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EMS by the numbers: Where we need to go next

Breaking down the National EMS Assessment 2020 insights on telehealth, health information exchange and disaster preparedness


The National EMS Assessment provides answers on who, how and with what, and this gives an indicator to the size and complexity of our national EMS delivery system.


Telehealth in the prehospital environment enables treat-and-refer or treat-in-place delivery models, while connecting patients to advanced levels of care in the field empowers EMS providers to provide the right level of intervention at the right time, and to transport patients to the best destination. In an EMS1 digital edition, “Care delivery in real-time: Implementing telehealth in EMS,” sponsored by Pulsara, learn implementation strategies from agencies successfully using telehealth in the field.

The National Emergency Medical Services (EMS) Assessment 2020 began in October 2018 and was completed and issued in pre-lockdown March 2020. The document lays out, in a graphical, easy-to-digest representation, the collective image of the state of EMS systems in the U.S. today. In the survey, 54 of 56 states and territories responded to the 61 question snapshot survey which has been collected, collated and reproduced produced in the report.

The assessment arrives at a key moment in our battle against COVID-19 as we look to advocate for and protect the interests of EMS as a vital part of the nation’s response to the pandemic. To understand what makes up EMS across the nation, type and volume are key metrics. The National EMS Assessment provides answers on who, how and with what, and this gives an indicator to the size and complexity of our national EMS delivery system. It also raises questions and offers a to-do list, particularly now that we have no choice but to operate in a new normal.

Covered within the assessment are sections on EMS organizations, its professionals, communications, response and patient care, information systems, workforce health and safety, funding and, perhaps importantly this month, disaster preparedness.

Patient care, intervention on the move

The time-honored saying of, “once you have seen one EMS system – you have seen one EMS system” may have some credibility as the report opens by identifying that agencies vary in the types of services they provide and state EMS offices vary in the types of regulatory oversight they administer. So, it is all the same – but different!

More than 18,200 local EMS agencies respond to 911 calls for medical emergencies and injuries, employing nearly 73,500 ground vehicles, such as ambulances and fire engines. Whoever said “don’t call us ambulance drivers” should take note, they are not autonomous vehicles – yet. Forty-one states responded that they conducted 42 million agency responses for EMS calls in 2018 – which means there were probably more. This staggering number means that out of the entire U.S. population, one person in 10 made a 911 call for assistance. Of course, we know that some callers have a greater frequency than just once a year, and this itself a primary target of community paramedic interventions and ET3 in the future.

EMS conducted 30 million patient transports from the scene to an emergency department, alternative destination or between facilities. By any measure, that is a considerable amount of mobile healthcare being delivered, which, as we all know, is more than just driving a patient to the hospital, but providing intervention, care and lifesaving on the move.

EMS workforce, age, gender and ethnicity

Fifty-four states reported a total of 1,052,843 licensed professionals, including 583,608 EMTs, 268,420 paramedics and 21,514 emergency medical dispatchers all overseen by 9,348 medical directors. If we could all lobby for change in the same direction, at the same time, we would be a force to be reckoned with! The age of providers provides a fascinating insight into our industry. Perhaps unsurprisingly, the majority sit in the 20-49 age groups, with the distribution peaking at 30-49 years old. Four states reported professionals older than 89 years of age. This perhaps highlights my long-held belief that EMS is not just a job, but a way of life.

In terms of ethnicity and gender, fewer states were able to report out. Respondents identified (the mean average) 50% of their workforce as white, with a 14% Asian, Black or African American workforce, and that 72% were male. This is an area we can and must do better in in terms of reporting and opportunity. EMS is most certainly an equal opportunity employer, and we welcome all-comers that seek to care for their fellow human beings. I previously worked in a state that was unable to quantify the ethnicity of its workforce in a time when it was (and still is) essential to understand if there was a diverse mix of both workforce and opportunity for all.

National Emergency Medical Services (EMS) Assessment 2020 At a glance


Telemedicine adoption

The National EMS Assessment identifies “EMS agency use of video telemedicine/telehealth in real-time is not common with 76% of respondents either reflecting no or unknown use of telemedicine.” The assessment also offered that, “it will be interesting to see the impact on these numbers with the advent of the Centers for Medicare and Medicaid Innovation pilot project on Emergency Triage, Treatment, and Transportation, or “ET3”, which requires real-time video telehealth for some purposes.”

That was a view from 2018/19 - as we now know, the future has rapidly arrived and CMS wavers opened telemedicine applications, which in turn enable the wider use of as-yet, uncompensated treat in place initiatives. The two-way camera and screen is inevitably the portal to future intervention, consultation and treatment, and I suspect in the space of these last few months, much has changed out of urgent necessity.

Aggregating EMS data

The survey offers an important focus on data and databases. The future exchange of information and intelligence must feature strongly in our ongoing evolution. Strikingly, the section of NEMSIS data collection raises concerns about how data is aggregated when using NEMSIS versions with different standards/definitions. One of the most powerful EMS COVID-19 era presentations I have seen so far employed NEMSIS data, aggregated on a national level to identify the cardiac arrest increase/STEMI decrease question. This level of intelligence product employed at national level is an essential service as we look after the health and public health of our population at risk.

Linking data sources also featured poorly in the question on other healthcare-related data systems that EMS may be connected to. Examples of systems we could be connected to, but most don’t, include:

  • Motor vehicle crash and traffic records systems
  • ED and hospital discharge databases
  • Stroke, STEMI and trauma registries
  • Health information exchanges

Only 6% of respondents were linked at the time to HIE. With the advent of COVID-19 released telemedicine wavers and more field and home-based treatments launching, this number has likely increased. This is one definite area for technological improvement. There are now EMS friendly tech companies that can now effortlessly join it all together, with cooperation and alignment we can make it happen.

Disaster and mass casualty preparedness

The survey provides a retrospective snapshot of each state’s mass casualty and disaster preparedness plans. Just a year ago, 28% or 11 states including Texas did not participate in the CDC Public Health Preparedness Program Cooperative Agreement. A further 58% of states did not take part in the FEMA Homeland Security Grant Program. It would be interesting to fast forward and gauge state involvement with both FEMA and CDC programs now.

In terms of MCI exercises and events, the most used scenario as declared by states was in fact drills of a biological nature followed by natural disasters. The most employed mobilization to an MCI in real time was to natural disaster, followed sadly, by the response to active shooter events. In 2020, hopefully, our participation in emergency operations center (EOC), emergency support function (ESF), and command posts has fully cemented the EMS place and role in disaster response and public health management.

It is encouraging that the report notes 90% participation in ESF 8 activities, which include the following duties:

  • Assessment of public health/medical needs
  • Health surveillance
  • Medical care personnel
  • Health/medical/veterinary equipment and supplies
  • Patient evacuation
  • Patient care
  • Public health and medical information
  • Vector control

I can personally vouch for the importance of this position in most disasters and long term emergencies, as I led the ESF 8 function (with my public health equivalent) within the City of Richmond EOC for many years through extreme weather events, to protests and demonstrations, and health and public health play a major part in all.

The lesson I have taken away from almost three decades of disaster participation and EOC, GOLD Command and ESF leadership is that the response is always well-rehearsed and attended – the recovery is often neglected – a case of winning the war is easy, keeping the peace is harder. Right now, recovery and peace are an absolute priority.

The National Emergency Medical Services (EMS) Assessment is a good read and the fact that it contained more images than words suited me well. Seriously though, it offered great stats on our industry and perhaps with a little answer interpretation provides insight to where and what we need to go and do next. In terms of report analysis, having digested the 2020 vision, perhaps we also need to dust off the recently published EMS Agenda 2050 to see if the arrival of COVID-19 and the disruptive change caused has blurred our image of the future.

EMS by the numbers: EMS One-Stop With Rob Lawrence

Listen to an audio version of this article below.

Rob Lawrence has been a leader in civilian and military EMS for over a quarter of a century. He is currently the director of strategic implementation for PRO EMS and its educational arm, Prodigy EMS, in Cambridge, Massachusetts, and part-time executive director of the California Ambulance Association.

He previously served as the chief operating officer of the Richmond Ambulance Authority (Virginia), which won both state and national EMS Agency of the Year awards during his 10-year tenure. Additionally, he served as COO for Paramedics Plus in Alameda County, California.

Prior to emigrating to the U.S. in 2008, Rob served as the COO for the East of England Ambulance Service in Suffolk County, England, and as the executive director of operations and service development for the East Anglian Ambulance NHS Trust. Rob is a former Army officer and graduate of the UK’s Royal Military Academy Sandhurst and served worldwide in a 20-year military career encompassing many prehospital and evacuation leadership roles.

Rob is a board member of the Academy of International Mobile Healthcare Integration (AIMHI) as well as chair of the American Ambulance Association’s State Association Forum. He writes and podcasts for EMS1 and is a member of the EMS1 Editorial Advisory Board. Connect with him on Twitter.