In my first report from the August 2026 meeting of the National EMS Advisory Council (NEMSAC), I described the new leadership, workflow reorganization (three newly defined subcommittees: Clinical Excellence, Systems Innovation and Integrated Informatics) and a positive wish for the future.
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Carrying on, the devil — as always — is in the details, and about an hour into the meeting, the conversation turned to the practical. Members began trying to decide where the many issues previously identified by the council should live. At first, it sounded like an exercise in putting topics into three separate buckets. By the end, the buckets looked more like an Olympic set of interlocking circles.
The list — shopping, wish or task?
Discussion topics included:
- Advanced automatic crash notification
- AI in EMS
- Alternative destinations
- Ambulance offload times
- Clinician safety and workplace violence
- EMS as an essential service
- EMS clinician mental health and wellness
- EMS Education Agenda 2050-related work
- EMS licensure and certification maintenance models
- Funding
- Integration of federal, state and local health and EMS data systems
- Interfacility transport metrics
- Measures of success
- Medical Operations Coordination Center-type models
- Military-civilian integration
- New EMS care models
- Patient outcomes
- Pediatric care
- Prehospital blood
- Readmission avoidance
- Reimbursement
- Resuscitation innovation
- Specialty certifications
- Standardized 911 Emergency Medical Dispatch protocols
- Sustainable MIH scaling
- System throughput and patient handoff efficiency
- Trauma care
- Treatment in place
- Vehicle extrication research
- Workforce recruitment and retention
That is not so much a work plan as a menu. And it raises the obvious question: if we are going to eat this elephant one bite at a time, what is the starter and what is the main course?
AI, EMS data, ambulance offload times, patient outcomes and measures of success were among the first topics proposed for the Integrated Informatics subcommittee. Members also discussed interfacility transport metrics, and the need to combine EMS and hospital data to understand why patients were transferred and what happened afterward. That all makes sense.
But the problem became obvious quickly. AI belongs in Informatics when the question is how data is analyzed, but it belongs in Systems Innovation when the question becomes how AI changes operations. Patient outcomes depend on Informatics to identify them, Clinical Excellence to interpret them and Systems Innovation if those outcomes indicate the model of care needs changing. The circles started overlapping almost immediately.
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Essential-service status: A systems issue, until it isn’t
Recognition of EMS as an essential service was allocated to the Systems Innovation subcommittee, which is probably its logical home. Sustainability, system design and the ability to expand services are clearly connected to how EMS is recognized and funded. But essential-service status is also a legislative and financial issue. So, as with many of the other topics, giving it a committee home does not suddenly make the other parts disappear. That became the recurring theme of the conversation: an issue may need a lead committee, but very few of these issues have only one owner. My thoughts on this issue, and from what we have seen so far, is that essential exists in the eye of the beholder (state).Essential doesn’t necessarily mean funded!
Prehospital blood administration
Prehospital blood was the clearest example of committee overlap. Blood initially seemed to fit comfortably within Systems Innovation when members discussed national expansion, logistics and even emerging concepts, such as drone delivery. But others quickly pointed out that blood obviously has a major Clinical Excellence component involving patient selection, administration, research, education and outcomes.
The council explicitly recognized that it would be problematic to simply hand the entire subject to one committee. Put blood on the Venn diagram and it lands directly across Clinical Excellence and Systems Innovation, with Integrated Informatics sitting underneath both to tell us who received it and whether it actually changed outcomes. By that stage, the neat three-circle diagram was already starting to look Olympic.
| MORE: Blood on Board: Federal funding paves the way for EMS blood programs
Workforce as clinical excellence
Members proposed workforce recruitment and retention fall under Clinical Excellence, linked to education and the need to retain experienced clinicians as EMS develops. Pediatric emergency and trauma care also found an obvious home there. The workforce decision is interesting because recruitment and retention are often viewed as HR or operational issues. Here, the council was effectively saying workforce stability is part of clinical quality.
That is probably right. You cannot deliver clinical excellence without enough clinicians. You cannot build increasingly sophisticated EMS systems if your most experienced people keep leaving. And you cannot separate patient safety from the physical and psychological safety of the clinicians delivering that care. Workforce may have been placed into one circle, but it touches all of them.
Treatment in place put reimbursement right in the middle
Alternative destination protocols were placed naturally under Systems Innovation. Then somebody added reimbursement, and the circles immediately started colliding again.
Members noted that reimbursement cuts across almost everything. Treatment in place was then added to the conversation, not simply as a care model, but as a method requiring a sustainable payment mechanism.
If I were actually drawing this Venn diagram, reimbursement would probably sit somewhere in the middle.
Clinical Excellence decides whether a patient can safely remain at home. Systems Innovation designs the care model. Integrated Informatics demonstrates whether it reduced ED use, avoided readmissions or improved outcomes.
But if nobody pays for the service, it does not scale.
That same problem applies to blood, MIH, alternative destinations and many of the innovations EMS is being asked to adopt.
Innovation without economics eventually becomes a pilot project.
Data may be the connective tissue
The more the discussion progressed, the more Integrated Informatics appeared less like a separate committee and more like the connective tissue between everything else.
Readmission avoidance was a good example. It fits naturally into Systems Innovation alongside MIH and treatment in place, but you need linked data to know whether the patient was readmitted and whether the intervention changed anything.
Ambulance offload delay is another example. It is an ambulance operations problem, a hospital-flow problem and potentially a clinical-outcomes problem. Informatics provides the connection between those pieces.
Good data does not solve any of these issues by itself. It does, however, tell us whether the thing we are trying actually works.
Three committees, three questions
Perhaps the simplest way to understand the new structure is not by looking at what subjects each committee owns, but by asking what question each committee should answer.
- Clinical Excellence: Is this the right thing to do for the patient?
- Systems Innovation: How do we make it work in the real EMS system?
- Integrated Informatics: How do we know whether it worked?
Look at the structure that way and the overlap becomes a feature rather than a problem. Blood touches all three, treatment in place touches all three, AI will touch all three, workforce arguably touches all three; even vehicle extrication research has a systems component, a clinical component and a data component. The mistake would be allowing the Olympic rings to become three separate circles.
Where to start?
With a list this long, NEMSAC will need to distinguish between what is important and what is foundational. Everything on the list is important, but some subjects unlock progress on others. Connected data creates evidence for payment reform. Payment reform allows treatment in place and MIH to scale. Workforce determines whether any new system can actually be staffed.
Prehospital blood may make a very good starter. Not because it is necessarily the biggest issue facing EMS, but because it already has federal momentum, a clear national objective and immediate relevance to all three committees. Clinical Excellence has to address clinical use. Systems Innovation has to work through scaling and logistics. Integrated Informatics has to measure implementation and outcomes.
Blood could therefore become an early test of whether the new NEMSAC structure can actually work the way the Venn diagram suggests it should.
And the main course?
The main course is rather larger and is perhaps the sustainable redesign of EMS itself.
How do we pay for healthcare rather than simply transportation?
How do we measure patient outcomes rather than operational activity?
How do we recruit and retain the workforce capable of providing increasingly sophisticated care?
How do we connect EMS to the wider healthcare system?
How do we use AI and other technologies without confusing novelty with value?
Those are not single-advisory questions, they are long-term system questions and in Olympic terms, this is going to be a marathon, not a sprint. NEMSAC has been handed a considerable workload, and federal advisory processes are not known for moving at 100-meter pace. The challenge will be keeping momentum, choosing priorities intelligently and ensuring that the council produces completed, actionable work, rather than simply adding more items to an already considerable list.
Eating the elephant one bite at a time may be the only realistic approach. The next question is deciding which bite comes first. And perhaps, in a meeting already full of Olympic rings and marathon distances, deciding where to start before tackling the main course is not a bad place to begin.
