EMS 2.0 – A Paramedics First Step in the plan to Revolutionize Healthcare

EMS Can “fix” the US healthcare system.

Let me repeat that above statement.

I believe that the Emergency Medical Services and the Profession of Paramedicine can offer a private sector solution to save the healthcare system billions of dollars in the short and medium term.

Until now, the EMS people haven’t been able to recognize or work towards their full potential due to a wide variety of competing interests, outside influences, and well… just a “difficult” perception out there of exactly who we are and what exactly it is we do.

Really, is EMS a public safety discipline? Are we allied health? Are we public health?

We’re none of those things because we’re all of those things. We are a profession that encompasses all of the above into our fold, has made all of those things our own, and has mastered our competing interests. We are professionals working in a dynamic field. We are adaptable and are able to work miracles with no support. We are the Professional Paramedics (and EMTs) working to advance our profession.

In the last post I said that it was time to end the talk about problems and instead to talk about solutions. This post is the first step in my solution to the problems facing EMS and the greater problems facing the US Healthcare system. I’m asking everyone who reads this to participate in the plan. Please get energized. Please pitch in and help. We’ll save countless lives, alleviate unimaginable suffering, and can have a huge impact on the US economy.

Here’s my hypotheses:

Paramedics are currently underutilized and have a much greater potential in the greater healthcare system. If we change the role of paramedics to include higher education and give them greater legal responsibility for healthcare decisions including the ability to make diagnoses and devise treatment plans for patients, we can have a huge number of additional primary healthcare providers on the street providing healthcare to the entire patient population. Paramedics and EMTs already work with the entire population of those seeking healthcare and have already proven to be masters of acute emergent healthcare. However as the laws are written at this time they cannot “treat and release” or make a decision to downgrade a patient’s treatment path to less acute and less expensive healthcare delivery points other than the Emergency Room, such as to an Urgent Care Center or Primary Physician. An Ambulance to Emergency room is life saving in cases of massive trauma, stroke, or heart attack. It is woefully too expensive in less acute conditions. By allowing Paramedics to treat and release minor complaints in the field, to divert moderate complaints to physicians in urgent care centers or to the “front-of-the-line” in their personal physician’s waiting line, and to provide community health services and help at-risk patients manage their chronic diseases, we can save billions of dollars in the overall healthcare system. Remember, the cost of an ambulance transporting a patient with a case of the sniffles to the ER is upwards of $7000.00 the cost under this plan, of the paramedic being educated and empowered to prescribe a decongestant and leave the patient at home is around $150.00. Which would you rather have your money pay for?

Here’s what I want to do to test this hypotheses:

    I would like to conduct a research project to test this. This research project will need participation from a number of players from different disciplines and, since this blog is read by an international audience, I would like participation from EMS people in other countries, especially the United Kingdom (Medic999, got any ideas?). This will be an on-paper test of the system with comparisons being drawn from the results of the current system and the proposed system.

Here are the steps:

1. Currently practicing, experienced field paramedics will be trained to complete a detailed physical exam and proposed treatment plan on non-emergent patients presenting with complaints that are not generally life threatening and do not require emergent admission to the ER. The diagnosis and treatment plan will be documented and saved for review. No actual field care will be changed. The paramedics will recommend the following:
   1. Examination and Release of the patient with field-performed and field-prescribed care only. (Treat and Release)
   2. Examination of the patient, some field care, and transport and/or referral of the patient to an urgent care center or primary care physician’s office (ER Diversion)
   3. Transport of the patient to the ER (traditional)

    

2. The documentation on these charts will be reviewed by a group of physicians, physicians’ assistants (PA-Cs), (and by UK paramedics) to determine the accuracy of the exam, the accuracy of the proposed diagnosis, and the appropriateness of the proposed treatment. They will adjust the training program to improve accuracy and record their opinions on the results of the treatment plans.

    

3. The results will be reviewed and we will share what we learn with the results.

The Training Program: With the aid of a group of physicians I would like to devise a training program for currently practicing, experienced field paramedics focusing on the following topics.

• Physical Examinations – There is an obvious difference in the ALS Patient Assessment provided by a paramedic in the field and the Physical Exam conducted by a physician in a clinic. These would need to be brought closer together with the Paramedics learning from the Physicians a more in-depth patient exam.
• Documentation – There is a difference between the EMS patient report and the charting performed by a physician. The Paramedics will need to learn how to document a detailed physical examination and proposed treatment plan so that a physician can adequately understand the patient’s presentation and prognosis with a chart review.
• Common treatment modalities – For commonly diagnosed conditions, there are commonly prescribed treatments. These would be the most commonly prescribed treatments prescribed for the most common conditions diagnosed in an urgent care setting. For example, a patient who comes in with burning upon urination, lower abdominal pain, and has leukocytes in their urine upon mechanical urinalysis is prescribed a 3 day treatment of Bactrim and pyridine tablets for symptom relief. They’re also advised to void frequently, and drink cranberry juice and water. There are other common complaints and common treatments that can be included.

It is important to note that the above is not a plan to educate paramedics for the change in their roles, just to train them for their roles in the research project. I am not a physician, I am a paramedic and I expect that the above will be modified by the physicians involved in developing the training program.

The Expanded EMS Documentation: I would like paramedics to compete expanded documentation on non-emergent patients presenting for EMS treatment. These patients would be from the current EMS patient population and would not include patients with acutely-emergent medical conditions such as a heart-attack or stroke. The documentation completed will include the following topics:

• Detailed History and Physical Exam – More in-depth and detailed than the EMS assessment, these would be closer to the examination provided by a physician.
• Proposed Diagnosis – While Paramedics will not be expected to know what the true, 100% acc
  urate diagnosis would be, they can be assumed to be able to make a close guess. This will be documented in addition to differential diagnoses and conditions that they ruled out.
• Proposed treatment plans: These fall into the category of: 1. Treat and release 2. ER diversion and 3. Traditional.

The Review Process: The data collected from the field providers will be analyzed and reviewed by physicians, physician assistants, and other entities and the results will be learned. I would also like to see if there are cost savings realized with the treat-and-release and ER diversion pathways.

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This was a long post! Please participate and forward this along to your peers. This can be a private solution to healthcare in the United States and the world. With your active participation we can make the overall plan a reality by taking baby steps towards our goal. It is possible, it is practical. With your help, it is near.

For more information:

The previous post: “EMS 2.0: A Paramedic Dreams of Changing EMS”