EMS, Medical Oversight Of Systems

Article Author:
Japheth Baker
Article Editor:
John Cole
8/24/2020 11:03:09 PM
PubMed Link:
EMS, Medical Oversight Of Systems


The role of the emergency medical service (EMS) medical director in EMS medical oversight is multifaceted, complex, and often misunderstood. Reaching out to state and local EMS medical directors, as well as the previous EMS medical director at the current location of employment, can be invaluable in understanding your new role. It is to the benefit of the EMS medical service, its employees, and the medical director of EMS oversight to have a clear understanding of the job description and the relationship it entails. The roles and requirements of the EMS medical director should be laid out clearly in the form of a contract. This should delineate the authority of the position and allow improvement of the system, the providers within the system, and the public in general. Numerous sources such as NAEMSP, AAEM, and ACEP have resources that can be modified to fit the legislative and regulatory statutes that govern the region in which one practices.[1]

EMS medical oversight requires an understanding of state, federal, and local legislation and regulations involving prehospital medical care and transport.[2] Due to the complexity of state, local, and federal regulations, the focus typically shifts to more of prehospital medical care and protocol management. Although this is easier for the medically inclined to wrap their mind around, it does sway from the understanding of regulatory protocols and procedures to master the craft of EMS oversight. Understanding the job description of the EMS medical director and EMS oversight is a solid foundation upon which to start. Fortunately for the EMS medical director, daily operational activities, as well as staffing and regulatory compliance, are largely handled by the service director and do not typically take away from the responsibilities of oversight.

While EMS medical oversight is thought of to be on a continuum, it can be broken up into 3 parts. Prospective oversight deals with education, training, and protocol development. This is thought of as the planning and preparation stage of medical oversight. Concurrent medical oversight deals with online and offline medical control and also on-scene response. It is the in the field, in the action, the here and now of medical oversight. Considering the advancements in technology, concurrent medical control can be directed via cellular, radio, direct patient care on-scene, and even telemedicine. Lastly, retrospective medical oversight involves system-related research and run reviews.[3]

Issues of Concern

It is imperative that EMS providers, as well as the EMS medical director,  have a clear understanding of the relationship between the goals of the EMS system and how it relates to public safety and wellness. EMS providers will have ideas, techniques, and products that they feel would be a benefit to the EMS system and it is the job of the EMS medical director to approve or reject such items based off of appropriateness, cost, and safety. As a steward with direct responsibility for protecting the general public, it is important that the EMS medical director utilize the authority to grant or suspend medical credentials for EMS providers. By making sure appropriate performance improvement reviews, quality assurance programs, yearly CME requirements, and skills reviews are instituted, the EMS medical director recognition of deficiencies that may require mediation or suspension of medical credentials will be more apparent. Evaluation for quality assurance, suspension for medical cause, and de-credentialing can take a toll on the EMS medical director.[4]  Although this is a necessary part of progress and protecting the public, it can also have a positive effect on nurturing a bond between your system providers and also enhancing respect and authority.

Prehospital EMS providers tend to be doers and action-oriented personnel. This can be an area of conflict for the EMS medical director and the EMS providers. Frequent quality control, process improvement, education, and remediation can be used to help direct EMS personnel to accept evidence-based techniques and practices, as well as protocols within the national scope of EMS. Simulation, testing, skills labs, and lecture series can help bring a level of camaraderie and openness to your EMS system. An EMS medical director that is easily approachable, open to teaching, and when needed, render appropriate redirection and remediation that can change the culture of an outdated EMS system. A simple, 8- to 12-hour monthly EMS ride-along with your EMS providers will show dedication to education, concerns, and well-being. This simple and crucial gesture will go a long way in understanding the EMS system that provides oversight and understanding the providers and public that it encompasses.

Online medical control allows direct communication via landline, cellular, or radio transmission between EMS providers and the EMS medical director. Even projects involving medical drones with GPS and telemedicine capabilities are being developed currently. As technology increases and the standardization of protocols along with the implementation of evidence-based medicine becomes the standard of care, differing opinions about online medical command are increasing.[5] Online medical command is viewed by some EMS medical directors as a 40-year-old bad habit that is hard to leave behind. But, with the increased protocol guidance and training, paramedics have more autonomy than ever before. It is possible for the EMS medical director to also delegate medical direction to other ED physicians. However, some states require certification to do so. Online command can lead to delays in appropriate care if too stringent while leading to medical oversight liability if too loose.[5] The growing trend involving online EMS medical oversight is that it should be tailored to the EMS system, the region, and the general populace that it serves.

Medical oversight supervision of EMS systems in the field has the benefit of providing patient care delivery suggestions, providing feedback for suboptimal behavior, and scrutinizing scene performance. Presenting in the field will foster provider advocacy, as well as being able to provide recommendations to management. By providing on-scene physician supervision, the medical director has improved medico-legal accountability. On-scene oversight requires an appropriate vehicle with communication devices, as well as necessary medical equipment.[5] If the EMS medical director is appropriately equipped, the responses need to be frequent and random. It can be just as important to respond to the nursing home transfer as it is to the multi-car collision on the interstate. Establishing criteria for notification of the EMS medical director is a safe way to ensure appropriate scene management. Examples for notification of the EMS medical director include hazardous events, mass casualty, specialized rescue, anticipated complications such as imminent delivery, airway catastrophe, complicated extrication, and amputations.[5]

In a progressive effort to be an early adopter of cutting-edge EMS procedure and practice, it is imperative that the EMS medical director practices good scholarly activities and stays up-to-date with evidence-based practices. Through the institution of quality metrics, EMS services can monitor and improve upon data collected that is unique to their service location, patient population, and diverse obstacles. EMS medical oversight in relation to these quality metrics can help propel an EMS system out of archaic prehospital medical practices and into a more efficient, economical, and public safety-centered model. National organizations, as mentioned, are great sources of information to help EMS medical directors obtain results.[5]

Tackling the job of the EMS medical director will require an allocation of both time and resources. In some situations, a vehicle may be warranted for the EMS medical director. Communication devices, such as cell phones, radio systems, and video conferencing abilities may be needed. Due to the breadth of responsibility, the job encompasses, appropriate staff, supplies, and office space may also be warranted. Although many EMS medical directors do this job on a voluntary basis, it would behoove the physician to make sure that they are properly compensated for the time spent improving the EMS system, as well as making sure appropriate liability coverage is maintained.[4] The role of the EMS medical director can be set up for failure if appropriate resources and compensation are not allocated in the very beginning.

Liability issues provide a large gray area for many practicing EMS medical directors. Due to this difficulty in obtaining a clear understanding of medico-legal liability and EMS medical oversight, some physicians may shy away from such a job. Although the relationship between EMS personnel providing medical care and the supervisory role of the EMS medical director does open the oversight position to liability, the more difficult and important area of liability involves limitations or modifications of a provider's ability to provide clinical care to the public. In today's climate more than ever, remediation, retraining, as well as discrimination and harassment provide large areas of legal liability.

Although the tabloids are full of new stories relating to fraudulent activities of EMS services, the generic claim that the perpetrator is stealing money is typically wrong. Fraud, as it relates to EMS, can simply be the result of filing a false claim. Failure to understand the rules and regulations, as it pertains to the submission of claims to obtain reimbursement from Medicare and Medicaid, can result in fines, repayment of overpayments, and jail time. Fraud investigations can originate from claims whether they are intentional or accidental.[6] Not understanding federal regulations will not be looked at as an acceptable excuse. 

Here are a few examples of intentional or accidental fraudulent billing of Medicare and Medicaid; filing for reimbursement for patients who could have been transported by other means rather than an ambulance. Also, filing claims at an event or support level when it is not warranted by documentation or the patient encounter. If a 911 call has been placed and it generates a paramedic response, it does not mean that the encounter will justify ALS billing. Even if a response call meets emergent response criteria, it does not mean that the return transport to an appropriate facility with the patient will meet emergent billing. The patient encounter and documentation must support such. Diligently document reasons for bypassing the closest facility, especially if they can care appropriately for the patient encounter. One of the most obvious red flags is filing claims that are in direct conflict with EMS patient care and physician documentation.[7][8]

Prehospital EMS providers have the responsibility of treating conditions that may require controlled substances. It is the responsibility of the EMS medical director to be accountable to and compliant with DEA regulations and proper completion and organization of required forms, such as DEA-222 forms. Very clear documentation as to usage and appropriate wasting of narcotic medications should be present in the patient care documentation of the patient encounter it was used. This documentation should contain the name of the medication, the amount used, the amount wasted, and documentation of a witness to the disposal of unused medication. An auditing procedure should be set in place by the EMS system to reflect both scheduled and random auditing of resupply and storage. It will be in the best interest of the EMS service to institute an investigative protocol if an inaccurate audit is obtained.[9]

Many services are understaffed, overburdened, and operating with suboptimal equipment. Finding funding to strengthen the foundation of your EMS system can be done in a multitude of ways. Although grant writing seems daunting, help is available through services such as EMSGrantsHelp.com. They service a grant database that looks at federal, state or available corporate grants. Other possible options are community, family, private foundations, and donor-advised funds. Newer techniques have been devised, such as crowdfunding sources, which help raise funding by getting a like-minded group of individuals behind an idea or goal. Although it is not the primary objective of the EMS medical director to be involved with fundraising and grant writing, it will foster respect and dedication from the EMS system for which they are strengthening.[10]

With the increasing uncertainty of scene safety and the environment in which the patient care encounter may take place, it is of the highest importance to practice, preach, and institute methods for provider safety. Not only is scene safety within patient encounters an area of large concern, but also the least talked about issues of work-related fatigue, stress, and overall well-being of our EMS providers. The office of EMS has started numerous initiatives with NHTSA in attempts to reduce and better understand the causes of work-related violence, burnout, ambulance crashes, and physical, mental, and sexual harassment peril. With appropriate resources and tools, a prudent EMS medical director will be instrumental in helping provide a safe and productive working environment.[11][12]

The weight of regionalization on trauma centers and specialty care centers (i.e., stroke and cardiac centers) is forcing EMS to get the right patient to the right hospital in the right amount of time with the right care. On a good day, that is a monumental task fraught with pitfalls. Most of these centers fall under standards of care that are governed by the Joint Commission,  American College of Cardiology,  American Heart Association,  American College of Surgeons Committee on Trauma, and numerous other coalitions to maintain certification. Hospital systems provide patient care and outcome data, typically as a condition of their designation as a specialty center. Transport protocol and EMS provider education must be provided by the EMS medical director to ensure proper triage and treatment related to bypassing the closest facility in favor of a specialty center when warranted by the patient encounter.[4]

Clinical Significance

The role of oversight in EMS systems is intimidating, yet extremely rewarding. With many areas of the United States lacking appropriate EMS medical physician oversight, a modest effort within one's own EMS system will help raise the bar nationally. Whether it is private, military, state, county or even volunteer EMS services, increasing the safety of the general public is well within the grasp of the EMS medical director. If one feels like they are overwhelmed and have no idea where to start to improve their EMS services, a great first step is a simple EMS ride-along, allowing one to meet the amazing providers and staff that work within one's oversight.


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