2020 Vision: EMS leaders offer predictions, tips for the decade ahead

From provider safety, to community paramedicine, degree requirements, retention, climate change and reimbursement; how to prepare for the challenges and opportunities the 2020s will bring EMS


As the decade draws to a close, it’s time to learn from the lessons of the past and look ahead to the critical issues, challenges and opportunities EMS faces in the decade ahead.  

EMS1 asked 20 EMS experts and EMS1 contributors to predict how the big issues in EMS will evolve in the decade ahead, and what EMS leaders will wish they had achieved by the end of the decade. 

Read their predictions in the article below, and scroll through the slideshow for their tips on how to thrive in the 2020s. Scroll to the end to add your predictions in the comments section. 

 

Career development 

I believe as EMS becomes more versatile and more integrated into the health continuum of care, professional expectations of EMS providers – paramedics in particular – will only grow. Both initial education and career advancement will hinge upon a higher standard of certification and licensure that will demand more education and more accountability for continuing education requirements. It is my hope that as we discover more sustainable ways to reimburse EMS for the tremendous care provided, the market will be able to pay our personnel in a way more commensurate with the value they bring to the health system and community at large.  

Tip: Invest in your providers. There are often ample opportunities for leadership and command staff to obtain professional development training, but the same level of opportunity for the street-level EMT and paramedic is lacking. If this isn’t remedied, I believe agency leaders/chiefs will regret a failure to invest in more practical medical training for their staff, beyond the ubiquitous “refresher course” where the same things are just rehashed. We haven’t taught our EMTs and paramedics how to evolve and change at the speed of medicine as well as we should, and the “how” of EMS continuing education needs to be addressed at the academic and operational levels to keep up with the evolution of EMS practice. 

— David K. Tan, MD, EMT-T, FAEMS, is president of the National Association of EMS Physicians. He is double board-certified in Emergency Medicine and EMS Medicine. He is associate professor and chief of EMS in the division of emergency medicine at Washington University School of Medicine in St. Louis. He also serves as chairman of the Metropolitan St. Louis Emergency Transport Oversight Commission and vice-chairman of the Missouri State Advisory Council on EMS. 

Mobile integrated healthcare 

MIH and CP will become the new normal, something almost everybody does in some form or fashion. Not doing it will be the exception. We’ve seen these programs grow from about four in 2009 to over 400 today. The CMS ET3 model, and the payer conversations occurring as part of that model, will demonstrate to the payers (taxpayers, Medicare, Medicaid, commercial insurance and patients) that EMS’s true value is in our ability to help patients navigate the healthcare system, taking some to an ED, but referring a lot of them to non-ED settings, and getting paid for that, instead of being paid by the mile. 

Tip: Pursue a degree in healthcare administration. EMS is healthcare. Leaders who have been able to implement and sustain EMS transformation have been able to do so because they understand the healthcare system, specifically healthcare finance. Reacting to 911 calls will always be a core of what EMS does, but research will continue to show that for the vast majority of the calls we respond to and transport to an ED, our interaction has no appreciable impact on the patient’s outcome. That may sound like heresy, but so did the Constitutional Congress, but it changed everything. EMS leaders with formal education and a keen insight into how to prove value in times of rising economic pressures will be able to articulate the value proposition and help their agencies succeed. 

— Matt Zavadsky, MS-HSA, EMT, is the chief strategic integration officer MedStar Mobile Healthcare in Fort Worth, Texas; and the president of NAEMT. He also chairs the NAEMT EMS 3.0 Committee. He has a master’s degree in Healthcare Administration, with a graduate certificate in Healthcare Data Management. 

Diversity 

Our strength is our diversity. And, in a city like New York, we can basically communicate with just about anybody who is here, and I think that’s just going to get better. For a young LGBTQ member, they see somebody like me sitting at the top of one of the most recognized fire departments in the world, with a job overseeing 4,000-plus EMS members, I think they see me as their possibility. And I’m proud to play that role, and I’ll continue to play that role, and I’ll reach back and help as many people as I can and help them understand that this is just as possible for them as it was for me. 

Tip: Embrace diversity now. In the FDNY, we are absolutely embracing diversity, and we don’t have to wait until 2030 to see the results, we’re seeing them now. Our EMS ranks are comprised of 59% people of color and 28% women. We have an active recruitment effort through JoinFDNY, we have several programs for young people in NYC which are helping us reach more communities about the benefits and rewards of a career in FDNY EMS, and we have our FDNY High School where high school students in Brooklyn take classes that put them on the path for a career as a member of FDNY EMS. From the previous 10 FDNY High School classes, 66 graduates are currently working for the Department with 11 graduates currently serving as Firefighters, one serving as a paramedic, and 54 as EMTs. To date, 164 FDNY High School graduates are State certified EMTs as well. 

— Lillian Bonsignore is chief of EMS, FDNY. She graduated from the FDNY Fire Officers Management Institute (FOMI) and has completed several leadership programs including the Naval Post Graduate School-Executive leadership, FDNY Officer’s Management Institute, FDNY/USMA Counterterrorism Leadership- Combating Terrorism, TEEX –EMS Operations and Planning for Weapons of Mass Destruction and multiple National Incident Management systems courses. 

Provider safety 

In the next decade, we will be well on our way toward becoming inherently safe. This means that safety is no longer an after-thought, instead, it is intrinsic, essential, and part of our nature. I am still baffled about how much we resist assuring our own safety and wellbeing. We’re often stubborn about buckling up; wearing disposable respirators; acquiring immunizations; staying fit; sleeping enough; and taking precautions during common activities like driving, lifting and approaching dangerous situations. If we start today, everyone will realize that we own safe practices. In the next decade, ownership of safety will be better defined to include every leader, manager, supervisor and clinician. 

Tip: Apply improvement science to safety. One thing that agency leaders will wish they had done in 2020 in regard to provider safety is to have learned, adopted and practiced improvement science. One of the greatest mistakes we make in safety improvement today is implementing changes that don’t actually make things safer. Change can be expensive. Failures after implementation can be embarrassing and can squash confidence. Improvement science involves developing an aim, creating measures that can show what improvement looks like, and providing a structure that encourages small tests, rapid failures, and measurements that lead to sound implementation of changes that work. 

— Ernesto M. Rodriguez, MA, LP, is EMS chief, Austin-Travis County EMS. 

QA/QC 

EMS is moving from using data for compliance to data for improvement. Traditionally, newly established EMS quality programs have focused on quality assurance (QA). QA processes are reactive, detecting errors after they have already occurred. Meanwhile, quality improvement (QI) programs are proactive, seeking to change systems to improve performance and prevent errors from occurring in the first place. Over the next decade, EMS will put greater emphasis on applying improvement science methodologies and using data to create meaningful systems changes. 

Tip: Understand variation. Leaders in EMS will wish they had learned the importance of looking at data over time sooner. Summary statistics, like averages, are easy to calculate, but hide variation within a process. Understanding variation and how to distinguish common cause from special cause variation is a key part of quality improvement. Models like the Institute for Healthcare Improvement’s Model for Improvement provide a useful framework for undertaking data-driven projects that lead to meaningful lasting change. 

— Remle Crowe, BS, MS, PhD, is a research scientist and performance improvement manager with ESO. She is a former research fellow with the National Registry of EMTs.  

Climate Change 

Over the next decade, EMS, as well as other public safety providers, will have to evolve to, respond to, and mitigate the growing impacts of climate change. We are already observing the impacts of climate change – hurricanes, floods, wildfires and droughts – on the communities and patient populations we serve. Scientists are now reporting climate change impacts occurring at a pace faster than predicted.  

Recruitment and retention emerged as the top EMS challenge in the 2010s. EMS needs to prepare for this to worsen. A shrinking potential public safety workforce, called to care for a growing and aging population, has more options than ever before for post-secondary education and skilled trades. At the end of this decade, the renewable energy sector, like wind turbine technician or photovoltaic solar installer, was the fastest growing area of employment in the U.S. I am optimistic that market forces will lead to accelerating opportunities for the purpose-driven young adults choosing careers in the renewable energy sector, but worry their efforts will be too little too late to stave off the catastrophic impact of climate change.  

Tip: Pre-plan and train with climate change in mind. EMS leaders need to continue efforts to prepare clinicians for treating patients respiratory compromise, secure and train on equipment to rescue citizens stranded by worst-ever floods and storm surges, and to harden facilities and critical business data systems against storms and prolonged power outages. From Super Storm Sandy, to annual wildfires in California, to flooded coastal communities, it should be clear to every EMS leader that pre-planning and training is required for emergent evacuation of hospitals and skilled nursing facilities.  

— Greg Friese, MS, NRP, is editor-in-chief of EMS1.com. Greg has a bachelor's degree from the University of Wisconsin-Madison and a master's degree from the University of Idaho. He is an educator, author, national registry paramedic since 2005. Greg is a three-time Jesse H. Neal award winner, the most prestigious award in specialized journalism, and 2018 Eddie Award winner for best Column/Blog. 

Professional development 

Professional development will become more integrated with life experience. In other words, those with non-EMS leadership and business experience will be highly sought after for EMS leadership positions. Online development and leadership continuing education will become more prevalent as travel and being away for face-to-face learning become more expensive.  

Tip: Embrace degree requirements. My prediction is that EMS leaders will have wished they had embraced the educational requirements at both clinical and entry-level leadership positions. While some continue to resist this trend, we should learn from other professions. Forty years ago, only two in 10 nurses had a Bachelor of Nursing degree, according to the Council of State Boards of Nursing. Today, two-thirds of nurses hold a BSN. Many have advanced degrees. What they also have is both the respect of the medical profession and significantly higher salaries. EMS should take a lesson.  

— Jay Fitch, PhD, is the founding partner of EMS/public safety consulting firm Fitch & Associates. He also serves as a commissioner for the American College of Paramedic Executives.  

Degree requirements 

EMS education has made tremendous strides to improve the quality of patient care through accountability and accreditation of programs. Education over the next decade should include the continuous process of quality improvement to support what employers and community expect from our providers. The future of EMS must also focus on requiring degrees for all paramedic graduates without a requirement to take EMT-Basic prior to taking Paramedic.  

Another thought of EMS professionals is to compensate every EMS professional that has completed a degree with an increase in pay.  

Tip: Embrace technology. One of the things that all EMS leaders should plan for is the many changes in technology and being ahead of the changes that will shape our world.  

— Melissa L. Stuive, BS, MEd, LP, is EMS program director, Del Mar College, Corpus Christi, Texas. She has served on the Coastal Bend Regional Advisory Committee and serves on the Education Committee for the Governor’s EMS and Trauma Advisory Council. Stuive is the current recipient of the 2019 EMS Educator of the Year award from NAEMT and EMS World. 

Reimbursement 

Reimbursement needs to change over the next decade. First, we need to end our dependency on CMS. We send a $1,500 ambulance bill out the door and we only receive $427 back in reimbursement. We now need to move our career field into the MIH/CP model of care and focus on the private payers that are looking to save billions and billions of dollars to keep people out of the emergency room. Whether it is a PM/PM or a cost share savings model, EMS will finally be the one to bend the healthcare curve. 

Tip: Get on board. The transition to MIH/CP has been going on well over a decade now. One of the challenges is that EMS leaders are fighting this transition tooth and nail. This concept is not going away, and is changing with more services as the months go by. I feel the one thing leaders will eventually realize is that they needed to get on this train sooner, and embrace the change 

— Chris Cebollero is a nationally recognized emergency medical services leader, author and advocate. Chris is a member of the John Maxwell Team and available for speaking, coaching and mentoring. Currently, Chris is the senior partner for Cebollero & Associates, a medical consulting firm, assisting organizations in meeting the challenges of tomorrow. 

Volunteerism 

Volunteer EMS agencies who remain viable in the next decade will demonstrate a commitment to achieving and maintaining a standard of excellence in patient care, and consistently reliable response unencumbered by the weight of institutional stagnation and a culture of chronically low expectations. In order to accommodate the needs of modern volunteers, most agencies will be comprised of more volunteers who will be expected to contribute fewer hours.  

Resistance to regionalization will probably continue, but the idea of forming collegial alliances with neighboring agencies in order to consolidate resources and benefit from economies of scale seems to be more palatable and could essentially accomplish most of the goals that regionalization offers without the loss of local response or identity.  

Tip: Overcome the cultural divide between paid and volunteer EMS responders. Instead of maligning or dismissing EMS volunteers, EMS agency leaders’ efforts should instead be focused on promoting a relationship between paid departments and volunteer departments that is symbiotic, not adversarial. It is in the best interest of the profession, and patients requiring emergency care that local EMS agencies work together, train together and project a positive public image.  

— Nancy Magee, a Connecticut native, now resides in Louisiana and offers her Volunteer Survival Series workshops and consulting services through MEDIC Training Solutions to agencies across the country.  

Documentation 

I predict that, over the next decade, EMS documentation will be entirely electronic. The few remaining agencies that are clinging to paper PCRs will be forced to make the switch for three reasons:  

  • Payment and reimbursement processing, particularly government, will rely increasingly on AI for compensation, predicting revenue and conducting statistical analysis 

  • Within the next 10 years, I predict that all of the major hospital corporations (Tenet, Kaiser, Community Health Systems, etc.) will all be completely paperless 

  • Industry-wide, agencies, departments and private ambulance companies will rely on the data available from ePCRs for everything from budgeting, to supply chain, to fleet management, to resource allocation. 

With all of the advances in technology that are intended to improve the quality of datapoint gathering and analysis, patient care narratives have been all but abandoned in favor of drop-down menus and check boxes. I predict that the day will come when provider agencies realize that they have a wealth of usable data that will be of no value if the care providers are not providing actual care. They will finally realize that the narrative documentation is where any patient care report lives and breathes.  

Tip: Train on the fundamentals. When they have all the data they could possibly need and can run all the analytics imaginable, EMS leaders will wish they had taken the time to teach their people how to write an effective narrative that actually advances patient care.  

— David Givot, Esq., is a practicing defense attorney. In addition to defending EMS providers, both on the job and off, he has created TheLegalGuardian.com as a vital step toward improving the state of EMS through information and education designed to protect EMS professionals – and agencies – nationwide.  

Tactical EMS 

Tactical EMS will not evolve far enough in the decade ahead. The snail’s pace and cyclical complacency will make most of us stand still until it hits us in the face. This trend of “home-grown” terrorists will soon be replaced by the real terrorist that will make a school shooting look like a literal walk in the park. The world has changed forever. 

Tip: Partner with law enforcement. Build the necessary relationships and not just grow them, but make the law enforcement element a continued collaborative partner. Neither of us (law enforcement or EMS) can – nor should we try – to do this alone.  

— Michael Wright is a fire captain, community paramedic, tactical medic and mobile integrated healthcare coordinator for the Milwaukee (WI) fire department. He is an active shooter training architect; president at MIH Solutions LLC; and CEO, Southeast Tactical LLC. 

Mental health support 

I think we will see groups like NHSTA and the NFPA require a minimum number of mental health hours as part of first responder education. I think we will also see more formalized mental health support programs and peer support teams run through or in conjunction with state EMS offices. Mental health will be added in more states as a presumptive diagnosis for Worker's Comp.  

I also think we will start to see fundamental changes to how the industry functions, such as agencies implementing mandatory hard limits on shift length and mandatory minimums for time off, similar to what pilots are subjected to.  

Tip: Implement sleep safeguards. The evidence regarding the negative effects of lack of sleep is strong. It's both a mental health concern and a general safety concern. If we don't take steps to ensure staff are well rested, I think we will eventually have to deal with external regulations like what pilots and truckers have to adhere to.  

— Ann Marie Farina is executive director, The Code Green Campaign, a campaign that raises awareness about mental health conditions and suicide in first responders. She is a NR-P in Washington state and has worked as a wildland fire medic, a dual-role firefighter/paramedic, a 911 transport medic and as an educator.  

EMS educators 

EMS educators are being held to a higher level of personal education requirements. The fact that a lead instructor is required to possess a bachelor’s degree to teach paramedic candidates is a move in the right direction. I believe as we move forward with the discussion of degree requirements for practicing paramedics, it wouldn't be surprising to see the educational requirements for EMS educators and program directors to increase as well. 

Tip: Emphasize a clinician-based mentality. I believe EMS leaders will look back and wish they would have explored and embraced more non-traditional educational models. For the most part, EMS training across the nation still falls under traditional forms of delivery. Many of these models are inefficient and cumbersome. This problem appears to be pervasive within initial, as well as continuing education programs. We as educators need to more aggressively explore and experiment with ways to increase educational efficiencies to shift the emphasis from technician-based delivery toward clinician-based mentality. This might also allow initial training programs to increase capacity to better meet the shortages of paramedics across the nation. 

— Bob Matoba serves as lead instructor for the St. Anthony Paramedic Academy in Lakewood, Colorado. He has been involved in EMS for over 37 years. His career has spanned many aspects of the EMS profession, first as an EMT for a private ambulance company, all the way to the EMS chief for a fire department.  

Community paramedicine 

Over the next 10 years, we will certainly see more patients and more patients of “a certain age” as us Baby Boomers like to say. There will be more technology, including the expansion of artificial intelligence, machine learning, and two or 12 things that have not been invented yet. There will be more data that will play a much bigger part in how systems are run, and patient-side care is provided. More emphasis will be place on addressing the inflammatory roots of chronic disease with a bigger focus on lifestyle medicine. EMS is well positioned to collaborate in the evolution of healthcare, but we don’t have the skills or track record of meaningful integration. My hope/intention is that we will make a full-on commitment to collaboration and interprofessional leadership.  

Tip: Plug into the greater healthcare system. The ones who missed the boat will wish that they had plugged into the rest of the healthcare system in a deep and meaningful way. The actual work that most of us describe as “community Paramedicine” today has a lot of players involved. Chronic disease management, readmission reduction, homeless healthcare, vaccinations and the like involve primary care providers, public health, community clinics, technology innovators, payers and hospitals. We are delusional if we think that this is our bus to drive or that we can do this – whatever this is – on our own. Effective leaders will serve on hospital and clinic boards. They will make sure that they have decision making clinically expert representatives on STEMI, stroke, trauma, sepsis and other hospital committees. They will read the journals that healthcare leaders read. They will belong to professional healthcare associations like the American College of Healthcare Executives. Those that don’t will find their photos in a display case next to the original AAOS Orange Book and a MAST suit.  

— Mike Taigman is the improvement guide for FirstWatch, a company which provides near-real time monitoring and analysis of data along with performance improvement coaching for EMS agencies. He holds a master's degree in Organizational Systems and is an associate professor in the Emergency Health Services Management graduate program at the University of Maryland Baltimore County. He’s also the facilitator for the EMS Agenda 2050 project. 

Racial equity 

Racial equality in many forms, including equality in EMS treatments, employment, promotion, board membership and community education will occupy a strategic pillar for EMS agencies as citizens and public officials demand greater transparency and accountability for high-quality EMS medical treatment for all patients, regardless of race, class and gender.  

Tip: Focus on equity of care. By 2030, I believe EMS leaders will be acutely aware of how quickly (or slowly) they incorporated a focus on equity of care as they reflect on the priorities they placed to establish internal systems for nimble and accurate data collection and analysis allowing for meaningful visibility of real time quality of care performance measures. 

— Jamie Kennel is an associate professor and program director of the Paramedic Program, a joint program between Oregon Health and Science University, and Oregon Institute of Technology. Jamie is also a co-founder of Healthcare Equity Group.  

Prehospital patient care evolution 

Testing the new emergency triage, treatment and transport reimbursement model will continue to have an impact on current emergency medical services operations over the next decade. The success of mobile integrated healthcare systems and community paramedicine programs will influence more changes to present-day processes to fit specific community healthcare needs to ensure patients receive the appropriate level of care. 

Tip: Embrace a culture of forward thinking. One thing EMS leaders may wish they had embraced in regards to the future of prehospital patient care is a culture of forward-thinking. As reimbursement, technology and evidence-based research advance, so will the practice of prehospital healthcare providers. EMS leaders are responsible for setting the tone and providing opportunities to promote future development of providers at all skill levels.  

— Nicole M. Volpi, PhDc, NREMTB, has experience in emergency medical services, law enforcement, military and civilian disaster response, and disaster management research. She currently works for the City of Westwego EMS as an EMT and volunteers for the City of New Orleans VIGOR program as an EMT. 

Retention 

When employees feel informed – like they’re communicated with, then they feel like they’re a part of a team – like there’s a connection. When there’s a connection, there’s an ambition for development. When there’s development, there’s engagement. Moving into 2020 – and toward 2030 – employee engagement needs to be at the forefront of every administrator’s mind. If it’s not, then you’re only going to continue on the same vicious path of having to oil that continuous, revolving door. 

Tip: Prioritize employee engagement. If your volunteer agency wants to survive through the next decade, then employee engagement has got to be toward the top of your priority list. Likewise, if your agency is hemorrhaging over retention and recurrent onboarding costs, then employee engagement has got to be toward the top of your priority list. 

— Tim Nowak, AAS, BS, NRP, CCEMT-P, SPO, MPO, is the founder and CEO of Emergency Medical Solutions, LLC, an independent EMS training and consulting company that he developed in 2010. He has worked as an EMT, paramedic and critical care paramedic, and has been involved as an EMS educator, consultant, item writer, clinical preceptor, board member, reference product developer, firefighter and HazMat technician. 

MIH/CP 

Every great journey begins with but one small step, and while MIH and community paramedicine have evolved in localities, in the last decade, spearheaded by forward-thinking, patient-centric organizations and individuals, it hasn’t taken off on a grander scale – yet. As we await with bated breath, the announcement of who will be in the first tranche of ET3-approved agencies, we look forward with a degree of hope that this will accelerate the pace into the next decade.   

The prospect of giving the right treatment in the right place, first time, every time is a tantalizing aspiration and is essential for the evolution of MIH.  As with every wholesale change, there will be a reliance on leaders staying the course, and politics and funding staying in place.  Our leadership is probably ready to run with this, but our funding and politics have to align (always a challenge in an election year).  With the proof of concept with the future ET3 organizations we should continue marching on into the next decade 

Tip: Start succession planning. As far as MIH and EMS in general is concerned, we cannot look back but only forward.  We now have a duty to train and mentor our replacements to take over and continue the journey to 2030 and on to the nationally envisioned 2050.  Chiefs reading this today have to help prepare for our tomorrow. 

— Rob Lawrence is the principal of Robert Lawrence Consulting. He previously served as the COO of Paramedics Plus in Alameda County, California; and the Richmond Ambulance Authority. He is a graduate of the UK's Royal Military Academy Sandhurst and served worldwide in the Royal Army Medical Corps. He is a former board member of the American Ambulance Association and currently serves as chair of its Communications Committee.   

Systems of care 

I believe that we will see a significant shift in how EMS gets paid as the transition now underway continues towards so called alternative payment models (APM). APMs give healthcare provider organizations added incentive payments to provide high-quality and cost-efficient care. As the APMS become more prevalent, hospitals and EMS providers will then have distinct financial incentives to work collaboratively to establish and refine high-functioning systems of care for time-sensitive emergencies that get the right patient to the right type of care in the right time frame. These financial incentives, which are likely to develop in parallel with increased accountability through public reporting of clinical performance levels, will become powerful forces that will erode way the barriers we now see in things like hospital capability designations, destination protocols, jurisdictional boundaries, and data exchange between hospitals and EMS agencies to drive systems level quality improvement. 

Tip: Start measuring performance objectively. I think that EMS leaders will regret not having started sooner on efforts to measure their clinical and operational performance in an objective and standardized way. As more and more of the payment for EMS care is distributed through alternative payment models (APMs), the EMS providers that have objective data to demonstrate their clinical performance and operational efficiency will have a substantial competitive advantage over those that don’t. EMS providers that do will be much more likely to be selected by at-risk payers for inclusion in provider networks established by accountable care organizations. That could mean the difference between staying in business or being shut out of the market. 

— Mic Gunderson is the president of the Center for Systems Improvement – a consulting firm specializing in design and value improvement for high-risk time-sensitive care. Over the course of his career, he served as a field EMT, paramedic and firefighter, clinical manager and director with military, private and governmental EMS agencies.  

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