Emergency Medical Services: Reported Needs Are Wide-Ranging, With
A Growing Focus on Lack of Data. (12-OCT-01, GAO-02-28).	 
								 
Local emergency medical systems (EMS) have reported substantial  
needs in such areas as personnel, training, equipment, and the	 
availability of doctors to advise emergency personnel in the	 
field. Federal agencies have supported EMS improvements by acting
as facilitators rather then by establishing requirements or	 
providing significant funding. The agencies provide technical	 
assistance, set voluntary standards for licensing EMS providers, 
and administer limited grant funding. The four federal agencies  
GAO studied have separately begun to collect EMS data or promote 
data consistency. However, progress in developing this		 
information has been slow. State and local EMS officials	 
attributed the lack of progress to the many competing demands on 
their time and said that EMS providers and local systems have few
incentives to collect and report EMS information.		 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-02-28						        
    ACCNO:   A02289						        
  TITLE:     Emergency Medical Services: Reported Needs Are	      
Wide-Ranging, With A Growing Focus on Lack of Data.		 
     DATE:   10/12/2001 
  SUBJECT:   Emergency medical services 			 
	     Personnel recruiting				 
	     Education or training				 
	     Interagency relations				 
	     Equipment inventories				 
	     Strategic planning 				 
	     HHS Healthy People 2010 Initiative 		 
	     Preventative Health and Health Services		 
	     Block Grant					 								 
	     HRSA EMS for Children Program			 

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GAO-02-28
     
Report to Congressional Requesters

United States General Accounting Office

GAO

October 2001 EMERGENCY MEDICAL SERVICES

Reported Needs Are Wide- Ranging, With A Growing Focus on Lack of Data

GAO- 02- 28

Page i GAO- 02- 28 Emergency Medical Services Letter 1

Results in Brief 3 Background 4 State and Local EMS Officials Report Wide-
Ranging Needs 5 Federal Agencies Support EMS Improvements Mainly By Acting
As

Facilitators 11 Concluding Observations 19 Agency Comments 19

Appendix I Organizations and EMS Systems Consulted 21

Appendix II Comments From the Department of Health and Human Services 22

Tables

Table 1: Major Areas for State EMS Improvement Cited in a 1999 Compilation
of EMS Assessments in 46 States (Conducted 1988 -1997). 10 Table 2: Priority
Objectives Identified in the 1999 EMS Agenda for

the Future: Implementation Guide 15

Abbreviations

CDC Centers for Disease Control and Prevention EMS emergency medical
services HCFA Health Care Financing Administration HHS Department of Health
and Human Services HRSA Health Resources and Services Administration NHTSA
National Highway Traffic Safety Administration USFA U. S. Fire
Administration Contents

Page 1 GAO- 02- 28 Emergency Medical Services

October 12, 2001 The Honorable Susan M. Collins The Honorable Russell D.
Feingold United States Senate

On a typical day in the United States, thousands of people face medical
emergencies that require immediate treatment before reaching a hospital. For
these people, emergency medical services (EMS) systems- including a 911
telephone dispatch center, medical treatment by responding emergency
personnel, and emergency transportation to a hospital- are the front line of
care. In some situations, emergency services can be the difference between
life and death. For example, chances of surviving a sudden cardiac arrest
decrease an estimated 10 percent for every minute?s delay in treatment.
People who need such emergency, prehospital care depend on well- trained
responders reaching them quickly, identifying the type of treatment they
need, and, in the case of life- threatening situations such as cardiac
arrest, administering needed life- sustaining treatment wherever the person
may be.

EMS systems are primarily local, but states play a major role in regulating
them. The federal government has also adopted a role supporting and
promoting efforts to improve EMS systems- for example, by making the
improvement of EMS a national health priority. In its Healthy People 2010
initiative outlining health care improvement goals for the next decade, the
Department of Health and Human Services (HHS) established a goal of
increasing the proportion of people who can be reached by EMS within 5
minutes in urban areas and within 10 minutes in rural areas. As an important
part of the public health safety net, EMS and the quality of prehospital
care have been of interest to the federal government, and four federal
agencies provide technical assistance and funding to state EMS systems. For
example, the Department of Transportation?s National Highway Traffic Safety
Administration (NHTSA) develops EMS training curricula and material and
provides technical assistance to state EMS agencies by sponsoring workshops
on such topics as quality improvement for EMS systems. Evidence suggests
that EMS systems vary widely in their ability to respond and in the outcomes
of the treatment they provide. For example, studies indicate that EMS
response time can vary significantly across areas and the chance of
surviving from an out- of- hospital cardiac

United States General Accounting Office Washington, DC 20548

Page 2 GAO- 02- 28 Emergency Medical Services

arrest can range, depending on locality, from 2 percent to more than 25
percent. 1 Because of the federal interest in improving EMS and the
variability across EMS systems, you asked us to identify (1) the needs
reported by local EMS systems and state regulatory agencies for improving
EMS outcomes and (2) the efforts of federal agencies in supporting and
promoting EMS improvements.

The information we collected and analyzed came from a variety of local,
state, and national sources, such as the National Association of State EMS
Directors? survey conducted in 2000 that assessed rural EMS needs and
federal assessments conducted from 1988 through 1997 covering the capacities
and needs of EMS systems in 46 states. We supplemented this information by
interviewing officials at national associations with an interest in
improving EMS. 2 To obtain more detailed examples of system needs, we
interviewed officials from nine local EMS systems and six states, chosen
because they reflected widely varying locations and system characteristics.
Our work at the federal level focused on four agencies that are involved
with EMS: (1) NHTSA, (2) HHS? Health Resources and Services Administration
(HRSA), (3) HHS? Centers for Disease Control and Prevention (CDC), and (4)
the Federal Emergency Management Agency?s U. S. Fire Administration (USFA).
We also consulted the Health Care Financing Administration (HCFA) 3 because
of its role in providing health insurance coverage for ambulance transports
under Medicare, the federal insurance program for the elderly which pays
more than $2 billion a year for ambulance services. We did not include
agency activities that support emergency disaster response in the scope of
our review. 4 We performed

1 For example see M. S. Eisenberg, B. T. Horwood, R. O. Cummins, R.
Reynolds- Haertle, and T. Hearne, ?Cardiac Arrest and Resuscitation: A Tale
of 29 Cities,? Annals of Emergency Medicine, Vol. 19 (1990), pp. 179- 186.

2 See appendix I for the specific organizations, localities, and states we
consulted. 3 In June 2001, HCFA was renamed as the Centers for Medicare and
Medicaid Services. Because our fieldwork was conducted while the agency was
known as HCFA, we are referring to the agency in our report findings by its
former name.

4 Other federal agencies support EMS with assistance for responding to
disasters. For example, HHS? Office of Emergency Preparedness provides
contracts to increase local emergency response capabilities to respond to
mass casualty events and the Department of Justice?s Office of Justice
Programs administers training and equipment assistance programs for state
and local emergency response agencies to better prepare for terrorist
incidents. For more information on this subject see: Bioterrorism: Federal
Research and Preparedness Activities (GAO- 01- 915, Sept. 28, 2001).

Page 3 GAO- 02- 28 Emergency Medical Services

our work in accordance with generally accepted government auditing standards
from November 2000 through August 2001.

In surveys and assessments conducted in recent years, local emergency
medical systems have reported substantial needs for improving the emergency
care they provide. These reported needs, which come under such categories as
personnel, training, equipment, and the availability of doctors to advise
emergency personnel in the field, tend to vary between urban and rural
locations. For example, rural systems were more likely to report training
needs in retaining basic clinical skills, while urban systems were more
likely to report training needs related to better serving diverse groups of
people within a community. The extent and impact of the reported needs is
difficult to ascertain, however, because there is little standard and
quantifiable information that can be used across systems. Most of the
available information about the effect of unmet needs is localized and
anecdotal. At the state level, agencies responsible for regulating and
improving EMS efforts report a need for better management tools and
information systems for assessing local systems? performance and determining
how best to improve the outcomes of EMS care.

Federal agencies that support and promote EMS improvements do so mainly by
acting as facilitators rather than by establishing requirements or providing
significant funding. The agencies provide technical assistance, set
voluntary standards for licensing EMS providers, and administer limited
grant funding (about $30 million in fiscal year 2000). In 1995, two of these
federal agencies, NHTSA and HRSA, brought together representatives of
federal agencies and 19 national organizations to develop a strategic plan,
called the EMS Agenda for the Future. In 1999, when EMS officials and
organizations revisited the Agenda in order to establish priorities for EMS,
the need for better information about EMS activities and outcomes was
highlighted as a longstanding issue of growing focus. As part of their
attempts to act as facilitators, each of the four federal agencies have
separately initiated attempts to collect EMS data or promote consistency in
the data. However, progress in developing such information has been slow. In
2000, for example, fewer than one- fifth of states responding to a national
survey indicated that they had the ability to collect information statewide
in a format developed by the EMS community. State and local EMS officials
said that a key reason for the lack of progress is that, faced with many
competing demands on their time, EMS providers and local systems have few
incentives to collect and report EMS information. Results in Brief

Page 4 GAO- 02- 28 Emergency Medical Services

In written comments on a draft of this report, HHS stated that the report
accurately reflected its programs and activities. In oral comments, the
liaison with the Federal Emergency Management Agency stated that the report
also accurately reflected its programs and activities. The Department of
Transportation said it had no comments.

EMS systems are designed to provide a quick, coordinated response of
emergency medical care resources for traumatic incidents and medical
emergencies. Persons who need such a response may need help for a variety of
medical conditions, such as cardiac arrest, diabetes, seizures, or
behavioral disorders, or they may have injuries such as burns, wounds, or
severe head or spinal damage. The major components of an emergency medical
system often include the following:

 A public access system. This is generally a 911 emergency telephone line
used to contact and dispatch emergency medical personnel.

 Emergency medical response. The goal for the initial response is to have
medically trained personnel available to the patient as quickly as possible
and to provide early stabilizing care. The level of care provided can be
either basic life support or advanced life support. 5 Because most EMS
agencies operate independently of other medical facilities and have
relatively few physicians among their providers, the ability of field
personnel to talk with a physician is important in ensuring appropriate
medical care. Such a link to ?medical oversight? ensures that field
personnel at the scene or during transport have immediately available expert
direction that can authorize and guide the care of their patients.

 Emergency medical transport or transfer. This involves getting the patient
to a hospital or other medical facility. Although an important component of
the system, emergency transport does not apply in all cases. Officials
responding to a recent survey of urban EMS systems indicated, for example,
that an average of 37 percent of emergency requests do not result in
emergency transport.

5 Basic life support responders provide basic first aid, such as stopping
bleeding, immobilizing fractures, and administering cardiopulmonary
resuscitation. Advanced life support responders provide basic first aid, but
also are trained to treat severe trauma and can administer drugs, establish
intravenous lines, open airways through endotracheal intubation, and apply
other lifesaving or life- sustaining techniques. Background

Page 5 GAO- 02- 28 Emergency Medical Services

EMS systems are typically managed and operated by local communities and
jurisdictions, such as counties or fire districts. Entities involved in
providing EMS for a particular community may include fire departments with
paid or volunteer personnel trained in both fire suppression and EMS or EMS
alone, for- profit or not- for- profit ambulance companies, volunteer
ambulance services or rescue squads, hospitals, and government- based EMS
organizations. The extent of involvement of each type of entity in local EMS
systems nationwide is not fully known. While some systems provide both
emergency response and emergency transportation within the same agency or
organization, others may use multiple organizations. For example, a fire
department may provide the first emergency response while a private
ambulance company provides most emergency transport. Varied sources of EMS
funding also exist, such as local taxes, billing for services provided,
private- sector donations, subscription services, and government grants.

At the state level, EMS agencies generally do not provide direct services
but rather regulate and oversee local and regional EMS systems and EMS
personnel. In most states, state laws and regulations govern the scope,
authority, and operations of local EMS systems. While the state?s authority
and role varies from state to state, the agencies typically license and
certify EMS personnel and ambulance providers and establish testing and
training requirements. Some establish standard protocols for treatment,
triage, and transfer of patients. State EMS agencies may also be responsible
for approving statewide EMS plans, allocating federal EMS resources, and
monitoring performance.

At the local level, the needs reported by EMS systems are wide- ranging and
diverse, reflecting the different environments in which they operate.
However, the available data allow a better understanding about the kinds of
problems reported than about their effects. At the state level, the reported
needs centered on the lack of information and systems for evaluating the
performance of EMS systems and deciding how best to make improvements.

At the local level, the challenges faced by individual systems are often
associated with variations in such factors as the characteristics of the
population served and the geography of the area. The area served by an EMS
system can range from isolated rural settings in mountainous terrain to
sprawling and densely populated urban settings with high- rise buildings and
traffic gridlock. Such differences tend to be reflected in certain State and
Local EMS

Officials Report WideRanging Needs

Reported Needs of Local EMS Systems Reflect Diversity of Environments

Page 6 GAO- 02- 28 Emergency Medical Services

aspects of the EMS system itself. For example, according to officials, rural
areas are less likely than urban areas to have 911 emergency dialing
(requiring callers to use a 7- or 10- digit number instead), and their
communication between dispatchers or medical facilities and emergency
vehicles are more likely to suffer from ?dead spots?- areas where messages
cannot be heard. Rural areas are also more likely to rely on volunteers
rather than paid staff, and these volunteers may have fewer opportunities to
maintain skills or upgrade their skills with training.

These differing characteristics affect what officials perceive and report as
key needs. For example, officials from national associations representing
EMS physicians have indicated that long distances and potentially harsh
weather conditions in rural areas can accelerate vehicle wear and put
vehicles out of service more often. By contrast, an urban area may be less
concerned with vehicle wear and more concerned with traffic problems. A 1994
study, 6 for example, compared New York City?s EMS response time for cardiac
arrest patients with response times reported from other locations. In New
York City, the time interval from patient collapse to arrival of EMS
personnel at the patient?s side was about 11.4 minutes, nearly half of which
(5.5 minutes) was spent negotiating city traffic. This interval was similar
to ambulance driving time reported in another large city, Chicago, but was
significantly longer than the 3. 3 minutes of driving time required in a
suburban county in the state of Washington.

The variety of EMS needs can be seen in the various categories of needs
reported by EMS officials. Far- reaching needs were identified in a March
2000 national survey on rural EMS needs, 7 from our own fieldwork involving
urban and rural EMS systems, from our review of the professional literature,
and in our conversations with EMS experts.

6 G. Lombardi, E. J. Gallagher, and P. Gennis, ?Outcome of Out- of- Hospital
Cardiac Arrest in New York City- The Pre- Hospital Arrest Survival
Evaluation (PHASE) Study ,? Journal of the American Medical Association,
Vol. 271 (1994), pp. 678- 683.

7 Challenges of Rural Emergency Medical Services - Opinion Survey of State
EMS Directors, 2000, http:// www. nasemsd. org/ rural_ emergency_ medical_
servic. html (cited Apr. 20, 2001). In March 2000, HRSA and the National
Association of State EMS Directors conducted a national survey asking state
EMS directors about their needs for ensuring adequate EMS services in rural
areas. Directors in 41 states responded. A similar survey on the needs of
urban EMS systems does not exist. The needs reported for urban systems are
thus based only on our interviews with urban officials.

Page 7 GAO- 02- 28 Emergency Medical Services

 Recruitment and retention of EMS personnel. In rural systems, personnel
needs reflected these systems? heavy dependence on volunteers. Rural systems
reported that it was getting more difficult to recruit volunteers,
especially for daytime shifts, and that inadequate staffing was a major
problem affecting the ability to quickly respond to emergencies. For
example, one predominantly volunteer EMS squad reported having difficulty
responding to early- morning calls because most of its volunteers also had
full- time jobs. Officials reported that in the past year, the service had
been unable to immediately respond to two early- morning calls involving
critically ill patients. Rural EMS systems also report encountering problems
with staff attrition due to increased demand on personal time for training
and calls, stress from treating relatives and neighbors, and poor working
conditions. For example, in one instance, closure of a local hospital
increased demands on staff by doubling the amount of time personnel had to
spend transporting patients. In another example, a state reported concerns
about the ability to retain volunteer staff because they had to use
antiquated and unreliable equipment, such as ambulances that frequently
stranded them in remote areas or that had unreliable lighting, requiring
them to provide care by flashlight. In urban systems, where there is less
reliance on volunteers, experts report that job stresses may involve very
different concerns, such as a higher possibility of encounters with violent
situations.

 Training and Education. Rural systems reported training and education
needs that focus on retention of infrequently used medical skills, as well
as training in management, budgeting, personnel, and organizational issues.
EMS officials said that in rural areas, the sparsity of staff and distances
were major impediments to providing in- person training. One local system
reported that some personnel certified to provide advanced care had never
performed certain advanced procedures, such as airway intubation. 8 This
system is currently trying to partner with a local hospital to provide the
necessary clinical experience. By contrast, some urban systems we consulted
reported needing specially trained staff to respond to patients with mental
disorders and personnel trained in different languages so they could better
communicate with the diverse populations they serve.

 Equipment. In the March 2000 survey, a wide range of equipment needs was
reported for rural systems, including communication equipment (73 percent of
respondents), medical equipment (68 percent of respondents), ambulances (54
percent of respondents), and buildings (34 percent of respondents). For
example, one survey respondent cited a rural county

8 Intubation refers to the insertion of a tube into the trachea (windpipe).

Page 8 GAO- 02- 28 Emergency Medical Services

that had one operational ambulance for 6, 500 residents (the state average
was 1 per 4,600 residents) and only three hand- held portable radios were
available for the six medical personnel on call. Asked to estimate the costs
of addressing the capital needs for rural EMS systems in their states, only
28 of the 41 state EMS directors responding to the survey said they had
enough information to provide an estimate. The average state cost, based on
the figures from 27 of these states, was $12. 2 million. 9 For urban
systems, no similar survey or set of estimates is available. Officials we
spoke with indicated that urban systems also face equipment needs.

 Financing. Both urban and rural systems reported examples of tenuous
financing. In rural areas, officials reported that it is difficult to fully
support the high fixed cost of operating around- the- clock EMS services
because the number of calls is generally smaller in sparsely populated
areas, limiting the opportunities to bill for services. This difficulty has
resulted in some communities going without local EMS coverage. For example,
one county reported going without the services of a dedicated EMS provider
for the past several years and instead relied on ambulance response from
other communities that may be located as far as 20 miles away. According to
officials, this county- with a population less than 3,000, no industry, and
a relatively small number of businesses- has an insufficient tax base to
support such services. Other states have reported increased response times
in their rural areas due to lack of funds to maintain greater capacity.
Urban systems reported financing problems caused by a growing demand for
services combined with tight community budgets. Officials of systems that
relied heavily on local government funds and levies to support their
operations said they were considering billing health insurers to supplement
the income of their EMS services. At the same time, some systems that were
relying on income from billing health insurers reported concerns about
declining reimbursement levels from these sources due to possible changes in
reimbursement rules.

 Medical oversight. Both rural and urban EMS officials we spoke with
expressed a need for improved medical oversight, but this need took
different forms. Officials from two urban systems pointed to the need to
centralize and standardize medical direction. One official said his system
was trying to provide consistent medical direction to EMS providers in the
field by centralizing the medical direction in one location, rather than

9 The states contributing to this estimate were located in different regions
of the country, and the percentage of the state considered rural (based on
self- defined criteria reported by the directors) ranged from 20 percent to
95 percent. One of the 28 state estimates was $3. 5 billion, 77 times larger
than the second highest estimate. The outlying figure was removed prior to
estimating the average cost of capital improvements.

Page 9 GAO- 02- 28 Emergency Medical Services

having it provided by six different hospitals. 10 Systems in other locations
may face different challenges. For example, a rural state reported that in
most communities, physicians providing medical direction were as far as 100
miles away. In addition, they were not always available.

While surveys and assessments give some indication of EMS needs, the full
picture remains incomplete. For instance, a survey on urban EMS needs has
not been conducted. In addition, the extent and impact of these reported
needs and problems in particular locations, relative to other local and
state systems, is unknown because systems are localized and thus there is
little standard and quantifiable information that can be used to compare
systems. The Institute of Medicine has noted that without reliable
information, it is hard for emergency care providers, administrators, and
policymakers to determine in a systematic way (1) the extent to which
systems are providing appropriate, timely care or (2) what they ought to do
to improve performance and patient outcomes. 11

At the state level, reported needs tend to revolve around basic components
for coordinating EMS programs, such as information about the activities of
local EMS systems and methods to evaluate the care being provided. These
reported needs come mainly from state- level assessments conducted by NHTSA.
This agency has a program that allows states to request federal assistance
in assessing the effectiveness of their EMS systems. In this process, NHTSA
assembles a team that evaluates states- based on in- depth briefings from,
for example, state EMS officials, public and private sector partners, and
members of the medical community- on 10 standard components such as medical
direction, human resources, training, and evaluation systems.

10 In this case, officials told us that a change in state law was required
to allow EMS agencies and providers to receive medical direction away from
their ?base? hospital. There were six base hospitals in this location, each
hospital with different philosophies and protocols for treating emergency
patients, resulting in inconsistent medical direction for emergency
responders. Officials were working towards having one center that would
provide medical direction for all EMS runs in the locality.

11 Institute of Medicine, Emergency Medical Services for Children
(Washington, D. C.: National Academy Press, 1993). The Institute is a
federally chartered, private, nonprofit, self- governing organization that
is responsible for advising the federal government, upon request and without
fee, on questions of science and technology. At the State Level,

Reported Needs Center on Basic Management Components

Page 10 GAO- 02- 28 Emergency Medical Services

A 1999 compilation summarizing the findings of a decade of NHTSA assessments
in 46 states showed that most states were missing important management
components. 12 For example, at the time of assessment none of the 46 states
had established EMS performance standards (such as the percentage of
response times that should fall within an established time frame), 91
percent did not have a functional system for collecting and analyzing data
from EMS providers, and 89 percent did not have a statewide system to
evaluate patient care. Table 1 documents 10 areas identified by the
assessments that were in need of greatest improvement. All of these areas
were cited then as a need in at least 80 percent of the 46 states evaluated.

Table 1: Major Areas for State EMS Improvement Cited in a 1999 Compilation
of EMS Assessments in 46 States (Conducted 1988 -1997).

Area of improvement

Pre- established EMS system performance standards Functional system for
collecting and analyzing data from prehospital providers Statewide quality
assurance program to evaluate patient care Comprehensive system of medical
oversight for all prehospital providers Current knowledge of the functional
capability of the facilities that receive patients from the prehospital
providers Standardized training or monitoring for on- line medical direction
Communications equipment and established system for monitoring reliability
of equipment Current state EMS plan Minimum standards for dispatch centers
Consistent quality assurance program for training courses and instructors

Source: NHTSA

These assessments are subject to some limitations in that time has elapsed
since they were conducted, they reflect the views of many different
assessment teams, and there are no data showing the negative effects that
resulted from the reported deficiencies. There are indications that some
improvement has occurred- but also that many problems continue. For example,
a preliminary update conducted by NHTSA in 2001 found that because enough
states had implemented a statewide quality assurance program and a state EMS
plan, the percentage of states still in need of

12 U. S. Department of Transportation, NHTSA, ?EMS System Development:
Results of the Statewide EMS Assessment Program December 1988 to October
1997, Interim Report,? Washington, D. C. (1999) (unpublished).

Page 11 GAO- 02- 28 Emergency Medical Services

improvement in these areas was less than 50 percent. However, a NHTSA
official provided information that showed that most states still have
significant needs in most of these areas. For areas of improvement other
than the quality assurance programs and state EMS plans, the preliminary
assessment found that 50 percent or more of states remained in need of
improvement.

While no single federal agency has lead responsibility for EMS activities,
four federal agencies help support and promote EMS improvements, acting
primarily as facilitators through activities such as technical assistance.
In 1995, two of these agencies facilitated an effort to gain EMS stakeholder
consensus on a comprehensive national strategy to improve EMS, called the
?EMS Agenda for the Future.? While progress in implementing the Agenda has
been made, federal EMS officials told us that a 1999 effort to revisit the
Agenda goals and set major priorities for achieving them highlighted a need
for improved EMS information and information systems. While this need had
been a longstanding issue for years within the EMS community, officials told
us that the process of setting priorities resulted in a growing focus on
this gap. This information gap was further highlighted when HCFA changed the
manner in which it reimbursed EMS providers for ambulance services. Federal
officials said progress in implementing the Agenda has been affected by the
lack of consistent information about EMS systems, and as part of their
attempts to act as facilitators, they have all attempted to collect EMS data
or promote consistency in the data. Several local agencies we contacted also
reported needing improved EMS data and information to monitor and improve
performance, but they recognized that data collection and reporting is
sometimes a low priority and an administrative burden in the face of
competing demands on EMS providers? time. Federal agencies, in different
ways, are working to collect and promote improvement of EMS data with
available resources.

Four different federal agencies are involved in supporting and promoting EMS
improvements. None imposes standards or enforces requirements on how EMS
systems should operate. Instead, the agencies undertake activities such as
providing technical support and guidance, providing funding for EMS
initiatives through various grant programs to states, and exploring avenues
for developing a consensus among EMS providers on policy needs and changes.
The agencies and their major activities are as follows: Federal Agencies

Support EMS Improvements Mainly By Acting As Facilitators

Federal EMS Activity Centers on Four Agencies

Page 12 GAO- 02- 28 Emergency Medical Services

 National Highway and Traffic Safety Administration. NHTSA?s EMS division,
with a budget of $1.4 million in fiscal year 2000, has several activities
that support the development and improvement of EMS care. A core goal is to
enhance the quality of EMS services, in part by developing national
curricula for training and certifying EMS responders. Other activities
include providing technical guidance to state EMS agencies through such
venues as seminars on designing and implementing information systems and
state assessments to identify system development needs and strategies;
conducting training for medical directors and administrators of EMS systems;
publishing educational and instructional materials on how to improve EMS;
and funding research and demonstration projects to promote EMS improvement.
According to NHTSA officials, the EMS division became involved in
standardizing emergency medical services in the 1960s after recognition at
the federal level of a need to improve and monitor the quality of EMS. NHTSA
also provides grants to states and territories for highway traffic safety.
In fiscal year 2000, about $4.9 million of this money was used for EMS
improvements. 13

 Health Resources and Services Administration. Two components of HRSA are
involved in EMS: the Maternal and Child Health Bureau?s EMS for Children
program and the Office of Rural Health Policy. The EMS for Children program
provides strategic planning to enhance the pediatric capabilities of EMS
systems, provides financial support to NHTSA for EMS projects and
conferences, and funds resource centers that provide technical assistance to
state EMS agencies. In fiscal year 2000, the EMS for Children program
provided approximately $9.8 million to states in the form of grants. The
Office of Rural Health Policy sponsored grants to states to strengthen rural
health and grants to rural health providers to expand access, coordinate
services, control the costs of care, and improve the quality of essential
health care services. Each of these grant types can be used to support
emergency services. HRSA officials estimate that states and providers
received $4.2 million in fiscal year 2000 to promote the development of EMS
systems in rural areas. 14 For example, one project established a
partnership between a trauma foundation, a university

13 These funds were provided through Department of Transportation, NHTSA,
Highway Traffic Safety Grants, Section 402 Grants. These state formula
grants are provided to encourage more effective programs to improve highway
safety. The states may choose to use the grants to improve EMS and trauma
care systems.

14 About $3.2 million of this funding was provided through the Rural
Hospital Flexibility Grant program. The remaining $1 million was provided
through the Rural Health Outreach Grant and the Rural Network Development
programs.

Page 13 GAO- 02- 28 Emergency Medical Services

telecommunication center, and the state department of health to provide
distance learning opportunities for rural EMS providers, helping them obtain
new knowledge, skills, and clinical competency. HRSA is also a leading and
coordinating agency for national objectives related to access to quality
health services, including emergency services, developed in the Healthy
People 2010 initiative for improving the nation?s health. One such objective
is to increase the proportion of people who can be reached by EMS rapidly,
in particular the proportion who can be reached by EMS within 5 minutes in
urban areas and within 10 minutes in rural areas.

 Centers for Disease Control and Prevention. CDC administers the Preventive
Health and Health Services Block Grant program that provides funds to states
for preventive health programs and projects, including projects to plan,
establish, expand, or improve EMS systems. In fiscal year 2000, 20 states
elected to use $11.1 million from their allocated grants to fund EMS
activities. CDC is also a leading agency for HHS? Healthy People 2010
objectives related to heart disease and EMS, such as increasing the
proportion of adults who are aware of the early warning signs of a heart
attack and the importance of accessing emergency care by calling 911.

 U. S. Fire Administration. USFA supports EMS systems operated by fire
departments. Approximately 80 percent of fire departments in the United
States provide some EMS services. USFA publishes guidance for EMS
administrators and provides training for managers and personnel through the
agency?s National Fire Academy. This agency also maintains a voluntary
database that captures fire and some EMS information, such as amount of time
spent at the emergency scene, and information about the types of medical
conditions seen and the procedures performed. Beginning in fiscal year 2001,
USFA administers a grant program for fire departments, which could include
some funding for EMS. 15

Federal funding through these four agencies for local and state EMS needs
totaled about $30 million in fiscal year 2000. However, half of these funds
are subject to federal restrictions that limit the amount that can be spent
on equipment or other capital needs. Many states use federal grant moneys

15 Congress established and funded for fiscal year 2001 a new grant program
administered by USFA to address the needs of fire departments in 14
categories, including the category of EMS provided by fire departments. For
that year, $100 million was appropriated. At the time of our review, it was
unclear the extent that this grant funding would be used to support EMS.
USFA identified six categories that would be funded: training, fitness
programs, vehicles, fire fighting equipment, personal protective equipment,
and fire prevention programs. USFA officials stated that even though the
specific EMS category was not selected, grant funding, for example, for
personal protective equipment needs, could potentially support EMS needs.

Page 14 GAO- 02- 28 Emergency Medical Services

to fund their basic regulatory functions. For example, several states used
Preventive Health and Health Services block grants from CDC to pay for
improvements to basic state administrative processes, such as licensing,
certifying, and inspecting ambulance operators and EMS personnel.

As part of their work as facilitators, federal agencies have assumed a
significant role in identifying and highlighting strategies for improving
EMS systems. A major effort in this regard occurred in 1995, when NHTSA and
HRSA facilitated a multi- disciplinary group to create an overall strategic
plan for improving EMS systems. This group comprised more than 100 EMS
stakeholders, including representatives of federal agencies, 19 national
organizations, and state and local EMS providers. The resulting strategic
plan, known as the EMS Agenda for the Future, identified 14 areas requiring
continued development for EMS systems to be maximally effective. These areas
encompass such matters as the need for continuous and comprehensive EMS
program evaluation, communication systems that result in the most effective
course of action, qualified medical direction for all EMS providers and
activities, a prepared work force, and a finance system that supports EMS
systems so they are prepared to meet the demands placed on them.

In 1999, NHTSA and HRSA issued a second key document after reconvening EMS
local, state, and national agencies and stakeholders to develop a list of
priorities for implementing the Agenda, which was published in 1996. This
document, the EMS Agenda for the Future: Implementation Guide, identified
over 90 objectives for implementing the Agenda?s goals. 16 Ten of these
objectives, shown in table 2, were highlighted as priorities because, among
other things, they addressed major pressing problems and had the potential
to improve EMS systems and patient outcomes. Officials at NHTSA and HRSA
told us that some progress in these areas has been achieved. For example,
federal agencies had convened a workgroup to develop an EMS research agenda
and worked with the American College of Emergency Physicians and the
National Association of EMS Physicians on a 2- year process to develop a new
set of guidelines on medical direction.

16 U. S. Department of Transportation, NHTSA, EMS Agenda for the Future:
Implementation Guide (Washington, D. C.: U. S. Government Printing Office,
1999). Agencies Helped Gain

Consensus on EMS Improvement Strategies

Page 15 GAO- 02- 28 Emergency Medical Services

Table 2: Priority Objectives Identified in the 1999 EMS Agenda for the
Future: Implementation Guide

Description of priority

Integration: Develop relationships between EMS agencies and other public/
community health and safety organizations to identify community health and
safety issues. Legislation: Each state should have EMS enabling legislation
authorizing a lead EMS agency with authority to support innovation and
geographic integration among local EMS systems consistent with the EMS
?Agenda for the Future.? Medical direction: Allocate adequate resources for
medical direction. Finance: Develop reimbursement systems between EMS
agencies and health care payers to provide financial incentives to improve
the efficiency and effectiveness of EMS. Prevention: Participate in
community- based efforts to reduce preventable injuries and illness.
Communication: Ensure nationwide availability of 911 as the emergency
telephone number. Communication: Ensure that all calls for emergency help
are automatically accompanied by location- identifying information.
Information systems: Develop information systems to generate valid,
reliable, and accurate data- taking into consideration hardware and software
compatibility, confidentiality issues, and training- that can be linked to
those of other health care providers, public safety agencies, and community
resources, to be used for tracking and reporting system utilization and
patient care and outcomes. Evaluation: Determine the cost and benefits of
EMS to the community. Research: Establish a national EMS research agenda and
distribute findings of research in guidelines for uniform reporting styles
and standard outcome measures.

Source: NHTSA

These agencies also had other activities designed to identify and address
EMS needs for specific concerns. For example, HRSA and NHTSA have also
joined with EMS experts to develop a 5- year strategic plan to address the
many gaps in emergency services available to children, most recently to
cover 2001 through 2005. This national blueprint serves as a road map for
many states and organizations and addresses issues parallel to those
identified in the Agenda such as need for including a pediatric component in
the development of EMS information systems. 17

17 U. S. Department of Health and Human Services, Health Resources and
Services Administration, Maternal and Child Health Bureau (2000). Five- year
Plan: Emergency Medical Services for Children, 2001- 2005. Washington, D. C:
Emergency Medical Services

for Children National Resource Center.

Page 16 GAO- 02- 28 Emergency Medical Services

Another area in which federal agencies have acted as facilitators has been
in developing a framework for promoting EMS information systems. In 1993,
HHS, NHTSA, and USFA sponsored a comprehensive project to address the need
for more consistently collected EMS data. 18 This effort produced a model
set of EMS data elements and definitions that states and local systems could
use as the basis for creating their own information systems. Data elements-
including the location of the medical emergency, the patient?s vital signs,
treatments provided, and information on EMS response times- were selected
based on their usefulness for several purposes, including documenting the
medical care provided; billing for services; evaluating, monitoring, and
improving the delivery of EMS care; operating EMS systems; and allocating
resources locally.

Gaining consensus on what these data elements should be has not translated
into substantial progress in putting them in place. Federal officials told
us that gaps in EMS data has been a longstanding concern and problem area
that emerged as major priority when objectives for implementing the Agenda
for the Future were discussed in 1999. In part, gaps in data grew as a focus
of concern because it is an underpinning to other Agenda for the Future
goals, such as determining the costs and benefits of EMS to the community
and improving research on EMS. The need for more and better data on EMS
services was also highlighted, they said, in HCFA?s development of a new
Medicare fee schedule for ambulance services in 1999 and 2000. During this
process, HCFA had difficulties determining how to target payments so that
EMS providers serving isolated areas could be appropriately reimbursed. In
part because of the limited data available on rural ambulance services, such
as the number of ambulance trips made, the agency had difficulty developing
a payment adjuster for ambulance providers that serve isolated areas. Such
an adjuster was needed to reflect potential differences in the volume of
services and unit service costs. Our work looking at this process also found
problems with the adequacy of data reported on ambulance claims. Claims for
reimbursement were being denied at varying rates across payers because
providers were not completing forms correctly and

18 Within HHS, seven agencies participated: Division of Trauma and Emergency
Medical Systems/ HRSA, National Center for Injury Prevention and Control/
CDC, National Heart, Lung, and Blood Institute/ National Institutes of
Health, Maternal and Child Health Bureau/ HRSA, Office of Rural Health
Policy/ HRSA, Office of Coverage and Eligibility Policy/ HCFA and the Office
of Science and Data Development/ Agency for Health Care Policy and Research.
Need for Consistent

Information is a Longstanding Issue of Growing Focus

Page 17 GAO- 02- 28 Emergency Medical Services

because of gaps in information on the beneficiaries? health conditions
linked to the appropriate level of EMS service. 19

Along with their federal counterparts, state, and local EMS officials we
contacted reiterated an interest and need for improved EMS data collection.
They said better, more consistent information was needed for such purposes
as the following:

 Improving EMS performance at the local level. Local EMS agencies and
providers often lack data to justify budget requests, answer questions about
patient outcomes, or support ongoing quality improvement and surveillance.
All nine local and six state systems we consulted indicated that information
and information systems were needed to monitor performance and to justify
and quantify needs at the local level for the public and for decisionmakers.
At the state level- where resource allocation decisions are often made-
officials reiterated the need for basic EMS data collected statewide to help
them determine how to set priorities for allocating scarce resources. For
example, one state is trying to identify different funding scenarios and
sources to reinvigorate its EMS agencies. In doing so, the state is using
data to quantify equipment needs to more accurately estimate potential
costs.

 Setting and monitoring national policy. In addition to data needs for
determining a Medicare ambulance fee schedule, the absence of national EMS
data is considered a major impediment to monitoring national health
priorities. Two goals under the national Healthy People 2010 initiative
involve improving response times and access to EMS services. However, HHS
officials told us that sources have not been identified or developed to
provide data for measuring the status and progress towards achieving these
goals. Lack of uniform definitions for data elements across data sources
compounds the difficulty of monitoring these goals. For example, while many
systems collect data on their response times, they often collect data
differently or use different definitions, making comparisons between systems
impossible. A survey of EMS systems conducted in 2000 involving the largest
200 cities across the country found that 45 percent of the cities started
the response- time clock when the EMS vehicle was dispatched to the scene,
while about one- third started the clock when the 911 call for

19 Rural Ambulances: Medicare Fee Schedule Payments Could Be Better Targeted
(GAO/ HEHS- 00- 115, July 17, 2000).

Page 18 GAO- 02- 28 Emergency Medical Services

help was received. In addition, researchers found that the systems defined

?dispatch? differently. 20

 Improving researchers? ability to assess EMS outcomes. Officials from
state and local EMS systems told us that the best- documented example of EMS
treatments affecting outcomes is for cardiac arrests, in which the
expediency of treatment is critical to the survival of the victim. Research
has documented the wide variation of cardiac arrest survival rates across
locations, but determining the reasons for these variations is hampered
because of inconsistent collection methods for EMS data on response times,
treatments, and other variables. For example, 1990 research on the survival
rates (discharged alive from the hospital) for outof- hospital cardiac
arrest showed rates ranging from 2 percent to 25 percent in 29 separate EMS
service areas. The researchers, however, were unable to determine whether
these differences were actual differences in outcomes or the result of
inconsistencies in data collection. 21

In addition to the 1993 effort to gain consensus on EMS data elements,
federal agencies, in their role as facilitators, have in different ways
acted to promote the collection of uniform EMS data. For example, since 1995
HRSA?s EMS for Children program has promoted EMS data collection by funding
a data analysis resource center. Staffed with three full- time employees,
the center provides technical assistance to states on EMS data collection
and systems development. Also, USFA expanded its voluntary National Fire
Incident Reporting database in 1999 to include the full range of fire
department activities, including EMS.

Despite these efforts, a survey performed in 2000 indicates that few states
are currently able to collect statewide data uniformly and consistently.
Recognizing the increasing need for such data, the National Association of
State EMS Directors, with support from HRSA, conducted this survey to

20 G. Cady and D. Lindberg, ?2000 200- City Survey - Operational and
Clinical EMS Trends in Large, Urban Areas,? Journal of Emergency Medical
Services, Vol. 26 (2001), pp. 24- 42. 21 This study compared the survival
percentage of cardiac arrest patients between types of EMS systems, as
defined by the training level of emergency responders and sequence of
emergency response, in 29 different locations. In addition to
inconsistencies in methodologies and terminology, the authors note that
other explanations for the variation in survival percentage include the type
of EMS system, response time, type and sequence of the treatment; quality of
the system; age of the patient population; and characteristics of the
community, such as how often bystander cardiopulmonary resuscitation is
administered. See M. S. Eisenberg, B. T. Horwood, R. O. Cummins, R.
Reynolds- Haertle, and T. Hearne, ?Cardiac Arrest and Resuscitation: A Tale
of 29 Cities,? Annals of Emergency Medicine, Vol. 19 (1990).

Page 19 GAO- 02- 28 Emergency Medical Services

assess the collection of information at the state and local levels. State
EMS directors were asked whether they collected EMS data statewide and
whether their systems collected data in line with the model data set
definitions. Eighteen of the 46 states responding did not collect any data
statewide. Of the 28 states that collected some EMS data at the state level,
18 said their data were compliant with this uniform data set, but 9 of those
18 states reported that they had not received information from all EMS
systems in the state.

According to state EMS officials, data improvement efforts are limited
because in the face of constrained resources and competing demands for staff
time, local systems have little incentive to collect and report electronic
data or to adopt a uniform data format that may differ from their own. EMS
officials told us that it is very challenging for state agencies to convince
local EMS providers, particularly volunteer agencies, to contribute to the
state EMS data pool. Officials said that an important component for
improving data collection is for local providers to see value in the data
they are collecting for improving their services. Officials told us that
creating information systems that allow providers to access the data would
help providers to see this value, and will be important to enhancing the
ability to collect data and to aggregate it at a national level.

Surveys and assessments of EMS systems have identified broad categories of
limitations and needs, showing that basic issues in such areas as staffing,
training and equipment, and financing are considered to be dayto- day
challenges of local EMS systems and state efforts to coordinate these
systems. Determining the magnitude of these problems and how to resolve
them, however, is itself a challenge because of the lack of information on
which to base an understanding of how these systems perform. Federal
agencies have played a significant role in gaining consensus on the long-
term national strategic goals and priorities for EMS. With available
resources, they are attempting to develop strategies for addressing
information needs. Progress in this area, however, is likely to remain slow
because EMS systems and providers have many competing demands and few
incentives to devote limited resources to data collection efforts.

We provided a copy of the draft report to HHS, the Federal Emergency
Management Agency, and the Department of Transportation for review and
comment. In its written comments, HHS stated that the report accurately
reflected its programs and activities. (See appendix II). Concluding

Observations Agency Comments

Page 20 GAO- 02- 28 Emergency Medical Services

Similarly, in oral comments, the agency liaison at the Federal Emergency
Management Agency told us that the report accurately reflected the agency?s
programs and activities. The Department of Transportation said it had no
comments.

In its comments, HHS also stressed that, given the terrorist attacks of
September 11, the key themes and findings of the report were even more
relevant. We agree that EMS systems are a critical part of the public health
safety net, both in responding to day- to- day emergencies of citizens and
in responding to disasters. We have modified our report to clarify that our
scope was to capture information on the stated needs of EMS systems apart
from issues related to disaster preparedness. HHS also expressed that its
Emergency Medical Services for Children, 5- year strategic plans should be
mentioned in the report. We believe the EMS consensus plan supported by HHS,
NHTSA and others- the EMS Agenda for the Future- better represents the EMS
needs for the general population, but we have added information about HHS?
latest strategic plan for children. HHS also provided technical or
clarifying comments related to its grant programs and other areas, which we
incorporated as appropriate.

As we agreed with your offices, unless you publicly announce the contents of
this report earlier, we plan no further distribution of it until 30 days
from the date of this letter. We will then send copies to the Secretary of
Health and Human Services, the Director of the Federal Emergency Management
Agency, the Secretary of Transportation, appropriate congressional
committees, and other interested parties.

If you or your staff have any questions about this report, please contact me
at (202) 512- 7119 or Katherine Iritani at (206) 287- 4820. Other major
contributors to this report were Tim Bushfield, Leslie Spangler, and Stan
Stenersen.

Janet Heinrich Director, Health Care- Public Health Issues

Appendix I: Organizations and EMS Systems Consulted

Page 21 GAO- 02- 28 Emergency Medical Services

In conducting our work, we consulted officials from national and state
organizations and other experts to obtain their views on EMS systems and
care. We also consulted officials from six state EMS agencies and nine local
EMS systems to obtain more detailed information. We selected these agencies
to obtain information from EMS systems with differing system characteristics
such as population (rural/ urban), level of EMS service (state/ county/
local), type of staffing (paid/ volunteer), and service organization (fire
department/ private ambulance services/ contracted).

Organizations American Ambulance Association American Heart Association
Center for Health Affairs International Association of Fire Fighters Medical
College of Virginia Medical College of Wisconsin National Association of
State EMS Directors National EMSC Data Analysis Resource Center National
Volunteer Fire Council University of Michigan University of Washington

State EMS Systems Alaska California Maryland North Carolina Pennsylvania
Washington

Local EMS Systems Columbus, Ohio Gray, Maine King County, Washington
Multnomah County, Oregon Phoenix, Arizona Pinellas County, Florida San Juan
Island, Washington Tacoma, Washington Washington County, Maine Appendix I:
Organizations and EMS Systems

Consulted

Appendix II: Comments From the Department of Health and Human Services

Page 22 GAO- 02- 28 Emergency Medical Services

Appendix II: Comments From the Department of Health and Human Services

Appendix II: Comments From the Department of Health and Human Services

Page 23 GAO- 02- 28 Emergency Medical Services (201101)

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