As previously noted, all EMS agencies must have a physician EMS medical director who oversees the medical care provided by the agency and its personnel. The primary responsibilities of EMS medical directors are to establish protocols and training for their providers and to perform quality improvement and quality assurance functions for their providers and agencies.
In Colorado, no state laws govern how medical direction must be established or funded. Medical direction oversight occurs within EMS agencies that provide services one of three ways, via: 1) a government provider, either county-based or special district-based, 2) a private service, or 3) a dual system with both fire (public) and EMS agencies (private) responding.
The various methods of funding EMS agencies are pertinent to medical direction in Colorado. The panel learned that in general, three different funding models are utilized for EMS medical direction:
- Medical direction is funded by a hospital system with which the physician is employed. These hospitals supply medical direction to agencies without charge. This model is most common in the Denver Metro area.
- Medical direction is funded by the EMS agency for which medical direction is provided.
- Medical direction is provided by a local community physician who volunteers for a local agency. A local physician provides medical direction pro bono because the local EMS agency does not have funds for an EMS medical director. This model is more often found in rural areas or smaller agencies.
The panel discussed the pros and cons of the various models and funding methods. Some models allow an EMS medical director more autonomy than others and some provide for better accountability than others. For example, all EMS medical directors have the right to remove an EMS provider from practicing under their direction. However, in some systems, the medical director who attempts to limit a provider’s practice or otherwise discipline a provider may run into pushback or experience resistance since doing so affects the number of employees available to respond. Further, an EMS agency medical director whose salary is paid for by a hospital will enjoy greater job security because the funding is not tied to the agency. Conversely, an appearance of bias may arise if a hospital pays a medical director’s salary and the medical director’s EMS agency frequently directs prehospital patients to that hospital system’s facilities.
Apart from these different service and funding models, significant variability exists in EMS medical direction in Colorado.
- Most medical directors maintain an active clinical practice, while others work in medical administration.
- Many provide medical direction for more than one EMS agency, so the number of EMS providers for which medical direction is provided varies greatly.
- Medical directors who provide medical direction for more than one agency or whose work is funded by a hospital system have support staff to assist them with their oversight responsibilities. Most medical directors serve in that capacity part-time.
- While all medical directors are physicians, their specialties vary. Some are board-certified in emergency medical services and/or emergency medicine, while others come from specialties such as family practice or pediatrics.
- Some medical directors collaborate with other medical directors in their region to develop consistent practice standards while others, especially in rural areas, have limited opportunities to do so.
This variability is due in part to the fragmented nature of Colorado’s EMS system, especially with respect to the oversight of EMS medical directors.
1. Decentralized Oversight of EMS Medical Directors
Three different entities have a role in the oversight of EMS medical directors: 1) the EMS ground ambulance agency that, as the county licensee, is required to have a medical director; 2) CDPHE, which regulates the minimum standards and medical direction oversight requirements applicable to EMS medical directors; and 3) the Colorado Medical Board, which is authorized to oversee physician medical licensure.
EMS ground ambulance agency oversight. Counties are the designated licensing entities for ground ambulance agencies.
- State law requires that the state Board of Health promulgate minimum standards for ground ambulance agency licensing by counties, including standards for medical oversight and quality improvement of ambulance services.[59] These standards are codified in CDPHE regulations at 6 CCR 1015-3, Chapter Four, Section 8. The regulations mandate that the county require each ambulance agency operating within its jurisdiction to have a primary medical director to supervise the medical acts performed by the EMS providers of the agency.
- Additionally, the county requires each licensed ambulance agency to have an ongoing medical continuous quality management (CQM) program consistent with CDPHE’s regulations for medical direction oversight at 6 CCR 1015-3, Chapter Two.
- Lastly, the county ambulance licensure application must include an attestation by the medical director of willingness to provide medical oversight and establish the CQM program for the ambulance service.
CDPHE regulations. Due to the medical nature of EMS, CDPHE’s oversight of EMS medical directors is set forth in regulations promulgated by CDPHE’s executive director (or by the chief medical officer if the executive director is not a physician).[60] These regulations define the duties and responsibilities of all EMS medical directors and the physician medical direction required for appropriate oversight of EMS providers. EMS medical directors must:
- Establish a medical continuous quality improvement (CQI) program for each EMS agency being supervised;
- Provide monitoring and supervision of the medical field performance of EMS providers;
- Ensure that all protocols issued by the medical director are appropriate for the certification or license and skill level of each EMS provider to whom the performance of medical acts is authorized and compliant with accepted standards of medical practice; and
- Be familiar with the training, knowledge, and competence of EMS providers under his or her supervision and ensure that EMS providers are appropriately trained and demonstrate ongoing competency in all authorized medical acts.
In addition, a Colorado EMS medical director must be currently licensed in good standing to practice medicine in the state, be actively involved in the provision of EMS in the community served by the EMS agency being supervised, be actively involved on a regular basis with the EMS agency being supervised, and be trained in Advanced Cardiac Life Support, to list a few of the regulations.
However, current Colorado regulations do not mandate any specific education or training for EMS medical directors. This is, in part, due to the diversity of Colorado, which consists of a few large urban areas and many suburban and rural areas spread throughout the state.
Colorado Medical Board (CMB). The Colorado Medical Board regulates EMS medical directors only to the extent that their activities rise to the level of violating physician standards of conduct set forth in the Medical Practice Act, Section 12-240-101 et seq., C.R.S. The CMB can discipline physicians who are found to have violated these standards, including suspending or revoking medical licenses.
All physician medical directors are subject to discipline by the CMB if they perform “any act or omission that fails to meet generally accepted standards of medical practice; . . .”[61] These generally accepted standards of medical practice are commonly referred to as “the standard of care.” The panel learned that the standard of care has two components: 1) a local standard of care and 2) a national standard of care. The national standard of care/practice is informed by national and specialty standards as applicable, and is typically understood to be the level and type of care that a reasonably competent and skilled EMS physician medical director with a similar background would have provided under the circumstances. Organizations like the NAEMSP and the Eagles Coalition focus specifically on national practice standards for EMS medical directors.[62] The local standard of care is derivative of the national standard of care, but allows for local variations based on practices in the same medical community and consistency with other local agencies. For example, the Denver Metro EMS Medical Directors (DMEMSMD) is a group of 36 Denver-area EMS medical directors that meets every two months to review medical practices and to develop joint protocols for all EMS agencies in the area. In this way, the care provided to a patient is similar, irrespective of which metro area EMS agency responds to the call.
In summary, three distinct entities have some degree of oversight over EMS medical directors. As a current EMS medical director explained to the panel, EMS medical directors are essentially responsible for complying with CDPHE regulations and following the standard of care for EMS physicians.
2. Panel Review of EMS Medical Director Oversight
The panel reviewed several examples of robust EMS quality improvement programs and acknowledged that such programs are not feasible for all EMS agencies. In rural areas especially, where many of the EMS providers as well as the medical director volunteer their time, the QI/QA programs are likely nominal. Moreover, the panel was in full agreement that relying solely on EMS medical directors to perform all continuous quality improvement and quality assurance functions is overly burdensome and unrealistic.
The panel learned the manner in which EMS medical director oversight occurs in other states. All other states except California regulate the EMS ground ambulance agencies at the state level and are therefore able to address EMS medical direction at the agency and personnel level. The panel reaffirms its position in Recommendation D.5 that CDPHE request the legislature to consider whether ground ambulance agency licensing should occur at the state level.
The panel also learned how some states credential EMS medical directors. For example, the state of Virginia preserves the independent function of requiring medical directors to be accountable to the state medical board. However, Virginia’s EMS office also requires EMS medical directors to complete the state’s EMS medical director credentialing process. The credentialing process requires EMS medical directors to become proficient in learning protocols as well as the state’s EMS regulatory structure. The Texas medical board tracks which physicians operate as EMS medical directors by requiring an attestation at the time of the physicians’ license renewals.
Other than a Medical Director Course and some position statements by the NAEMSP (see position statement) providing guidance on principles of medical direction, the panel learned that training specific to the practice of EMS medical direction is scarce. In the panel’s experience, some Colorado EMS medical directors practice conservatively while others do not have built-in redundancies or sufficient oversight. More could be done to ensure consistency and rigor in Colorado’s EMS medical director practice and to mitigate the effect of Colorado’s fragmented oversight system.
In 2011, the State Emergency Medical and Trauma Services Advisory Council (SEMTAC) recommended that grant funding be provided to Colorado’s 11 Regional Emergency Medical and Trauma Services Advisory Councils (RETACs) for EMS medical direction. SEMTAC determined that funding that supports a medical direction resource for all EMS medical directors within a region would lead to standardization of protocols and care within the region and would ultimately benefit both the agencies and the patients they care for. Most RETACs have adopted this regional medical direction model, although some areas have a more difficult time recruiting and retaining physicians to serve as regional medical directors. Most regional medical directors are also providing medical direction to agencies within that region.
After this regional medical director concept became widely adopted, the EMPAC formed a committee, aptly entitled Regional Medical Directors. This committee meets prior to the EMPAC meeting each quarter; its members share best practices and discuss pressing issues. The EMPAC, RETACs and the Regional Medical Direction committee are valuable resources for Colorado’s EMS medical directors, leading the panel to recommend increased engagement between medical directors and their RETACs.
PANEL RECOMMENDATIONS
Physicians should be required to take a CDPHE-approved training course pertaining to EMS medical direction as a prerequisite to serving as an EMS medical director.
CDPHE should establish a credentialing or certification program for EMS medical directors.
EMS medical directors should collaborate and engage with other medical directors and with their RETACs and the RETAC medical director regarding professional matters such as the development of protocols and standards.
CDPHE should provide forums or opportunities in which medical directors can collaborate with one another.