Promoting Innovation in EMS: The PIE Project`s Top Priorities

Over 2018 EMS World, in conjunction with the National Association of EMTs, will provide detailed implementation strategies for key recommendations of the Promoting Innovation in EMS (PIE) project. The PIE project utilized broad stakeholder involvement over four years to identify and develop guidance to overcome common barriers to innovation at the local and state levels and foster development of new, innovative models of healthcare delivery within EMS. Each month we will focus on one recommendation and highlight the document’s actionable strategies to continue the EMS transformation. 

Our series up to now has described the processes used for the PIE project, the methods used by the members of the NAEMT EMS 3.0 Committee for prioritizing its recommendations, and the key ingredients necessary to prepare for innovation. This month let’s begin delving into the actual high-priority recommendations from the PIE team and discuss the strategies for implementation.

EMS Quality Measures

Recall from one of our earlier columns that the prioritization scores for the myriad of recommendations from the PIE report were based on:

• Feasibility—Can it be initiated, maintained, and sustained?
• Value—Does it position EMS to demonstrate value to stakeholders?
• Alignment—Does it align with the EMS 3.0 mission?

The recommendation with the highest overall priority score from the NAEMT committee is found in the “Data & Telecommunication” section of the PIE report, and it focuses on the need for EMS to determine ways to prove value. The subsection “Transforming Data Into Meaningful Information” contains extensive discussion surrounding EMS quality indicators and the EMS Compass initiative.¹ Here are some of the key quotes from this section of the report:

“In the era of value-based purchasing, EMS agencies need to understand if their actions have an effect on a patient’s healthcare utilization downstream, and ultimately the cost of care. This will be essential information in order to enter into risk-based contract agreements for new or existing services.”

“To complement technology, EMS must steward the development and adoption of meaningful measures of quality. In this respect, the EMS Compass initiative is vital, as it seeks to define EMS measures relevant to agencies, regulators, and patients. More broadly, EMS leaders should advocate for incentivization of the meaningful use of EMS data, whether that be through state or federal governmental programs, or by working with health plans and potential beneficiaries of the information that might be gleaned by analyzing, connecting, and reporting EMS data.”

The specific recommendation reads, “National EMS associations should steward the development, harmonization, and dissemination of EMS performance measures.” Note that this recommendation is directed at national EMS associations. One of the most valuable aspects of the PIE report is that it directs recommendations to specific “actors,” the organizations that most logically have the role, and perhaps the responsibility, to act upon the recommendation. In this case the report authors felt national EMS associations were the most appropriate groups to act upon this recommendation.

EMS Compass developed 14 EMS process measures classified into eight categories:²

• Hypoglycemia
• Medication error
• Pediatric respiratory
• Seizure
• Stroke
• Trauma
• Trauma pain
• Vehicle operations safety

The EMS 3.0 committee may determine that since the National Association of State EMS Officials (NASEMSO) was the initial lead agency for the EMS quality measures initiative, and the project was funded by the National Highway Traffic Safety Administration (NHTSA), these two agencies could be the primary actors for this recommendation. The committee may suggest implementation strategies that may include the following:

1. Ensure the National EMS Information System (NEMSIS) is structured to capture and report on the clinically related measures;
2. Require licensed EMS agencies to report the data necessary to track and publish the measures as a condition of licensure or eligibility for grant funding through federal programs;
3. Create a national online dashboard, with lookup capabilities, to facilitate comparing the performance of EMS agencies;
4. Ensure key stakeholders are made aware of the measures by publishing the results directly to organizations such as America’s Health Insurance Plans (AHIP), the National Committee for Quality Assurance (NCQA), the Agency for Healthcare Research and Quality (AHRQ), and the National Safety Council (vehicle operations).

NASEMSO and NHTSA should not be the only actors for this recommendation. Other associations should assist with the dissemination of quality measures to their internal and external stakeholder groups as well.
For example, associations such as the National Association of EMTs, American Ambulance Association, National EMS Management Association, and International Association of EMS Chiefs each have memberships that could assist with the development of communication strategies to promote the use of value measures for EMS.

The Value of EMS Data

The second-highest-rated recommendation from the EMS 3.0 Committee relates to promoting EMS data as valuable to the rest of the healthcare system. It is contained in the “Data & Telecommunication” section of the report and relevant highlights include:

“The power of EMS data to augment population-based health analysis and intervention is just being unlocked. Within the storage centers of emergency communication centers reside terabytes of valuable data. Recent studies have begun to demonstrate that geocoded, atomic clock-synchronized fire and EMS data can inform on better approaches to the management of sudden cardiac arrest, major trauma, substance abuse, diabetes, STEMI, and a range of other health issues. For example, when EMS data were explored with GIS analytic tools, it became evident that socioeconomic variables within communities significantly influence the performance of bystander CPR, providing opportunities to address unrecognized barriers to survival.”

“EMS data can be used to assess outcomes for a variety of other complex challenges. For example, the number of EMS transports is an accepted metric to assess interventions for serial inebriates, chronically homeless, and other frequent users.”

The specific recommendation reads, “National EMS associations should…advocate for expansion of EMS registries (e.g., CPR, CARES, STEMI, stroke, trauma) and to increase access for researchers to those registries.”

Once again the PIE report identifies national EMS associations as the actors for this recommendation, and many of the strategies listed in the previous recommendation could be applied here as well.

It is also likely that the implementation of robust clinical outcomes reporting is essential for the successful implementation of this recommendation. 

Potential strategies for implementing this recommendation that could be considered by the EMS 3.0 Committee may include:

1. Partnerships with organizations such as the American Heart Association, American Stroke Association, and American College of Surgeons to encourage or require the incorporation of specific EMS data elements as a condition for accreditation as cardiac, stroke, or trauma centers;
2. Development of a single data repository and reporting process for clinical processes of care for CPR, STEMI, stroke, and trauma; 
3. Development of publicly accessible dashboards for comprehensive outcome reporting for clinical processes of care across the continuum (prehospital to hospital discharge) and patient outcomes; 
4. Require EMS agencies and hospitals to report specific data elements as a condition of licensure, accreditation, and/or payment.

Arguably, some of these strategies may appear radical or unattainable, but our country is experiencing rapid changes to the delivery of healthcare. Payment reform is occurring at a frenetic pace, tied primarily to the value of delivery models.

This may be the right time to create high-value partnerships with our aligned stakeholders to find ways to demonstrate the value EMS brings to the care continuum. If not now, when? If not us, who?

In next month’s column we will review implementation of the next two highest-priority PIE recommendations: Medicaid payment policy and healthcare data integration with EMS. 

References

1. Munjal KG, Dunford J, et al. Promoting Innovation in Emergency Medical Services. Mount Sinai Health System, University of California, San Diego, https://dot.sinaiem.org/wp-content/uploads/2017/05/PIE-All-Chapters-9-23-16-CLEAN.pdf.

2. National Association of State EMS Officials. EMS Compass Performance Measures, https://www.nasemso.org/Projects/EMSCompass/documents/10252016_Website_EMS_Compass_Measure_v10.3.pdf.

Matt Zavadsky, MS-HSA, NREMT, is chief strategic integration officer at MedStar Mobile Healthcare, the exclusive emergency and nonemergency EMS/MIH provider for Fort Worth and 14 other cities in North Texas. He is a member of the EMS World editorial advisory board.