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.

 10In 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.

11Institute 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

 12U.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

 13These 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.

14About $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

 15Congress 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.

 16U.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

 17U.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

 18Within 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

 19Rural 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

 20G. 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.

21This 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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