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The new normal: Nationwide reciprocity?

Will the COVID-19 pandemic accelerate the move to doing away with psychomotor exams in favor of a skills portfolio?


The new normal will require more EMS, and when the next pandemic hits - not if, but when - we’ll need even more trained providers able to cross state and county lines to manage the surge.


As the coronavirus pandemic winds down (and this will likely take years, not months) and our healthcare system returns to pre-COVID-19 staffing levels and operational tempo, I wonder how many of the innovative solutions we’ve used to deal with the challenges of COVID-19 will stick around in our “new normal.”

The NREMT found a way for candidates to take the cognitive exam from home, using AI and virtual proctoring. They extended recertification deadlines by 90 days, temporarily implemented provisional certification when states suspended psychomotor exams, and allowed all continuing education content to be through distributive education.

The world didn’t end.

States allowed recently retired EMS personnel to work with expired credentials.

The world didn’t end.

Because they were having difficulty staffing ambulances, states and municipalities allowed different crew configurations, such as EMT/medic, EMT/EMR, and so on, whereas before they mandated dual-medic crews.

The world didn’t end.

Agencies and hospitals collaborated to provide alternative destination transport, non-transport, 911 call screening, even in-home COVID-19 testing and health monitoring. Telemedicine resources were mobilized and heavily utilized. And this wasn’t just agencies that had active community paramedicine programs, it included many agencies who hadn’t previously considered the benefits of mobile integrated healthcare.

The world didn’t end.

EMS task forces provided ambulance staffing and EMS coverage for hard-hit areas. Artificial practice distinctions and geographic boundaries didn’t matter so much anymore.

The world didn’t end.

Now, with the outbreak of protests and civil unrest in the wake of George Floyd’s death, some cities are actively considering defunding or dismantling their police departments in favor of a more holistic public safety model that will utilize social workers, EMS and other healthcare workers to respond to many calls that were formerly handled by police.

While I am dubious that those political leaders have rationally considered the unforeseen consequences of such a radical makeover of law enforcement agencies, it is clear that the future will require more EMS personnel, when we’re already experiencing a staffing shortage. The new normal will require more EMS, and when the next pandemic hits - not if, but when - we’ll need even more trained providers able to cross state and county lines to manage the surge.

National EMS reciprocity

Luckily, we’ve already got a model in place for nationwide EMS reciprocity. I’m talking about the Mark King Initiative and REPLICA, the interstate EMS personnel licensing compact.

Currently, NREMT certification is recognized as a certification standard by all 50 states, and 46 states use the NREMT cognitive exam as their basis for initial licensure. However, not every state requires licensed EMS providers to maintain NREMT certification, and there is wide variety in flavors of psychomotor exams, continuing education and recertification requirements. Thus, in practice, EMS still doesn’t have nationwide reciprocity.

The provision of EMS is a local issue. Staffing levels, response times, crew configuration, funding – all of those should rightfully be determined by the community that EMS system serves. Yet we have always operated with the odd misconception that a CHF patient in New York somehow behaves differently than one in New Orleans, or an asthma patient should be treated differently by EMTs in Charleston, West Virginia, than one in Charleston, South Carolina.

In some states, you can be an EMT or medic in your own district, but step across a county line or pass a city limit sign, and suddenly your scope of practice changes, or disappears entirely. Walk into a Walmart in any city in this country, and you can buy and use a glucometer with zero training, yet some state medical directors still consider it beyond the scope of their EMT personnel.

EMS without borders

EMS is a bit of a unicorn among allied health professions in that we still require a psychomotor exam. Every other profession requires some version of a psychomotor skills portfolio, and EMS is steadily moving toward that. I have heard rumors – from reliable sources, but nonetheless rumors – that NREMT has long been considering doing away with psychomotor exams in favor of a skills portfolio, and the COVID-19 pandemic has accelerated those plans.

If every state adopted the NREMT cognitive exam, eliminated the psychomotor exam and implemented a standardized skills portfolio – even if you don’t practice that skill at your agency – we’d only be a small step away from nationwide EMS reciprocity.

Mark King was the State EMS Director for West Virginia and a board member of the National Registry of EMTs. It was his vision that every state would not only require providers to obtain NREMT certification, but also to maintain it. The intent of the Mark King Initiative is, in the words of the NREMT, is:

“… to establish an expedient and politically feasible method for a state to adopt the National Registry EMS Certification as the basis for State EMS licensure. States wishing to re-adopt the National Registry as the basis for initial state licensure frequently encounter difficulty transitioning to use of the National Registry because there are many formerly Nationally Certified EMS providers who, although State licensed, have not maintained their certification. In a Mark King Initiative (MKI) state, this policy allows the National Registry to reinstate a lapsed national certification if the individual has maintained unrestricted state licensure at or above the level of the last National Certification held.

The Mark King Initiative provides a template for states to remove legislative and regulatory barriers to maintaining or re-acquiring NREMT certification. My own state doesn’t participate simply because we require maintenance of NREMT certification as the basis for licensure; there is no such thing as a currently state-licensed EMT or Medic in Louisiana who does not have current NREMT certification. If more states were to participate in the MKI, then providers in that state would have a smoother path to reciprocity in other states that use NREMT certification as the basis for licensure.

REPLICA, or Recognition of EMS Personnel Licensure Interstate Compact, is currently recognized by eighteen states. The EMS Compact is governed by a board of commissioners composed of voting representatives – typically the state EMS director – of each participating state. In states of emergency, like natural disasters, terrorism, or the current coronavirus pandemic, member states can enact the provisions of the REPLICA legislation that allows cross-border practice of EMS personnel in other member states.

No more artificial restrictions on practice. No more “I’m a paramedic in my state, but when I cross the state line, I’m a layperson.” You’re able to practice as an EMS professional according to the laws of that state, without further paperwork.

Imagine what EMS would look like if every state required NREMT and every provider in that state could easily be reinstated under the Mark King Initiative, and every state participated in REPLICA. We’d have de facto nationwide EMS reciprocity.

We’d truly be EMS without borders.

Read next: Provisional certification: What if it weren’t just an emergency measure? columnist Kelly Grayson, is a paramedic ER tech in Louisiana. He has spent the past 14 years as a field paramedic, critical care transport paramedic, field supervisor and educator. Kelly is the author of the book Life, Death and Everything In Between, and the popular blog A Day in the Life of An Ambulance Driver.