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Individual states regulate the education, certification, and licensure of their EMS providers. Historically, the federal government has support EMS development at the state, regional, and local levels. The EMS Systems Act passed by Congress in 1973 created a categorical grant program to support developing state and regional EMS systems and led to the distribution of more than $300 million for EMS research, planning, operations, and improvement.1 While the act identified 15 essential elements of EMS systems (communications, training, manpower, mutual aid, transportation, accessibility, facilities, critical care units, transfer of care, consumer participation, public education, public safety agencies, medical records, independent review and evaluation, and disaster linkage), it did not set national standards how these elements were to be enacted. In 1974, the Robert Wood Johnson Foundation contributed an additional $15 million to 44 regional EMS project, marking one of the largest private grants for EMS. Without a unified EMS model, states' EMS systems became significantly different from each other and customized to their needs.


  • Discuss common types of providers within EMS systems, including firefighters and first responders, EMTs, flight nurses, physician assistants, and physicians.

  • Discuss national standard EMS provider certifications, as well as regional and state-specific designations (eg, EMT-D, EMT-I99, EMT-CC, licensed paramedic, critical care paramedic).

  • Discuss types of other medical personnel involved in prehospital care and transport.

  • Discuss state versus NREMT certification and reciprocity issues.

  • Discuss some occupational health concerns for EMS providers.

The Omnibus Budget Reconciliation Act of 1981 folded federal EMS funding with preventative health block grants to states.2 States determined how these grants were divided and distributed, leading to a significant reduction in total funding for EMS across the Unites States. Differences between licensure levels and scopes of practice persisted. In 1996, a minimum of 44 levels of EMS certifications existed across the United States.3 In 2005, a survey of 30 states found 39 different licensure levels still existed.4 Even with the same title, providers' scopes of practice varied between states. This disparity created four specific obstacles for EMS personnel:

  1. Public confusion

  2. Reciprocity challenges

  3. Limited professional mobility

  4. Decreased efficiency due to duplication of efforts

In 1996, the NHTSA and HRSA published a consensus document, the EMS Agenda for the Future, outlining a vision of EMS fully integrated with health care and supporting the health of their communities.3 Designed to help all levels of government guide planning, decision making, and policy regarding EMS, the Agenda addressed 14 attributes requiring improvement including education.

Building on the Agenda, the EMS Education Agenda for the Future: A Systems Approach released in 2000 by the NHTSA proposed a nationally consistent system of education, certification, and licensure for all levels of EMS professionals.5 The Educational Agenda outlined five primary components: national EMS core content, national EMS scope of practice, national EMS educational standards, national EMS education program accreditation, ...

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