BILL ANALYSIS                                                                                                                                                                                                    Ó



                                                                    AB 1129


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          Date of Hearing:  April 21, 2015


                ASSEMBLY COMMITTEE ON PRIVACY AND CONSUMER PROTECTION


                                  Mike Gatto, Chair


          AB 1129  
          (Burke) - As Amended April 6, 2015


          SUBJECT:  Emergency medical services:  data and information  
          system


          SUMMARY: Sets standards for the electronic patient record  
          systems that emergency medical services (EMS) providers in  
          California use. Specifically, this bill:


          1)Requires EMS providers to use electronic patient record  
            systems that: 


             a)   Meet California Emergency Medical Services Information  
               System (CEMSIS) data standards; and 


             b)   Can be integrated with a Local Emergency Medical  
               Services Agency (LEMSA), so that the LEMSA can collect data  
               from the EMS provider.  


          2)Prohibits a LEMSA from mandating an EMS provider use a  
            specific system (i.e., specific software or hardware) to  
            collect and share electronic patient records with the LEMSA.









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          EXISTING LAW:  


          1)Authorizes counties to develop an EMS program and designate a  
            LEMSA responsible for planning and implementing an EMS system  
            and authorizes LEMSAs to plan, implement and oversee  
            day-to-day EMS.  (Health and Safety Code (HSC) Section  
            1797.200, et seq.)

          2)Establishes the state Emergency Medical Services Authority  
            (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 EMS system.   
            (HSC 1797.100, et seq.)

          3)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.  (HSC  
            1797.102)

          4)Prohibits, under the State Confidentiality of Medical  
            Information Act (CMIA), providers of health care, health care  
            service plans, or contractors, as defined, from sharing  
            medical information without the patient's written  
            authorization, subject to exceptions, including among others,  
            certain research.  (Civil Code Section 56, et seq.) 


           
           5)Protects, under the federal Health Insurance Portability and  
            Accountability Act (HIPAA), the privacy of patients' health  
            information and generally provides that a covered entity, as  
            defined (health plan, health care provider, and health care  
            clearing house), may not use or disclose "protected," i.e.,  
            individually identifiable, health information except as  
            specified or as authorized by the patient in writing.  (45  








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            Code of Federal Regulations Section 160, et seq.)   


           FISCAL EFFECT:  None. This bill has been keyed non-fiscal by the  
          Legislative Counsel. 



          COMMENTS:  


           1)Purpose of this bill  .  This bill is intended to help ensure  
            that LEMSAs can collect data from and oversee EMS providers by  
            requiring them to use electronic data collection and sharing  
            systems that are compliant with that CEMSIS and NEMSIS.  While  
            the bill sets data system standards for EMS providers, it  
            specifically prohibits LEMSAs from requiring EMS providers to  
            use a specific data system, so that EMS providers are not  
            inadvertently forced to maintain two or more separate data  
            systems - one for each of the LEMSAs the EMS provider serves.   
            This bill is sponsored by the California Ambulance  
            Association.


           2)Author's statement  .  According to the author, "A key  
            requirement for any electronic patient record is compatibility  
            with CEMSIS and NEMSIS standards to ensure that both the state  
            and federal authorities can track EMS trends accurately. There  
            are currently 60 different software packages that are NEMSIS  
            compliant. Over 90% of California's EMS providers already have  
            a NEMSIS compatible data system in place. In many areas, EMS  
            providers can choose the electronic patient record software  
            that best meets their needs and budget, so long as it is  
            NEMSIS compatible."  


            "However, without guidelines in law, LEMSAs are able to  
            require EMSs in their jurisdiction to purchase specific  
            software or hardware for electronic patient records and data  








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            collection.  While that may be acceptable for EMS providers  
            that only serve a single LEMSA, for providers, like air  
            ambulance providers, that cover multiple LEMSAs specific LEMSA  
            requirements for software and or hardware can be an  
            unnecessary and costly burden."


           3)EMSA, NEMSIS, and CEMSIS  .  Prior to 1980, California did not  
            have a central state agency responsible for coordinating EMS  
            services (ambulance, fire, emergency helicopter services)  
            statewide.  The Legislature established EMSA as a lead agency  
            to oversee emergency and disaster medical services throughout  
            California. EMSA is one of thirteen departments within  
            California's Health and Human Services Agency.  EMSAS provides  
            leadership and direction to California's 33 LEMSAs that  
            provide EMS for California's 58 counties. 


            One of EMSA's goals is to ensure that data systems in EMS are  
            positioned for the electronic capture of data and transmission  
            to the hospital in real time.  Specifically, EMSA's  
            responsibilities for data collection include the development  
            and maintenance of an aggregated statewide pre-hospital  
            database, the establishment and maintenance of core measure  
            data set for California emergency services, and the provision  
            of guidance and technical assistance to LEMSAs for the  
            development and improvement of local EMS data collection  
            systems.  

            According to the EMSA website, CEMSIS is a demonstration  
            project for 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. When LEMSAs send  
            data to CEMSIS, they gain access to digital tools for running  
            comprehensive reports on their own data at no cost.  However,  
            participation in CEMSIS is voluntary, and currently less than  
            half - 14 of 33 - LEMSAs submit data to CEMSIS.  According to  
            EMSA, the authority for the creation of CEMSIS stems from the  








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            general statutory authority granted to EMSA to "asses  
            each...LEMSA service area to determine the need for additional  
            EMS services, coordination of EMS services, and the  
            effectiveness of EMS services." (HCS 1797.102)

            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.

            In order to improve local data quality and prepare California  
            EMS providers for the new federal health information exchange,  
            EMSA recently adopted a new data standard known as NEMSIS  
            Version 3, which provides 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. 

           4)Medical privacy  .  In California, 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 by law. Under federal law, HIPAA  
            requires the protection and confidential handling of protected  
            health information.  HIPAA provides federal protections for  
            personal health information held by covered entities and gives  
            patients an array of rights with respect to that information.   
            Disclosure of personal health information is permitted when  
            needed for patient care and other important purposes.  On the  
            other hand, HIPAA specifies a series of administrative,  
            physical, and technical safeguards for covered entities to use  
            to assure the confidentiality, integrity, and availability of  
            electronic data.








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          The American Civil Liberties Union (ACLU), Electronic Frontier  
            Foundation, and the Consumer Federation of California have  
            opposed prior legislation, AB 1621 (Lowenthal) of 2014, on the  
            grounds that EMSA and CEMSIS may not be entities covered under  
            CMIA or HIPAA. 

          5)Comments and questions for the Committee  .  As local EMS  
            providers adopt systems that meet CEMSIS and NEMSIS standards,  
            the state will be able to collect more comprehensive data  
            about EMS care provided to patients throughout California.  
            With 100% participation, EMSA estimates CEMSIS will receive  
            more than three million EMS events every year.  EMSA plans to  
            use the data to develop and coordinate high quality emergency  
            medical care in California through activities such as health  
            care quality programs that monitor patient care outcomes,  
            agency collaboration across jurisdictional boundaries, and  
            public health surveillance.   

          While improving the quality of emergency care in California  
            through statewide reporting of EMS patient data is a worthy  
            goal, policymakers should also have the objective of ensuring  
            the data held in statewide databases is protected - both under  
            current privacy laws and also against cyber security breaches.  


          The author and the Committee may wish to consider whether  
            legislation is needed to require EMSA to assess and address  
            the privacy and data security issues associated with  
            maintaining a comprehensive database of all EMS transactions  
            in the state, such as: the extent to which CEMSIS data is  
            protected under current medical privacy laws, data retention  
            standards, and limits on sharing personally identifiable  
            information. 

           6)Arguments in support  . The California Ambulance Association  
            states in support of AB 1129, "EMS data collection practices  
            are inconsistent with and contrary to the goal of NEMSIS,  
            which is the setting of a standard for the exchange of health  








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            care information among different providers and agencies.  It  
            is not meant, nor necessary, to mandate particular software to  
            meet the NEMSIS standards."  



          The Los Angeles County Ambulance Association writes, "Mandating  
            specific software creates the need for duplicative systems  
            because many providers serve multiple counties throughout the  
            state."  

          According to AmbuServe, "A goal of federal healthcare reform is  
            to hold costs down? If each LEMSA has a different software  
            requirement for sharing healthcare information, an EMS or  
            other health care provider would essentially have to run  
            duplicate systems, all at great cost to the private sector."
           7)Arguments in opposition  .  The Emergency Medical Services  
            Administrators Association of California (EMSAAC) and the EMS  
            Medical Directors Association of California (EMDAC) state in  
            opposition to this bill that, "EMSAAC and EMDAC are generally  
            supportive of the concept of expanding the use of electronic  
            emergency medical services data; however, we are ]opposed to  
            AB 1129's prohibition that?LEMSAs?may not adopt a single  
            system-wide patient care record system?While it is not common  
            for a LEMSA to mandate a single system-wide patient care  
            record system, such an approach may clearly be in the best  
            interest of patients in order to assure the transfer and  
            continuity of patient care data from and to prehospital  
            providers, receiving hospitals, and specialty care centers."





            The California Right to Life Committee, Inc. opposed this bill  
            on the basis this bill "could eventually include the data on a  
            statewide Physicians' Orders for Life Sustaining Treatment  
            Registry (POLST) and other similar end of life registries.  
            CRLC is opposed to the POLST type form of end of life decision  








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            making in which medical or non-medical personnel complete a  
            form and the patient does not have to sign or verify its  
            statements?The person's name on such a registry or data base  
            could negate the patient's true choices for end of life  
            treatment."



           8)Author's amendment  .  The author would like to accept the  
            following minor amendment to address the concerns expressed by  
            some opponents:


              On Page 6, line 2, strike out "is compliant" and insert:


                 exports data in a format that is compatible


           9)Prior legislation  .  AB 1621 (Lowenthal) of 2014 would have  
            required the EMSA to adopt a single statewide standard for the  
            collection of information regarding pre-hospital care for its  
            CEMSIS. Would have required EMSA to develop standards for  
            electronic patient care records systems used LEMSAs and local  
            pre-hospital EMS providers to ensure compatibility with  
            CEMSIS, and required local EMS agencies 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) of 2014 would require 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), of 2013 would have increased the membership  








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            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.


           10)Double-referral  .  This bill was double-referred to the  
            Assembly Health Committee where it was heard on April 14,  
            2015, and passed on a 16-0 vote. 


          REGISTERED SUPPORT / OPPOSITION:




          Support


          California Ambulance Association (CAA) 


          AmbuServe Ambulance


          Los Angeles County Ambulance Association, Inc.


          Care Ambulance Service


          Shoreline Ambulance


          Emergency Ambulance Service










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          Opposition


          California Right to Life Committee, Inc. 


          EMS Medical Directors Association of California (EMDAC)


          Emergency Medical Services Administrators Association of  
          California 




          Analysis Prepared by:Jennie Bretschneider / P. & C.P. / (916)  
          319-2200