RESUMEN
Why were these applications of simulation technology unsuccessful? Parochialism, the volunteer nature of EMS planning, and limited regional commitment to resolve such complex problems at the local level all combined to present significant barriers to implementation. Political factors which posed the most significant barriers included: conservative attitudes concerning the funding and regulation of EMS activities by local governments; general opposition to governmental intervention in the private sector; strong resistance to mandatory standards for EMS; jurisdictional disputes between EMS-related agencies; lack of cooperation between the local governments; competition between prehospital-care providers and between hospitals; overemphasis on local jurisdictional boundaries in the planning and delivery of services; and the allocation of EMS resources, such as ambulances, according to political priorities, rather than more objective criteria. Based upon the results of the four field tests, the following observations are relevant: 1. RURALSIM is a very complex simulator. While every effort was made to assure generalizability, for any given situation, it required extensive modification and tailoring. The result was a model capable of handling a rather diverse set of situations, but one that could not be turned over to the general public for use. To implement RURALSIM required the participation of the University of Pittsburgh research team. The newer simulation languages now available alleviate this problem somewhat. 2. RURALSIM's complexity was needed to examine the different alternatives proposed by local planners. It was particularly needed in order to simulate each region's existing system. Such "base-line" simulations were required in order to achieve face validity and provide a basis for comparing alternatives. 3. With hindsight, a major weakness was the limited amount of face-to-face interaction between local planners and decision makers and the University of Pittsburgh staff. Only two trips to the region were budgeted. This proved to be insufficient and placed too much responsibility for model interpretation and analysis on the local contractors. 4. In none of the four test sites did the contractors and/or local health planners have the authority, influence and/or incentives necessary to develop regional EMS systems. In particular, none of the contractors were in the position to be decision makers, nor was there ever only one decision maker. This is not a criticism of the contractors, who did their best under difficult circumstances. Rather, it is a criticism of the state of eMS system development in the US in the early 1980s. There were few examples where regional systems developed successfully in the face of serious opposition from local interests.(ABSTRACT TRUNCATED AT 400 WORDS)