EMD TRAINING
in the Age of Managed Health Care
by Randall D. Larson
SIDEBAR:
| EMD TRAINING Additional Considerations |
This article can be found on
page 36 of the Mar/Apr 1997
issue of 9-1-1 Magazine.
W ith Emergency Medical Dispatching being seen as a standard of care in many jurisdictions, more and more agencies are adopting EMD programs and training dispatch personnel to provide Pre-Arrival Medical Instructions either through internally-developed programs or through national EMD systems such as those developed by Medical Dispatch Priority Systems, PowerPhone, and the APCO Institute. Additionally, organizations such as the National Communications Institute provide instructor training for an agency's own EMD system. Now, with the specter of Managed Health Care (MHC) looming largely over both EMS and EMD providers, both the provision of and training in Emergency Medical Dispatch must adapt to (or face competition from) Managed Care Organizations (MCOs) and their own cadre of call triage centers.
The Specter of Pathway Management
"Managed Care will either cause a lot more work for dispatch centers because of MCOs wanting to have a much more complete interrogation and having several MCOs in one general location to have to contend with," said Richard Spurgeon, EMD Program Manager for the APCO Institute. "Or it's going to be a lot less work for PSAPs because managed care will do it themselves."
"Managed Health Care has become Big Business," said Patrick W. Lanzetta, Medical Director for PowerPhone. "Like any other business, if it is to profit it expects high value, low/reasonable cost, predictability, consistency, efficiency, and the satisfaction of its customers for the services they receive. MHC will expect no less from EMD and 9-1-1 dispatch centers. It is a consumer's approach to medicine and will not pay for things that don't work."
"MCOs are developing systems to deliver the right service, at the right time, to the right health care provider to their members," said Geoff Cady, a Consultant with Medical Priority Consultants, Inc. "The coordinated effort directed toward achieving this goal is typically described as a `demand management' strategy which includes member education activities and the use of medical call centers or nurse triage centers. In some situations, third-party callers have inappropriately called these centers to report someone in cardiac arrest, which often results in delayed EMS response and the absence of dispatch life support."
"MHC will take a much more tiered approach regarding not only facilities and services but also transport and pre-hospital care," said Lanzetta. "Transportation will range anywhere from ALS/BLS to wheelchair vans to taxi and bus vouchers to reimbursement by the health care plan for use of a private vehicle. The EMD/9-1-1 dispatcher will be expected to make the right call not only at determining the level of pre-hospital care needed but also the facility to which the patient should be transported."
"The creation of medical call centers and direction to MCO membership to use them to obtain advice prior to calling 9-1-1 by MCOs is bifurcating the traditional access point (9-1-1) for EMS and confusing the public," said Cady. "However, this strategy is unlikely to change until 9-1-1 center managers attempt to become part of the solution instead of exacerbating the problem of EMS overuse. The solution, therefore, will consist of a relationship between the 9-1-1 center and MCOs that permits the `repatriation' of MCO members to their medical call centers once the presence of a bona fide medical emergency has been ruled out. Only through proof of compliance to a mutually agreed upon EMD protocol will `at risk' healthcare providers and MCOs have sufficient control and accountability to contract with 9-1-1 centers. For many centers, the creation of the solution will result in a revenue opportunity that has not existed before for 9-1-1 centers."
If enhancing public safety or adding dollars to the center's operating budget isn't incentive enough, Cady points out, it's important for 9-1-1 center managers to understand public policy fundamentals that may come to play in the not-so-distant future. "The present structure of 9-1-1 systems and allocation of resources (funding) has been established through 9-1-1 enacting legislation," he said. "Politicians create and change legislation. Need more be said? In 1994, the Wall Street Journal published an article entitled: `HMOs Pile-up Billions and Don't Know What To Do With It.' Well, it doesn't take too much imagination to see where they might spend it when you begin to see the whole picture."
"EMD training will have to make dispatchers familiar with the concepts of managed health care and the protocols that are in place with those companies, and that's going to extend the amount of time necessary to learn EMD," said APCO's Spurgeon. "It's one thing to learn the basic concepts, but then to go back in and learn all the protocols depending on which HMO is involved for a particular call is going to be vast. But I also see this as a challenge for PSAPs at the same time. This could be revenue-generating for the communication division, by getting managed health care to where they would actually pay for quality service within the communication center rather than having to do it themselves"
Charles Carter, director of the National Communications Institute and founder of the National Communications Officers Association, sees the association between EMD and MHC in a more positive light. "The EMD can play a vital role in Managed Health Care," he said. "Emergency communications personnel should be trained to dispatch an emergency response (lights and siren) only to life-threatening emergencies. All other calls for medical assistance should be responded to by dispatching a non-emergency vehicle or the caller transferred to a non-emergency responder agency. It is a mis-allocation of valuable resources to encumber the availability of emergency vehicles on non-emergency calls."
"By implementing and effectively managing a protocol-based advanced triage process, the EMD can safely triage callers who are part of an MCO plan out of the 9-1-1 system," Cady said. "The 9-1-1 center-based EMD process, therefore, becomes the `front-end' to the medical triage process, permitting the transfer of callers to their MCO/health care provider's medical call center once the presence of a true emergency is ruled out." Although the development of a contractual relationship with MCOs may appear to be a complex process, Cady feels that the number and regional orientation of most healthcare providers make the process manageable.
"The future EMD will need a very high level of training and this must be ongoing," Lanzetta said. "This will involve not only his/her present responsibilities as an information gatherer and provider of pre-arrival instructions but will also need to address highly efficient resource allocation, triage, care management, and `gate keeper' functions. It is extremely important that the training program makes it very clear to the EMD just what his/her `scope of practice' is and how to recognize its limitations."
"The development of integrated systems of 9-1-1 centers and MCO medical call centers will significantly reduce or eliminate caller confusion over which number to call - 9-1-1 or 1-800," said Cady. "It will create a safer and more accountable medical triage process, and reduce or eliminate political pressure from MCOs to change the present structure of 9-1-1 systems."
It will be more important than ever that the EMD be taught the proper communication skills and stress management techniques he/she will need to work effectively and survive in what will be an even more demanding and critical field.
EMD TRAINING What are some of the other challenges in providing contemporary EMD training? According to Paul Rasch, Jr., Training and Development Manager for PowerPhone, overcoming misconceptions has been a big one. "The three most common misconceptions involve liability, training/staffing, and national certification," said Rasch. "EMS and the providing of pre-arrival instructions does not increase liability - not doing so does. You needn't be a paramedic or work in a multi-person PSAP to be involved in EMD; a competent telecommunicator who has successfully completed an EMD training course can be qualified and effective in EMD. The final misconception is the existence of a "national certification" - there is no such thing. There are national standards, established by the DOT, but unless and until the federal government starts certifying dispatchers there will be no national certification." "One of the biggest challenges in EMD training is to truly impart to the student the absolute necessity to `follow the protocol,'" said Medical Priorities' Geoff Cady. "The protocol is the authorization by the medical community for EMDs to practice Dispatch Life Support medicine. Without a protocol, EMD as we know it would not exist today." APCO's Richard Spurgeon points out that EMS dispatching is being done predominantly by law enforcement controlled dispatch centers, simply because that's who controls most of them. "We need to insure we have a program that will be acceptable to all facets of public safety while meeting the goals of EMS," Spurgeon said. "The difficult position you're sometimes put in, in dealing with police, fire and EMS issues, is that you may have to conform to specific policies set down by one agency. It's important that EMS, police, and fire work together to have a cohesive public safety policy, especially in dispatch." "The parallels between EMT in the early `70s parallels EMD in the `90s," said NCI's Charles Carter. "Just as nurses resented EMTs and paramedics being able to practice emergency medicine under the license of an EMS physician after a relatively short training period, it is now the EMD field personnel who seem skeptical about the abilities of communications officers providing medically-approved instructions to a caller while they are en route. The next greatest challenge is convincing chiefs, sheriffs, and 9-1-1 directors that EMD is a national standard of care. The choice isn't whether or not EMD will be provided, the choice is whether or not they are going to be negligent by failing to meet a standard of care." |
