EMS at 60 and the Road to 70

In 1966, a report titled “Accidental Death and Disability: The Neglected Disease of Modern Society” laid the groundwork for the modern-day EMS system, as detailed by this EMS World story.

In late September, Florida EMS leaders gathered at the Florida Center for EMS (FL-CEMS) in Tampa for the Innovation Conference for Emergency Medical Services to mark the 60th year of emergency medicine, with a panel discussion about what lies ahead in the next decade.

Older Adults Make Up More Calls

By 2035, those ages 60 and older will comprise 31% of the population and will represent approximately two out of every three patients encountered, noted Bruce Moeller, PhD, FL-CEMS executive director and University of South Florida Morsani College of Medicine Department of Emergency Medicine assistant professor. 

“The implications for what’s happening demographically across the U.S., with Florida being a leader in that area, is going to be something we have to contend with and understand,” he said.

Older adults present with more complex chronic disease, falls, and frailty as polypharmacy increases. Dementia and behavioral health emergencies add to calls. Other patient challenges include substance use and social needs; repeat utilization and unmet primary care needs, and patients who need care, but not always in the ER.

“The patients have changed, the medicines change, technology has changed, expectations in the communities change,” Moeller said. “But how we're funded, how our legislators understand us, who provides the service — much of that has not and it’s a disconnect.”

EMS Complexity

EMS is becoming more complex, noted Angus M. Jameson, MD, MPH, FACEP, FAEMS, medical director for Pinellas County EMS and Florida Department of Health EMS director, as well as associate professor, USF Health-Morsani College of Medicine.

“It's being accepted as another subspecialty in the house of medicine, but what it also reflects is that there may be roles for others beyond traditional EMTs and paramedics in the EMS space,” he said.

Moeller noted it’s key to communicate to the community what EMS does akin to how the fire service addresses community risk reduction.

“The value that EMS has in the minds of citizens is one of the highest rated of anything that government provides,” he said. “We want to think innovatively about how we can build on that.”

Joel Rowe, MD, MSE, FAEMS, Florida Center for EMS Systems Innovation director and assistant professor, USF Health-Morsani College of Medicine, noted the most transformative change is that what once started as a transportation medium has evolved into a clinical medium.

Technology Can Help Achieve Milestones

Addressing milestones that should be achieved, Jameson noted “I don't think we've done a good enough job of educating people about our capabilities and what we do” which, if understood, could create EMS access to hospital outcomes data on the patients they transport and participation in health information exchanges.

That may entail full implementation of technology, Moller noted, including there is much discussion about using AI.

“There’s a much larger picture when we're looking at a patient-centric environment that some of those silos start connecting and sharing information so the practitioner can see what’s been happening with that patient over time,” he said. “Better information will certainly yield better outcomes.”

Body cams could be leveraged at the point of patient care, said Jameson, adding they provide decision support and real-time translation to facilitate telemedicine and automate charting.

The barriers are statutory, he said.

“The traditional role of government is to fill something that the free market won't be able to handle, and EMS is clearly there,” Moeller said. “The overwhelming majority of EMS agencies are governmental entities that have significant subsidies. The big monster is reimbursement.

“Technology will help us justify our usefulness. Insurance companies will see that as well. There will be an opportunity to fund programs at a level that aligns with the community's expectations of us from a clinical and response perspective, but also in helping engage that patient in other opportunities for healthcare from the larger system.”

Rowe noted “The future isn't necessarily AI or something that's going to replace a paramedic. The potential is can we empower our EMS clinicians so at the point of contact, they arrive with the informational capacity of the entire healthcare system at their fingertips that they can readily and accessibly use and leverage in that setting to optimize what they're doing at that point in time.

“There’s a very humanistic point and integral part of what we do that needs to remain very much a human relationship. Technology should extend that human clinical relationship rather than get more devices out in the field and try to make something happen at that point to further the humanism that exists in helping people at their most vulnerable points. We should take an active effort to preserve that.”

Barriers include funding, cybersecurity, infrastructure, and onboarding, Rowe added.

Future Care Models

Rowe said using the activation of the 9-1-1 system as a point of demarcation can divide service capabilities and potentials into post-activation optimization and pre-activation.

While post-activation addresses factors such as alternative destination, “we’re talking about now what's potentially feasible is getting pre-activation care that ultimately prevents the activation of the system, a fundamentally different approach to what we've done conventionally in the delivery of pre-hospital or out-of-hospital care,” he said.

Moeller added if the future care model involves a larger perspective than just responding to emergencies, that could entail following up on some of the patients to see the outcomes and support them in that initial post discharge period.

That will require buy-in from policymakers, federal, state, local legislators, and workforce changes, he added.

The EMS Workforce

Building and sustaining a strong EMS workforce is a concern, panelists agree, adding tracking vacancy numbers, recruiting, training, providing career paths, and retention are key factors.

Panelists noted generational differences: Older EMS workers typically stayed in a job for the long run while younger ones will leave a job if it lacks satisfaction.

 “We can’t recruit our way out of a system people don't want to be a part of,” Rowe said. “If we want to build the opportunities and make attractive careers, we have to present them with those opportunities.”

“We should be blending in mental health supports as a normal part of operations, and not just relying on individual resilience to see individual medics through, because the medics will internalize that they have failed as they must not be resilient enough,” said Heather Henderson, PhD, CAP, CRPS, assistant professor and director of the Division of Social Emergency Medicine, Population and Global Health, USF Health Department of Emergency Medicine. “It’s not their fault. The system is putting those pressures on their mental health. That really needs to be integrated going forward as a way to make sure the workforce stays strong and able to provide services.”

Partnerships

Addressing partnerships is critical to improving patient outcomes and system efficiencies. Jameson noted that if EMS can’t have appropriate data outcomes exchanged with the hospitals with information available to the treatment teams at the time of treatment and follow-up, patient outcomes and system efficiency will not improve.

“I see EMS as a connection point between the healthcare system and community because medics are often the only people who see where the patient lives,” Henderson said. “EMS needs to be treated as a full partner rather than just a transport service at the periphery of the healthcare system.”

Henderson added partnerships that would matter the most include behavioral health crisis systems, harm reduction programs, opioid treatment programs, social service agencies, peer-recovery organizations, and an actual partnership with emergency departments.

Moeller remembered his clinical time at an Illinois system hospital.

“There was a relationship with every paramedic who went through a paramedic program in their hospital,” he said. “Our agencies have to work to establish that relationship with their healthcare systems.”

That may entail inviting others in the system to EMS directors’ meetings, Moeller said, adding that may be difficult in rural areas, “but make those relationships because we're going to need those to handle the challenges on that road ahead.”

“What fuels EMS is the relationship between an EMS clinician and an oversight physician,” Rowe added. “We haven't necessarily done the best job as an industry to increase the awareness of what we do on a day-to-day basis with our healthcare colleagues.”

Henderson added that partnerships are critical, “but there won't be any sort of scalable, sustainable impact to the organization as a whole unless there's some sort of organizational framework for who is owning that process of building those partnerships and solidifying connections with the hospital, the community and EMS systems.”

Challenges and Opportunities on the Road to 70

Addressing challenges and opportunities over the next decade, Jameson said if Florida voters pass an amendment on the November ballot to expand the nonschool property tax exemption, it would reduce local government revenue and severely impact EMS funding.

The demand to keep growing is a challenge, Henderson said.

“We have an aging population, the housing crisis, the overdose crisis, the behavioral health crisis,” she said. “The workforce is already stretched thin. I'm worried systems are going to try to manage that demand by frequent caller policies, billing practices, or diversion that just moves the patient somewhere else and doesn't really fix the problem. That's often back to the emergency department or the street.”

Henderson said she is encouraged by the opportunity to approach matters differently in this current ecosystem that could be funded by a significant amount of opioid settlement money “pouring into multiple counties across our region that would fund the kind of partnerships we're talking about: peer programs, community-based care.

“That lets EMS plan for its highest-need patients in being proactive instead of reactive. There's growing recognition across medicine that social conditions are driving health outcomes, which gives EMS leaders a stronger basis to make the case for that proactive partnership-based model.”

Rowe said EMS needs to be vigilant about different operational expressions for programs and innovation that if it left uncoordinated with a larger system “merely propagates more fragmentation”.

Funding challenges and a lack of recognition also represents significant risk, he added.

Addressing the vision for EMS at year 70, Jameson said “I would love to see EMS evolve to have academic EMS systems that are rigorously and continually working to drive forward this practice.”

Henderson’s vision is that EMS has a solid plan for the most structurally vulnerable patients, established community partnerships with those who serve them “and that we care for our own clinicians with the same passion and drive we bring towards patient care.”

Rowe said he envisions EMS “still being exceptional at providing emergency care, but also more fully recognized as an anchor partner in a discipline of out-of-hospital medicine that is capable of connecting people to the resources and care in the ways that they need to be best served.”

Moeller said his vision is that “we are better at 70 than we were at 60 — not that we're bad now — and that history will judge that we've moved the ball forward, made it better.”