Max Rorty is a social worker at Cottage Hospital in Santa Barbara, Calif., and a public speaker and author on transgender healthcare.

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However, by doing so, we are also breaking the law, unless we are operating under the Emergency Management Assistance Compact (EMAC) where this is allowed. In recent years, state EMS officials have been increasingly challenged with federal and other EMS personnel deploying to a state and practicing as an EMS provider without being licensed by that state. While these EMS personnel are providing a valuable service, their actions could be interpreted as practicing medicine without a license, which is a felony in most states. To the best of my knowledge, no EMS providers have been charged for working in another state without a license, but the risk is very real.

EMS personnel from those member states will be allowed to function in their home state as well as the remote member state.

Understanding that this is a significant problem for all federal EMS workers, the Department of Homeland Security contracted with the National Association of State EMS Officials (NASEMSO) to develop a “consensus-based and legally sound” solution in the form of an interstate compact.1 NASEMSO decided that this was the prime opportunity to not only address the federal problem, but the everyday state problem too, with the development of a compact. Compacts are used for a variety of purposes, such as EMAC for state-to-state assistance in times of declared emergencies and the Driver License Compact (DLC), which allows states to share drivers’ information and allows us to drive in other states without having to have a license for each state.

In early 2013, a national advisory panel was established with representatives from all areas of the EMS profession, and this group developed the high-level objectives and provided direction to the drafting team. The drafting team then began work on a document to meet the panel’s objectives while also addressing the necessary components of a compact. NASEMSO’s project proposal stated that, “The outcome is a model compact for states to adopt allowing universal, rapid and, in select circumstances, immediate recognition of state issued EMS personnel licenses by compact states under specified conditions.”¹

This draft model compact was presented to the state EMS officials and all other interested parties on Feb. 18, 2014. The proposed compact is designed to serve as a contract between states; create a governmental commission to establish rules and a national database; allow states to extend privileges to EMS personnel from other compact member states; and gain authority over those EMS personnel from other states when they are functioning in the compact state. The compact also establishes home state obligations that include not only the ability to receive and investigate complaints, but to also notify the commission of actions against EMS personnel; it requires that the member states use the National Registry of Emergency Medical Technicians (NREMT) examination process. Within five years, member states must also have a criminal background check process in place.

EMS personnel from the member states must be at least 18 years old, they must have a current license to function as an EMS provider and they must practice under the supervision of a physician advisor or medical director. Additionally, the individual will function in the remote state under their normal scope of practice and home state protocols until the remote state establishes specific protocols.

Simply put, once the compact has been adopted and is in place, EMS personnel from those member states will be allowed to function in their home state as well as the remote member state. States will need to pass legislation to become a member of the compact, and that process should begin as soon as June 1 of this year.

Ultimately, our EMS personnel will no longer have to worry about the law or maintaining licenses in multiple states.

Ultimately, our EMS personnel will no longer have to worry about the law or maintaining licenses in multiple states. An example given in one of the panel meetings was of a flight medic who had to maintain seven state licenses because his employer flew into all of those states. With this compact in place, he would only need one. Couple this with all of our providers who cross state lines in the course of normal daily operations, and the compact becomes a very realistic solution. For those of us who have been in this profession for any length of time, this will truly be one giant leap for EMS.

For much more information on the interstate compact, visit: www.nasemso.org/Projects/InterstateCompacts/ index.asp.

Reference

1. NASEMSO. (October 2012). Model insterstate compact for emergency medical services personnel licensure for state adoption project proposal. NASEMSO. Retrieved on April 30, 2014, from www.nasemso. org/Projects/InterstateCompacts/documents/NASEMSO-Interstate-Compact-Project-Background-Scope-Oct2012.pdf.

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The magnitude of what’s in store for EMS organizations in the next few years is coming to light. New operational approaches, service delivery methods and payment models, along with other government policy changes, present substantial risk to the way EMS agencies operate, plan cash flow and receive reimbursement. When considering opportunities such as moving into a mobile integrated healthcare program (MIHP) or community paramedic project, it is critically important that agencies execute well. A “ready, fire, aim” approach will not lead to a successful outcome for the agency or for our profession as a whole.

Evaluating risk

Risk assessment is a data-intensive step requiring involvement from executives; financial, clinical and operational managers; and caregivers. Functioning as a team, these experts can identify high-risk intersections associated with operations, relationship management, expense and revenue generation. For example, there are multiple clinical and administrative considerations. Clinical issues include the development of caregiver competencies and understanding regulatory authority and medical control. From an administrative perspective, leaders must develop a business case for making the transition from a volume culture to a value culture, and determine how to cost-effectively implement technology, to name just a few hurdles.

Prioritize actions

With the highest risk areas identified, the team can begin the prioritization of issues and opportunities based on factors unique to their market and system design. Assigning a priority level to every process or procedure will allow the agency to determine how and when to best expend resources. Planning for organizational structure changes, technology acquisitions and training for both caregivers and customers are all required to better prepare for a different service model.

Track performance

Many agencies would be well served by implementing a comprehensive analytics package now to help monitor performance benchmarks. Detailed metrics must be collected at every step of the service cycle to ensure that the agency is capable of producing the documentation required by accountable care organizations (ACOs).

Fragile organizations today remain primarily focused on financial metrics rather than using a more balanced approach that incorporates process improvement, customer satisfaction and development of caregivers within the organization. These four factors are the basis of today’s balanced scorecards. Managing the agencies’ performance will become more critical under new delivery models such as community para-medicine programs that are contemplated for EMS under healthcare reform. While the balanced scorecard is a well-accepted way to report key performance indicators, more agile organizations increasingly use business intelligence software capable of alerting executives at trigger thresholds and other occurrences that are designed to help achieve the principles of the Triple Aim.

Developed by the Institute for Healthcare Improvement (IHI), the Triple Aim objectives are: (1) improve health of the population by encouraging a better awareness of health status; (2) enhance the patient experience, and; (3) provide the best possible (evidence-based) care while lowering per capita costs. The IHI Triple Aim is elegantly simple, yet will be extraordinarily complex to achieve. It is clear why analytics software is a wise investment.

Compare results

Being able to measure clinical, operational and financial benchmarks—such as outcome data, utilization, change trends, days in accounts receivable review, and denials against peer organizations—is essential to operating a high-reliability EMS system. Comparative analytics, as opposed to internal tracking, can reveal the degree of an organization’s competitiveness and how it matches up against best practice standards. As we move into new service lines such as MIHP, comparative analytics are even more important given there is no organizational history against which to compare performance. It is vital to frequently compare metrics of similar size and type entities as the transition to new service delivery models occurs.

Looking ahead

While payment models are changing, there has been some comfort expressed that more individuals will likely have some form of insurance offered through the exchanges. Unfortunately for EMS, many of these plans have high deductibles. That fact, coupled with falling transport volumes, could spell trouble for non-agile agencies. Thoughtful planning for the future is required.

Not everyone shares that view. One chief I recently spoke with said: “I’m not worried. The community knows we save lives and will support us no matter what happens with healthcare reform.”

Risk assessment is a data-intensive step requiring involvement from executives; financial, clinical and operational managers; and caregivers.

So where’s the real risk, you ask? One transport agency we are working with recently experienced a double-digit decrease in Medicare transports. It seems that the region’s ACO did an outstanding job in working with its members, physicians and nursing homes to re-direct patients to alternative care and significantly reduced the need for ambulance transport. Operating costs for the agency did not go down but its patient mix (and reimbursement) has changed significantly in recent months.

The real risk for EMS agencies in turbulent times is complacency. Be ready to demonstrate value. The consultant’s crystal ball on exactly what will happen with healthcare reform initiatives after the mid-term elections remains murky. My confident EMS chief could be right. But, as the impact of reform on EMS becomes clearer, my advice is to have the data ready.

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Mark Van Arnam is the president and CEO of American Emergency Vehicles.

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In the late 1960s Gene Roddenberry, creator of Star Trek, envisioned a future society in which people could communicate from the ground to an orbiting starship, utilize a moderately-sized electronic device to take environmental readings and use an even smaller device that could be passed over the human body to diagnose injuries and illnesses.

We’ve seen some of these items come to fruition in modern times—Roddenberry’s communicators, CGIs and tricorders are our direct-connect phones, combustible gas indicators and thermal imagers—but we have yet to see the medical scanning device. We are close, however, and those of us who have been in EMS for a significant length of time have witnessed the changes that technology has brought to EMS, many of which have only just occurred within the last 10 years or so.

We are now on the precipice of taking the next big leap with the coming of the nationwide public safety broadband network (NPSBN). The First Responder Network Authority (FirstNet) has been tasked with developing and managing this network, and its Public Safety Advisory Committee has requested that organizations submit potential current and future applications that could operate on this network. The National Public Safety Telecommunications Council’s (NPSTC) EMS working group within the interoperability committee developed and submitted a list of broadband applications for consideration.

The first item on the list is a standard application programming interface (API) between EMS patient care equipment and the network. The intent is that the “interface will allow existing EMS equipment to communicate across the FirstNet network to dispatch centers and receiving hospitals.” Patient care, through the use of audio, video and data transmissions between the field provider and base hospital, could be greatly enhanced with the ability to discuss and treat a patient’s condition in real time with specialists who may be hundreds or even thousands of miles away. Rural EMS stands to benefit greatly from this technology alone.

Once the ability to communicate is established, there are a number of applications that can then be employed to include speech-to-text integrated patient care records, video-assisted patient care and vehicle design and extrication guides. Imagine having the ability to record real-time patient care information, contact the hospital and transmit data hands-free, all while remaining securely seated in the patient care compartment. Couple that with helmet cameras, point-of-care testing, portable ultrasounds and even portable brain scanners (look up the Medlogic Infrascanner 2000), and we have literally delivered the ED to the field.

Other potential applications on the list include patient tracking systems, monitors for patients with mild cognitive impairment (MCI), interactive EMS databases, resource management of personnel, EMS vehicles, helicopters, EDs, geographic information system (GIS) data and incident command systems (ICS). I could go on and on, and the list actually has 37 specific items with varying degrees of priority, but you get the gist of where this is going.

So far we have been fortunate enough to realize the benefits of dramatically improved technology and, to some degree, it has been Star Trek-like. We have improved patient care through the use of 12-lead electrocardiograms (ECGs), continuous positive airway pressure (CPAP), pulse oximetry, capnography, and blood glucose level (BGL) testing in the field, just to mention a few. We can wirelessly transmit this data from the device to a laptop computer and then on to the receiving facility where the staff can be prepared for our arrival. Ten years ago, many of us would have laughed if we had been told we would be doing these things today. Yet, here we are: We can see the future, and we are thirsting for more. While we may be part of the original series, we are rapidly advancing to The Next Generation. Our only limitation is our imagination.

For a complete list of the EMS broadband applications, go to www.npstc.org.

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A key principle in EMS system design is creating incentives that align the needs of patients and the community with what the ambulance services, medical first response agencies and 9-1-1 communications centers can provide. Simply put, it’s implementing positive consequences when the various organizations meet expectations and negative consequences when they do not.

At a high level, state and provincial laws and regulations create these incentives. Meeting patient and community needs are the basis of EMS laws and regulations. Non-compliance results in negative consequences. High levels of compliance may result in positive recognition or less frequent reviews by the state or provincial regulatory agency. This creates an alignment of incentives. Good things happen when EMS providers meet the needs of patients and the community, and bad things happen when they do not.

Accountability & penalties

Local units of government, including local EMS regulatory agencies and medical oversight providers, can do the same. EMS performance contracts between local units of government and private ambulance companies commonly establish standards for response times, equipment, staffing, training and data reporting. Non-compliance can result in fines. Chronic non-compliance can result in loss of contract and forfeit of a performance bond that funds the transition to a new contractor. High levels of compliance can have positive consequences such as extension of the current contract and waiver of fines for minor variances exceeding the response time standards.

Current performance-based ambulance contracts tend to focus accountability and penalties on compliance to response time interval standards.

In my September column for EMS Insider ,¹ I noted that current performance-based ambulance contracts tend to focus accountability and penalties on compliance to response time interval standards. It seems that response time performance has become a surrogate measure of clinical quality and patient satisfaction. I have suggested that clinical quality and patient satisfaction be measured directly and become the more dominant accountabilities in performance contracts. This could be done by creating standards for clinical performance and satisfaction and then holding contractors accountable for meeting those standards.

Political leverage

That approach may be fine for aligning the interests of private ambulance services operating under performance contracts with the needs of patients and the community. But how do we establish alignments between governmental EMS agencies and the needs of patients and the communities they serve? It might not make sense for a regulatory agency in a governmental unit to impose a fine on a government-operated EMS service. That’s just moving money from one pocket to the other within the public coffers. Extending a governmental unit’s contract to be an EMS service provider is usually a forgone conclusion. So how else might we create alignments of incentives? How else might we reward high levels of performance and create negative consequences for failure to meet performance standards?

Political capital is a currency with strong influence on how government agencies operate and make decisions. It is spent when an agency seeks support for its proposed budget, to be spared from budget cuts, to retain its managers after an untoward event and when seeking support for a new initiative. Political capital is earned when the agency improves its reputation, gains public and media support, gains employee/union support and gains support from other appointed and elected government officials.

Similar to the financial incentives and penalties applied to private ambulance contractors, alignments of incentives for government EMS providers may be crafted by creating mechanisms that add or subtract from their political capital.

The first step is setting meaningful performance standards. As discussed earlier, current science suggests that good patient outcomes are less associated with short response times and more associated with optimizing clinical processes (e.g., increasing chest compression fractions, reducing false positives and negatives for STEMI alerts, getting stroke scores and then making early hospital notifications when stroke alert criteria are met).

A second step is to make service commitments. Using language similar to private sector performance contracts, articulate what services are provided, the standards to be adhered to and mechanisms by which that agency will be held accountable for meeting those standards. The service commitments may be made between departments within units of government. For example, service agreements can be established between the 9-1-1 communications centers, medical first response agencies, ambulance services, hospitals and even the EMS regulatory agency. They agree to hold each accountable for their respective parts of the EMS system.

Similar service commitments can be made between neighboring units of government, particularly with regard to giving and receiving mutual aid and the quality of service that each should expect to give and receive. This can be particularly important in areas where there are a lot of cities in the same metropolitan area with significant interdependencies and sharing of resources (e.g., hazmat, tactical, specialty rescue units).

Similar to the financial incentives and penalties applied to private ambulance contractors, alignments of incentives for government EMS providers may be crafted by creating mechanisms that add or subtract from their political capital.

When a government ambulance service, medical first response agency or 9-1-1 communications center simply meets the standards, there might not be any political capital gained or lost. They did what was minimally required and expected. However, when the minimum standards are exceeded, there should be a proportionate reward in the level of positive recognition, which drives the amount of gain in political capital. Conversely, if the government EMS provider failed to meet the standards, the level of negative recognition drives the amount of political capital lost.

Identifying mechanisms

The EMS system design for government EMS providers should create not only the performance standards, but the mechanisms for variable positive and negative recognition, which drives the consequential gains and losses of political capital. Senior government officials need to recognize the utility of such a system to help move the government-operated EMS system in a net positive direction. This should trump what a senior government official might perceive as a threat to their own political capital by having anything negative said about an agency for which they have ultimate stewardship. That can be offset by their own gain in political capital by demonstrating transparency and accountability in how their unit of government serves the citizens’ interests.

There are many potential mechanisms for variable positive and negative recognition. One of the most basic is public reporting of performance. The level of impact on political capital will be proportionate the level of visibility. Burying a performance report four layers down inside a government EMS agency’s section of the city or county website will make it virtually invisible and have no impact on positive or negative political capital. In contrast, putting the performance report at the top page of the agency’s website and then sending links with performance summaries—coupled with sending out the reports and press releases to elected officials, major media outlets, hospital emergency departments, other local EMS providers, community groups and other key stakeholders—will give the same scorecard the significant power to add or subtract from the agency’s political capital.

Oh, and by the way, political capital mechanisms can make sense for inclusion in the performance contracts of private EMS service providers as well.

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The National EMS Management Association (NEMSMA) has spent the past two years developing a set of national EMS officer competencies to provide future leaders with the tools they need to be successful. In the interest of the profession, the competencies will be made available to the entire EMS community, not just NEMSMA members.

NEMSMA is a professional association of EMS leaders dedicated to the discovery, development and promotion of excellence in leadership and management of EMS systems, regardless of system model, organizational structure or agency affiliation.

The project was a significant undertaking with a laudable goal. “We are going to set a path for the future of EMS,” says Ryan Greenberg, division chief of Hackensack (N.J.) University Medical Center EMS and chair of NEMSMA’s Leadership Competencies Project.

The issues addressed by NEMSMA include a lack of measurable expectations for EMS leaders, plus the fact that there is no national standardized training for leaders and thus no clear path for advancement for future leaders. NEMSMA determined that what is needed is a definition of leadership duties to prepare new managers and allow those working their way up the ranks to decide if they really want to take a leadership job in the first place. If so, what core competencies are needed to achieve this goal?

The committee developed the competencies in two parts: First it identified the levels of leadership; then it developed the expected educational, performance and improvement requirements for each level. These include basic leadership skills and traits, augmented with specific EMS knowledge. Individual organizations can supplement the training with their particular needs.

The committee identified three officer levels:

• Supervising offcers who provide frstline supervision to EMTs and paramedics in the field.

• Managing offcers who are responsible for managing major components of EMS organizations, or serve as division or unit heads or staff specialists responsible for administrative and clinical functions in EMS organizations.

• Executive offcers who provide general management and top-level leadership to an EMS organization.

As part of the oversight process, the committee presented its work to another NEMSMA committee for review. “We felt we needed a second—and in some cases third—set of eyes to meet the various needs of the people in our profession,” Greenberg says. The feedback was rewarding. “Reviewers stated it was more comprehensive than they expected,” he says.

Next steps

Now that the leadership competencies are in the final preparation stages before release, the committee’s next step will be to work on a credentialing process. “That’s down the road,” Greenberg says.

The EMS officer leadership curriculum will be built around the competencies while taking into account EMS leaders’ often busy schedules. “Part of the beauty is that we are not limiting where they get that training, as long as it meets the credentials. What we are hoping for is a variety of curriculum and a variety of learning applications—not just classroom-based, but a blended learning environment,” Greenberg says. “We don’t see people replacing education. We see a standardization occurring.” He hopes that the first course will be ready to launch by fall 2014.

Greenberg acknowledges that the work of developing the competencies and curriculum will never be wholly complete. “The expectations of an EMS leader will change in the next five to ten years. We want this to be a living, breathing document,” he says.

According to Greenberg, the impetus for the project was NEMSMA’s Management and Leadership Development in America: An Agenda for the Future. “We felt this is a critical part of the development of our profession. Many times managers don’t even know what is expected of them. We are really excited to provide this. Hopefully, it is only step one in helping [EMS] move forward,” he says.

Additional information about this project, including the competencies once released, can be found at the NEMSMA website (www.nemsma.org).

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I began my career 25 years ago as a street paramedic; today, I’m a lobbyist for EMS and healthcare. Although I’ve witnessed a lot of changes within EMS during that time, the last few years have brought an unprecedented shift from inpatient to outpatient care, and the development of medical homes and care coordination models. As a result, I believe that successful integration of EMS into the CP and MIHP concept will look very different from location to location.

My home state of Minnesota has been on a fast track to reform the healthcare delivery system. Our reform efforts include an array of payment model types and the development of multiple Medicare and Medicaid Accountable Care Organizations (ACOs), in which healthcare providers are at risk for the total cost of caring for their attributed patients. EMS is a critical component of these arrangements. Minnesota is unique in the sense that we have large, nonprofit EMS systems that are integrated into and owned by our healthcare systems. The Mayo Clinic, Allina Health, North Memorial Health Care, HealthEast Care System and Hennepin County Ambulance Service provide the vast majority of the state’s EMS transportation.

The importance of state legislation

Many around the country have asked why Minnesota law defines community paramedic as a new provider, rather than expanding the existing definition of paramedic as an extender of the ambulance service medical director. In response, I offer a few comments that I hope will demonstrate the importance of describing a practitioner in legal terms, distinct from using an umbrella term such as MIHP.

We have maintained a strong EMS presence in Minnesota at both the state legislature and with other healthcare and regulatory agencies. That presence, in turn, has paved the way for us to innovate as an industry within healthcare reform discussions and always have a seat at the table. For years, the Healthcare Committee chairs within the state legislature have reached out to the Minnesota Ambulance Association (MAA) seeking any ideas regarding reform. With our strong relationships within Minnesota’s Office of Rural Health and Primary Care, we have been able to focus on the workforce shortage with regard to access to primary care. The legislature and key state agency leadership have approached our administrators numerous times to focus on a new healthcare practitioner to help “fill the gap” in the healthcare work force shortages.

Because Minnesota’s ambulance industry doesn’t compete for emergency ambulance requests for service, as an industry we have been able to sit around the table and discuss the CP concept, presenting our recommendations to the legislature, which were received with warm support. Additionally, we recognized the need, as an industry, to offer a career path to our aging work force of paramedics, who possess invaluable diagnostic and patient care skills.

Community paramedic legislation

Now to the question of why Minnesota chose to face the uphill battle of taking the legislative route for CP. It’s fair to say that this endeavor was one of the hardest pieces of legislation we have ever moved along through the legislative process, but ultimately, it has been the most rewarding. We held numerous stakeholder meetings and—with the help of smart legislators and advice from the Minnesota Nurses Association and the Minnesota Home Health Association—we developed both the enabling language for CP and a Medicaid payment model. We had numerous discussions with legislative research, our independent EMS board and other trade associations regarding the scope of practice and the Home Healthcare Act. After countless stakeholder discussions, it was clear we needed a strong definition of the community paramedic in law.

Everyone involved in the discussion made it clear from the start that we needed to do a few important things to make the new CP practitioner accepted by the healthcare community. These included:

• Defne to the legislature the CP concept and what tasks an existing paramedic performs;

• Develop an articulate and repeatable message on what a CP is, and what it isn’t;

• Employ a defned curriculum, clinicals and testing standard;

• Educate the opposition that we were filling a gap, not competing for current home care or nursing jobs;

• Be statutorily recognized so we can be paid consistently for our services as a new practitioner;

• Have an agency to certify and take any complaints, providing professionalism to the new CP practitioner; and

• Provide legal protection for EMS medical directors to provide CP oversight.

Once we legitimized the CP in law, the remaining phases of the CP program fell into position at the legislature. During the second year after the initial legislation had passed, additional laws allowed Medical Assistance coverage for CP services at $60 an hour after Centers for Medicare & Medicaid Services (CMS) was approved as part of a State Plan Amendment. The Minnesota Department of Human Services made it clear that we needed a defined CP statute to seek a state plan amendment for CP coverage with CMS. Year three legislation included 12 hours of continuing education in primary care for CP certification, beyond the 48 hours required to maintain an emergency paramedic certification.

Final recommendations

As an umbrella term, the definition of CP is strong in some states, while MIHP has a stronger presence in others. Minnesota’s CP model clearly has a strong primary care focus intended to address several patient care and workforce needs. As such, we have enjoyed successful implementation of the program. Your EMS service’s level of integration with a healthcare delivery system may decide whether you should explore a CP or MIHP model.

It’s imperative that your plan protects you from duplicating services and ensures you are recognized as a part of a coordinated team of healthcare providers. Minnesota accomplished this by clarifying, in law, that all CP visits require a primary care plan and/or enrollment in a medical home. The primary care linkage has proven to be a key to CP functioning in a healthcare coordination system.

The climb up the legislative hill to have the CP recognized in law is well worth it—for our patients who require access to properly trained practitioners and for our paramedics who embrace an additional career path option within the EMS field.

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