and 48 objectives. Each objective had a specific plan that identified national needs, suggested activities and mechanisms to achieve the objective, and listed potential partners. In 1998, the plan was updated with baseline data, refined objectives, and progress in completing activities [65].
EMS Physicians 1982‐1996
Throughout the 1970s, emergency physicians and the fledgling ACEP supported regional EMS programs. By 1983, emergency physicians and the embryonic state chapters of ACEP were primarily focused on developing their new specialty and care in emergency departments. During this period, medical directors for EMS systems around the country increasingly began to publish articles in scientific journals on prehospital research and on their experiences with prehospital care. Gradually, they began to meet and, in the process, found many areas of common interest. After a series of organizational meetings that began in Hilton Head, South Carolina, in 1984, the National Association of EMS Physicians (NAEMSP) was created in 1985, with Dr Ron Stewart as its first president. By the late 1980s, emergency physician specialty groups such as ACEP and the Society for Academic Emergency Medicine also placed more emphasis on EMS and began to encourage EMS‐related activities among their members.
Training 1982‐1996
In the early 1980s, NHTSA developed an EMT‐I curriculum and by 1992 developed the EMT‐B curriculum (EMT‐basic, formerly the EMT‐A level), which was a success and adopted by most states. The EMT‐B curriculum included the use of automated external defibrillators as recommended by the AHA [42] and assisting patients with their medications. The National EMS Training Blueprint Project Task Force, sponsored by the NREMT, began a process in 1993 to define more clearly the scope of practice of EMS personnel [66].
Transportation 1982‐1996
Encouraging the use of voluntary ambulance standards was common from 1983 to 1990. By 1990, issues of ambulance operations, safety, and optimal mode of response were starting to be a risk‐management concern and more services began to use medical priority dispatch systems. The number and availability of medical helicopters increased, but with as many as 44 air ambulance crashes in one year, safety concerns began to increase as well.
1996‐2008: The Role of the Federal Government Matures, the United States Faces Terrorism, and EMS is at the Breaking Point
EMS Agenda for the Future
In 1996, NHTSA and HRSA published the EMS Agenda for the Future [67]. This document was the culmination of a year‐long process to develop a common vision for the future of EMS. The federally funded project was coordinated by NAEMSP and NASEMSO with involvement of hundreds of other organizations and EMS‐interested individuals who provided input to the spirit and content of the agenda. In addition to describing a vision for the future of EMS, the document discusses 14 attributes of the EMS system and outlines steps that will enable progress toward realizing that vision (Box 1.3). Shortly after its initial publication, thousands of copies of the EMS Agenda for the Future had been distributed to guide EMS system‐related planning, policy creation, and decision‐making.
Box 1.3 EMS Agenda for the Future attributes of the EMS system.
Integration of health services
EMS research
Legislation and regulation
System finance
Human resources
Medical direction
Education systems
Public education
Prevention
Public access
Communication systems
Clinical care
Information systems
Evaluation
Source: Modified from [67].
EMS Education for the Future: A Systems Approach
In December 1996, NHTSA held a conference to address the EMS education recommendations of the EMS Agenda for the Future report published earlier in the year. Over the next two years, an EMS Education Task Force was established. The goals were expanded to include defining the essential elements of a national EMS education system, as well as the education organizational and disciplinary interrelationships necessary to achieve the recommendations in the Agenda.
The outcome of the Task Force was the document entitled the EMS Education for the Future: A Systems Approach [68]. It called for development of five components of an overall EMS education system following the model of medical education: a national EMS core content, a national EMS scope of practice model, national EMS education standards, national EMS education program accreditation, and national EMS certification. General responsibility for each of the components was assigned to specific disciplines of the EMS community: EMS core content – physicians; scope of practice – state regulators; education standards – EMS educators; national program accreditation – educational programs; and certification – assumed by NREMT. Subsequent projects and documents for each of these areas were developed to fill those needs:
EMS Core Content publication – 2005; updated 2012 and 2019
EMS Scope of Practice publication – 2005; updated 2019
EMS Education Standards publication – 2009; planned update 2021
National Ambulance Fee Schedule
Complaints about Medicare reimbursement for ambulance services based primarily on transportation of the patient increasingly became an issue during the 1990s. Specifically, there were concerns about the lack of uniformity in reimbursement from region to region. The Balanced Budget Act of 1997 required the Health Care Financing Administration (HCFA) to commence a negotiated rule‐making process with industry groups and develop a national fee schedule for ambulance services. That process began in 1999 when HCFA established a rules committee that included HCFA, the American Ambulance Association, the International Association of Fire Chiefs, the International Association of Firefighters, the National Volunteer Fire Council, the AHA, the National Association of Counties, NASEMSO, the Association of Air Medical Services, and a single physician representing both ACEP and NAEMSP.
The regulations and national fee schedule that resulted from the negotiated rule‐making process became effective on April 1, 2002 [69]. The fee schedule established seven national categories of reimbursement for ground ambulances: BLS (emergency and non‐emergency), ALS (emergency and non‐emergency), a second level of ALS for complex cases, paramedic ALS intercept, and specialty care transport. In addition, there were two categories for air medical transport: fixed‐wing and rotor‐wing. The final rule also included adjustments for regional wage differences as well as for services provided in rural areas where the cost per transport is generally higher due to the lower overall numbers of transports. Reimbursement, however, was
