The EMS profession is changing from its original purpose, which since its inception in the early 1970s has been the rapid and safe treatment and transportation of the sick or injured to a medical facility. This paradigm worked well for more than 50 years.
But it was predicated on a couple of key factors.
First, the public only using the system for true emergencies that required immediate treatment and transportation to a medical facility. Second, the availability of medical facilities in the community. Increasingly, those two factors are becoming irrelevant.
According to the Community Paramedic Program, an estimated 75 million people live in rural areas of the United States, areas where people needing health care far outnumber health care options, e.g., physicians, nurses and facilities. Demographically, those rural communities already include disproportionate numbers of the elderly, immigrants, families living in poverty and those in poor health, according to CPP.
Those residents must often travel great distances and at great expense, even when the most basic health care option is available. Given those circumstances, too many of them receive no care at all.
In other communities, a shifting paradigm is having an adverse impact on existing EMS systems. This shift includes an increase in numbers of calls for service – many of which do not require ambulance transportation to a hospital, an increasingly older patient population – many of whom have pre-existing medical conditions and changes in the way agencies are reimbursed for their costs.
These are just some of forces that are prompting EMS agencies, including fire-based EMS organizations, to look at community paramedicine programs. These programs, which also go by the titles of community telemedicine and mobile integrated health care, are one option for meeting the public’s growing expectations for a mobile health care system.
The mission of CPP is to bring together community stakeholders in developing community paramedicine programs as an option for addressing those needs by expanding the role of EMS personnel. Those stakeholders include: those residents who lack access to basic health care; elected officials; public health officials; and colleges and universities. According to CPP, a community paramedicine program can serve communities more broadly in the areas of:
- Primary care.
- Public health.
- Disease management.
- Prevention and wellness.
- Mental health.
- Oral health.
Paying for a current EMS system is one more driving force. On the prehospital side of the equation, Medicare and Medicaid and private insurance companies typically have not reimbursed EMS agencies for treatment without patient transport incidents. More recently, they have significantly modified their reimbursement policies for ambulance transportation that was not medically necessary transports.
On the hospital side, those same entities are more closely scrutinizing patient readmissions – patients coming back to the hospital for the same medical conditions. Medical facilities face potential penalties, from Medicare and Medicaid, for such readmissions and for keeping patients in the emergency department longer than necessary for treatment and then billing for such things as boarding.
Community paramedicine programs can offer a potential win for both EMS agencies and hospitals, particularly as reimbursement policies for pre-hospital care continue to evolve for the reimbursement of patient care without transport.
The hospitals win when their emergency departments – many of which see a significant number of patients who could be treated in the field – once again become the gateway for injured or ill patients to receive initial care before being sent to a patient care treatment bed.
Patient care technology enhancements
As paramedic programs came about in the early days of EMS, being able to contact the base hospital by radio and speak with medical control and send a patient’s ECG rhythm via telemetry and deliver drugs during transport, were a huge step beyond load-and-go basic care.
In a presentation to the 2017 International Roundtable of Community Paramedicine, Curt Bashford, CEO at General Devices, addressed the topic of Technology in Community Paramedicine and Mobile Telehealth. Bashford outlined how new mobile telemedicine applications give patient care providers the ability to share voice, text, photos, video clips – and even stream live videos – over secure communication pathways that are HIPAA-compliant. These apps can be used on smartphone and tablets to provide direct communications with the physicians and specialists that a patient’s condition calls for.
According to Bashford, such advancements in mobile telemedicine give patient care providers a better toolbox that includes three key improvements.
1. Better decision-making support from emergency department staff as well as access to medical specialists.
2. The ability to communicate a wider variety of the patient’s medical and physiological data to the emergency department so that the staff can be better prepared to receive the patient.
3. Better patient care documentation for more accurate billing, along with better quality assurance and continuous quality improvement programs.
Before taking the bold step of initiating a community paramedicine program, any fire department that’s currently providing EMS for its community should first conduct a thorough needs assessment. Take a close look at connectivity, reporting software and point-of-care devices to identify what tools and technologies your program will need.
Connectivity between the field and physicians
Communication is the foundation of a community paramedicine system. Whether it’s 3G, 4G, or LTE service, from cellular providers or WiFi, WiMax, or satellite service, care providers in the field need to have consistent connectivity, particularly in a moving ambulance. Keep an eye on how FirstNet builds out in your state and its impact on community paramedicine. This will determine future communication options, equipment needs and capabilities for all responders.
Patient care reporting software
While your department may already be using an electronic patient care reporting system, that ePCR system may not allow your care providers to access the patient’s past medical history. Community paramedicine system care providers need to have access to the patient’s past medical history as well as caregiver notes from previous encounters with a patient. This makes for better continuity of care, potentially impacting patient outcomes and safety.
According to World Advancement of Technology for EMS and Rescue, such an ePCR system should provide your caregivers with easy-to-use guidance through the ePCR charting process for more efficient and effective patient care encounters. Additional features should include the tools for your EMS providers that enable them to:
- View and set patient health care goals, review any history of prior visits and identify trends to tailor care with each new visit.
- Inventory a patient’s medications to help prevent errors.
- Receive automated alerts when vital signs or lab values are out of the patient’s normal range.
- Provide an overview of new referrals, making it easier to manage caseloads.
- Share critical patient data with other health care providers like the patient’s primary physician or specialists.
The National EMS Information System is a national effort to standardize the data collected by EMS agencies. Any information collection and management system should be compliant with the current version of NEMSIS, Version 3.4.0.Since the 1970s, the need for EMS information systems and databases has been well established, and many statewide data systems have been created. However, these EMS systems vary in their ability to collect patient and systems data and allow analysis at a local, state and national level. NEMSIS is the national repository that will be used to potentially store EMS data from every state in the nation.
Point-of-care testing devices
Your department may already be using several point-of-care biomedical devices when providing patient care. These can include pulse oximetry, capnography and 12-lead ECG. One challenge for initiating a community paramedicine in your community will be integrating the information from those stand-alone devices into your department’s ePCR software for more effective documentation.
Another challenge is having the ability to get that same information into the communications pipeline to other health care providers. That’s the importance of connectivity.
During an EMS conference presentation Desiree Partain, clinical program manager with MedStar Mobile Health, spoke of how community paramedics are using handheld, portable blood analyzers. According to Partain, community paramedics using a portable blood analyzer can provide physicians with more comprehensive information on the patient’s condition than just the patient’s symptoms and vital signs. A care provider using a portable blood analyzer can measure the patient’s blood levels for: acid base (pH); partial pressure of carbon dioxide (ppCO2); bicarbonate (HCO3); and sodium, potassium and glucose.
Ultrasound devices are another point-of-care diagnostic tool that has made the transition from the hospital to EMS and can be a valuable tool for your community paramedicine program. In 2016 a presentation to EMS providers, Howie Mell, MD said, “Ultrasound is the next 12-lead. It is the next piece of vital information you can provide to the hospital about your patient.”
Portable ultrasound devices are also a great tool for:
- Confirming proper placement of an endotracheal tube.
- Identifying a pneumothorax or hemothorax.
- Real-time imaging of the heart and great vessels.
- Assist the care giver in finding a suitable vein for establishing venous access for IV and drug therapy.
Whether that communication with the physician is for treatment guidance for the caregiver – or for continuity of care when the patient arrives at the hospital – speed, portability, convenience and quality assurance are tangible benefits of having point-of-care testing devices as part of your community paramedicine program.
References
1. Community Paramedic. http://communityparamedic.org/
2. EMS1. The benefits of ultrasound in EMS. https://www.ems1.com/ems-products/medical-equipment/articles/1245660-The-benefits-of-ultrasound-in-EMS/
3. EMS1. Community Paramedicine. https://www.ems1.com/community-paramedicine/
4. LifeBot. LifeBot 5. http://www.lifebot.us/lifebot5/
5. World Advancement of Technology for EMS and Rescue. Street Sense. http://wateronscene.com/StreetSense.html
