knows what impact things like artificial intelligence will have on prehospital care? (Despite the efforts to commercialize package delivery by drone, I still don’t see patient transport that way becoming the norm!)

I am pleased to see how far EMS has come, and it is clear that advances continue. I’m proud I was a part of this (albeit a long time ago) and hope to be around to see how it changes over the next 20 years.

John Erich is the senior editor of EMS World. Reach him at john.erich@emsworld.com.