EMS DOCS’ PERSPEC TIVES ON STREE T MEDICINE
Stop responding to penny problems with $100 solutions
By Mark E.A. Escott, MD, MPH, FACEP
The call comes in … it’s 9 p.m. “What’s your emergency?” “Well, I took my blood pressure;
it’s 160/100 and I ran out of my medicine.”
The caller then shares that she’s been out of
her medication for three days—and that she
has no symptoms, but wants to go to the ED
tonight so she can get another prescription.
The solution for most EMS systems across
the United States is to send an ambulance, and
maybe a fire apparatus, followed by transport
to the hospital.
The problem with this scenario: We have a
$100 solution for what is, essentially, a penny
problem. The cost of the ambulance trip alone
may have paid for a supply of her hypertension medication … for life!
TRANSPORTING OR NAVIGATING?
As we discussed in the September column,
our job in EMS is no longer simply transporting patients to the ED. Rather, our job
now involves navigating patients to the appropriate resource.
Over the past decade, EMS systems across
the U.S. have created mobile integrated healthcare and community paramedicine (MIH-CP)
programs, among others, to address these
navigation-related challenges, which usually
involve sending a paramedic for evaluation.
Although in-person paramedic evaluation
may be necessary for some patients, there
may be other circumstances, like medication
refills, that can be handled without ever sending anyone. “Hear and treat,” rather than “see
and treat,” is an option that doesn’t involve
turning a wheel, and is a much less expensive
solution for these low-acuity calls.
The “hear and treat” solution is one that’s
been booming across the U.S. over the last
As telemedicine legislation in many states
has loosened, we’ve seen the development
of physician-based telemedicine programs
that charge a fee for telephone or video con-
sultation. Physicians can then call in a pre-
scription, complete a medical note based on
a virtual physical exam with the assistance
of the patient and provide recommendations
for follow-up with a primary care physician.
These programs have not only been championed by the for-profit companies, but also
by insurance companies searching for a lower-cost solution to more expensive urgent care
and ED visits.
There are several essential questions to
consider when thinking about the applicability of these programs in the EMS setting.
The first is regarding quality. Is telemedi-
cine as safe and effective as in-person physi-
cian or paramedic evaluation? The answer is
… not sure! The better question to ask is, “Is
it good enough?”
There’s a reality we must come to realize
in America: We can’t have healthcare for all
and maintain our current spending habits on
healthcare; it’s simply not sustainable. This
includes EMS. We must look for opportuni-
ties to decrease expenses for the large number
of low-acuity calls while still maintaining our
ability to respond quickly to life-threatening
The second question is how would paramedics fit into this telehealth era of EMS?
Although we’ve experienced some notable
advances in EMS telecommunications over
the last 40 years, the most significant changes
will occur over the next 5–10 years.
We’ll see some paramedics of the future
sitting behind a console interacting with
patients, perhaps collecting data from in-home
wearable medical monitors.
We may see paramedic practitioners examining patients through their tablets and writing prescriptions that can be emailed to the
pharmacy. “Virtual EMS” will be the reality
for at least a portion of the population who
calls 9-1-1 for help.
AN EMS TRANSFORMATION
This innovation in healthcare could be transformational for EMS—and one that could
ensure its future as we look for solutions to
address population health.
There will always be a need for rapid
response of highly-skilled paramedics to a wide
variety of emergencies in our communities, but
we must also meet the other healthcare needs
of our community. In some circumstances,
Well-insured patients have access to many
options to address their healthcare needs. The
uninsured and under-insured members of
our community need other options beyond
expensive ambulance transport and ED visits.
They need affordable and effective options
to help them through their emergency, to
manage their ongoing health maintenance.
EMS has an opportunity to lead the way and
to leverage its trusted place in the community
to engage it like never before. JEMS
Mark E.A. Escott, MD, MPH, FACEP, is the
medical director for Austin-Travis County
EMS System. He’s also a medical director and
founder of Rice University EMS in Houston,
Texas and clinical assistant professor of Surgery and Perioperative Medicine at the University of Texas at
Austin-Dell School of Medicine. He serves as the chair of the
American College of Emergency Physicians Section of EMS
and Prehospital Medicine and is board-certified in emergency
medicine and subspecialty board-certified in EMS.