Point of View: How You Can Use the IOM Report to Improve EMS

     The Institute of Medicine's report on EMS, Emergency Medical Services at the Crossroads, summarizes EMS's problems, human-resource issues and potential methods to improve prehospital care. The most notable recommendations suggest a regionalized, coordinated and accountable emergency care system and the promotion of EMS workforce standards. These recommendations, if followed, would reverse the 20-year trend toward fragmenting and decentralizing emergency medical services. Efforts in the 1970s to design regional EMS systems with federal oversight, funding and training were reversed in the 1980s in favor of empowering states to create training levels, and local governments to provide funding and organization.

     Our emergency system is laboring to address the bigger issues of healthcare in America. Emergency care, in both the prehospital and emergency department settings, is the first element to bleed under the pressures of decreasing capacity and funding and increasing demand. There has been a failure to identify two of the greatest healthcare success stories in America: the reduction in premature death from sudden cardiac arrest and the reduced morbidity from trauma and burns. These are developments that match the impact of anesthesia for surgery and vaccines and antibiotics for infection. Preventing premature death allows many more Americans to lead productive lives, and eventually to develop diseases of older age (e.g., cardiac disease, cancer, diabetes and neurologic deterioration). Those diseases have exacerbations that will predictably lead to the need for emergency care, and our economic system has not been adequately prepared to account for the cost of providing care to an aging population with more chronic illnesses. Instead of treating this as a healthcare system success, America has focused on the unprecedented expenses and the failure of the healthcare delivery system to match the customer-service successes of other industries.

     We should begin the process by congratulating American emergency providers for their success in treating emergency patients, and for their role in preventing premature death. We have opportunities to build on those successes to design a better emergency care system through use of tools from other industries, including GPS technologies, electronic records and communication systems. There are dramatic opportunities to integrate the emergency system at the regional level by delivering more care at sites appropriate for the patient.

     We developed a program in Dayton, OH, called CareNow, that delivered unscheduled medical services through the phone or computer, utilized home healthcare services through a variety of providers, and linked regional EMS services for the most effective use of personnel. This program was too far ahead of its time for its funding to be sustained, but it's exactly the kind of model that innovative regions can design and implement to improve care and system effectiveness.

     The federal government has created an environment that has only made emergency medical care more difficult and expensive. Laws such as EMTALA and HIPAA have had dramatically unexpected consequences that are negative for patients and providers. The open-ended liability environment has forced emergency-care providers to develop extensive risk-management programs, due to daily interfaces with patients who have emergency events and unexpected bad outcomes. Unproductive dollars and energy are dedicated to malpractice protection and focusing on the legal aspects of the patient interaction.

     The federal government, through its Centers for Medicare & Medicaid Services, is the single leading payer for emergency services in the prehospital and hospital settings. CMS has led other payers to construct progressively complex payment systems that are particularly unfriendly to emergency providers. In the design of their payment systems, payers have created a "shell game" for providers to try to collect money for taking care of patients.

     There is no industry that spends more to collect its revenue than emergency medical services and ED providers! With this, combined with the dramatic jump in malpractice premium expenses, many emergency organizations cannot stay in business, and employee retention problems mount.

     The Institute of Medicine report should be shared with every federal legislator, White House staffer and Supreme Court justice. If they could understand and apply the recommendations of the report, and apply groundbreaking efforts to support the emergency system, the energy of the EMS system could be dedicated to regional improvements and personnel retention.

Jim Augustine, MD, serves on the clinical faculty in the Department of Emergency Medicine at Emory University, Atlanta, GA. He also serves as Medical Director for the Atlanta Fire Department. Contact him at jaugust@emory.edu.