10 reasons we are on the cusp of Peak EMS
A bold prediction that EMS patient transport to the hospital by ambulance is sure to peak, level off and decline as we near 2020
This article, originally published December 16, 2018, has been updated with current information
As we close in on 2020, it’s likely we are about to reach Peak EMS Transports, a term I am co-opting from Peak Oil, a phrase that has been used to describe the date in the future at which the extraction of oil will have reached maximum levels. After Peak EMS, there will be a flat or slowing demand for scene-to-hospital transport services by ambulance.
Here’s why I predict Peak EMS Transport is not only inevitable but on the near horizon for our profession.
1. ET3 Model - Emergency Triage, treat and transport
The February 14, 2019 announcement of ET3 - the Emergency Triage, Treatment and Transport reimbursement model, makes Peak EMS Transport an almost guaranteed inevitability. The Centers for Medicare and Medicaid Services and the U.S. Department of Health and Human Services jointly announced the 5-year ET3 program to create a new set of incentives to make it possible for participating EMS agencies to partner with qualified healthcare practitioners, such as urgent care clinics and telemedicine provers, to deliver treatment at the patient's home without transport or to transport patients alternative destination sites, including a primary care physician.
CMS will release a Request for Applications during the summer with intent to begin the program in 2020.
"ET3 seeks to realign Medicare’s incentives so we can cut down on those surprise bills and make sure beneficiaries are getting appropriate care at the right time and place," Seema Verma, CMS administrator, said in a Tweet.
ET3 is sure to be a watershed moment in the history of EMS and top contributor to achieving Peak EMS Transport volume and most importantly improving patient outcomes by delivering the right care to patients by the right route.
The Emergency Triage, Treat & Transport (ET3) model will make it possible for participating ambulance suppliers & providers to partner w/ qualified healthcare practitioners to deliver treatment on the scene and with alternative destination sites. https://t.co/vYF3cnplS0 pic.twitter.com/hkLwU16ITG— Administrator Seema Verma (@SeemaCMS) February 14, 2019
2. Don’t call 911, get an Uber
An ambulance is an expensive and economically inefficient mode of transport for many patients, especially those who don’t require lifesaving, emergency care. The market – the broad collection of patients, payors, and even EMS leaders and administrators – is matching this realization with the widespread availability of on-demand ridesharing services like Uber and Lyft.
In late 2017, a University of Kansas economist concluded ambulance usage by low-risk patients has decreased by at least 7 percent in major cities where Uber is available. The increasing availability of ridesharing services and their use for transport to a hospital received tremendous media attention – free advertising for these multi-billion dollar companies – throughout 2018, like these stories from Virginia, Las Vegas, Pittsburgh and Orlando.
The messaging to the public is mixed. Medical directors, EMS chiefs, and even Uber and Lyft themselves urge caution about calling a rideshare to the hospital because drivers don’t have the same training or equipment as an ambulance.
"An Uber driver is not going to be able to diagnose your stroke or heart attack, asthma, sepsis," Deputy Chief Rich Wales, Orlando Fire Department, said to WFTV.
But there are plenty of medical conditions where an Uber might be the most appropriate mode of transport.
"If I injured myself and it's minor and I don't think I need a friend or it's not serious enough for a trained professional to take me, I can call an Uber and get down to the hospital fairly quickly," Gregory Hall, emergency physician and emergency department director said to WCSC.
The price for an Uber or Lyft is known at the time of request and immediately debited from the user’s account. The cost of an ambulance is variable from community to community and usually unknown to 911 callers. Look for ridesharing to continue growing as a viable transport mode for patients in need of medical attention in 2019 because the Uber for EMS is Uber. And if you haven’t been interviewed by your local media about Uber or Lyft as an alternative to an ambulance ride, prepare your talking points on “Ambulance vs. Uber,” because that interview is inevitable.
3. Uber and Lyft want in on non-emergent transports
Transporting stable, non-emergent patients from the emergency department to home, home to dialysis, dialysis to home, or hospital to rehab center is a significant service line for many EMS agencies. Many of these patients simply lack reliable transportation for self-conveyance. Getting patients to medical appointments, especially appointments that treat or monitor a chronic condition, like a wound check, is also a service provided by some EMS agencies.
Just as EMS is beginning to embrace its role in chronic disease monitoring, management and prevention of exacerbation through community paramedics, the rideshare companies are also recognizing the revenue potential for providing scheduled non-emergent transports. Uber Health partners with medical providers to transport patients to appointments and uses its technology to schedule rides and text message reminders to patients.
Lyft provided more than 7,000 non-emergency medical transports to CareMore health in 2017. Those transports, 91 percent of all rides scheduled by CareMore, were more likely to show up on time, have lower wait times, have a higher rate of patient satisfaction and cost less than other types of non-emergency medical transport.
The early results of rideshare services for non-emergency medical transports have been promising enough that I see significant growth for the rideshare companies as patients become more familiar with the technology and the applications improve to match the needs of clinicians and payers. The growth for Uber and Lyft will be mirrored by a decline in transports for EMS agencies that provide non-emergent patient services.
4. Patients find hospitals with apps, not 911
One of your superpowers as a paramedic or EMT is you know the location and best route to the hospitals in your community. You likely know where the hospitals are in neighboring cities and maybe even the Level I and II trauma centers in your region. In a strange city, you have an intuitive sense where the closest hospital is, plus you know the white “H” on a blue rectangle is pointing the way to a nearby hospital.
Most people don’t have the nearest hospital locating superpower. Instead, they have an app – Google, Google Maps, Waze, Siri or Apple Maps – to find the nearest emergency department.
“Find the Closest ER” is an iPhone skill that with the press of a button, uses the iPhone’s GPS and map software to find nearby hospitals and emergency rooms, offer directions and even connect you to a ridesharing app. Of course, there are risks to the patient of relying on an app instead of 911. Those risks are:
- Their time might have been better spent calling 911 than navigating the app.
- Their emergency might be best treated by EMS, not a friend or Uber driver.
- The app might suggest a Level III trauma center instead of Level I or II. Or a primary stroke center instead of a comprehensive stroke center.
Tens of millions of us have access to media, news, information and resources with voice-activated devices like the Amazon Echo, Google Home or Apple HomePod. Access to information, from locating the nearest hospital to giving chest compressions, is only a question away.
Alexa is getting smarter. The same technology that is helping me find a playlist for a holiday party through natural conversation will be adaptable to helping direct me when I say, “Alexa, I am not feeling well, what should I do.” Alexa has a set of HIPAA-compliant skills to help patients schedule an urgent care appointment, check home-delivery of prescription medications, and update users on their most recent blood sugar level.
There is a good chance a futre Alexa skill will ask me the OPQRST and SAMPLE questions to guide the urgency with which I should seek medical attention by calling 911 or a Lyft ride for me.
5. 911 dispatches a non-ambulance
In 2019 and beyond, millions of people will call 911 with minor injury and illness complaints, but 911 dispatchers are increasingly able to send something other than an ambulance to transport the patient to the hospital or urgent care. RapidSOS, a technology company with stunning growth in 2018, has gone from serving dispatch centers responsible for 10,000 people to covering more than 180 million people in the U.S. The RapidSOS technology integrates patient location data and diagnostic details to help the dispatcher determine the type of response and best destination for the patient.
MedStar Mobile Healthcare is a long-time leader and advocate of triaging low-acuity callers to a nurse who helps the patient identify the best resources for their problem and, if a hospital visit is necessary, the best way to get to the hospital. According to MedStar:
“Since June 2012, 11,262 low-acuity 911 callers have been referred to this program, and 34 percent of these patients have had a response other than an ambulance to the emergency department. This reduction has saved $4.4 million in healthcare expenditures for ambulance transport and emergency department expenditures ($1,157 per enrolled patient).”
Peak EMS Transport to the hospital is within sight when dispatch centers and EMS agencies are proactively facilitating patient use of other non-ambulance transport methods.
6. Freestanding ERs want drive ups
The freestanding emergency department and walk-in urgent care at a Walgreens or CVS is a relatively new phenomenon. With a smaller footprint and a much lower operating cost, these healthcare facilities are making the nearest hospital closer by moving out of city centers, along major thoroughfares and near suburban big box stores. These facilities advertise aggressively, especially their short wait times for walk-ins, and offer ample free parking.
Since the dawn of McDonalds convenience, predictability and fast service has upended the restaurant industry. The pressure to rapidly innovate continues to force regular change on restaurants. Those same forces are now coming to urgent and emergent healthcare.
The millennial generation, the largest generation in the workforce and rivaling the size of the baby boomer generation, is attracted to freestanding EDs. “One of the more profound parts of this phenomenon is that millennials are using these things extensively [freestanding EDs],” Jay Wolfson, a professor at the University of South Florida’s Morsani College of Medicine, said to the Tampa Bay Times. “Probably because there are lower wait times.”
7. Tech comes to healthcare, finally!
Constant heart rate monitoring, tracking and reporting is a standard feature on many wearable devices. Apple Watch EGC monitoring capability was one of the top consumer tech stories of 2018.
As the data set from wearable devices expands to trillions of heart beats, machine learning will surely be used to recognize patterns and alert the wearer of an impending adverse event. Rather than calling the hospital when the condition becomes obvious and severe, the wearer might use those extra minutes to self-transport to a hospital or complete a telemedicine visit with their physician.
The data available from patient wearables is expanding exponentially from a daily check-in, perhaps by a community paramedic, to a near constant data stream of heart rate, respiratory rate and blood pressure. Myia Labs receives and analyzes data from sleep sensors, scales and wearable devices used by heart failure patients. The aggregated information is used to improve the patient’s care and prevent their condition from worsening to the point an ambulance trip or hospital readmission becomes necessary.
We are surrounded by devices that have the hardware and software for initiating and completing a telemedicine visit. Chatbots, if not already doing so, will soon initiate a patient assessment, based on programmed algorithms, to understand the patient’s severity and determine if a live video assessment is the appropriate next step or if the patient needs an ambulance.
A call to most physicians’ offices starts with a recorded, “If this is a medical emergency, hang up and dial 911.” This is dumb technology. If I knew I was experiencing a medical emergency, I would have called 911.
Innovators are sure to harness the power of the microprocessor to ask a couple of questions to determine if I am having or not having a medical emergency. This conversation could be as simple as:
Machine: Are you having trouble breathing?
Machine: Please hold while I connect you with a 911 dispatcher.
911 dispatcher: Are you able to speak normally.
The dispatcher, likely assisted by artificial intelligence software, will determine if the caller needs an ambulance or could be transferred to a triage nurse.
Many apps offer to assist patients in complying with treatment regimens, tracking the patient’s health data and reminding the patient to take medications. MyMeds reminds patients to take their medications with messages and notifications. The Mayo Clinic offers its patient education resources within the app.
The reSET-O app is prescribed to opioid addicts to assist them in completing outpatient treatment by issuing medication-assisted treatment reminders and delivers cognitive behavioral therapy lessons by text or audio. Those lessons may include videos, animations and graphics.
Instead of a dispatcher asking, “What’s your emergency?” the Solv website connects patients with common medical ailments to a same-day doctor visit. Click on a button to begin the booking process.
Solv user data shows 14 percent of its users would have gone to an emergency department if they had been unable to book a same-day urgent care visit. Patients with urgent care problems don’t belong in the emergency department any more than they belong in the ambulance.
I suspect patients who adhere to their medication regime or can book their own symptom-based appointment are less likely to need an EMS transport, taking another nibble out of the ambulance transport business.
8. Computer-assisted assessment will revolutionize dispatch
Artificial intelligence is “the theory and development of computer systems able to perform tasks that normally require human intelligence, such as visual perception, speech recognition, decision-making and translation between languages.”
Researchers in Denmark fed thousands of dispatch recordings into a computer program to teach the program to recognize cardiac arrest based on the 911 callers’ responses to dispatcher questions. Although Copenhagen dispatchers can recognize cardiac arrest over the phone 73 percent of the time, the AI program has a 95 percent success rate, and “trains itself” to analyze factors in the background, such as yelling or sirens. The computer recognizes cardiac arrest faster than the dispatcher and shaves seconds off the time it takes to begin hands-only CPR instructions and put an ambulance en route to the scene.
Every year, EMS generates hundreds of millions of data points through dispatch recordings, cardiac monitor data and electronic patient care reports. The potential impact on EMS is significant as researchers recognize our treasure trove of data and ask meaningful questions about how the data can be used to inform assessment and care. In the years ahead, computer-assisted assessment will be used by bystanders, dispatchers and EMS personnel to recognize these patients and route them to the most appropriate care, potentially negating the need for a second ambulance transport from the initial receiving facility to a definitive care facility:
9. Even less trauma for EMS to transport
One of the top surprises for many new EMS professionals is the lack of traumatic injury patients. Recruitment efforts often promise blood and guts lifesaving drama, but the reality is that for most jurisdictions, trauma is a small percentage of EMS responses. Many technological and cultural changes are reducing the risk of traumatic injury. Each of these has the potential to lessen the number of patients an EMS agency transports to the hospital.
Semi-autonomous vehicle collision avoidance technology is built into most vehicles to maintain direction of travel, automatically adjust speed and decelerate faster than the driver could do on their own. These advances, building off the tremendous improvements in vehicle structure and injury-preventing airbags, result in less motor vehicle collisions. Though, these technological advances might be offset by the risk of inattentive and distracted drivers.
The percentage of Americans working in dangerous occupations is declining and expected to continue downward as the macroeconomy transitions from production of goods to the delivery of services. Even if injury rates remain level in construction, agriculture, manufacturing, mining, commercial fishing and public safety, the total number of people injured is going to decline as labor participation changes.
At the same time, the percentage of Americans working from home is continuing to grow; 8 million people now work from home. These people avoid the risks for traumatic injury associated with commuting, primarily motor vehicle collisions and workplace violence.
Perhaps the biggest impact on reducing the number of ambulance transports of trauma injury will be increasing law enforcement adoption of the Philadelphia scoop and run practice for penetrating trauma victims. In 2017, continuing a long-running department practice, police transported a third of Philadelphia’s 1,223 shooting victims to a trauma center rather than waiting for an ambulance.
We’ve long known that IV fluids and advanced airways don’t save penetrating trauma patients. Surgeons save those patients. If police can transport these patients to the surgical suite faster, they should.
EMS leaders can participate in the process of making this happen in their community. Here are three guidelines from Page, Wolfberg and Wirth for creating a policy to allow transport of seriously injured patients by means other than ambulance.
10. Life expectancy is on the decline in the U.S.
The opioid epidemic and an increase in suicide deaths is lowering the life expectancy of Americans. Though an overdose or self-harm are likely to generate an ambulance response, the patient’s death reduces to zero all future ambulance trips.
It’s morbid and tragic to consider how these deaths will reduce future ambulance transports, but the impact can’t be ignored, especially as these deaths often impact people that are otherwise young and have general good health.
“The latest CDC data show that the U.S. life expectancy has declined over the past few years. Tragically, this troubling trend is largely driven by deaths from drug overdose and suicide,” Robert R. Redfield, M.D., CDC director said. “Life expectancy gives us a snapshot of the Nation’s overall health and these sobering statistics are a wakeup call that we are losing too many Americans, too early and too often, to conditions that are preventable.”
In 2017, there were 70,237 drug overdose deaths in the United States at an age adjusted rate that was 9.6 percent higher than the rate in 2016.
Is this Peak EMS?
What do you think of these predictions? Are EMS ambulance transports to hospitals leveling off or declining in your jurisdiction? Share your predictions in the comments or email me firstname.lastname@example.org.