By Jeff Poland, FP-C
While the adage, “You never want to be the first or the last to start using a new treatment,” has held true for ages in the hospital environment, it also applies to EMS agencies and individual providers. While it provides a good general guideline, it doesn’t tell us exactly when we should start in implementing new practices.
Perhaps the diffusion of innovations theory, which is well known in the technology sectors, can help. It provides a framework for how new technologies integrate into a given population (for example, how cell phones went from a novelty in the business sector in the early- to mid-1990s, but gradually came to replace traditional landlines and even expand to allow previously unheard of access to information over the next several decades).
While this theory is extraordinarily useful for goods in the technology sector, it has recently been used to explain the diffusion of a great number of other tangible and intangible items, including knowledge, procedures, techniques and even devices and medications within the healthcare sector.
The diffusion of innovations theory relies on a relatively even distribution of adoption plotted against time, adjusted to a bell curve. This means that within a certain demographic, new technologies and practices are not adopted immediately when they become available. When new technology becomes available, certain people will instantly scoop it up and begin to use it (imagine those who camp out in front of the store to get the latest Galaxy phone), while others prefer to wait to see how it pans out, even more will get it when it starts to become mainstream, yet more will get it once it actually is mainstream, and the last few will have to be dragged forward, kicking and screaming into what has become the new standard.
The categories mentioned above illustrate the main groups associated with the theory:
- The innovators – think of the engineering team at Apple.
- The early adopters, who tend to camp out in front of the store.
- The early majority, who create the collective “push” to send the technology mainstream.
- The late majority, like the people who accept the new technology once the benefits have been pretty well demonstrated.
- And finally, the laggards, who just don’t see a need for the new technology, but adopt it only when the older alternatives are all but gone.
The innovators and early adopters
The innovators are the group who come up with the new technologies and practices, the true early pioneers who set out to make a difference in their chosen field. These are people like R Adams Cowley, who through his experimentation developed the Golden Hour concept, as well as a number of other staples of critical care, such as using positive end expiratory pressure routinely in ventilated ICU patients to prevent atelectasis. While his ideas have been refined and further clarified and then widely adopted throughout the emergency medicine world, they didn’t start out that way.
It goes without saying that the innovators, by virtue of being the first, assume a great deal of risk. The entire premise of current medical practice is based upon a foundation of solid, good-quality evidence (so-called evidence based medicine). Naturally, good quality evidence takes time, and innovators and early adopters take on a fair bit of risk. Risks can be mitigated by a solid understanding of the basic scientific principles underlying a treatment, or research into intended outcomes of new practices, but that doesn’t mean things always work out the way they are anticipated. For example, look at the Galaxy S7 exploding battery fiasco – in some cases, early adopters face challenges ironed out by the time late adopters come into the picture.
The early and late majority
Once an idea gains traction, it begins to spread throughout the medical community. In the past, ideas and information were spread through word of mouth from colleague to colleague, and then spread via ideas and abstracts at conferences. Now, however, ideas are disseminated much more quickly through the use of social media. Twitter, blogs and podcasts with the hashtag #FOAMed (free, open-access medical education) allow the sharing of ideas and debate over safety and efficacy to go on in real-time, decreasing the time for the early adopters to become the early majority.
The tipping point of early to late majority comes after the ideas have been kicked around at conferences for a while, usually a couple of years, and tactics have generally become considered to be best practices, or programs have demonstrated positive results. Often, this is when you’ll see changes to guidelines being made, or more stakeholders coming on board.
There is an old adage that says if you get your practice ideas from conferences, you’re about five years behind the cutting edge; from journals, you’re about 10 years behind; and from guidelines and textbooks, you’re about 15 years after the ideas first came into play. This, obviously, is a gross oversimplification, but it serves to highlight just how quickly medicine changes.
The laggards
The final group is comprised of those who have to be dragged, kicking and screaming, into the present. Often, the laggards make no effort to change or better their practices. These are the providers who have been “doing it this way for 30 years,” and have no intention to change now. By the laggard stage, it is almost, but not quite, guaranteed that you are either doing harm to patients, or at the least, not providing the best care.
Evaluate where you want your EMS services to be
Every provider, practice area and system is different. Some systems do not allow for much freedom of innovation via rigid, “shall and must” wording, while others allow a significant amount of leeway for each individual provider’s comfort zone. While I personally prefer to be an early adopter (and innovator when the situation allows), not everyone has the time, education, experience or background to sit at this level safely. This allows for checks and balances, and in many cases can reduce harm – both from too early and too late adoption.
So what if you want to be an early adopter? Get your medical direction involved. Seek out new treatments, innovations or ideas, and bring them up to your medical director or clinical oversight committee. But before you do, you need to do the research, read the articles, research and understand all of the physiology, pathophysiology and minutiae of the procedure, medication, device or treatment. There will be skeptics and those that push back against innovation, which is why it is essential that you fully understand and can cogently argue the benefits (as well as clearly understand and acknowledge the risks) of whatever it is that you are proposing.
EMS as a whole has a history of jumping on treatments with poor evidence or physiology base (loading 2 liters of chilled fluids into post-ROSC patients, anyone?), and this can be curbed by those who will wait to adopt a certain strategy until the utility has been shown. Those who are unwilling or unable (not bad in this context) to critically evaluate the complexities associated with a treatment do their patients no good by adopting a treatment that they don’t fully understand, but sounds “cool.” We need people like that. Continue to thoroughly question your eager coworkers until you are satisfied with the answers – but keep an open mind.
CP-MIH adoption
Take community paramedicine and mobile integrated health as they move through the innovation cycle. In the three years since NAEMT published the results from the first comprehensive survey of MIH-CP programs in 2014, formal measures to evaluate EMS-based mobile integrated healthcare programs have been released to help create and evaluate community paramedicine programs across the country.
Programs are growing across the country, and CP success stories abound, including:
- In St. Charles County (Mo.), a collaborative effort between paramedics and BJC Healthcare resulted in an estimated $149,000-plus expenditure savings and vast improvements in patients’ health status self-assessments.
- The Central Jackson County/Community Assessment and Resource Evaluation Service has seen a decrease of 54.6 percent in superusers.
- Fishers (Ind.) Fire and Emergency Services partnered with Community Hospital North and was able to reduce CHF patients’ readmission rate by 15 percent.
- Albuquerque (N.M.) Ambulance Service, started three years ago, reduced frequent users’ ED utilization by 70 percent.
These standardized measures to evaluate, benchmark and publicly report the outcomes of EMS-based MIH programs; the continued adoption of community paramedicine programs and initiatives as external stakeholder resistance decreases; and the numerous success stories show the transition of community paramedicine through the adoption life cycle.
So, EMS1 readers, where does your department stand? Where do you stand? And where will you stand in the future? Sound off in the comments below.