BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 503
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|AUTHOR: |Rodriguez |
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|VERSION: |March 23, 2015 |
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|HEARING DATE: |July 1, 2015 | | |
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|CONSULTANT: |Vince Marchand |
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SUBJECT : Emergency medical services.
SUMMARY : Permits a hospital to release patient-identifiable medical
information to an emergency medical services provider, to the
local emergency medical services agency, or to the Emergency
Medical Services Authority, for quality assessment and
improvement purposes.
Existing law:
1)Establishes the Emergency Medical Services Authority (EMSA),
which is responsible for the coordination and integration of
all state activities concerning emergency medical services
(EMS), including the establishment of minimum standards,
policies, and procedures.
2)Requires EMSA to develop planning and implementation
guidelines for EMS systems which address specified components,
including communications, system organization and management,
and data collection and evaluation.
3)Authorizes counties to develop an EMS program and designate a
local emergency medical services agency (LEMSA) responsible
for planning and implementing an EMS system, which includes
day-to-day EMS system operations.
4)Establishes an 18-member Commission on EMS, within the
California Health and Human Services Agency. Defines the
duties of the Commission to include reviewing regulations,
standards, and guidelines developed by EMSA; advising EMSA on
a data collection system; advise on emergency facilities and
services, emergency communications, medical equipment,
personnel training, and various aspects of the EMS system;
and, to make recommendations for further development of the
AB 503 (Rodriguez) Page 2 of ?
EMS system.
5)Requires the Commission on EMS to review and approve
regulations, standards and guidelines to be developed by EMSA
for implementation of the EMS System and the Prehospital
Emergency Medical Care Personnel Act.
6)Defines "Emergency Medical Technician-I" or "EMT-I" as an
individual trained in all facets of basic life support, as
specified. Defines an "Emergency Medical Technician-II,"
"EMT-II," "Advanced Emergency Medical Technician," or
"Advanced EMT" as an EMT-I with additional training in limited
advanced life support according to specified standards. Both
EMT-Is and EMT-IIs are certified by local EMS agencies.
7)Defines "Emergency Medical Technician-Paramedic," "EMT-P,"
"paramedic" or "mobile intensive care paramedic" means an
individual whose scope of practice includes the ability to
provide advanced life support, as specified, including
administering specified medications. EMT-Ps are licensed and
regulated at the state level through EMSA.
This bill:
1)Permits a general acute care or psychiatric hospital to
release patient-identifiable medical information under the
following circumstances:
a) To an EMS provider, information regarding a
patient who was treated, or transported to the
hospital by, that EMS provider, to the extent that
specific data elements are requested for quality
assessment and improvement purposes; and,
b) To EMSA or to the LEMSA, to the extent that
specific data elements are requested for quality
assessment and improvement purposes.
2)Defines an "EMS provider," for purposes of this bill, as an
organization employing an Emergency Medical Technician-I,
Advanced Emergency Medical Technician, or Emergency Medical
Technician-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.
AB 503 (Rodriguez) Page 3 of ?
3)Limits an EMS provider, LEMSA, or EMSA to requesting only
those data elements that are minimally necessary, in
compliance with specified provisions of federal regulations
governing the Health Insurance Portability and Accountability
Act (HIPAA) Privacy Rule.
4)Requires EMSA to develop minimum standards for the
implementation of data collection for system operation,
patient outcome, and performance quality improvement.
5)States 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.
FISCAL
EFFECT : According to the Assembly Appropriations Committee,
this bill will result in minor staff costs to EMSA to revise
existing regulations, estimated at around $20,000 (existing
federal grant funds).
PRIOR
VOTES :
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|Assembly Floor: |78 - 0 |
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|Assembly Appropriations Committee: |16 - 0 |
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|Assembly Health Committee: |17 - 0 |
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COMMENTS :
1)Author's statement. According to the author, pre-hospital EMS
providers, such as ambulance companies, need
patient-identifiable outcome information to evaluate the
effectiveness of their clinical and operational procedures in
order to improve patient care outcomes. Hospitals also rely
on such information to improve their patient safety and
quality outcomes, particularly for emergency service programs
such as trauma, stroke, and heart attacks. HIPAA regulations
permit hospitals to release patient-identifiable medical
information to pre-hospital emergency medical services
providers for quality assessment and improvement purposes
AB 503 (Rodriguez) Page 4 of ?
about a patient that the hospital and the pre-hospital
provider have in common. HIPAA regulations also permit
hospitals to release patient-identifiable medical information
to government health care oversight agencies. However, state
law does not explicitly permit such disclosures to EMS
providers. This bill seeks to explicitly permit these EMS
disclosures in state law.
2)HIPAA Privacy Rule. HIPAA was enacted in 1996 in order to
improve portability and continuity of health insurance
coverage, to combat waste, fraud, and abuse in health
insurance and health care delivery, and to simplify the
administration of health insurance, among other purposes.
Title II of HIPAA, and its ensuing implementing regulations,
focused on combatting waste fraud and abuse, as well as
administrative simplification. One of the major set of
provisions of Title II is known as the "Privacy Rule," which
regulates the use and disclosure of "protected health
information" (PHI, which is basically any information
concerning health or health care that can be linked to an
individual) that is held by "covered entities" (which include
health insurers and medical service providers, among others).
The Privacy Rule governs when covered entities are permitted
to use or disclose PHI, and specifies that a covered entity is
permitted to use or disclose PHI for treatment, payment, or
"health care operations." In the case of disclosure for health
care operations, the entity that receives the information must
be another covered entity that has had a relationship with the
individual who is the subject of the PHI. Health care
operations are defined as, among other activities, "conducting
quality assessment and improvement activities, including
outcomes evaluation and development of clinical guidelines."
3)Confidentiality of Medical Information Act (CMIA). The
California Civil Code contains an extensive body of law on
medical privacy, known as the CMIA. While the HIPAA Privacy
Rule preempts state law where state law is contrary to federal
regulations, the HIPAA Privacy Rule does provide for an
exception to this preemption where state law is more
protective of privacy rights. Under the CMIA, a health care
provider, health plan, or contractor is prohibited from
disclosing medical information regarding a patient without
first obtaining an authorization from the patient, with
specified exceptions. Among the various exceptions in the CMIA
that permit the disclosure of medical information, are the
AB 503 (Rodriguez) Page 5 of ?
following:
a) Information may be disclosed to providers of health
care, health plans, contractors, or other health care
professionals or facilities for the purposes of diagnosis
or treatment, and this specifically includes, in an
emergency situation, the communication of patient
information between emergency medical personnel at the
scene of an emergency, and emergency medical personnel at
a health facility;
b) Information may be disclosed to organized committees
and agents of professional societies or of medical staffs
of licensed hospitals, licensed health care service
plans, professional standards review organizations,
independent medical review organizations, utilization and
quality control peer review organizations, if these
entities are engaged in reviewing the competence or
qualifications of health care professionals or in
reviewing health care services with respect to medical
necessity, level of care, or justification of charges;
and,
c) Information may be disclosed to public agencies,
clinical investigators, health care research
organizations, and accredited public or private
educational or health care institutions for bona fide
research purposes.
d) Information in the possession of a provider of
health care or health plan may be reviewed by a private
or public body responsible for licensing or accrediting
the provider of health care or health plan, however, no
patient-identifying medical information can be removed
from the premises.
4)NEMSIS and CEMSIS. NEMSIS was formed in 2001 by the National
Association of State EMS Directors, in conjunction with the
National Highway Traffic Safety Administration and the
Trauma/EMS Systems program of the Health Resources and
Services Administration's Maternal Child Health Bureau, in
order to develop a national EMS database. NEMSIS is the
national repository that will be used to potentially store EMS
data from every state in the nation, and was developed to help
states collect more standardized elements to allow submission
to the national database.
According to EMSA, CEMSIS is a demonstration project for
AB 503 (Rodriguez) Page 6 of ?
improving EMS data analysis across California. CEMSIS offers a
secure, centralized data system for collecting data about
individual EMS requests, patients treated at hospitals, and
EMS provider organizations. EMSA states that at least 14 of
California's 33 LEMSAs currently send a variety of local data
collections to CEMSIS on a voluntary basis, and in return,
these local agencies gain access to digital tools for running
comprehensive reports on their own data at no cost. EMSA
states when fully operational with 100 percent local
participation, it is estimated that CEMSIS will catalogue more
than three million EMS events per year. According to EMSA, it
will use the data to develop and coordinate high quality
emergency medical care in California through activities such
as healthcare quality programs that monitor patient care
outcomes, agency collaboration across jurisdictional
boundaries, and public health surveillance.
In order to improve local data quality and prepare California
EMS for health information exchange, EMSA is planning to adopt
new data standards known as NEMSIS Version 3, which will
provide a set of tools that EMS professionals can use to
integrate EMS patient care data with electronic medical
records at hospitals, leading to better patient outcomes and a
smarter system of care. On October 1, 2014, the NEMSIS
Technical Advisory Committee announced that California was the
first state to successfully transmit NEMSIS Version 3 EMS data
to the national repository using field and state level
software "certified compliant" with the NEMSIS V3 standard.
According to EMSA, through its partnership with the Inland
Counties Emergency Medical Agency, test data from three
different software vendors was sent to NEMSIS.
5)Related legislation. AB 1129 (Burke), requires an emergency
medical care provider, when submitting data to a LEMSA, to use
an electronic health record system that is compatible with
specified standards, and that includes those data elements
that are required by the LEMSA. Prohibits a LEMSA from
mandating that a provider use a specific electronic health
record system. This bill is scheduled to be heard in this
committee on July 1, 2015.
6)Prior legislation. AB 1621 (Lowenthal, 2014), would have
required the EMSA to adopt a single statewide standard for the
collection of information regarding pre-hospital care for
CEMSIS, required EMSA to develop standards for electronic
AB 503 (Rodriguez) Page 7 of ?
patient care records systems used by LEMSAs and local
pre-hospital EMS providers to ensure compatibility with
CEMSIS, and required LEMSAs to submit patient information to
EMSA utilizing the single statewide standard in a timely
manner. AB 1621 was held on the Senate Appropriations
Committee suspense file.
AB 1975 (R. Hernández, 2014) would have required LEMSAs to
contract with the American College of Surgeons every five
years to conduct a comprehensive assessment of their regional
trauma system. AB 1975 was held on the Assembly Appropriations
Committee suspense file.
SB 535 (Nielsen, 2013) would have increased the membership of
the EMS Commission from 18 to 20 members, and required the
additional members to be an air ambulance representative
appointed by the Senate Committee on Rules, and representative
appointed by the Speaker of the Assembly from a public agency
that provides air rescue and transport. SB 535 was vetoed by
the Governor.
7)Double referral. This bill is double referred. Should it pass
out of this committee, it will be referred to the Senate
Judiciary Committee.
8)Support. This bill is sponsored by the California Hospital
Association (CHA), which states 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. CHA
states that this bill would permit hospitals to release
patient-identifiable medical information to pre-hospital EMS
providers, such as ambulance companies, and the LEMSA, for
quality assessment and patient care improvement purposes. CHA
states that improved pre-hospital care from continuous quality
improvement initiatives will result in patients needing less
expensive emergency and inpatient care, leading to potential
cost savings. The California Ambulance Association states in
support that obtaining this data would help the patient by
improving the quality of care provided, and that state law
does not explicitly permit these disclosures.
9)Opposition. The Emergency Medical Services Administrators
Association of California (EMSAAC) states in opposition that
it is concerned that this bill will actually limit a LEMSA's
AB 503 (Rodriguez) Page 8 of ?
access to hospital data. EMSAAC states that LEMSAs rely
extensively on dispatch, prehospital care records, hospital
records, and trauma registries to fulfil their statutory
mandate to evaluate the local EMS system and improve the speed
and effectiveness of prehospital, receiving hospital, and
specialty care center services. According to EMSAAC, if this
bill becomes law, hospitals may choose not to provide LEMSAs
with the hospital patient treatment data needed to effectively
evaluate the EMS system, including critical trauma registry
data.
10)Author's amendments. The author intends to offer the
following two amendments to address issues that have been
brought to their attention:
a) Air ambulances have pointed out that because they
employ registered nurses and physicians instead of EMTs,
they are not covered under the definition of "EMS
provider." The author intends to offer the following
amendment on page 2, line 29:
(d) For purposes of this section, "EMS provider" means an
organization employing an Emergency Medical Technician-I,
Advanced Emergency Medical Technician, registered nurse,
physician, or Emergency Medical Technician-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.
b) A concern has been raised that by requiring EMSA to
develop minimum standards for the implementation of data
collection, this could be interpreted to mean that
hospital would not be able to share information until
these standards have been adopted as regulations. The
author intends to address this issue by offering the
following amendment on page 2, line 26:
(c) The authority shall may develop minimum standards for
the line 27 implementation of data collection for system
operation, patient line 28 outcome, and performance
quality improvement.
11)Policy discussion. Both CHA (the sponsor) and EMSAAC (which
opposes this bill) agree that many hospitals are currently
providing this information to LEMSAs, though it varies by
AB 503 (Rodriguez) Page 9 of ?
county and by hospital. CHA has expressed some concern that
while providing this information is permitted under federal
HIPAA regulations, HIPAA also permits states to have more
restrictive privacy protections, and since this disclosure is
not specifically authorized, the legality of these disclosure
are in doubt. As discussed above, the CMIA permits the
disclosure of medical information for the purposes of
diagnosis or treatment, including in an emergency situation
between EMS providers and the hospital. Additionally, the CMIA
permits medical information to be disclosed to public agencies
for bona fide research purposes. Finally, medical information
that is in the possession of a provider of health care "may be
reviewed by a private or public body responsible for licensing
or accrediting the provider of health care?however, no
patient-identifying medical information may be removed from
the premises?nor shall that information be further disclosed
by the recipient?"
In sum, the proponents assert that while the disclosures
proposed by this bill are expressly permitted by HIPAA,
California law is not as clear. While one could point to the
various provisions in the CMIA that permit disclosure, and
argue that one or more of those provisions cover the
disclosure of this information from the hospital to the LEMSA,
and perhaps in some instances to the EMS providers as well,
the purpose of this bill is to remove any doubt.
EMSAAC, on the other hand, representing LEMSAs, assert that they
are already allowed to obtain this information from hospitals,
and do so routinely. EMSAAC's concern is that this bill is
expressly making this disclosure permissive, rather than a
requirement, which might result in some hospitals refusing to
continue disclosing information because of the cost. EMSAAC
says this might be even more likely, because by expressly
authorizing ambulance companies and other EMS providers to
request this information, hospitals may become inundated with
disclosure requests, and decide to just stop providing this
information.
SUPPORT AND OPPOSITION :
Support: California Hospital Association (sponsor)
Association of California Healthcare Districts
California Ambulance Association
Dignity Health
Paramedics Plus
AB 503 (Rodriguez) Page 10 of ?
Oppose: Emergency Medical Services Administrators Association
of California
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