Best Practices in High-Value EMS

This is the final installment of a yearlong series of articles developed by the Academy of International Mobile Healthcare Integration (AIMHI) to help educate EMS agencies on the hallmarks and attributes of high-performance/high-value EMS system design and operation. Watch for further content in 2018. For more on AIMHI, visit www.aimhi.mobi. For a collection of all our 2017 HPEMS content, see www.emsworld.com. 

Thank you for following along with us this year as we walked through the various components of high-performance/high-value EMS. As we close out this journey, here are the editor’s picks of the key concepts and principles covered throughout the year.

Performance Hallmarks

There are generally three domains of performance evaluation:

• Clinical proficiency—The externally verified provision of quality patient care beyond simple proficiency in interventions such as IVs or advanced airway placement. New value determinations center around compliance with clinical bundles proven through peer-reviewed studies to make a difference in patient outcomes. Clinical bundles for conditions such as STEMI, stroke, trauma, hypoglycemia, and asthma have been published and supported by organizations such as the Eagles Consortium. Additionally, a single source of quality oversight for all EMS, first response, and ambulance components helps ensure all providers share common credentialing and quality improvement processes. 
• Operational effectiveness—Maximizing resource utilization within the EMS system by matching necessary resources with the geospatial and temporal demands of the system. Generally this is accomplished through flexible deployment of staff (peak-load staffing) and moving available resources dynamically within the system’s geography as call patterns change.
• Fiscal efficiency—The provision of EMS is expensive, and reimbursement’s becoming more challenging, whether through fees for service or tax subsidies. EMS leaders need to continually seek out new ways to enhance the fiscal performance of their systems. Principles such as regional service delivery, enhanced service delivery, and alternative payment models help improve fiscal efficiency.

Structurally, the system design features and models that consistently produce high-performance/high-value outcomes are:

• Sole provider—Having one provider for emergency and nonemergency ambulance services helps ensure the high infrastructure and personnel costs are used for all calls across the service area, enhancing operational, clinical, and fiscal effectiveness.
• External accountability—Requiring the provider to routinely and publicly report on its performance to an organization or governing body that can hold it accountable helps ensure continual review and enhancement of the system.
• Control center operations—It is difficult if not impossible to effectively manage EMS system resources unless you can control the resources. This means the EMS provider must be able to control the dispatch center for EMS resources.
• Revenue maximization—Typically this means the sole provider can do all the emergency and nonemergency calls. Providing 9-1-1 service is expensive, with generally low collection rates. Allowing the ambulance provider to conduct all the nonemergency service helps improve revenue generation and reduce the need for tax subsidy to cover the cost of 9-1-1 service.

Transitioning to High Value

EMS is healthcare, and everything in healthcare today is about value. To be successful EMS providers, we need to figure out our payers’ value perspective. Payers are patients, taxpayers, and insurers, and each has a different perspective on value.

For the patient it may be how nice the provider was, whether they included the patient in decision making, whether they gave the patient a choice in treatment and referral options, and the patient’s out-of-pocket expense. For the taxpayer value could be making efficient use of tax dollars and delivering services they feel are worth their money. A commercial insurer determines value based on whether the EMS agency makes effective use of the in-network healthcare options available to the patient and improves the patient’s experience of care, in terms of both satisfaction and access to the most appropriate care. 

EMS in Canada

In many respects EMS in Canada is similar to EMS in the United States. There are, however, some key differences. Canadian EMS systems are integrated with the provincial health systems, led by each province’s ministry of health. Ambulance services operate as part of the emergency services branch of the health ministry. The system is financed completely through tax dollars—there is no private billing for health services, including ambulance services. The tax burden is shared at the provincial and municipal levels, each contributing half the funding for the system, and overall control of the funding is at the municipal level. 

Generally municipalities are responsible for providing ground ambulance services, with the province handling the communication operations and infrastructure for almost all municipalities. The local provider develops their ambulance deployment plan and delivers it to the provincial communications center for implementation.

Consistent with some of the hallmarks of high-value EMS, Canadian providers are required to report clinical outcomes and operational performance to both their municipality and province. Funding is based on the transparent reporting of performance measures. Canadian AIMHI members use system status management to move resources around the region to maximize operational performance based on both temporal (volume) and geospatial modeling.

When asked what attributes of the Canadian EMS system should be replicated in the U.S., our friends to the north suggested:

• Credentialing of paramedics—In Canada the training and credentialing program recognizes the value paramedics bring to the healthcare system. Paramedics undergo up to three years of training and are truly considered healthcare providers. This results in excellent pay and helps with recruitment and retention, something with which U.S. systems often struggle. 
• The economic model—The Canadian funding model facilitates focusing on clinical care and system performance, not the ability to collect user fees for ambulance transport. This also facilitates development of mobile integrated healthcare programs due to their valuable impact on the greater healthcare system.
• Performance reporting—The transparent reporting of performance metrics compared to other ambulance systems helps with transparency and performance improvement.

New Economic Models 

For years economic modeling has been pretty simple: Respond to a call, transport a patient, and (maybe) get paid for the transport. However, our payers and other partners are shifting from volume to value, moving from economic models of healthcare as a transaction to models based on value and outcome. For some this new reality is already here. Here is a framework to prepare for different models that may be perceived as more valuable or more closely aligning our incentives with those of our partners.

• Know your cost of service delivery—Know your cost per unit-hour produced, per response, and per transport. This will help you understand the impact of potential alternative payment models (APMs).
• Know the value EMS brings—This applies to both traditional and enhanced service models. Downstream savings to payers based on prevention and/or navigation are of increasing interest to payers. Often they are willing to pay you differently to bring them more value.
• Don’t be afraid to try something new—Almost all participants in the healthcare system are trying new models. Some work, some don’t. Keep testing innovations.
• Get help—There are resources available, including cost templates via NAEMT’s MIH-CP toolkit, as well as AIMHI members willing to help you.

Community Relations

Community trust is one of an EMS system’s most valuable assets. Cultivate and manage it carefully. Building your agency’s trust takes a concentrated effort and specific strategy. Top strategies include:

• Deliver rock-solid service—You can put lipstick on a pig, but it’s still a pig.
• Know your community—This is a relationship. You need to know them, and they need to know you.
• Create a community advisory board—Public or private agencies can benefit from being guided by local leaders.
• Conduct an EMS citizen’s academy—Much like with citizen police and fire academies, people who know about the services you provide and how you do it can be invaluable ambassadors.
• Leverage the power of the media—Don’t fear them; know and partner with them to get your agency’s name before the public as much as possible.
• Host community benefit events—Blood and bone marrow drives, golf tournaments, and other cobranded events (even cobranded ambulances) leverage valuable partnerships.
• Publish outcome dashboards—Performance and value can be demonstrated using this tool to regularly report your agency’s impact on your community.
• Publish an annual report—This is a great way to communicate your best news of the year. Plus, it can be done completely online.
• Harness the power of social media—Facebook, Twitter, Instagram, Periscope, and even Snapchat can be excellent ways to communicate with your internal and external stakeholders.

Cybersecurity in EMS

High-performance, high-value EMS agencies routinely collect and analyze data. Data helps drive decisions to make agencies more clinically proficient, operationally effective, and fiscally efficient. Collecting and mining data comes with inherent risk of security breaches that could compromise an organization and the patients it serves. And as healthcare system stakeholders are increasingly interested in sharing data with us, there’s a need for EMS to understand what real cybersecurity is. Frank Gresh from EMSA in Oklahoma provides some top strategies:

• Take cybersecurity very seriously—Threats need to be top of mind, always. The impact of a security beach to your reputation and finances cannot be overstated.
• Understand that your perception of cybersecurity and those of other healthcare partners may be different—You may think your systems are secure, and from an EMS perspective that may be true. But payers, health systems, and others take cybersecurity to a higher level.
• Conduct security audits—Find a vendor you’re comfortable with to do this. By design, it should be someone from the outside, so they look at everything with clear lenses. Then listen to what the auditor finds and act. When it comes to security audits, make sure your IT manager does not get defensive. The audit is designed to find vulnerabilities. Even the best systems have some. Learn from the audit, be proactive, decide where your greatest risks are, and manage them.
• Assess all your attack vectors continually—There are new viruses and approaches to hacking literally every day. The systems and processes you have in place today may not be effective tomorrow. Use software and structural controls that evolve. Some of the software EMSA uses, such as Mimecast, updates multiple times per day as new hacking processes are discovered.
• Don’t be afraid to ask for help—We’re paramedics, not security experts. Don’t let your pride get you in trouble. The risk and consequences are real, but with diligence they can be mitigated.

Oversight vs. Operations

In many EMS systems the role of the medical director falls somewhere between senior leadership and off to the side of the operations division. This can create an ongoing tension. Most would agree that both the medical director and operations leadership should want the same things: to provide high-quality patient care; transport the patient to the next appropriate level of care as expeditiously as possible; and get them there in the best possible medical condition. Here are the best strategies for achieving balance:

• Create a seat at the table—Both sides need seats at the leadership table. Providing opportunities to share perspectives, problem solve, and collectively work toward organizational goals creates opportunities to turn barriers into catapults and leads to a more deeply integrated organization.
• Understand the paths leading toward success—The goal is clearly defined, yet the path to achieve it may be different for operations than medical oversight. Both sides need to be willing to walk each other’s paths to better understand the needs, barriers, and challenges. This can be accomplished through increased interaction and stepping outside of defined roles and experiencing what it takes to run the operation or understanding the liability and challenges of medical oversight. 
• Focus on healthcare—Prehospital healthcare is a rapidly changing and evolving discipline. Operations and medical oversight have to agree that the services being provided are part of the bigger healthcare system and that decisions made operationally and clinically have a large impact on the patient and healthcare systems in our communities. 

We hope you enjoyed this series. To review all its content, visit www.emsworld.com. For inquiries about AIMHI: www.aimhi.mobi.

Doug Hooten, MBA, is president of AIMHI and CEO of MedStar Mobile Healthcare, Fort Worth, Tex.