An Interview With Dia Gainor on State EMS Offices

Each state and territory in the United States has a lead EMS agency. These agencies are usually part of the state health department, but in some states they are part of the public safety department or are even a stand-alone state agency. (See the December 2004 issue of EMS Magazine for a detailed listing of all state and provincial [Canadian] agencies.) State EMS agencies are often responsible for the overall planning, coordination and regulation of the EMS system within the state, as well as licensing or certifying EMS providers. Additional responsibilities can include: development of statewide medical protocols for EMS providers, administration or coordination of regional EMS programs, as well as planning for and coordinating the medical response to disasters and mass casualty incidents. Federal initiatives that have been supported by various state EMS offices include: Rural Access to Emergency Devices (RAED) implementation and widespread installation of E9-1-1, which provides the location and telephone number of every landline caller to the receiving emergency communication center.

Just as the responsibilities of these offices are disparate, likewise the staffing levels of the various state EMS offices also vary widely—and may be subject to severe cutbacks and work reassignments. Recent years have seen some states take the distinct areas of responsibility for EMS offices (or even the offices themselves) and merge them into public safety or fire-based oversight bureaucracies. This lack of singular identity can significantly impact the identity of the overall EMS system and its core mission.

To shed some light on these issues, I spoke with Dia Gainor, MPA, bureau chief for the Idaho Department of Health EMS Bureau, regarding the various roles and responsibilities of state EMS offices, as well as current and future directions for these offices. Gainor has previously served as president of the National Association of State EMS Directors (NASEMSD) and has written numerous articles regarding state EMS offices and the utilization of quality improvement techniques based on the principles of Six Sigma, a method of eliminating defects in any process.

There are typically four functions that the majority of state EMS offices share: EMS personnel credentialing and local agency licensure; EMS system planning and development; EMS data collection; and the management of multiple federal grants targeting special interests or needs in EMS systems, such as EMS for children and rural AEDs. All this requires striking a careful balance between regulatory functions and EMS system support activities.

In a survey conducted by the University of North Carolina at Chapel Hill last year, only one function was common to all 50 states and one territory: complaint investigations. However, the true constant among all state and territorial EMS offices is managing change. EMS is a rapidly evolving science, discipline and public policy field; states play an integral role in the stewardship of the system.

Most readers are familiar with the National Association of Emergency Medical Technicians (NAEMT) and the National Association of EMS Educators (NAEMSE). This is less true with the National Association of State EMS Directors. Can you tell us about NASEMSD?

The vision statement of the NASEMSD says it best: “The National Association of State EMS Directors is the lead national organization for EMS, a respected voice for national EMS policy with comprehensive concern and commitment for the development of effective, integrated, community-based, universal and consistent EMS systems.” We’re true believers in looking at EMS and all of its complexities as a system, and collaborating across and among states to assure that EMS systems evolve in an orderly and coordinated fashion. Ultimately, all of the work of our association is intended to improve the quality of care for ill and injured patients. In some ways, the work we do serves the individual state EMS director—creating a forum for thought, ideas, solutions and professional development. In other areas, we strive to improve conditions for EMS systems at large, through projects of national significance such as the Rural and Frontier EMS Agenda for the Future and the National EMS Scope of Practice Model Project.

What is the National EMS Information System (NEMSIS) and why is it important to EMS?

The importance of quantifying and analyzing the performance and quality of EMS systems at every level has been a challenge for state EMS offices for decades. How can we insist that EMS makes a difference when we can’t prove it? Even where states have an EMS data collection system in place, it may not be possible to benchmark with other states or draw comparisons between services within a state. In the early 1990s, NASEMSD led the charge to establish the National Uniform Prehospital Data set in partnership with the National Highway Traffic Safety Administration (NHTSA).

While that was a good start, there was sufficient evidence that a more comprehensive set of standards would be essential before we could truly evaluate EMS system performance at the local, state and national levels. NHTSA and another federal partner, the Trauma/EMS Systems program in the U.S. Department of Health and Human Services, awarded funds to the NASEMSD for an ambitious two-year project that will create version 2.0 of the NHTSA Uniform Prehospital Data set; define a subset of those data that, if submitted by all states, would comprise a national EMS information system; devise a physical database plan mapped to the NHTSA data set with XML linkage for use on the Web; and create a business plan for implementation. We’re fortunate to have very bright and dedicated principal and co-investigators; and 51 states and territories have committed to promote the implementation of the data set. Evaluation of EMS system structures, processes and outcomes has a very promising future!

What are your feelings on the establishment of a lead federal EMS agency? How would the creation of such an entity impact the individual state EMS offices?

This is a very important and as yet unresolved question. If anything should be established at the federal level, it would be an overhauled Federal Interagency Committee on EMS (FICEMS) and an EMS Research Institute. I don’t think many people are aware of the number and diversity of federal programs that contribute to the mosaic of EMS system development throughout the country. From my perspective—after recently concluding 10 years of service on the executive committee of NASEMSD—we benefit from the patchwork quilt of federal partners, each of which bring different interests and resources to bear. The assertion that a single (and therefore lead) federal agency would automatically improve something about EMS is not grounded on any evidence—what’s the problem it is intended to solve?

However, FICEMS would be the ideal proving ground for leadership issues and maximized coordination of federal programs—the concept of revitalizing it is getting some legs in federal legislation (HR 3550/S.1978 and S.2351). If individuals and local EMS agencies want to direct their energy on the federal level, Advocates for EMS would be their most fruitful effort. This is a nonprofit entity devoted to educating members of Congress about EMS and promoting federal initiatives that benefit EMS systems (see www.advocatesforems.org). Many of the problems EMS has experienced in recent years are attributable to a lack of a unified voice for EMS on Capitol Hill, not the absence of a single bureaucracy devoted exclusively to EMS.