September 26, 2019
This summer, Dr. Howard Backer retired from his post as Director at the California EMS Authority. Over the last nineteen years, he has held numerous prominent positions across California’s Health and Human Services Agency and worked on issues ranging from bioterrorism planning to strategic deployment of emergency resources. In his final role with the Authority, he propelled critical developments such as community paramedicine, health information exchange, and quality improvement processes.
Dr. Backer’s journey through medicine and ultimately into public service was guided by an early desire to work with people. Despite a great interest in science as a teenager, he realized early on that he did not want to spend his life in a laboratory with test tubes and animals. He instead decided to pursue a career in medicine where he could work at the intersection of sciences and humanities.
He was accepted to the University of Michigan, where he studied language, literature and premedical sciences in preparation for medical school. During his undergraduate years, he also traveled abroad to Switzerland. This experience further solidified his love of the outdoors, which would steer some of his career choices later in life.
After finishing at Michigan, Howard was ready to escape the midwest. He sent medical school applications off to both coasts and ultimately chose the University of California at San Francisco, for its strong reputation and proximity to many outdoor destinations. He arrived in the Bay to begin his medical studies during the rise of the Haight-Ashbury and the peak of anti-war protest.
During his studies at UCSF, outside of the emergency department at San Francisco General Hospital, Dr. Backer had limited exposure to emergency medical services and paramedicine—both newly forming areas of health care. He intended to exit medical training as a generalist before further specialization, an accepted practice at that time. Accordingly, he took a rotating internship position at Highland Hospital in nearby Alameda County.
A year later—with just two weeks until internship graduation—Howard’s next career move was still undecided. When he received a fateful phone call from a former Highland Hospital nurse. She asked him if he was interested in a seasonal position at Lake Hospital in Yellowstone National Park. His response: “I’ll be there in two weeks.”
Dr. Backer spent the summer working as a general practitioner responsible for multiple aspects of the hospital and clinic services, including working on the hospital’s ambulance. He worked alongside the park’s rangers who provided rescue services but not emergency medical care. When an incident occurred, a physician and nurse would jump into the ambulance, and a maintenance person would fill in as a driver.
The work was a cross of summer camp and the TV series MASH. The beauty and adventure of the park intermixed with frequent serious emergencies such as cardiac patients at Old Faithful, major trauma from road accidents, thermal pool burns, and wild animal attacks. The typical, non-critical injuries and illnesses (familiar to any paramedic) were also a part of the practice. His career in emergency medicine and EMS had begun.
Dr. Backer went on to work at Yellowstone for the next three years, returning to the Bay Area to work in emergency departments during the off-seasons. It was during one of these off-seasons that he was offered a fellowship position in a newly forming emergency medicine program at San Francisco General Hospital. His considerable experience garnered at Yellowstone allowed him to work with confidence in the urban environment.
Dr. Backer said yes to the fellowship with a caveat. He would like to continue to work at Lake Hospital. Since the program was still evolving and somewhat flexible, they agreed. And so it went. Howard would spend his summers in Yellowstone. Where his experiences demonstrated the skills and training on which to focus his education back in the Bay Area.
Following this training, Dr. Backer joined the faculty at SFGH briefly. Soon after he went back across the Bay to the new Emergency Medicine Residency at Highland Hospital, where he worked alongside well-known EMS leaders such as Drs. Bob Daley, Mike Callaham, and Jim Pointer. In Highland ED, he met his wife Anita and started a family. He also continued to pursue his interest in wilderness and resort medicine with clinical stints in Vail and Tahoe.
After nearly 25 years of practice in various environments, Howard was looking back on a career of beautiful experiences and fascinating medicine. But he also understood that it was hard to sustain a direct care role in emergency medicine. The timing was right for him to pursue other medical interests, one of which was public health.
Dr. Backer initiated his move into public health through a second residency in Preventive Medicine. The unique program included both a Master’s in Public Health (MPH) at UC Berkeley and a project-based externship through Kaiser of Oakland. He then began work in immunization and infectious diseases at the California’s Department of Health Services, which had offices located in Berkeley at the time. Then 9/11 happened.
Howard was quickly tapped to plan for threats of biological terrorism. The first project centered on smallpox vaccination for medical and first responders. He then went on to prepare for medical response to pandemic influenza and anthrax attacks. These projects took Dr. Backer out of the Immunization Branch, instead working with the directorate in the Department of Public Health. He would ultimately be asked to serve as the interim Director of that department on two separate occasions.
Dr. Backer enjoyed this new role of working on developing policy, building programs, and working with public health and medical system stakeholders. Never one for managing in the hospital setting, he found that he rather enjoyed management challenges in a government setting. Howard applied the decision style of an emergency physician—rapid decision-making with limited data with re-evaluation and no shame in changing direction when necessary. This turned out to be a successful approach in public health, as well as emergency medicine.
After working on everything from influenza to radiation to chronic health issues, Dr. Backer was reassigned to a role reporting directly to the Secretary of Health and Human Services Agency. In this role, he was tasked with coordinating emergency and disaster response across the entire Agency.
Dr. Backer’s work was foundational to the development of California’s Emergency Support Functions (ESFs) in the areas of Public Health and Medical and Mass Care and Shelter. Subsequently, during the next gubernatorial transition from Schwarzenegger to Brown, he was appointed as the Director of the EMS Authority.
The Authority had not had much recent stability at the Director level. However, the staff was well experienced, and work at EMSA continued to advance. What Dr. Backer lacked in EMS provider experience, he made up with his strong relationships across the Health Agency and his understanding of the state government process.
Howard quickly identified multiple areas of focus across the California emergency medical services (EMS) landscape. There was a profound lack of usable data being provided to policymakers and EMS agencies. And where information did exist, it was often siloed from other end users. EMS systems lacked comparable quality assurance methods that were well established in other areas of health care. Paramedic treatment protocols were highly variable across the state. And there was clearly a need in California for the newly evolving paramedic roles, such as community paramedicine.
Under Dr. Backer’s leadership, the Authority worked to increase both data creation and reporting by EMS localities. The department funneled millions of dollars in federal grants to initialize health information exchanges connecting paramedics to regional health systems to give patients better continuity of care. Other high-impact programs, such as the Patient Unified Lookup System for Emergencies, or PULSE, were also launched.
The ongoing success of these implementations represents significant technical and bureaucratic achievement. California is now considered a national leader in data and information exchange incorporating EMS providers. This program is actively developing longitudinal data improvements and ultimately, a clearer picture of patient outcomes, which will help steer future practice and policy.
During his tenure, Dr. Backer also pushed local medical directors toward more standardized, evidence-based protocols. The adoption of a unified scope of practice for critical care and flight paramedics, including competency maintenance and demonstration illustrates the collaboration among medical directors and provider agencies.
In the realm of community paramedicine, Dr. Backer’s connections across the Health Agency allowed for multi-departmental support of pilot programs that have shown a great success. This exploratory work is currently awaiting codifying legislation. These efforts will soon make community paramedicine available throughout the state.
Dr. Backer is also recognized for advancing EMS quality assurance and quality improvement. He envisions a system that is aligned more closely to the broader healthcare model with significant transparency, quality improvement, and patient focus. This represents an essential change in prehospital systems that will better integrate EMS and health care systems and support the evolving roles for EMS.
In just eight years, Dr. Backer has significantly advanced California’s EMS systems and successfully moved the goalposts in an industry seeing rapid evolution. His achievements are being continued by a new generation of paramedics, physicians, and administrators who embrace evidence-based practices, advancing technology, and positive change. His departure leaves large shoes to fill at the EMS Authority, but his precedent will undoubtedly help his successor hit the ground running.