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EMS Medical OversightPractical Issues

The nuts and bolts (and screws)

Edward M. Racht, MDChief Medical Officer

AMR Medicine  Evolution HealthClinical Associate Professor of Emergency Medicine

UT Southwestern School of Medicine

Thanks again to Tom Blackwell for his contributions

to EMS

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Practicality…

The How behind the What…

EMS v. 4.0______________

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The business of Medical OversightThe business of Medical Oversight

EMS is a practice of medicine …EMS is a practice of medicine …

The 9 areas of focusThe 9 areas of focus

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Establishment, implementation and maintenance of an expected

clinical standard of care

Establishment, implementation and maintenance of an expected

clinical standard of care

Oversight and delivery of training, education & professional

development

Oversight and delivery of training, education & professional

development

Performance / quality / outcomemeasurement & management

Performance / quality / outcomemeasurement & management

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Regulatory functionsRegulatory functions

Public education & integrationPublic education & integration

ResearchResearch

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Patient, provider and profession advocacy

Patient, provider and profession advocacy

Innovation and developmentInnovation and development

Practice managementPractice management

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Dissecting the business of EMS Medical Oversight (or any business, for that matter)

Dissecting the business of EMS Medical Oversight (or any business, for that matter)

• What am I expected to do?

• What do I have the authority to do?

• Who am I doing it for / with?

• How am I supported?

• How am I protected?

• What am I expected to do?

• What do I have the authority to do?

• Who am I doing it for / with?

• How am I supported?

• How am I protected?

…more specifically……more specifically…

Scope, authority & responsibility Reporting structure Compensation Support structure

– Human resources– Physical resources

Liability coverage Political climate

Scope, authority & responsibility Reporting structure Compensation Support structure

– Human resources– Physical resources

Liability coverage Political climate

Scope, authority & responsibility

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Scope, authority & responsibilityScope, authority & responsibility

• Job description

• Your role

• What the system, community, chief, etc expect from you

• The breadth and depth of your involvement

• Job description

• Your role

• What the system, community, chief, etc expect from you

• The breadth and depth of your involvement

Defining your job descriptionDefining your job description

• Be specific in potentially controversial areas

• Define reporting structure and expectations

• Review at least every year

• Be specific in potentially controversial areas

• Define reporting structure and expectations

• Review at least every year

Areas of focus(this will look familiar)Areas of focus(this will look familiar)

• Clinical practice• Education and professional

development• Performance / quality /

outcome management• Regulatory• Research• Public education • Advocacy• Innovation• MD Practice (OMD)

• Clinical practice• Education and professional

development• Performance / quality /

outcome management• Regulatory• Research• Public education • Advocacy• Innovation• MD Practice (OMD)

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Reporting structure

Reporting structureReporting structure

• Critical

• Political

• Defines authority in a practical way

• Defines allegiances

• The nature of the relationship is critical

• Critical

• Political

• Defines authority in a practical way

• Defines allegiances

• The nature of the relationship is critical

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Define the medical reporting & coordinating structure

Define the medical reporting & coordinating structure

Compensation(scary music)

EMS is a practice of medicine …EMS is a practice of medicine …

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It is appropriate to be fairly compensated for Medical Oversight services

It is appropriate to be fairly compensated for Medical Oversight services

Compensation

Difficult to talk about

No “fair market value”

“Low bid” issues No resources Potential loss of

liability protection

Difficult to talk about

No “fair market value”

“Low bid” issues No resources Potential loss of

liability protection

Compensation models

Dollar amount per every patient transport (can be billed)

Dollar amount per 911 activation (for example -$5.00)

Dollar amount per medic hour worked (“tax” on medic hours for medical oversight)

Fixed stipend Purchase hours at going ED hourly rate – define

EMS hours Buy time from current practice

Dollar amount per every patient transport (can be billed)

Dollar amount per 911 activation (for example -$5.00)

Dollar amount per medic hour worked (“tax” on medic hours for medical oversight)

Fixed stipend Purchase hours at going ED hourly rate – define

EMS hours Buy time from current practice

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Compensation models*Cautions*

Check impact on liability protection Clearly evaluate any conflicts of interest Beware of performance based contracts

linked to number of transports Be careful of compensation that can be

increased BY YOU for protocol changes Never take cash from unconscious

patients…

Check impact on liability protection Clearly evaluate any conflicts of interest Beware of performance based contracts

linked to number of transports Be careful of compensation that can be

increased BY YOU for protocol changes Never take cash from unconscious

patients…

Barter

Support resources

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Think about what you need to get the job done…Think about what you need to get the job done…

… and specifically what you need to respond and care for patients in the field… and specifically what you need to respond and care for patients in the field

Medical Director practice essentials(use what Medics have as a reference)

Personal protective equipment

Identification / Access – Branding

Radio Response vehicle

options Medical equipment***

Personal protective equipment

Identification / Access – Branding

Radio Response vehicle

options Medical equipment***

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Medical Director support

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A critical message about resources…

Walk the walk and play by the rules Walk the walk and play by the rules

Communication

Liability

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Medical Director Liability in EMSMedical Director Liability in EMS

• Medical malpractice– Personal care delivered– Care delivered under your

guidelines / protocols by others

• Inappropriate oversight– Protocols / guidelines / credentialing– Quality improvement issues

• Employment issues– Wrongful termination– Demotion– Restraint of trade– Harassment

• “Every day” liability with a physician twist

• Medical malpractice– Personal care delivered– Care delivered under your

guidelines / protocols by others

• Inappropriate oversight– Protocols / guidelines / credentialing– Quality improvement issues

• Employment issues– Wrongful termination– Demotion– Restraint of trade– Harassment

• “Every day” liability with a physician twist

Managing liabilityManaging liability

• Get appropriate coverage* and have it professionally reviewed

• Medical Directors should rarely be involved in the day to day employment issues of Providers (including hiring and firing)

• Communicate clearly, fairly and in writing on difficult issues

• Clearly define expectations of credentialing up front

• Get appropriate coverage* and have it professionally reviewed

• Medical Directors should rarely be involved in the day to day employment issues of Providers (including hiring and firing)

• Communicate clearly, fairly and in writing on difficult issues

• Clearly define expectations of credentialing up front

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System

Percent Refusals/ No Transports

Fort Wayne, IN 29%Fort Worth, TX 20%Kansas City, MO 22%Oklahoma City, OK 22%Pinellas County, FL 19%Reno, NV 24%Richmond, VA 23%Tulsa, OK 21%Clark County, WA 20%Davenport, IA 19%Little Rock, AR 15%Mecklenburg, NC 23%Monterey County, CA 29%Solano County, CA 25%

Mean 22%Median 22%

Responses Resulting in Refusals

Consider five deadly sins(Everyone knows up front and knows the consequences)

Consider five deadly sins(Everyone knows up front and knows the consequences)

• Intentionally harming a patient

• Intentionally withholding needed care from a patient

• Falsifying a medical record

• Providing care while impaired

• Failure to remediate

• Intentionally harming a patient

• Intentionally withholding needed care from a patient

• Falsifying a medical record

• Providing care while impaired

• Failure to remediate

Medical Director Liability OptionsMedical Director Liability Options

•EMS Medical Director’s Insurance

•EMS Assurance

•EMS Medical Director’s Insurance

•EMS Assurance

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The politics of EMS medicine

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Never, ever, ever, ever forget the importance of integrity and

transparency.

You are both a public official and a physician.

Never, ever, ever, ever forget the importance of integrity and

transparency.

You are both a public official and a physician.

What to do…

A To Do list……

Review any state law regarding Medical Direction of EMS in your State

Review your state licensure requirements specific to EMS

Review and enhance contract or agreement for what you do

Meet with THE person you report to and clearly define their expectations of you and medical oversight

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A To Do list…

Determine your resource needs and get them

Review your policy / procedure protocols for:

Decredentialing

Incident review

Refusals

Transport against patient will

Communicate regularly – figure out how

Asinanypracticeofmedicine,goodbusinesshelpsdelivergoodmedicine

Asinanypracticeofmedicine,goodbusinesshelpsdelivergoodmedicine

EMS is no different…EMS is no different…

EMS is a practice of medicine …EMS is a practice of medicine …

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Thanks for the privilege today…Thanks for the privilege today…