The same concepts of essential medical leadership, system oversight, coordination of guideline development for routine and disaster care, identification and implementation of best practices, system quality improvement, and research apply to physicians involved in EMS medical oversight at a regional or local level. Understanding the medical oversight model and the statutes, rules, or other authorities that enable it is important for every physician who provides out-of-hospital emergency care or is involved with the treatment of patients who may be served by the EMS system. It is equally important for physicians to become aware of the procedures and opportunities to influence these bodies of public policy. Chapter 8 of this volume addresses this subject more extensively. Emphasis in this chapter is put on statutes at the state level because these often drive the arrangements for managing EMS systems down to the local level.

The role of legislation, regulation, and ordinance

The foundation of EMS legislation, regulation, and ordinance is protection and specifically the protection of patients served by EMS. This is a legitimate and important consideration, particularly in light of the setting in which EMS occurs.

When patients select primary care physicians, they have many options for learning about practitioners. Most states provide publicly accessible databases that include information about licensure status, academic background, practice specialty, hospital affiliations, and malpractice experience. The public can see this information, speak with trusted friends and neighbors about their experiences with a particular physician, talk to other health care providers, or pursue other means to learn about a physician in advance of establishing a doctor–patient relationship.

When a person dials 9-1-1 with a medical emergency, the experience is very different. Patients have no choice about who arrives to provide their care. Patients in an emergency environment are poorly equipped to protect themselves against incompetent practice. Often, they open their homes to EMS personnel they have never previously met and about whom they know nothing. These EMS personnel are given access to the patient’s medications and sensitive information about their medical history, all at a time when the patient may be unable to observe the EMS personnel’s actions. The EMS experience often takes place with virtually no advance notice. Patients count on these people to safely and effectively provide life-saving interventions, many of which carry significant risk if not done properly. It is easy to see in this circumstance why there is a public interest in the cautious and conservative regulation of EMS. The role that physicians are assigned in statutes, rules, or other authorities to oversee and assure the quality of EMS in the out-of-hospital setting is an important public protection responsibility.

The language and structure of legislation, regulation, and ordinance

Terminology surrounding the subjects of EMS legislation, regulation, and ordinance can sometimes be confusing. States may use slightly different titles for similar bodies of public policy. The Minnesota Legislature’s website provides a useful discussion of terminology regarding laws, statutes and rules that is broadly applicable to most states [5].

• Statutes, also called laws, codes, or sometimes legislation, are federal or state laws that have been created by acts of publicly elected members of Congress or a state legislature. Most state EMS statutes tend to be written in fairly broad language. Often their purpose is to describe the duties and authority of a responsible state EMS agency. State statutes frequently establish structures such as EMS advisory committees or councils.
  
• Rules, sometimes also called regulations, are typically created by a state agency under authority provided in a state statute. Rules often have similar enforceability as statutes. They are usually created through an administrative procedure where notice of the rule-making process is given and there is an opportunity for public input. Rules are often more technically detailed than statutes and frequently are longer.
  
• Ordinances are municipal or local laws. They may be created by a city, county, town, village, or borough under an authority delegated in state statute. Ordinances often deal with matters of public safety, health, and morals. Communities may establish noise ordinances, leash laws, or building codes that define local standards for the subject of the ordinance. At the community level, ordinances often deal with important EMS matters such as cost, level of service, response times, vehicle and equipment specifications, quality management provisions, and similar subjects of EMS operations.

Central to the concept of statutes, rules, and ordinances is that no lower-level language may conflict with or supersede that of a higher level. Federal statutes trump state statutes. State rules may not usurp language established in state statutes, and ordinances typically may not conflict with state rules. Beyond statutes, rules, and ordinances are other legal or quasi-legal documents that affect the provision of EMS. Contracts may exist between private EMS providers and counties, cities, or towns for the provision of EMS. Contracts are agreements between parties for compensation in exchange for goods or services delivered and sometimes penalties for failure to perform. Policies exist within all forms of EMS agencies to describe expectations or requirements for all matters of daily operations.

Emergency medical services legislation, regulation, and policy evolve constantly. Federal statutes are the most difficult to change. State statutes represent the next level of effort to modify. State rules or regulations are normally easier to amend than state statutes. Local, county, or municipal ordinances or policies may be less complicated to change than state rules or regulations. Contracts often have periodic opportunities to be amended or renewed. Local EMS agency policies and procedures are generally the easiest to modify.

One strategy for establishing standards in statutes and rules is incorporation by reference. An example of this is the National EMS Scope of Practice Model (Scope Model) [6]. The Scope Model was established as a component of The EMS Education Agenda for the Future: A Systems Approach (Education Agenda) [7]. The Scope Model is a voluntary form intended for use by individual states to establish their specific scopes of practice for EMS personnel. It was developed through a consensus process that included broad input from all elements of the EMS community. The Scope Model represents a floor rather than a ceiling, with the intent that all states who use it assure that EMS personnel licensed in their state are authorized to perform at least the specified skills and interventions. While a state can elect to add more education and skills to a particular level, the Scope Model sets a common expectation that states can have when EMS personnel move between one state and another. Some states have begun to incorporate the Scope Model by reference in their laws or rules. The Scope Model is intended to evolve in the future as more evidence for safe and effective EMS practice is established. States that have incorporated it by reference do not need to reopen their legislative or rule-making processes to make updates. This is an important strategy that enables the debate and discussion of best practice and scientific evidence to occur among the relevant professional EMS organizations rather than within the halls of elected officials who often have little technical knowledge of medical practice. Incorporation by reference has gained popularity with the proliferation of technology that enables most source documents to be easily accessed through the internet.

The incorporation of the Education Agenda is a good example of successful policy implementation using the concept of incorporation by reference as well as other concepts mentioned above. In 1998, at the request of NASEMSO, NHTSA supported the development of the Education Agenda. This document followed the original EMS Agenda for the Future with a specific focus on establishing a national system of EMS education that would parallel other allied health professions. The Education Agenda has five components: core content, scope of practice model, education standards, national certification, and national EMS program accreditation. Implementation of the Education Agenda has been a significant national undertaking that was completely voluntary by states. Many implementation efforts are still ongoing.

As states have moved to implement the Education Agenda, most have had to amend components of their EMS statutes and/or rules. The majority of states now require NREMT certification to become state licensed, although this is not all states and not for all levels of licensure. Eligibility to hold NREMT certification as a paramedic now requires graduation from an accredited program of education. Accordingly, states that require NREMT certification for paramedics have also either directly or de facto established a requirement for national paramedic program accreditation by the Committee on Accreditation of Educational Programs for Emergency Medical Services Professions (CoAEMSP). As many states adjust their statutes and rules to reflect adoption of the Education Agenda, the language of each state’s statutes and rules is not standardized but the concepts behind these licensing and certification authorities are becoming more aligned.

National implementation of the Education Agenda is also helping to standardize terminology about the authorization for EMS personnel to function. The Education Agenda calls the verification of entry level competence by NREMT a “certification.” The document issued by the state EMS authority enabling a person to function is called a “license.” Some have felt that the term license

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