The Vision

The Agenda provided the following overall vision for EMS in the Future:

Emergency Medical Services (EMS) of the future will be community-based health management that is fully integrated with the overall health care system. It will have the ability to identify and modify illness and injury risks, provide acute illness and injury care and follow-up, and contribute to treatment of chronic conditions and community health monitoring. This new entity will be developed from redistribution of existing health care resources and will be integrated with other health care providers and public health and public safety agencies. It will improve community health and result in a more appropriate use of acute health care resources. EMS will remain the public's emergency medical safety net.

The following vision of EMS education is paraphrased from the EMS Agenda for the Future:

EMS education in the year 2010 develops competence in the areas necessary for EMS providers to serve the health care needs of the population. Educational outcomes for EMS providers are congruent with the expectations of the health and public safety services that provide them. EMS education emphasizes the integration of EMS within the overall health care system. In addition to acute emergency care, all EMS educational programs teach illness and injury prevention, risk modification, the treatment of chronic conditions, as well as community and public health.

EMS education is of high quality and represents the intersection of the EMS professional and the formal educational system. The content of the education is based on nationally developed National EMS Education Standards. There is significant flexibility to adapt to local needs and develop creative instructional programs. Programs are encouraged to excel beyond minimum educational quality standards. EMS education is based on sound educational principles and is broadly recognized as an achievement worthy of formal academic credit.

Basic level EMS education is available in a variety of traditional and non-traditional settings. Advanced level EMS education is sponsored by institutions of higher education and most are available for college credit. Multiple entry options exist for advanced level education, including bridging from other occupations, basic EMS levels and for individuals with no previous medical or EMS experience. All levels of EMS education are available through a variety of distance learning and creative, alternative delivery formats.

Educational quality is assured though a system of accreditation. This system evaluates programs relative to standards and guidelines developed by the national communities of interest. Entry level competence is assured by a combination of curricula standards, national accreditation, and national standard testing.

Licensure is based upon the completion of an approved/accredited program and successful completion of the national exam. This enables career mobility, advancement, and facilitates reciprocity and recognition for all levels.

Interdisciplinary and bridging programs provide avenues for EMS providers to enhance their credentials or transition to other health career roles, and for other health care professionals to acquire EMS field provider credentials. They facilitate adaption of the work force as community health care needs, and the role of EMS, evolves.

In December 1996, NHTSA convened an EMS Education Conference with representatives of over 30 EMS-related organizations to identify the next logical Agenda implementation steps, including, in particular, determining NHTSA's future contributions to EMS education. This meeting's consensus is broadly summarized by the following recommendations:

• National EMS Education Standards are necessary, but need not include specific declarative material or lesson plans. NHTSA should support and facilitate the development of National EMS Education Standards.

In January 1998, NHTSA formed a Blueprint Modeling Group to develop the procedures for revising the National EMS Education and Practice Blueprint. During their initial deliberations, the group determined that the Blueprint should be only one component of a more comprehensive EMS education system of the future. Consequently, they changed their name to the EMS Education Task Force. They expanded their goal to include defining both the elements of the education system and the interrelationships necessary to achieve the vision of the EMS Agenda for the Future. This document, the EMS Education Agenda for the Future: A Systems Approach, is the result of their deliberations.

Executive Summary

The EMS Education Agenda for the Future: A Systems Approach is a vision for the future of EMS education, and a proposal for an improved, structured system, to educate new out-of-hospital emergency providers. The EMS Education Agenda is based on the broad concepts for EMS education laid out by the 1996 EMS Agenda for the Future. The EMS Education Agenda for the Future builds on these concepts to create a comprehensive plan for an education system that will result in improved efficiency for the national EMS education process, enhanced consistency in education quality, and ultimately, greater entry-level student competence.

The EMS Education Agenda for the Future: A Systems Approach was developed by a Task Force representing the full range of professions involved in EMS education including EMS administrators, physicians, regulators, educators, and providers. This document proposes an education system with five integrated primary components:

The proposed system maximizes efficiency, consistency of instruction quality, and student competence by prescribing a high degree of structure, coordination, and interdependence among the five components.

Key among the benefits of this system approach is the ability to influence consistency in instructional quality through an interaction among National EMS Education Standards, National EMS Education Program Accreditation and National EMS Certification. At the higher levels of education, this strategy for ensuring consistency allows the use of less prescriptive National EMS Education Standards in place of the current National Standard Curricula. With less dependence on a prescriptive National Standard Curriculum, instructors will have greater flexibility for targeting instruction to specific audiences, resulting in enhanced comprehension and improved student competence.

The EMS Education Agenda for the Future describes an interdependent relationship among the five system components and recommends specific lead groups for development and revision responsibilities.

The National EMS Core Content is a comprehensive list of skills and knowledge needed for out-of-hospital emergency care. Specification of the Core Content is primarily a medical concern and will be led by the medical community, with input from the system regulators, educators, and providers.

The National EMS Scope of Practice Model divides the National EMS Core Content into levels of practice, defining minimum knowledge and skills for each level. Since this determination is fundamentally a system issue, the system regulators will have the lead in its development, with input from the other stakeholders.

The National EMS Education Standards take the place of the current National Standard Curricula, specifying minimum terminal learning objectives for each level of practice. Being basically an educational task, the development of the National EMS Education Standards will be led by educators, with input from other stakeholders.

National EMS Education Program Accreditation and National EMS Certification will be full coverage and universal, enhancing consistency of instruction quality and outcomes by covering each of the provider levels and all education programs. Full coverage accreditation will require the development of appropriate standards and guidelines for each level of practice. To achieve accreditation, an education program will need to provide instruction which is consistent with the National EMS Education Standards. In order to be eligible for National EMS Certification, a student must have graduated from an accredited program.

Administratively, the system proposed in the EMS Education Agenda offers a number of benefits, including greater predictability for component development cycles, and a clear and definite method for introducing changes to the system. These provisions will clarify the process for accommodating medical advances, technology development, and other needs that affect the scope or content of EMS education while following the attributes of the 1996 EMS Agenda for the Future.

Introduction

Since its inception, emergency medical services (EMS) education has evolved and matured. As is true of most new professions, no "master plan" was conceived to guide its evolution systematically. Excellent individual components of quality EMS education have emerged during the last thirty years, including national standard EMS curricula, accreditation standards, and a national registration system. Unfortunately, these individual parts have developed independently and currently there is no formal EMS education system in which the components are clearly defined, their interrelationships articulated, and the decision-making process for modification and improvement established.

Although many outstanding EMS providers have been educated during the last thirty years, the absence of a formal education system has resulted in considerable state-by-state variability in EMS education, licensing standards and a lack of clear-cut future direction. Without a formal EMS education system, it has been difficult to bridge from one level of education to another, there have been inconsistencies among the various curricula, there has not been a consistent method of providing input to the national EMS education decision-making process, while the national standard curricula have limited instructor flexibility, yet are infrequently updated. EMS education is at a crossroads in its evolutionary process.

In the 1970's, the stakeholders of EMS had no way to predict the challenges that would face EMS in its rapid growth period. The diversity of EMS providers (from paid, full-time peronnel to volunteers), system design (hospital-based to public safety-based), and local variations of practice have presented unique challenges that do not face other allied health care professions. As identified in the EMS Agenda for the Future, there are numerous challenges to preparing EMS providers for their role in the next millennium. Clearly, there is the need for a national EMS education system to serve as a "master plan."

To accommodate the increasing sophistication and changing nature of EMS systems, the EMS Education Agenda for the Future: A Systems Approach describes the structure and the process by which the EMS education system (master plan) of the next millennium will evolve. This document defines the EMS education system elements, describes their interrelationships, clarifies a decision-making process, establishes methods for input and accommodates improved data and research. It defines a system which promotes national consistency but is flexible for individual states while facilitating rapid inclusion of innovative methods of patient care. The synergistic effects of the system are enormous; clearly, the whole is greater than the sum of its parts. The system's infrastructure must outlive its architects while assuring a viable framework for national EMS education decision-making and future planning.

As the sophistication and complexity of medical care increased, the 1960s saw a number of allied health professions join the ranks of nurses and physicians to provide care to patients in this country. In 1966, Congress passed The Allied Health Professions Training Act. This legislation provided a formal system of physician-directed practice and gave the American Medical Association (AMA) the authority to grant authorization to institutions that sponsor and provide instruction to allied health professionals.

Through the Commission on Allied Health Education Accreditation (CAHEA), the AMA developed a system which accredited educational institutions to conduct allied health educational programs. The CAHEA model of accreditation (now administered by the Commission on Accreditation of Allied Health Education Programs - CAAHEP) was similar to the process used by nursing and medical schools. Each recognized allied health occupation developed a Joint Review Committee (JRC), consisting of membership from physician and professional associations. With broad community input, each JRC was charged with developing essentials or standards which would be used as the basis of evaluating and accrediting programs.

Throughout the past three decades, allied health has experienced a transition from on-the-job training to education in formal institutions of higher education. Initially allied health education programs were generally sponsored by health care institutions. Since the late 1960s, the trend toward collegiate and university settings has been rapid and steady. Most allied health fields continued to press for more and better training and have instituted educational requirements which include formal academic degrees (Farber and McTernan, 1989). By 1980 over half of the allied health programs in the United States were housed in collegiate settings (Ford, 1983). By 1998 there were 16 accrediting agencies and 47 recognized allied health occupations (AMA, 1998).

Most allied health programs have a registration or certification process which is national in scope and typically sponsored by a professional association. Although there are some exceptions, eligibility for registration or certification is typically limited to individuals who have graduated from accredited training programs. Since authorization to practice is a state function, state licensure is usually granted to individuals who have completed the examination process established or endorsed by the profession.

The past frequently can help us to understand the present and to plan for the future. The depth of our educational past is how we are able to arrive at today and be prepared for tomorrow. The history of EMS education is largely synonymous with the history of emergency medical services systems. Pioneers in EMS clearly recognized the importance of strong educational programs. For each of the following time periods, a summary of the pertinent EMS education developments is presented, followed by a summary of the issues which are important to the development of the EMS Education Agenda for the Future. This summary is not to criticize the review of the processes or the decisions of those times, but to highlight opportunities for future improvements. We are able to identify these issues with the benefit of hindsight. The EMS pioneers who were instrumental in developing EMS education laid the foundation upon which future generations can build. From our current vantage point, our systems-oriented thinking and the current evolution of emergency medical services education, it is a natural time to reevaluate the past and look toward the future.

1950 to 1970

EMS Education Developments

In the mid-50's, the American College of Surgeons (ACS) developed the first training program for ambulance attendants. The American Academy of Orthopedic Surgeons (AAOS) also conducted courses for ambulance service personnel culminating in 1967 with the first "Orange Textbook", Emergency Care and Transportation of the Sick and Injured, edited by Doctor Walter Hoyt. Combined with the text Training of Ambulance Personnel and Others Responsible for Emergency Care of the Sick and Injured at the Scene and During Transport, developed by the National Academy of Sciences and National Research Council (NAS/NRC), these two documents were the first national attempt to standardize EMS training (Becknell, 1997).

The NAS/NRC's Accidental Death and Disability: The Neglected Disease of Modern Society, which suggested that the quality of prehospital care was an important determinant of survival in sudden injury, stimulated the development of federal funding through the Highway Safety Act of 1966. In 1969, the Highway Safety Bureau, later to become the National Highway Traffic Safety Administration (NHTSA), came into existence and the development of the first curriculum to standardize ambulance attendant training (EMT-Ambulance) was begun by Dunlap and Associates under contract to NHTSA.

Issues Important to EMS Education Agenda for the Future: A Systems Approach

1970-1980

EMS Education Developments

In 1971, the EMT-Ambulance: NSC was delivered to NHTSA by Dunlap and Associates. This NSC provided information on course planning and structure, objectives, detailed lesson plans, specific content material, and suggested hours of instruction. In response to model legislation recommended by NHTSA, many states adopted the national standard curriculum in either law or rules; the curriculum and the scope of practice became intertwined.

The Emergency Medical Services Systems Act (P.L. 93-154), passed by Congress in 1973, provided categorical grant funds for the establishment of regional emergency medical services systems which embraced fifteen key components, including training and manpower. Training was thereby assured a prominent place in EMS system development.

Perceiving a need for a separate EMS training program for law enforcement officers, NHTSA developed the 40 hour Crash Injury Management for the Law Enforcement Officer training program in the early 1970s. Subsequently, this evolved into the First Responder: NSC (1979).

The first Board of Directors meeting of the National Registry of Emergency Medical Technicians (NREMT) took place in 1970. The purpose of the National Registry was to provide uniformed standards for the credentialing of ambulance attendants (NREMT, 1997).

In 1975, the American Medical Association (AMA) recognized the EMT-Paramedic as an allied health occupation. The Essentials for EMT-Paramedic Program Accreditation were developed in 1976 and adopted in 1978 by the AMA Council of Medical Education. The Joint Review Committee on Education Programs for the EMT-Paramedic (JRCEMT-P) made the "Essentials" the standard for evaluating programs seeking accreditation (JRCEMT-P, 1995). Although EMS education and allied health education developed at approximately the same time, they frequently took divergent paths.

Primarily in response to developments in the early management of cardiac patients, the first EMT-Paramedic: NSC was developed by NHTSA in 1977 and included 15 modules of instruction. Subsequently, the National Council of State EMS Training Coordinators, Inc. (NCSEMSTC) and the NREMT developed an additional EMS level between the EMT-Ambulance and the EMT-Paramedic levels of practice. This grew out of the perceived need to have certain emergency capabilities available to victims even though they could not support a paramedic level service. Modules I, II, & III of the EMT-Paramedic: NSC (Roles & Responsibilities, Human Systems: Patient Assessment, & Shock and Fluid Therapy) plus the esophageal obturator airway and anti-shock trouser lessons were designated as the EMT-Intermediate: NSC.

Increasingly, the NHTSA curricula became national standards for EMS education and continued to be referenced in many state laws and administrative rules as the basis for scope of practice.

Issues important to the EMS Education Agenda for the Future: A Systems Approach

1980-1990

EMS Education Developments

In 1984 the NCSEMSTC, under contract to NHTSA, revised the EMT-Ambulance: NSC and increased the number of hours from 81 to 110. There was little EMS system involvement in this revision process. The EMT-Paramedic: NSC revision was completed by NCSEMSTC and was reorganized into a 6 division/27 subdivision format. A stand-alone EMT-Intermediate: NSC was also developed by the NCSEMSTC. Common to most of these curricula were detailed instructor lesson plans, course guides and refresher courses.

In addition to an increase in the number of EMS providers trained and certified, there was an increase in both the number and the quality of textbooks and educational support material referencing the national standard curriculum.

Issues Important to the EMS Education Agenda for the Future: A Systems Approach

1990-2000

EMS Education Developments

Recognizing the need to look more comprehensively at the future of EMS education, NHTSA in 1990 convened the Consensus Workshop on Emergency Medical Services Training Programs. For the first time, representatives of the EMS community discussed the national curricula needs of EMS providers and identified the priority needs for EMS training. The priorities established at this consensus meeting determined the national priorities for EMS education for the 1990s.

A formal, national, multi-disciplinary consensus process was used to develop the National EMS Education and Practice Blueprint in 1993. This was the first attempt to determine prospectively and systematically the levels of EMS providers. The purpose of the Blueprint was to establish: 1) nationally recognized levels of EMS providers; 2) nationally recognized scopes of practice; 3) a framework for future curriculum development projects; and 4) a standardized pathway for states to deal with legal recognition and reciprocity. This consensus process, involving initial peer review and subsequently a formal national consensus meeting moderated by an independent facilitator, set the stage for future EMS consensus activities.

In 1994, Samaritan Health Services completed the EMT-Basic: NSC (renamed from EMT-Ambulance) under contract to NHTSA. The curriculum, which remained at 110 hours by contract, changed the emphasis of EMT-Basic education from diagnosis-based to assessment-based. "Nice to know" information was de-emphasized and "need to know" information was stressed. Despite an expert panel approach, the changes in the EMT-Basic curriculum generated considerable national discussion and attention. Increasingly, there was recognition that the method of changing the curriculum was as important as the content. The 1994 EMT-Basic: NSC again provided detailed declarative material for each section without formal instructor lesson plans.

In 1995, the First Responder: NSC was revised by the Center for Emergency Medicine of Western Pennsylvania under contract to NHTSA. This curriculum also provided detailed declarative material without formal instructor lesson plans.

That same year, the EMS community, as represented by numerous national organizations, adopted the EMS Agenda for the Future. The document provided broad guidance for continuing development of the EMS system along with a number of specific EMS education recommendations.In 1996, NHTSA convened an EMS Education Conference with representatives of over 30 EMS- related organizations to identify the next logical steps to implement the education section of the EMS Agenda for the Future. The recommendations of this group eventually culminated in the preparation of this document.

The proliferation of EMS textbooks and instructional materials has continued. Alternative methods of EMS education (e.g., Internet, CD-ROM, distance education) are becoming more prominent.

In 1998, the EMT-Intermediate and EMT-Paramedic: NSC were revised by the Center for Emergency Medicine of Western Pennsylvania under contract to NHTSA. This revision utilized an expert panel and modified national consensus approach. Although reasonably consistent with the National EMS Education and Practice Blueprint, the emphasis on expanded skills and a more diagnosis-based approach to EMT-Paramedic education made it dichotomous with the recently revised EMT-Basic: NSC. These issues generated considerable national controversy. Most discussion centered around the scope of practice and the degree of declarative information rather than on educational methodology. The close relationship between curriculum and scope of practice issues made the resolution of challenges more difficult. Detailed content outlines were still included.

Issues Important to the EMS Education Agenda of the Future: A Systems Approach

Although there was more involvement on the part of providers, medical directors and state EMS offices in determining the direction of the 1990 training consensus meeting and the National EMS Education and Practice Blueprint, there was still not a well-defined infrastructure and system to guide future EMS education.

In many states, the scope of practice was still driven by the national standard curricula, thus politicizing and complicating the writing of national standard curricula.

Although the National EMS Education and Practice Blueprint defined provider levels and their requisite level of knowledge and skills, the overall purpose and philosophy of the document was not well understood by many decision makers. Also, a systematic and well-defined method of updating the Blueprint did not exist.

National standard curricula development was expensive, fraught with political and practical difficulty, consumed enormous resources and energy, and frequently fragmented the national EMS community.

Quality education resources supplied by the private sector increased substantially by way of textbooks, instructor lesson plans, CD-ROM, Internet, distance education and others. The national standard curricula, however, continued to include declarative material that was frequently used in place of instructor lesson plans.

The EMS Agenda for the Future made a number of recommendations for the EMS education system of the future. The recommendations included the development of core content to replace current curricula, increased EMS education program academic affiliation, increased reliance on an accreditation process, additional flexibility for local programs while assuring minimum entrance level competencies, and an improved ability to bridge from one education level to another.

Leaders of national EMS organizations representing EMS administrators, physicians, regulators, educators, and providers met at a NHTSA-sponsored EMS education meeting and specified that EMS needed a cyclic process for curriculum revision that embraced all provider levels and enhanced flexibility, yet promoted national consistency.

The EMS Education Agenda for the Future Task Force met and initiated the development of this document.

During the past thirty years, considerable progress has been made in EMS education. As we approach the next millennium, public expectations and the changes in health care are creating new opportunities for EMS. This document, the EMS Education Agenda for the Future: A Systems Approach, is a proposal that will enable EMS to evolve, advancing the system capabilities during this unique period in history.

• Current limitation: There is not an established national EMS education system or master plan.

Proposed solution: The EMS Education Agenda for the Future: A Systems Approach proposes a system consisting of the following five components:

National EMS Core Content
National EMS Scope of Practice Model
National EMS Education Standards
National EMS Education Program Accreditation
National EMS Certification

The responsibility for each component's accomplishment is clearly delineated, the participants identified, the process for participation established, the decision-making process defined and the components' interrelationships specified.

• Current limitation: The overall domain of EMS knowledge and skills has not been defined. Each time curricula are developed, this issue is revisited, causing extensive discussion and considerable frustration.

  Proposed solution: Develop a National EMS Core Content which describes the entire domain of out of hospital emergency medical care. Establish a schedule and method for updating the National EMS Core Content. Consequently, there is not a need to revisit the medical appropriateness of each procedure or cognitive domain each time the standards are revised. With this essential framework, the architects of the other system components need concentrate only on their specific area of responsibility, not defining and redefining the overall domain of practice.

• Current limitation: National standard curricula drives the scope of practice for EMS providers.

Proposed solution: Scope of practice should drive national education standards. Revise the National EMS Education and Practice Blueprint and rename it the National EMS Scope of Practice Model. The National EMS Scope of Practice Model will define, by name and by function, the levels of out of hospital EMS providers based upon the National EMS Core Content. The National EMS Scope of Practice Model, rather than the curricula, will drive the scope of practice and national provider level nomenclature and establish the entry level competencies. With the scope of practice no longer determined by the curricula or the National EMS Education Standards, there will be considerable flexibility in designing EMS education programs.

With an established schedule and method for updating the National EMS Scope of Practice Model, state-established scopes of practice can be regularly and consistently updated and will keep pace with EMS practice analysis and EMS research. Medical directors, EMS providers, state officials and others will know precisely how and when they can provide input to the Blueprint.

• Current limitation: The EMS national standard curricula, with their detailed declarative material, limit instructor flexibility and the ability to adapt to local needs and resources.

  Proposed solution: The National EMS Education Standards will have broadly defined educational objectives that define goals and terminal performance objectives for each level of EMS provider. It will be regularly updated. These standards will serve as the basis for detailed declarative instructional materials and instructor lesson plans to be developed by instructors, educational institutions, publishers and others.

  Rather than having national standard curricula which define one national method of instruction, a greater variety of lesson plans will be available from vendors of educational materials and from educational institutions. The National EMS Education Standards will promote improved flexibility for the instructor and allow multiple methods of reaching educational objectives while still remaining consistent with National EMS Education Standards.

• Current limitation: Quality of EMS education is variable throughout the nation. Adherence to the NSC in and by itself does not assure quality.

  Proposed solution: Develop National EMS Education Standards along with a program of accreditation and national certification. Consistent National EMS Education Standards, combined with national accreditation of EMS programs and national certification, will provide greater assurance of the quality and consistency of both the process and outcome of EMS education.

• Current limitation: The appropriate disciplines do not have the appropriate responsibilities in the current scheme. Physicians and regulators make educational decisions, educators and regulators make medical decisions, physicians and educators make regulatory decisions.

Proposed solution: The proposed system will align the primary responsibilities appropriately with the content experts while recognizing that the entire system is a fully cooperative effort. National EMS Core Content is developed by physicians with input from regulators, educators and providers. National EMS Scope of Practice Model is developed by regulators with input from physicians, educators and providers. National EMS Education Standards are developed by educators with input from physicians, regulators, administrators, and providers.

• Current limitation: It is not clear who ultimately makes decisions about the education components, nor how one has input or participates in the decision making process.

Proposed solution: The EMS Education Agenda for the Future clearly delineates who is responsible for each component, how input is provided, how decisions are made and when the components are updated.

• Current limitation: There is considerable variability in the names of EMS provider levels from state to state.

Proposed solution: Providing regulators with the primary responsibility for establishing the National EMS Scope of Practice Model and clearly defining the levels should facilitate greater consistency of provider levels across political jurisdictions. When this is combined with national certification and program accreditation, there will be considerable incentives for standardization of provider levels.

• Current limitation: There is considerable variability in EMS provider licensure standards from state to state.

Proposed solution: Establishing uniform National EMS Education Program Accreditation combined with National EMS Certification will reduce variability in licensure standards.

• Current limitation: There is considerable variability in the EMS educational program standards from state to state.

Proposed solution: Consistent program accreditation standards, including realistic methods for full service accreditation, will significantly reduce this variability.

• Current limitation: EMS education is based on perceived needs rather than practice analysis and research.

Proposed solution: A regular feedback loop connecting the core content, practice analysis and research efforts will gradually improve the empirical basis of EMS education.

• Current limitation: The locus of control for EMS education is placed within government, not the educational facility, program and faculty.

Proposed solution: The EMS education system of the future will facilitate an appropriate role for government and educational facilities. This will provide significantly greater flexibility for educational institutions and programs while still assuring reasonable national standards.

• Current limitation: The content of national standard curricula is perceived to be determined by the federal contractor.

Proposed solution: Establishing an EMS education system will provide for a balanced approach to EMS education and reduce the perception of a disproportionate influence by any single participant. The establishment of specific responsibilities, combined with the interrelationship of system components, will provide reasonable checks and balances.

• Current limitation: The national standard curricula are in various formats and frequently are not consistent with each other. This reduces the ability to "bridge" from one level to another.

Proposed solution: Replacing the national standard curricula with National EMS Education Standards will eliminate this problem. Guided by the National EMS Core Content and consistent with the National EMS Scope of Practice Model, the National EMS Education Standards will assure reasonable uniformity while providing flexibility in approach and educational format.

• Current limitation: The national standard curricula are frequently out of date.

Proposed solution: Given the time and expense of writing national standard curricula, it is difficult to revise them frequently. In the EMS education system of the future, the National EMS Core Content and National EMS Scope of Practice Model will be periodically updated based upon new information and research. The National EMS Education Standards will be revised frequently with minimal time and expense. Publishers can update their books and their instructor lesson plans as frequently as the market demands. Instructors will have current information available to them.

• Current limitation: The national standard curriculum development process is very expensive and frequently fragments the community.

Proposed solution: Revising the National EMS Scope of Practice Model and the National EMS Education Standards will be less expensive and time-consuming. Because there will be a standardized method of updating them and the decision-making process will be less contentious, there will be greater cooperation in the EMS community. Instructors will be free to choose instructional support materials and there will be competition between publishers to assure products of high quality.

• Current limitation: Most state authored EMS licensure examinations do not follow the accepted methodology for verifying entry level competency.

Proposed solution: National EMS Certification will be based upon an up-to-date practice analysis and will follow accepted psychometric methodology for identifying entry level competency.

• Current limitation: The EMS educational process has developed separately from the formal post secondary education system. This has frequently precluded EMS personnel desiring to obtain academic credit from doing so. This impedes EMS personnel from pursuing higher education which would ultimately further the EMS profession.

Proposed Solution: The EMS education system of the future is compatible with an academically-based approach to EMS education and more closely parallels the developments in other allied health education. The system will also support alternative methods of educating EMS providers and can promote innovative relationships between academic and non-academic programs.

The EMS education system of the future has these attributes:

• The EMS education system is national in scope while allowing for reasonable state and local flexibility;
• The EMS education system is guided by patient care needs, is educationally sound and politically feasible;
• The components of the EMS education system are clearly articulated, with a lucid definition of their interrelationships;
• The responsibility and time frames for updating each of the system components are clearly delineated;
• The method of providing input to and participating in the outcome of each component is clearly defined with an established role for providers, administrators, physicians, regulators, educators and others;
• The ongoing system evolution is guided by scientific and educational research and the principles of quality improvement.
• The EMS education system is stable enough and strong enough to outlive its architects and exists independently of the current leadership of any national EMS organization;
• Physicians are primarily responsible for determining the medical content; regulators for determining regulatory issues; and educators for determining educational issues;
• The EMS education system supports multiple instructional methodologies.

Implicit within this document and underlying the EMS education system design are the following assumptions:

National EMS Education System

Today's education system is going thorough dramatic and profound changes. In response to extraordinary technological changes in society, education is expected to emphasize high level cognition, problem solving and the ability to deal with ambiguity and conflicting priorities. The public and employers expect graduates to be competent in a wide range of practical skills and have the ability to adapt to an ever changing and complex environment.

The public and employers demand that health care education produce graduates who are responsive to the needs of the patient, have excellent communication skills, and are able to adapt to changes in their responsibilities. They demand graduates who are technically competent, socially conscious, and culturally sensitive. In addition to their traditional role as emergency care providers, EMS providers will need to be able to identify and modify illness and injury risks, provide acute illness and injury care and follow-up, and contribute to the treatment of chronic conditions and community health monitoring.

The changing expectations of EMS education, the EMS provider's constantly changing role in the health care delivery system and a rapidly increasing body of EMS research necessitate a clearly defined and responsive EMS education system with the attributes defined previously in this document.

This document defines the infrastructure of an EMS education system of the future as one which will promote national uniformity while being responsive to local needs. It will be driven by research while recognizing the needs for reasonable consistency and stability. This document also articulates the responsibilities of the individuals or agencies responsible for each component of the system.

This section identifies the system components and analyzes each in three ways:

Particular emphasis is placed on the interrelationships of the components and how they are mutually supportive. Consideration of individual components must include the interrelationship with the other components. The reader should strive to take a systematic view, and is cautioned against making judgments on the individual components before considering how they affect and relate to each of the other components.

The EMS Education Agenda for the Future: A Systems Approach has five interrelated components:

National EMS Core Content
National EMS Scope of Practice Model
National EMS Education Standards
National EMS Education Program Accreditation
National EMS Certification

Appendix A portrays a graphical representation of the components and their interrelationships. It demonstrates the dependent relationship each component has on the others, as well as how components and the entire process can be impacted upon. The supportive components (practice analysis, EMS research, past experience, and the EMS Agenda for the Future) are found across the top. These components guide the development of the National EMS Core Content, which represents the entire domain of out of hospital knowledge and skills. The National EMS Core Content drives the National EMS Scope of Practice Model which names and defines the national levels of EMS practice. The National EMS Education Standards define the terminal knowledge and skill objectives for each level of practice identified in the National EMS Scope of Practice Model. The National EMS Education Standards are also a part of the National EMS Education Program Accreditation requirements and are a resource in the development of instructional support materials and instructor development programs. National EMS Education Program Accreditation helps to assure the ongoing quality and consistency of EMS instruction. Graduation from an accredited program is required to participate in National EMS Certification which is based on the levels defined by the National EMS Scope of Practice Model. In addition to the National EMS Education Standards, the practice analysis guides the development of National EMS Certification. National EMS Certification is one requirement for state licensing of EMS professionals.

The entire process follows a continuous quality improvement model, with review and revisions at regularly scheduled intervals. The EMS education system is defined by a continuum ranging from National EMS Core Content through National EMS Certification. National EMS Core Content is revised the least frequently while National EMS Certification is revised the most frequently. Revision of National EMS Core Content may necessitate a revision of every other component. During the revision of each EMS education system component, interested parties may find out exactly how, and when, they may provide input and participate in the process. The decision-makers are clearly defined.

In addition, the system is designed to respond to major changes immediately, if needed. Since the National EMS Education Standards reference terminal objectives, most classroom and program educational changes will occur at the local level. If a major change is needed nationally, it will be made at the level deemed appropriate by system review.

EMS faces many unique local and regional challenges. The current EMS education process reflects a potpourri of solutions to these problems. Additionally, the philosophy, career needs, and professional expectations are not consistent among the various levels of current provider (First Responder, EMT-Basic, EMT-Intermediate, and EMT-Paramedic). Clearly, a rigid and prescriptive system will not meet the needs of all constituents. Any system must have enough flexibility to meet the needs of the diverse communities that it serves.

This document draws on the experience of EMS and other allied health professions to propose an education system consistent with this vision and its stated attributes. It allows for continued and systematic growth of the EMS education system and will assist EMS leaders in making informed decisions about their future.

Following initial certification of entry level competence, an EMS provider may become incompetent due to their failure to keep up with constant changes in the art and science of medicine. Technical and professional persons are at significant risk of becoming outdated in their skills and their knowledge. It is not enough for them to maintain the competence acquired in the years of formal education. In the profession, the information is not static; perpetual change is the norm (Dubin, 1977).

Continuing education is only one part of continued competency assurance. In turn, continued competency assurance is only one component of a quality assurance program. A well-designed continued competency assurance program includes performance and outcome indicators which correlate to the practice analysis and scope of practice. EMS continuing education and continued competency assurance is an integral part of a comprehensive educational system, but is not addressed in this document. A similar "systems approach" to continuing education and continued competency assurance in EMS should be developed.

National EMS Core Content

Core content is used in some physician education programs to define the scope of a specialty discipline, develop residency training programs, and identify material for board examinations. Core content has been very useful in achieving these objectives, and can be used for similar purposes in emergency medical services.

National EMS Core Content, which defines the entire domain of out of hospital EMS education, serves as the broad base for the rest of the EMS education system. It addresses knowledge content globally so that state-of-the-art changes and regional practice patterns can be reflected within its broad framework. It is medically directed, based upon research and the practice analysis, and periodically revised.

Currently, there is no National EMS Core Content, or any document that serves the purpose of defining the entire domain of out of hospital medicine. The National EMS Education and Practice Blueprint, created in 1993 by a multi-disciplinary group of EMS leaders, generally defines the domain of the prehospital EMS profession, but this is intermingled with definitions of EMS provider levels which delineate scope of practice. The 1993 Blueprint broke new ground by introducing uniformity in the definition of provider levels without dependency on a specific version of a curriculum. The validity and utility of the Blueprint could be enhanced by separating the development of the core content from the provider level designation. This would allow leadership for the development of each document to be assumed by the most appropriate group.

The National EMS Core Content presents the broad domain of knowledge and skills which encompass the out of hospital EMS disciplines by identifying the general practices of EMS providers without reference to discrete provider levels. The National EMS Core Content document is authored primarily by the EMS medical community, with input from EMS regulators, EMS educators and EMS providers. The EMS medical community is defined as physicians who have direct involvement in EMS. The National Highway Traffic Safety Administration is responsible for overseeing the process.

The EMS Agenda for the Future is the guiding document setting the vision for EMS and is reviewed and updated periodically, under NHTSA leadership. The National EMS Core Content is created and revised by utilizing the EMS Agenda for the Future, practice analysis, EMS related research, and the body of knowledge created by practical experience. The National EMS Core Content is updated at regular intervals -- every 5 to 7 years, or more frequently as needed, to reflect current developments in EMS practice, clinical advances and education.

A practice analysis is conducted for each nationally recognized EMS level by the national certification agency and helps to identify the practices of currently functioning EMS providers. The practice analysis is national in scope and follows sound qualitative and quantitative methodology. The practice analysis should be updated at least every 5 years. It is one of several pieces of information used in revising the National EMS Core Content.

The National EMS Core Content is the result of a consensus process, led by a group consisting of physicians with direct involvement in EMS, with input from EMS regulators, EMS educators and EMS providers. The drafts will be extensively peer and community reviewed.

The National EMS Core Content is developed by using input from a number of sources. The EMS Agenda for the Future and a needs assessment will provide a vision for the direction of EMS. A formal practice analysis and EMS research provide the authors of the Core Content with information about the current practices of EMS. Finally, the core content is based on the foundation of past experience.

NHTSA should assume the leadership role for the development, implementation, and distribution of the National EMS Core Content. This document, once completed, serves as the domain of practice from which the National EMS Scope of Practice Model is derived.

National EMS Scope of Practice Model

Few, if any, other allied health profession have a document similar to the current National EMS Education and Practice Blueprint or the proposed National EMS Scope of Practice Model. The diversity of EMS and the multiple levels of practice within EMS necessitates the discrete division in the scope of practice among these levels. The National EMS Scope of Practice Model defines the national levels of EMS providers including their entry-level skills and knowledge.

In 1993, the National EMS Education and Practice Blueprint was developed through a national consensus process. This document established uniform definitions of EMS provider levels, including their entry-level knowledge and skills. Based on the assumption that EMS knowledge and skills are on a continuum, it was designed to encourage "bridging" from one level to another, to facilitate reciprocity, to be the basis for national curriculum development, and to assist states in defining scopes of practice.

While the National EMS Education and Practice Blueprint received wide approval and acceptance in concept, it has been inconsistently applied in practice. Moreover, curriculum developers felt it lacked the specificity to adequately guide curricular change.

Many states have not changed their current provider levels to comply with the National EMS Education and Practice Blueprint, and many state laws and regulations continue to refer to the national standard curricula when defining EMS provider scope of practice. While the concept of the Blueprint is solid, it has become apparent that a single document cannot adequately address all of these issues. Since the development of the Blueprint in 1993, no revision has been completed.

The National EMS Education and Practice Blueprint is revised based upon the National EMS Core Content and re-titled the National EMS Scope of Practice Model. Because the Scope of Practice Model defines levels of practice which must be recognized in state laws and administrative rules, the revision is authored and directed primarily by EMS regulators with input from the EMS medical community, EMS educators, and EMS providers. The Scope of Practice Model defines the nationally recognized levels of EMS providers and identifies their minimum entry level knowledge and skills. The National EMS Scope of Practice Model is used by each state to determine scope of practice and to facilitate reciprocity.

The National EMS Core Content provides the foundation for the revision of the National EMS Education and Practice Blueprint. This revision will be renamed the National EMS Scope of Practice Model. The revision is a consensus process led by a group of EMS regulators responsible for certifying and licensing EMS providers, with input from the EMS medical community, EMS educators and EMS providers. The drafts will be extensively peer and community reviewed.

NHTSA should assume the leadership for the revision, implementation, and distribution of the National EMS Scope of Practice Model. This document, once completed, guides the development of the National EMS Education Standards and defines uniform levels of licensure in each of the states. Licensure is the legal authority to practice granted by a state agency.

National EMS Education Standards

Education standards are needed to guide programs and instructors in making appropriate decisions about what material to cover in classroom instruction. Additionally, these standards are used as one component of program evaluation in the accreditation process, and are used by publishers to develop instructional materials. In most allied health professions, education standards are developed by professional associations with broad community input. The complexity, interdisciplinary nature, and extensive state level oversight of EMS necessitates a slightly different approach.

Currently the content of most EMS education programs is based on a national standard curriculum. These National Standard Curricula (NSC) are funded, developed, and updated periodically by the National Highway Traffic Safety Administration (NHTSA). NSC have been developed for all nationally recognized levels of EMS education and consist of detailed, highly prescriptive objectives and declarative material. Since these documents are closely tied to scope of practice and because their revision is the only national venue for the discussion of scope of practice, the NSC revision process is time consuming and expensive.

Many EMS education programs and faculty strictly follow the NSC in defining the content of their courses. A measure of quality for such programs has been their adherence to the current NSC. Although the use of the NSC has contributed to the standardization of EMS education, there remains variation in the quality and length of programs nationally. The reliance on the NSC has decreased flexibility, limited creativity, and made the development of alternative delivery methods difficult. The strict focus on the NSC may result in the development of narrow technical and conceptual skills without consideration for the broad range of professional competencies expected of today's entry level EMS providers.

The National EMS Education Standards are derived from the National EMS Scope of Practice Model. Each National EMS Education Standards document will provide the minimal terminal objectives necessary for successful program completion of one of the levels of EMS providers identified in the National EMS Scope of Practice Model. All programs must adhere to these standards, but there will be significant flexibility in how to achieve the standards. The standards will be designed to encourage creativity in delivery methods such as problem based learning, computer aided instruction, distance learning, programed self-instruction and others. Without the constraint of an unduly prescriptive NSC, EMS educational institutions are held more accountable for the content and quality of their instruction. This would require, at a minimum, that institutions conduct evaluations of both educational process and outcome quality.

With less prescriptive curriculum standards, it is much easier to modify curriculum content, both locally and nationally. Changes based on research, practice analysis, future direction of the profession and experience are quickly reflected in education content, and these changes are communicated to programs through a variety of mechanisms. While all programs must meet national standards, they are encouraged to continually improve and excel.

There are a variety of outstanding instructional materials including instructor lesson plans available from publishers, educational institutions and other interested parties to support local EMS instruction. EMS instructors will utilize published materials or develop their own for classroom use.

The scope of practice for EMS providers is not defined by education standards or curriculum. National EMS Education Standards are designed to prepare EMS providers who are competent to perform within a specific scope of practice. Education supports, rather than defines, scope of practice. The scope of practice for EMS providers is based on the National EMS Scope of Practice Model.

The National EMS Education Standards will be developed by a group of EMS educators, with input from EMS providers, the EMS medical community, and EMS regulators. The drafts will be extensively peer and community reviewed. National EMS Education Standards should be developed for and based upon each level of EMS provider specified in the National EMS Scope of Practice Model. Accredited EMS programs will utilize the appropriate National EMS Education Standards document as the basis for their education program. Accreditation agencies will use the National EMS Education Standards to evaluate the appropriateness of program curriculum.

The EMS community, and most EMS education programs, have a long history of reliance on the NSC. The shift from a standardized curriculum to a system of National EMS Education Standards must occur with the growth and maturation of the other system components. We cannot decrease our dependence on the NSC before strengthening other components of the system, especially accreditation and national certification. We are moving from a system where consistency was ensured through standard content to one which seeks consistent high quality educational outcome.

National EMS Education Program Accreditation

In most countries government assumes the responsibility for assuring the quality of post secondary education. However, in the United States accreditation has become the accepted method of assuring students and the public of the quality of higher education. The primary purpose of accreditation is student and public protection. This is achieved by providing an independent, external, objective review of institutional and/or programmatic quality in comparison to accepted standards. While accreditation has benefits to the institution, this is secondary to it's role in consumer protection.

Accreditation is defined as a non-governmental, independent, collegial process of self and peer assessment. The purpose of accreditation is provide a system of public accountability and the continual improvement of academic quality. Education accreditation generally involves three major activities:

• A team of peers selected by the accrediting agency reviews the evidence, visits the program, interviews the students, the faculty, administration, and staff and writes a report of its assessment.

• Guided by a set of expectations about quality and integrity, a commission reviews the evidence and recommendations, makes a judgment, and communicates the decision to the institution and the public.

Education accreditation provides a national standard and may eliminate the need for states to develop a separate program recognition process. Accreditation represents a method to assure the students and the community that an education program meets uniform, nationally accepted standards. Accreditation review includes assessment of structure, process and outcomes. Institutions are encouraged to develop creative and flexible methods to meet or exceed accreditation standards.

For institutions, accreditation stimulates continuous self-assessment and encourages self-improvement. It promotes sound educational change and provides institutions with validation to obtain the resources that they need to improve. The essential values of accreditation are: continuous self-improvement, professional excellence, peer review and collaboration, and civic responsibility.

While technically not accreditation, most states have some process for approving EMS education programs. The requirements for these state approvals vary widely, from simply filing paperwork to extensive self studies and site visits. State approval is granted to institutions, courses, or individual instructors. Currently, accreditation is voluntary and available only at the paramedic level. In most states, national accreditation is optional. In 1999 there were approximately 100 accredited paramedic programs in the United States. No national accreditation exists at other EMS provider level programs.

The only nationally recognized accreditation available for EMS education is through the Commission on Accreditation of Allied Health Education Programs (CAAHEP) Joint Review Committee on Accreditation of Educational Programs for the EMT-Paramedic (JRCEMT-P). In 1998, CAAHEP accredited 18 recognized allied health occupations.

Most allied health professions limit licensure eligibility to individuals who have graduated from an accredited education program. In this way, professions control educational quality. For EMS, this linkage has occurred in only five states, and only at the paramedic level, as of 1999.

The concept of National EMS Education Program Accreditation is universal and supported by the EMS leadership organizations and stakeholders. A single, nationally recognized accreditation agency has established standards and guidelines for each level of EMS education which recognize the special issues involved with accrediting the entire range of EMS programs and provide unique processes for this encompassing accreditation.

Universal acceptance of National EMS Education Program Accreditation has resulted in extensive self assessment of EMS education programs and the implementation of continuous quality improvement initiatives. Having clear standards and guidelines, programs have improved their faculty and the overall quality of instruction. They are structure, process, and outcome oriented. Programs and instructors use the National EMS Education Standards and commercially available or locally developed instructional support material to develop curriculum materials.

Accreditation standards and guidelines provide minimum program requirements for sponsorship, resources, students, operational policies, program evaluation, and curriculum. These standards have been developed with broad community input and peer and professional review. National EMS Education Program Accreditation is universal and required for each level of EMS recognized by the AMA as an allied health occupation. In order to be eligible for National EMS Certification and state licensure, a candidate must have graduated from an accredited program. Accreditation is a process of self analysis in relation to the standards and guidelines, site evaluation, and committee review.

Some EMS levels are not recognized by the AMA as allied health occupations (e.g., First Responder). Accreditation for these EMS programs is achieved by a process as close to allied health occupations accreditation as possible, given the resources and constraints imposed by the system. In order to be eligible for state licensure, a candidate must have graduated from a state approved and nationally accredited program.

Approval to conduct EMS education is extended by the states to all accredited programs, in accordance with state laws.

A single national accreditation agency is identified and accepted by each state regulatory office. This accrediting agency has a board of directors with representation from a broad range of EMS organizations. The accreditation agency develops standards and guidelines for all levels of EMS education with broad community input. All EMS accreditation includes self study, site visitation, and commission review, but the standards and guidelines vary according to level. The accreditation agency adopts the National EMS Education Standards as the basis for evaluating the content of all EMS instruction and develops a process for accreditation that is appropriate for each level of EMS instruction as determined by the National EMS Scope of Practice Model.

All EMS education programs must achieve National EMS Education Program Accreditation. A graduated time line will be developed for each level by the lead EMS agency in each state. Milestones will be established based on how extensive the gap is between the current level of functioning and the standards and guidelines. These milestones are consistent with the national time line.

The accreditation agency should conduct regional accreditation workshops to increase the understanding of National EMS Education Program Accreditation and help programs achieve the accreditation standards and guidelines. Funding is critically needed to support short term educational improvement projects which make accreditation more achievable.

National EMS Certification

Certification is the process of verifying competency at a predetermined level of proficiency. Licensure is the process of a state government agency granting official permission to practice within that given state. Although there are distinct differences, the terms "licensure" and "certification" are often used interchangeably. In actuality, licensure is the process of an agency making a declaration of competence to practice. The determination of eligibility for licensure is usually based on the completion of education requirements and the passage of an examination. Most licensure processes require some form of certification by either a state or national agency to assure minimum competence.

In most professions, development of examinations is the responsibility of an independent national board. State governments then use the certification as part of their licensing process. In the EMS professions, state government frequently assumes the responsibility of certifying eligible individuals as competent to practice based upon either locally developed, state developed or contractor developed examinations. In these circumstances, state government assumes the responsibilities of both certification and licensure.

There is great confusion and inconsistency in the definition and application of the terms certification, licensure, and registration throughout the states. Some form of testing is one of the stages of granting licensure to EMS providers. Testing often includes both practical and written components. There is wide variability in the quality and difficulty levels of these examinations. Because of these variations, reciprocity and standardized minimum entry level competencies have been difficult to achieve.

Many local and state authored examinations do not adhere to the standards established by the American Psychological Association's (APA) Standards for Educational and Psychological Testing utilized by other allied health care professions. In some instances locally authored examinations are necessary because the state EMS provider levels do not match the nationally recognized levels.

Currently (1999), 40 state EMS regulatory agencies use some form of the National Registry of Emergency Medical Technicians (NREMT) examinations. This may include use of a single level examination or the use of their examinations for all levels of EMS providers. The NREMT examinations are based on a current practice analysis and the National EMS Education and Practice Blueprint. Their examinations are authored by a multi-disciplinary group of experts with input from various EMS related organizations. Validation of each level of examination is done on a continuous basis.

Barriers to the universal use of the NREMT examinations include, but are not limited to, cost of implementation and administration, political issues, the use of a mandated practical examination, lack of local support, and perceived failure rate.

National EMS Certification is conducted by a single independent national agency under the leadership of a board of directors with multi-disciplinary representation. National EMS Certification is accepted by all State EMS offices as verification of entry level competency. National EMS Certification is one of the steps leading to licensure for levels of EMS providers specified in the National EMS Scope of Practice Model. In order to be eligible for National EMS Certification, candidates must be graduates of a nationally accredited EMS Education Program.

Certification examinations are based on the APA's standards and a practice analysis. A nationally recognized, validated, and reliable examination is used by all state EMS agencies as a basis for state licensure. National EMS Certification would not replace the state's right to license, but would be used as only one component of eligibility for licensure to practice within the state.

A single, national certifying organization is identified and accepted by each state regulatory office. This certification agency has a board of directors with representation from a broad range of EMS organizations. The national certification agency regularly conducts a comprehensive practice analysis for each level of nationally recognized EMS provider. This practice analysis is used to develop and to revise examinations for each level identified in the National EMS Scope of Practice Model.

Examinations are designed to verify entry level competence. Certifying examinations adheres to the American Psychological Association's Standards for Educational and Psychological Testing. Entrance level competence is identified by the practice analysis. Certifying examinations are based on practice analysis and the National EMS Scope of Practice Model, not on educational standards, curricula, or textbooks.

A graduated phase-in plan is developed for implementation of national certification. Each state should identify a graduated time line for adoption. After the phase-in date, all graduates must have completed an accredited program of instruction and have successfully completed national certification to qualify for state licensure.

The national certifying organization should conduct regional workshops to increase the understanding of National EMS Certification and emphasize the overall system advantages. This identified national certifying organization should also help states overcome the barriers of implementation whenever possible.