BILL ANALYSIS Ó AB 503 Page 1 Date of Hearing: April 7, 2015 ASSEMBLY COMMITTEE ON HEALTH Rob Bonta, Chair AB 503 (Rodriguez) - As Amended March 23, 2015 SUBJECT: Emergency medical services. SUMMARY: Allows a health facility to release patient-identifiable medical information to an emergency medical services (EMS) provider and to a local emergency medical services agency (LEMSA) when specific data elements are requested for the purpose of quality assessment and improvement. Requires the Emergency Medical Services Authority (EMSA) to develop minimum standards for the implementation of this data collection system. Specifically, this bill: 1)Allows a health facility, as defined, to release patient-identifiable medical information, upon request, to the EMS provider that provided treatment or transported the patient, when those data elements are to be used for quality assessment and improvement. 2)Allows a health facility, as defined, to release patient-identifiable medical information, upon request, to EMSA or to the LEMSA when those data elements are to be used for quality assessment and improvement. AB 503 Page 2 3)Limits the data elements that an EMS provider, LEMSA, or EMSA may request to those that are minimally necessary, in compliance the Health Insurance Portability and Accountability Act of 1996 (HIPAA). 4)Requires EMSA to develop minimum standards for the implementation of a data collection system to monitor patient outcomes and performance quality improvement. 5)Defines, for the purposes of this bill, an EMS provider as an organization employing an Emergency Medical Technician (EMT) I, Advanced EMT, or EMT Paramedic for the delivery of emergency medical care to the sick and injured at the scene of an emergency, during transport, or during an interfacility transfer. 6)States that it is the intent of the Legislature to encourage data sharing between EMS providers and hospitals in order to improve system effectiveness, quality of care, and the impact of EMS on death and disability. EXISTING LAW: 1)Establishes the state EMSA which is responsible for the coordination and integration of all state activities concerning EMS, including establishing the minimum standards for the policies and procedures necessary for medical control of the statewide EMS system. 2)Requires EMSA, utilizing local and regional information to asses each EMS area or LEMSA service area to determine the need for additional EMS services, coordination of EMS services, and the effectiveness of EMS services. AB 503 Page 3 3)Authorizes counties to develop an EMS program and designate a LEMSA responsible for planning and implementing an EMS system. 4)Establishes the 16-member EMS Commission within the California Health and Human Services Agency, specifies its membership and appointing authorities, and defines the duties. 5)Defines "prehospital EMS providers" to include: an authorized registered nurse or mobile intensive care nurse; EMT-I; EMT-II; EMT-paramedic; lifeguard; firefighter; or, peace officer, as defined, or a physician and surgeon who provides prehospital emergency medical care or rescue services. 6)Establishes under federal law, HIPAA, which among various provisions, mandates industry-wide standards for health care information on electronic billing and other processes; and, requires the protection and confidential handling of protected health information. 7)Establishes under state law the Confidentiality of Medical Information Act (CMIA) which governs the disclosure of medical information by health care providers, Knox-Keene Health Care Service Plan Act of 1975 (Knox-Keene) regulated plans, health care clearinghouses, and employers. FISCAL EFFECT: This bill has not been analyzed by a fiscal committee. COMMENTS: 1)PURPOSE OF THIS BILL. According to the author, prehospital providers of emergency medical care or transport, such as ambulance companies, need patient-identifiable outcomes in order to evaluate the effectiveness of their clinical and operational procedures to improve patient care and outcomes. The author further states that public policy should permit and encourage quality improvement and systems effectiveness between AB 503 Page 4 hospitals and prehospital emergency service providers. The author argues that while federal law allows this to occur, state law does not and this bill would allow such disclosures to occur under state law. 2)BACKGROUND. In 2012, EMSA received a grant from the California HealthCare Foundation (CHCF) to increase the accessibility and accuracy of prehospital data for public, policy, academic and research purposes to facilitate system evaluation and improvement. The grant included a review of EMSA's existing system, the development of a core measures program, and engagement with LEMSAs to facilitate uniform reporting. As part of the project, EMSA has begun implementation of the new national data standards and integrating electronic health information systems. The CHCF-funded projected revealed: a) that the existing system had a number of weaknesses that made it difficult for EMSA to validate EMS information for reporting, impacting its suitability for statewide sustainability and transition to the new national data standards; b) that variability in data collection methodology (in some cases related to the use of paper vs. electronic patient records) limited the usefulness of data submitted; and, c) the lack of hospital outcome data, particularly for cardiac arrest cases limited the ability of LEMSAs to obtain universal outcome data. The capacity of the current system was also assessed by the Health Services Advisory Group, an External Quality Review Organization network contractor, which found similar weaknesses to those identified in the CHCF core measures project. The recommendations for EMSA included better standardization of data collection from LEMSAs. 3)CALIFORNIA'S EMS SYSTEM. California operates on a two-tiered EMS system. EMSA is the lead agency and centralized resource to oversee emergency and disaster medical services. EMSA is charged with providing leadership in developing and implementing LEMSAs throughout California, and in setting standards for the training and scope of practice of various levels of EMS personnel. California has 32 LEMSAs that provide EMS for AB 503 Page 5 California's 58 counties. (Seven regional EMS systems comprised of 33 counties and 25 single-county agencies provide the services.) Regional systems are usually comprised of small, rural, less-populated counties, and single-county systems generally exist in the larger and more urban counties. LEMSAs are responsible for planning, implementing, and managing local trauma care systems, including assessing needs, developing the system design, designating trauma care centers, collecting trauma care data, and providing quality assurance. 4)MEDICAL PRIVACY. a) CMIA. In California, the CMIA governs the disclosure of medical information by health care providers, Knox-Keene regulated plans, contractors, health care clearinghouses, and employers. Specifically, the CMIA prohibits a provider of health care, health plan, or contractor from disclosing medical information regarding a patient or an enrollee or subscriber without first obtaining an authorization, unless the disclosure is permitted. b) HIPAA. HIPAA, among various provisions, requires the protection and confidential handling of protected health information (this is commonly referred to as HIPAA Privacy Rules). The HIPAA Privacy Rules provide federal protections for personal health information (PHI) held by covered entities and give patients an array of rights with respect to that information. Disclosure of PHI is permitted when needed for patient care and other important purposes. On the other hand, HIPAA's Security Rule specifies a series of administrative, physical, and technical safeguards for covered entities to use to assure the confidentiality, integrity, and availability of electronic PHI. 5)SUPPORT. The sponsor of this bill, the California Hospital Association (CHA), writes in support that prehospital EMS providers, such as ambulance companies, need patient-identifiable outcome information to evaluate the AB 503 Page 6 effectiveness of their clinical and operational procedures to improve their patent safety and quality outcomes, particularly for emergency services programs such as trauma, stroke, and STEMI (ST segment elevation myocardial infarction - a type of heart attack). CHA maintains that public policy should permit and encourage quality improvement activities between providers and hospitals to improve quality and patient safety and ultimately improve emergency patient survival rates. According to CHA, HIPAA regulations permit hospitals to release patient-identifiable medical information to prehospital EMS providers for quality assessment and improvement purposes 6)RELATED LEGISLATION. a) AB 70 (Waldron) changes the reporting requirement that EMSA report annually to the Legislature on the effectiveness of the statewide trauma system to once every five years. AB 70 is currently pending hearing in the Assembly Health Committee. b) AB 430 (Roger Hernández) requires EMSA to develop a statewide trauma plan that addresses all aspects of a trauma care system and report the status the plan to the Legislature no later than March 31, 2016. Requires LEMSAs implementing trauma care systems to commission an independent nonprofit organization or governmental entity qualified to assess trauma systems to conduct a comprehensive regional assessment of equitability and access to its trauma system at least once every five years. AB 430 is currently pending hearing in the Assembly Health Committee. c) AB 1129 (Burke) requires an emergency medical care provider, when collecting and sharing data with a LEMSA, to use a system compatible with California Emergency Medical Services Information System and National Emergency Medical Services Information System standards, as specified. Prohibits a LEMSA from mandating that a provider use a specific system to collect and share this data. AB 1129 is AB 503 Page 7 currently pending hearing in the Assembly Health Committee. 7)PREVIOUS LEGISLATION. a) AB 1975 (Roger Hernández) of 2014 would have required LEMSAs to contract with the American College of Surgeons every five years to conduct a comprehensive assessment of the county trauma system. AB 1975 was held on the Suspense file in the Assembly Appropriations Committee. b) AB 1621 (Lowenthal and Rodriguez), also of 2014, would have required EMSA to develop the State Emergency Medical Services Data and Information System in order to assess each EMS area or LEMSAs service area to determine the need for additional EMS services, coordination of EMS services, and the effectiveness of EMS. AB 1621 was held on the Suspense file in the Senate Appropriations Committee. c) SB 266 (Romero) of 2005 would have required EMSA to establish a trauma care advisory committee and required the committee to develop a statewide trauma care plan by January 1, 2007. SB 266 was vetoed by Governor Schwarzenegger, stating " I am directing EMSA, informed by its Trauma Advisory Committee, to complete its statewide trauma care plan and provide me recommendations by no later than June 1, 2006." d) AB 1988 (Diaz), Chapter 333, Statutes of 2002, requires EMSA to convene a task force to study the delivery and provision of EMS. Requires the task force, among other things, to develop a plan to ensure that all Californians are served by appropriate coverage areas for emergency and trauma services and that sufficient numbers of emergency departments and trauma centers exist to serve each area's population. AB 503 Page 8 REGISTERED SUPPORT / OPPOSITION: Support California Hospital Association (sponsor) California Ambulance Association California Fire Chiefs Association Fire Districts Association of California Opposition None on file. Analysis Prepared by:Patty Rodgers / HEALTH / (916) 319-2097 AB 503 Page 9