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Paramedic Specialization: A Strategy for Better Out-of-Hospital Care

Authors:
  • International Board for Specialty Certification

Abstract

Demographic, economic, and political forces are driving significant change in the US health care system. Paramedics are a health profession currently providing advanced emergency care and medical transportation throughout the United States. As the health care system demands more team-based care in nonacute, community, interfacility, and tactical response settings, specialized paramedic practitioners could be a valuable and well-positioned resource to meet these needs. Currently, there is limited support for specialty certifications that demand appropriate education, training, or experience standards before specialized practice by paramedics. A fragmented approach to specialty paramedic practice currently exists across our country in which states, regulators, nonprofit organizations, and other health care professions influence and regulate the practice of paramedicine. Multiple other medical professions, however, have already developed effective systems over the last century that can be easily adapted to the practice of paramedicine. Paramedicine practitioners need to organize a profession-based specialty board to organize and standardize a specialty certification system that can be used on a national level. Copyright © 2014 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.
November-December 2014 265
Abstract
Demographic, economic, and political forces are driving
significant change in the US health care system. Paramedics
are a health profession currently providing advanced emer-
gency care and medical transportation throughout the United
States. As the health care system demands more team-based
care in nonacute, community, interfacility, and tactical
response settings, specialized paramedic practitioners could
be a valuable and well-positioned resource to meet these
needs. Currently, there is limited support for specialty certifi-
cations that demand appropriate education, training, or expe-
rience standards before specialized practice by paramedics. A
fragmented approach to specialty paramedic practice cur-
rently exists across our country in which states, regulators,
nonprofit organizations, and other health care professions
influence and regulate the practice of paramedicine. Multiple
other medical professions, however, have already developed
effective systems over the last century that can be easily
adapted to the practice of paramedicine. Paramedicine practi-
tioners need to organize a profession-based specialty board to
organize and standardize a specialty certification system that
can be used on a national level.
The Challenge
Health care in the United States has been characterized as a
fragmented “nonsystem” with very high costs, significant inef-
ficiencies, and disappointing outcomes.1As a result of both
rising costs and the reforms initiated by the Patient Protection
and Affordable Care Act, it is anticipated that team-based care
by a variety of health professionals in nonacute care settings
will increase.2Among the health care professions, there is sig-
nificant variability in educational preparation and ongoing
controversy over the scope of practice boundaries between
various groups of health professionals.3Because of rising
health care costs driven by an aging populace and rising costs
in acute care services, however, a more cost-effective deploy-
ment of nonphysician health care professionals in the out-of-
hospital environment will be required, especially considering
the lack of primary care resources in many areas. Currently, a
significant amount of health care costs are driven by hospital
services, many of which could be reduced or avoided by
improved management of chronic care in the community,
more accessible and appropriate evaluation and resolution of
unscheduled needs for care, regionalization of emergency
services, and a reduction in hospital readmissions. More
accessible and appropriate evaluation and resolution of
unscheduled needs for care offer the promise of rerouting the
estimated 15% of emergency medical service (EMS) trans-
ports to the emergency department for nonemergent condi-
tions and are estimated to save $283 to $586 million per
year.4Likewise, regionalization of care at designated specialty
centers, including both EMS and transportation components,
has been shown to reduce mortality and long-term disability
in patients with time-sensitive acute care conditions, includ-
ing trauma, ST-segment elevation myocardial infarction,
stroke, and sepsis.5- 8
However, these opportunities to improve outcomes depend
on a competent, coordinated, 24/7 accessible network of
community-based clinicians and transportation resources
capable of providing a range of scheduled and unscheduled
care service. Paramedics with specialty training may be what
is needed in most communities to integrate existing resources
through the use of practitioners already located within the
EMS and air and ground medical transportation systems.
Could EMS Providers Play a Role?
Virtually all communities have a local EMS system, and
many have developed regionalized air and ground medical
transportation systems based on regional acute and emer-
gency transportation needs. These services are provided by a
combination of paid and volunteer providers working in fire
department, hospital-based, local government, or nongovern-
mental organizations that offer universally accessible 24/7
health care to the vast majority of the US population. These
systems also maintain or work with dispatch centers capable
of prioritizing requests for service, tracking the availability of
resources, and accessing additional resources from adjacent
communities when requests for service exceed capacity. A
number of authors have proposed that the EMS system could
play a meaningful role in the coordination and delivery of
mobile integrated health care within communities and is an
integral resource for the regionalization of care.9,10 However,
these roles will require an EMS workforce that has a variety of
new specialized skills built on the existing emergency care
educational model.
Overview of EMS
EMS in the United States has existed in its current form for
more than 4 decades. In 2011, an estimated 203,000 para-
medics were credentialed in the United States by various state
and territorial jurisdictions.11 In October 2013, it was further
reported that almost 80,000 paramedics were currently certi-
fied by the National Registry of Emergency Medical Technicians
(NREMT),12 a nongovernmental national certification organiza-
tion. Although it is unknown how many of those paramedics
have obtained or use additional specialized knowledge to
enhance their practice beyond traditional emergency response
activities, paramedic practitioners have been historically
involved in a number of specialty areas including critical care
transport,13 tactical EMS, military, wilderness medical care, and
occupational medicine. In addition to these areas, significant
efforts are now being undertaken to better understand and
develop the paramedic role in primary care,14 particularly as it
relates to mobile health care, community paramedicine, and
Paramedic Specialization: A Strategy for Better Out-of-Hospital Care
Sean M. Caffrey, MBA, NRP, CEMSO, John R. Clark, JD, NRP, FP-C, CCP-C, CMTE, Scott Bourn, PhD, RN, EMT-P, Jim Cole, MA, NRP, FP-C,
CEMSO, CMTE, John S. Cole, MD, EMT-P, Maria Mandt, MD, Jimm Murray, Harry Sibold, MD, FACEP, David Stuhlmiller, MD,
and Eric R. Swanson, MD
home health services. Many of these areas of specialization
require knowledge and skills that are beyond the scope of typi-
cal paramedic education and practice. For the paramedic to
perform effectively in these areas and to ensure the public is
protected from harm, a comprehensive and uniform national
approach to paramedic specialization is required. Many states
have individually addressed specialized EMS practice issues
through the regulation of education, scope of practice, or
physician medical direction; however, these efforts remain
parochial and uncoordinated. It is time now for paramedicine
practitioners to embrace the development of a comprehensive
and professionally driven specialty certification system that can
be effectively used by EMS and transport services, policy mak-
ers, regulators, fellow health care providers, and the public. A
formalized, specialty certification system will serve to define
and validate the expertise required for paramedics to safely and
effectively perform at the highest levels of paramedicine and
should be modeled after similar efforts already undertaken by
other health professions.
The publication of Accidental Death and Disability, The
Neglected Disease of Modern Society in 1966 by the National
Academy of Sciences is widely credited as the foundation of
modern EMS in the United States.14 Subsequent efforts to
organize EMS delivery led to a Presidential Commission on
Highway Traffic Safety that, in 1969, recommended the cre-
ation of a national certification agency to establish uniform
standards for training and examination of personnel active in
the delivery of emergency ambulance service. Acting on that
recommendation, the NREMT was founded in 1970.16
Contemporaneously to these events, a number of localities
began piloting paramedic or mobile intensive care programs to
advance the level of EMS care within their communities.17 After
the passage of the federal EMS Systems Act of 1973, states were
encouraged to develop licensing programs for EMS person-
nel.18 Although the terms “licensing” and “certification” have
been used interchangeably and argued for many years,19 EMS
providers are generally required to be certified as competent
either before or during the process of obtaining a state license,
sometimes called a state certificate, and before beginning prac-
tice. The paramedic education and certification process arose
35 years ago from a national curriculum developed by leading
EMS agencies and the University of Pittsburgh.20 The National
Standard Paramedic Curriculum was revised by the US
Department of Transportation in 1998,21 and the current
National EMS Education Standards for paramedics were com-
pleted in 2009. As of 2013, the NREMT, a national independ-
ent organization that implements and maintains uniform
requirements for the entry-level certification and recertification
of all levels of EMS practitioners, is recognized as a component
of licensing in 46 states.22 The NREMT, however, does not offer
certification in any specialty areas.
Paramedic Practice in the United States
In 1996, the National Highway Traffic Safety Administration
published a consensus document intended to guide the future
development of EMS entitled “The EMS Agenda for the
Future”. From this work came the “EMS Education Agenda
for the Future: A Systems Approach”. A collection of docu-
ments were subsequently published by the National Highway
Traffic Safety Administration NHTSA including the “National
EMS Core Content”, the “National EMS Scope of Practice
Model”, and the “National EMS Education Standards.” These
documents collectively provide the basis for the scope of prac-
tice and educational requirements for paramedics. In conjunc-
tion with the development of these documents, “The EMS
Agenda for the Future” noted a disconnect between EMS edu-
cation and formal higher education systems.23 “The EMS
Agenda for the Future” further called for the universal accredi-
tation of EMS educational programs.24 Although not yet fully
implemented, the NREMT requires that applicants seeking
NREMT certification as paramedics must have completed an
educational program accredited by the Commission on
Accreditation for the EMS Professions (CoAEMSP).25 Most
paramedic programs currently involve 2 to 4 semesters of col-
lege-level courses with associated clinical and field practica.
Despite the fact that most paramedic education already
includes, or is eligible for, college credit, currently no state nor
the NREMT requires a college degree at any level as a condi-
tion for national certification.
An EMS practitioner’s scope of practice varies signifi-
cantly between states and may include a formal list of
allowed assessments, procedures, and medications. EMS
practice in the United States has also historically required
close supervision of the practitioner by a physician. In
many instances, this supervision is more direct than that
seen in other allied health professions. In a few cases, state
credentialing may be dependent on an individual supervi-
sion agreement between a paramedic and a physician. One
justification for this degree of oversight has been the
reluctance on the part of the EMS community to accept
the rigor of formal education and/or degree requirements
that are common in other health professions such as nurs-
ing and respiratory therapy with associated broader scopes
of practice.
Despite the fact that specialized EMS practice has existed
for many decades, formalized systems to educate, certify,
license, and regulate these specialized paramedic providers
have only begun to evolve. Although the few existing certi-
fications continue to gain acceptance among air and
ground specialty transport programs and their accrediting
bodies, they have yet to gain widespread acceptance within
the state regulatory community. This disconnect between
paramedics currently practicing as specialists and regula-
tors most certainly is multifactorial in etiology. In many
instances, medical directors are afforded a high degree of
latitude in determining functional scope of practice, likely
contributing to the perceived lack of need for specialty cer-
tification. Additional causes are best illustrated through
discussion of the evolution of specialty practice in other
health professions.
266 Air Medical Journal 33:6
Could Specialization Improve the Quality of
EMS Practice?
Although not all specialized environments a paramedic
might practice in require substantial additional education,
training, or certification and some areas of specialization lie
outside of the domain of paramedicine, it is clear that many
specialty areas do exist and that the established EMS educa-
tion, certification, and state licensing systems have generally
avoided specialization. The NREMT has also considered spe-
cialization at multiple points in the last decade but has to date
elected not to develop specialty certification examinations.
Unlike other health professions such as nursing that provide a
broad educational foundation, paramedicine practice has
almost exclusively been developed to address initial prehospi-
tal response to acute illness and injury without expanding
into the continuum of out-of-hospital health care. Virtually
no mention is made of advanced or specialized paramedic
practice areas in the formative industry documents including
the EMS Act of 1973,26 the 1996 “EMS Agenda for the
Future,”27 the 2006 Institute of Medicine report “Emergency
Medical Services at the Crossroads,”28 the 2007 “National
EMS Scope of Practice Model,”29 or the “National EMS
Education Standards.”30
The absence of current consensus in the educational, clini-
cal, operational, and regulatory communities around para-
medic specialization is likely the result of either inattention to
the topic or overall ambiguity regarding specialized roles at
the professional, state, and national levels. In recent years,
priority has been placed on standardization and accreditation
of traditional EMS education and credentialing nationwide
that may have contributed to this disregard for formalization
of specialty certification. What has been accomplished in the
specialization area, however, has been the result of patchwork
efforts by individual EMS organizations, a small number of
states, and a handful of nonprofit organizations.
Should Specialization Only Be for Paramedics?
In the United States, the title “paramedic” is recognized as
the highest level of credentialing paramedicine practitioners
involved in EMS and medical transportation activities.
Although some states may recognize and/or license additional
levels, the 4 universally recognized provider levels in the
National EMS Scope of Practice model in ascending order are
emergency medical responder, emergency medical technician,
advanced emergency medical technician, and paramedic.31
Each level represents an increasing breadth and depth of
understanding of the treatment of acute injury and illness,
and all of these practitioner levels can be considered partici-
pants in the practice of paramedicine. Any level of EMS
provider may function in specialized environments, and some
may be provided additional knowledge and/or allowed to per-
form additional skills in certain settings and in some jurisdic-
tions. However, the recommendations for specialization
described here are intended as a supplemental certification
for practitioners already credentialed at the paramedic level.
Specialization in Other Health Professions
Medicine
Specialization by physicians began to evolve in earnest in
the 19th century and was a contentious topic in the United
States well into the early 20th century.32 The American
Medical Association opposed the listing of physician spe-
cialty interests in directories published by local medical
societies throughout the 19th century on the grounds that
general practice was the primary duty of physicians. Over
time, the prevailing counterargument was that advance-
ments in medical science and technology required special-
ization. This evolution of thought, combined with the
adoption of comprehensive physician education require-
ments following the Flexner Report in the early 20th cen-
tury,33 led to extensive improvement and standardization of
physician training programs including the development of
residency programs and certification examinations. The
structure of the health care system in the United States, par-
ticularly the fee-for-service medical insurance programs that
evolved in the mid-20th century, further rewarded most
specialists with higher incomes. By the turn of the 21st cen-
tury, almost all physicians completed specialized training
after graduation from medical school. The American Board
of Medical Specialties reports that 80% to 85% of licensed
physicians in the United States are certified through 24
medical specialty boards responsible for over 150 specialties
and subspecialties.34 Current standards for board certifica-
tion as a physician include the following:
• Completion of 4 years of undergraduate premedical edu-
cation at an accredited college or university
Completion of a 4-year medical education program at
a qualified medical school with a medical degree (MD
or DO)
• Currently hold unrestricted license to practice in Canada
or the United States
• Completion of a 3- to 5-year full-time residency program
accredited by the Accreditation Council for Graduate
Medical Education
Pass a written and, in some cases, oral examination
administered by an American Board of Medical
Specialties member board
Unlike other countries, such as Germany, in which specialty
certification systems are based solely on training and creden-
tials, the American system evolved based on examination.35
EMS represents a new physician subspecialty introduced by
the American Board of Emergency Medicine in 2010.36 As a
new specialty that has not yet deployed a significant number
of accredited EMS residency programs, 3 pathways to certifi-
cation currently exist including the following:
EMS practice pathway: demonstration of at least 400
hours of EMS practice per year over a minimum of 60
months as an EMS medical director, direct provider of
prehospital care, or another EMS leadership role within
the last 6 years
267November-December 2014
EMS practice plus training pathway: successful comple-
tion of an unaccredited fellowship in EMS and demon-
stration of at least 400 hours of EMS practice per year
over a minimum of 24 months as an EMS medical direc-
tor, direct provider of prehospital care, or another EMS
leadership role within the last 6 years
• EMS fellowship training pathway: completion of an EMS
fellowship accredited by the Accreditation Council for
Graduate Medical Education
Completion of a board certification examination, developed
by a 14-member committee and offered for the first time in
October 2013, also will be required.37 These pathways to cer-
tification, created to accommodate active practitioners enter-
ing a new certification process, may provide a template for
EMS practitioner specialty certification.
Nursing
One of the first articles discussing specialization in nursing
appeared in 1900 and suggested that nurses could increase
their level of knowledge in certain areas and supplement the
work of specialized physicians.38 The American Board of
Nursing Specialties (ABNS) was formed over 9 decades later
in 1991 and, as of 2013, had a membership of 33 specialty
nursing boards that administered 1 or more specialty certifi-
cations available to licensed registered nurses. Unlike physi-
cian specialties that widely use similar processes for
certification of postgraduate specialists and subspecialists, the
ABNS recognizes specialty certification programs that are
available to any registered nurse (RN) as well as programs
only available to advance practice nurses with graduate-level
education.39 The ABNSC standards further allow for some
member boards to certify non-RN team members supervised
by RNs. Recognition of a specialty is based on a number of
criteria including but not limited to 1) evidence that the spe-
cialty exists from a professional and scientific standpoint, 2) a
distinct body of scientific knowledge apart from basic nurs-
ing, 3) evidence of societal need, and 4) support for the spe-
cialty from national or international nursing organizations.
By way of example, the Board for Certification of
Emergency Nurses (BCEN) currently offers certification pro-
grams for nurses practicing in emergency and transport areas
to include certified emergency nurse, certified flight RN, and
certified transport nurse. The BCEN also offers a certification
in pediatric emergency nursing in collaboration with the
Pediatric Nursing Certification Board. All BCEN certifications
require an unrestricted nursing license from a US state or ter-
ritory and successful completion of a written examination.
The BCEN further recommends, but does not require, 2 years
of experience in the specialty area.40
The American Association of Critical-Care Nurses offers
certification as a critical care RN, which is also recognized as a
critical care nurse specialization. Critical care RN credential-
ing requires both successful completion of a didactic exami-
nation and clinical practice requirements, including
minimum experience in specified clinical areas of practice.
The American Academy of Nurse Practitioners, by contrast,
offers nurse practitioner–certified programs for adult, adult-
gerontology, and family nurse practitioner certification.
Qualifications to sit for these examinations include 1) gradua-
tion from accredited graduate, postgraduate, or doctoral
nurse practitioner program; 2) 500 hours of supervised clini-
cal practice; 3) current RN licensure; and 4) evidence of com-
pletion of certain core course work.41
Nursing specialty certifications represent a wide range of
care specialties available to nurses with varying levels of edu-
cation across many facets of the health care system. These cer-
tification programs further show flexibility within the sphere
of specialty certification.
Other Health Professions
A number of additional health professions also recognize
specialization. For example, the American Board of
Professional Psychology, which oversees and authorizes the
credentialing activities of 13 specialty boards,42 offers sophis-
ticated certification programs, many of which require exten-
sive graduate education and supervised clinical practice.43
The American Board of Physical Therapy Specialists oper-
ates a unified specialization program that manages 8 specialty
certifications. The board was created by the American
Physical Therapy Association (APTA), which approves new
specialty areas.44 In order to be certified as a specialist, physi-
cal therapists must be licensed to practice physical therapy
and provide evidence of 2,000 hours of clinical practice in the
specialty area or complete an APTA credentialed postprofes-
sional clinical residency.
Additionally, practitioners in the sports medicine specializa-
tion must document training in emergency care and car-
diopulmonary resuscitation that may include certification as
an emergency medical technician or paramedic.45 The board
also offers a discounted examination fee for APTA members.
Finally, the American Registry of Radiologic Technologists
(ARRT) has served as the registry for registered technologists
in the field of radiology since 1922. In addition to initial certi-
fication examinations, the registry has offered “postprimary”
specialization examinations since the 1990s.46 Currently, the
ARRT offers 5 primary pathways and 10 postprimary path-
ways for registrants. As of January 1, 2015, the ARRT also will
require an associate degree in any field in order to be eligible
for primary pathway registration. In addition, candidates for
postprimary certification currently are required to meet clini-
cal experience requirements. Beginning in 2016, structured
education requirements also will go into effect for postpri-
mary candidates.47
The physical therapy and radiologic technology specializa-
tion programs centralize specialty certification in their profes-
sions and further address experience, degree requirements, and
the validity of current experience in areas in which educational
programs have yet to evolve. The association between the
American Board of Physical Therapy Specialists and the APTA
is a closer connection than what is seen in other professions,
268 Air Medical Journal 33:6
although it is likely that many professional associations have
had a hand in the development of many of these now inde-
pendent boards.
Certification and Recertification
Although requirements related to training, education, resi-
dency, and/or experience may exist, all specialty certification
programs noted previously require a written examination. In
most cases, these examinations are delivered in a computer-
based format through a variety of testing vendors. In rare
instances, oral examinations also may be part of the certifica-
tion process. One of the primary purposes of specialty certifi-
cation boards is to develop the examinations and certification
requirements. In most cases, examination development is
done in conjunction with outside firms that specialize in
examination development and validation. In all cases, how-
ever, the governing boards of specialists direct the body of
knowledge to be examined, whereas subject matter experts,
sometimes including the governing board members, develop
the examination content.
In all of the specialty certification examination examples
reviewed, a valid and unrestricted license within the domain
of practice is required as a prerequisite to specialty certifica-
tion. Additionally, a fee is charged for the initial certification
and renewal of the certification. Associated costs range from
over $100 to well over $1,000. These fees are in addition to
any state-imposed fees necessary to maintain licensure.
Additionally, a recertification process exists for all of the
professional specialization programs discussed previously.
In almost all cases, recertification is available through exam-
ination and may include ongoing clinical practice require-
ments. A number of specialty boards allow for a “retired
designation” for inactive, but previously certified, providers.
Most specialty boards also offer various alternatives to reex-
amination, including continuing education, clinical prac-
tice, and other professional development requirements such
as committee participation, quality improvement work, and
similar activities.
Specialized Paramedic Certification Today
Currently, specialized paramedic practice has not been
widely recognized or accepted by state regulatory agencies.
There is also no universal agreement regarding whether spe-
cialization should be viewed as another practitioner level or
as a specialty certification available to currently licensed prac-
titioners. The only EMS-related specialty certification board,
the Board for Critical Care Transport Paramedic Certification
(BCCTPC), was formed in 1999 as an independent organiza-
tion at the urging of the National Flight Paramedics
Association (now the International Association of Flight and
Critical Care Paramedics). The BCCTPC currently offers 3
certifications through a didactic written testing mechanism
including the certified flight paramedic,48 the certified critical
care paramedic for ground providers, and the certified tactical
paramedic. No educational, experiential, or skills demonstra-
tion are currently required for these certifications. Two years
of relevant clinical experience are recommended, and a valid
state license is required.
Fourteen states recognize a critical care paramedic special-
ization through licensure, certification, endorsement, or an
expanded scope authorization process.49 Only California has
passed legislation to recognize the BCCTPC certification
process as the basis for state licensure as a critical care para-
medic.50 Similarly, the Montana Board of Medical Examiners
has established requirements and issues a professional license
to all levels of emergency medical technician practice in their
state and uses the BCCTPC certification process to issue a
critical care paramedic endorsement to an existing Montana
paramedic license.51
Few other paramedic specializations have been recognized
officially. Minnesota, however, has recognized a community
paramedic specialization process that includes experience,
education, and medical direction requirements.52 However,
the limited acceptance of paramedic specialization is not sur-
prising because it has taken well over 3 decades for most
states to accept the NREMT certification as the basis for initial
state credentialing as an EMS practitioner.
Despite this lack of acceptance, a variety of programs have
proliferated over the past 2 decades with the goal of providing
specialized education to EMS practitioners. Many of these
programs are 1 to 4 weeks in length and offer a certificate of
completion issued by the educational provider. One of the
most notable is the Critical Care Emergency Medical
Transport Program, developed and franchised by the
University of Maryland Baltimore County in the 1990s.53 A
similar program, the Certified Intensive Care Paramedic
Program, is available through the Cleveland Clinic.54 Both of
these programs advertise that they prepare candidates for
BCCTPC examination. EMS practitioners who have com-
pleted these programs often adopt these certificate credentials
(Critical Care Emergency Medical Transport Program,
Certified Intensive Care Paramedic Program, and so on).
Despite the knowledge contained in these programs, it should
be noted that none of these programs subject their curricula
to external approval, nor are certificate holders subject to
independent verification by examination. While providing
excellent education, none are recognized by governmental or
professional entities, and in most cases, are wholly controlled
by their sponsoring organization as business ventures.
In addition to specialty certification and education pro-
grams, the supervised nature of EMS practice also requires
oversight and/or approval by physician medical directors.
Although requirements vary substantially between jurisdic-
tions, it is likely that specialized paramedic practice requires
active oversight by a physician including but not limited to
clinical protocol development, direct online consultation
requirements, and quality improvement initiatives. Based on
the particular state regulations, additional approvals, includ-
ing organizational licensure or accreditation, may be neces-
sary to operate a program using specialized paramedics.
269November-December 2014
Role of State Regulation
Occupational licensing in the United States is within the
purview of state governments. A patchwork of practitioner of
licensing standards evolved throughout the 1970s, 80s, and
90s. In 1996, the “EMS Agenda for the Future” recommended
that although states retain the responsibility for licensing,
they should increase reliance on available national resources
and nongovernmental organizations for certification and
accreditation.55 Subsequent to this recommendation, a num-
ber of states have increased the use of NREMT certification
for licensure purposes as well as CoAEMSP accreditation for
paramedic education programs. The evolution of EMS educa-
tion, certification, and licensure by state governments, how-
ever, places the field of paramedicine in sharp contrast to
medicine, nursing, and other allied health professions. These
groups developed profession-based, standardized educational
requirements and primary certification programs that have
subsequently been adopted by state governments as the basis
of licensure. However, EMS professional requirements were
created mostly by state governments with federal funding in
the 1970s and 80s and developed either before or simultane-
ously with EMS professional organizations. This development
of requirements on a state-by-state basis has disrupted and
delayed the development of standardized professional certifi-
cation processes and has likely inhibited professional devel-
opment and workforce mobility. Considering that specialty
certification in other health professions is almost universally
avoided as a direct function of state licensing bodies in other
health professions, it would be beneficial for state govern-
ments to also avoid specialty licensing within the realm of
paramedicine. Unfortunately, however, a national, well-
designed, and profession-based specialty certification pro-
gram has not yet been developed or recognized as a
mechanism to outline scope of practice, employer credential-
ing, and medical direction while providing for public protec-
tion. To the extent that specialization is regulated, it is often
and appropriately confined to scope of practice regulation.
Historically, however, it has been difficult for the EMS com-
munity to separate the concepts of core content, scope of
practice, initial education, advanced education, independent
certification, state licensing, and organizational privileges.
This confusion is likely the result of many state regulatory
agencies having been placed in the position to develop and
manage all of these system components as previously noted.
Recommendation for EMS Specialization
To better address the issue of paramedic specialty certifica-
tion, EMS regulators should look to other areas of medicine
as a model to establish the core content of specializations,
define educational requirements, and provide specialty certifi-
cations. This approach should engage the profession itself as a
partner to maintain public safety and would also serve as a
driver to enhance the quality and accountability of care. As in
other health professions, paramedicine must acknowledge
that rapid advancements in medical science and technology
will demand specialization to maintain care quality. An inde-
pendent board of specialties within paramedicine should be
empowered by the profession to serve as a multi-disciplinary
board to review and approve core content for paramedic clini-
cal specialties. Ideally, this board may further establish com-
mittees to administer certification of established clinical
specialties and/or develop alliances with outside certification
organizations providing specialty certifications in both clinical
and nonclinical areas (ie, EMS telecommunications, educa-
tion, leadership, management, and so on). This board of para-
medicine specialties should further ensure that certification
programs meet the requirements established by the National
Commission for Certifying Agencies. This board should work
collaboratively with the NREMT as well as state and federal
EMS officials to inform and guide these governing agencies
regarding current and emerging specialty areas within para-
medicine. Critically, this should occur in an independent
manner driven by paramedicine practitioners. This board
should be non-governmental and separate from the initial cer-
tification activities managed by NREMT. This board should be
structured in a fashion similar to the American Board of
Medical Specialties, the American Board of Nursing
Specialties, or the American Board of Physical Therapy
Specialties. The Canadian system of a provincial College of
Paramedics may also serve as a guide in this area.
All candidates wishing to be board certified in a specialty
area of paramedicine must be required to pass a rigorous,
validated examination developed and administered by the
respective certification committee or affiliated certification
organization. All examinations should conform to the high-
est standards of professional certification and be validated
by an independent certification organization. This examina-
tion process must not be marginalized by local or regional
practice issues.
The board should develop appropriate and rigorous educa-
tional standards and experience requirements for candidates
to further ensure the competence of board-eligible candi-
dates. The absence of meaningful educational standards that
include classroom, laboratory, and clinical experience compo-
nents invites disruption and incongruity because states would
likely attempt to apply their own parochial requirements in
the absence of robust national standards. Such variability
would serve only to diminish the validity and acceptance of
specialty certification. Looking back to the NREMT example,
the examination items tested for all levels of EMS provider are
driven not by the NREMT themselves but rather by ongoing
practice analysis and the National EMS Education Standards.
Therefore, the board should work closely with other profes-
sional associations in paramedicine to develop education
pathways to ensure that EMS providers obtain the necessary
didactic and psychomotor skills to successfully secure spe-
cialty certification. Additionally, considering that most para-
medic training programs are currently or soon to be
accredited by CoAEMSP and almost universally offer college
credit, the certification board should strongly consider the
270 Air Medical Journal 33:6
enactment of academic degree requirements for specialty can-
didates. Such requirements provide educational credibility to
the certification process and are similar to that of other allied
health professions.
To ensure parity with other health care professions, this
board should consider experience requirements for certifica-
tion, such as those used by the BCEN. These experience
requirements should be evaluated over time to determine if
a formal residency or fellowship would be more appropri-
ate, as is common in medical specialties and some allied
health professions.
Perhaps, most importantly, states should refrain from creat-
ing additional licensure levels above the paramedic level. The
addition of disparate licensure levels by states has already cre-
ated disparities and confusion related to specialized practice
that will likely only compound if new license levels prolifer-
ate. By contrast, state regulatory efforts should be focused on
scope of practice concerns, and those efforts should align
state regulations with the core content developed by specialty
boards at the national level. A broad approach to the regula-
tion of specialty practice at the state level would also be useful
to limit conflicts with national standardization yet allow for
medical directors and employers to exercise additional con-
trol through credentialing requirements. State governments
should also be cautious in applying additional requirements
for practice beyond standards adopted by the specialty board.
In most allied health and medical professions, specialization
is not the responsibility of state licensing agencies, and efforts
in this area could lead to significant disruption. Employers
and medical directors, by contrast, should enact requirements
for specialty credentialing at the local or organizational level
that could be used to grant privileges to practice as a special-
ist, which is common in health care.
This is not a structure that will develop in an instant. To
institute permanent and lasting change for the paramedic
profession, organizations that offer nonclinical specializa-
tions such as the National Association of EMS Educators,
the Center for Public Safety Excellence, and the Association
of Air Medical Services should consider affiliating their cer-
tification activities with the paramedicine specialties board.
This will ensure cooperation and consistency within the
profession as a whole, similar to the process used by the
American Board of Nursing Specialties that spans a wide
array of nursing specializations.
Summary
Paramedics across the United States currently are engaging
in specialized practice areas that require substantial additional
knowledge and experience than what can be expected from
an entry-level practitioner who has completed initial para-
medic education. The historic evolution of paramedicine has
further created a situation in which specialized practice is not
well-defined or accepted yet is demanded by advances in the
science of medicine. Furthermore, federal and state govern-
ments have been placed in a position to substitute for the
professional self-governance seen in medicine and in many
other health professions because of a variety of historic and
political factors.
Appropriate regulation of specialized practice has devel-
oped over nearly 2 centuries. Although it is clear that spe-
cialty certification processes evolve slowly, there are many
models in medicine, nursing, and other allied health profes-
sions for effective, safe, and standardized specialty education,
examination, and practice. The Board for Critical Care
Transport Paramedic Certification is an example of an organ-
ized and functional specialty board that could expand its mis-
sion to all specialties in paramedicine. The success of the
certified flight paramedic has created a universally recognized
means for medical professionals, employers, and the public to
understand that paramedics holding this specialty certifica-
tion have additional knowledge in the domain of paramedi-
cine beyond that of an entry-level paramedic. The creation of
50 or more unique and disparate state schemes to address
practice in specialty areas would further fragment paramedi-
cine, stagnate the advancement of the profession, and perpet-
uate parochial jurisdictional barriers. A preferred approach
would be the creation of a single, independent, profession-
based, and collaborative board of paramedic specialties to
administer the specialty certification process. Such an
approach would serve to ensure public safety while advancing
the status and service of paramedicine practitioners among
their health care colleagues.
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Sean M Caffrey, MBA, NRP, CEMSO, is the EMS programs
manager in the Section of Pediatric Emergency Medicine at
University of Colorado School of Medicine in Denver. John R.
Clark, JD, NRP, FP-C, CCP-C, CMTE, is the chief operating offi-
cer of the Board for Critical Care Transport Paramedic
Certification in Snelville, GA. Scott Bourn, PhD, RN, EMT-P, is the
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272 Air Medical Journal 33:6
MedEvac in Friday Harbor, WA. John S. Cole, MD, EMT-P, is the
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Section of Pediatric Emergency Medicine at the University of
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FACEP, is the State EMS medical director for the Montana Board
of Medical Examiners in Helena. David Stuhlmiller, MD, is the
medical director for Air Methods LifeNet of New York/Guthrie Air
in Newton, NJ. Eric R. Swanson, MD, is a clinical professor in the
Division of Emergency Medicine at the University of Utah School
of Medicine.
Disclosure
While the authors have no financial conflicts of interest to dis-
close, a number of the authors hold leadership positions in national
organizations that have a professional, operational or regulatory
interest in the topic being presented. The opinions expressed, how-
ever, are those of the authors and do not represent the official posi-
tion of any organization.
1067-991X/$36.00
Copyright 2014 by Air Medical Journal Associates
http://dx.doi.org/:10.1016/j.amj.2014.07.020
273November-December 2014
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... Similarly, Newton [37] discussed the multiple terms used to describe paramedics in the UK: 'practitioner'; 'specialist' and 'emergency care practitioner' and, while doing so, expressed a hope that paramedics with an extended scope of practice continue to use the designation that contains the professional and protected title of 'specialist paramedic'. The introduction of a 'specialist paramedic' is also proposed in an Australian study on industrial paramedics [38], where the authors suggested that an 'industrial paramedic' is 'an advanced clinical practitioner in paramedicine with an expanded scope of practice'. ...
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Community paramedicine is an evolving specialist stream of paramedic practice and aims to provide patients in the community with options to navigate more efficiently the healthcare system and avoid unnecessary presentations to a hospital emergency department. This study examined the transition of paramedics from a work role in traditional paramedicine to a specialist work role in community paramedicine. The unique knowledge generated by this study allows for additional targeted intervention points for paramedics to better engage in the transition process and may decrease the time frame to deploy high-quality and ready-to-work paramedics in the community.
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