BILL ANALYSIS �
AB 1621
Page 1
Date of Hearing: April 29, 2014
ASSEMBLY COMMITTEE ON HEALTH
Richard Pan, Chair
AB 1621 (Lowenthal and Rodriguez) - As Amended: April 21, 2014
SUBJECT : Emergency medical services: data and information
system.
SUMMARY : Requires the Emergency Medical Services Authority
(EMSA) to develop the State Emergency Medical Services Data and
Information System (SEMSDIS) in order to assess each emergency
medical service (EMS) area or local emergency medical services
agencies (LEMSAs) service area to determine the need for
additional EMS services, coordination of EMS services, and the
effectiveness of EMS. Specifically, this bill :
1)Requires EMSA to develop SEMSDIS, on or before July 1, 2016,
and, after approval by the Commission on Emergency Medical
Services (EMS Commission), adopt minimum standards to
implement and maintain SEMSDIS. Requires SEMSDIS to include,
but not be limited to, data and information relating to
prehospital care and specialty care. States the purpose of
SEMSDIS is to monitor and determine the quality and
effectiveness of the statewide EMS system.
2)Requires EMSA to develop guidelines and standards for LEMSAs'
and local prehospital EMS providers' electronic care record
systems to ensure compatibility with SEMSDIS. Requires the
guidelines and standards to include: a common data dictionary;
integration of first responder data and transport provider
data; and, patient outcome data consistent with current
national standards and privacy requirements in state and
federal law.
3)Requires EMSA to consult with stakeholders in the development
of standards and of SEMSDIS, including air ambulance providers
and other entities not included in the EMS Commission.
4)Requires prehospital EMS providers to implement the electronic
care reports using the standard procedures, definitions, and
interoperable coding, as adopted by EMSA in the minimum
standards for SEMSDIS, and submit completed reports to the
LEMSA in a timely manner. Defines "prehospital care reports"
to include, but not be limited to: documentation of the
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event, incident, or medical condition precipitating the need
for EMS, the treatment provided, and the patient's medical
history.
5)Requires LEMSAs, using information from the completed reports
submitted by prehospital EMS providers, to submit patient
information data consistent with the standards and guidelines
of SEMSDIS to EMSA in a timely manner, using national
standards when available.
6)Requires EMSA to post any proposed rules described in 1) and
2) above, on its public Internet Website no later than 9
calendar days prior to the effective date of the proposed rule
and include a method for public comment and the date by which
those comments must be received in order to be taken into
account by EMSA.
7)Makes the enactment of this bill contingent upon an
appropriation in the annual State Budget.
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 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.
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; emergency
medical technician (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
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rescue services.
6)Establishes under federal law, the Health Insurance
Portability and Accountability Act (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, the mission of
the EMSA is to ensure quality patient care by administering an
effective, statewide system of coordinated emergency medical
care, injury prevention, and disaster medical response. 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. The author states, that while EMSA has utilized its
California Emergency Medical Services Information System
(CEMSIS) to collect data from LEMSAs, submission of
information by local agencies is voluntary.
The author also argues that accurate and timely data collection
is limited by the lack of statewide standards for reporting,
pre-hospital patient care record methodology (both paper
records and various electronic records are used), the data
points collected and reported to EMSA, the lack of integration
with hospital patient records for outcomes, and the
limitations of EMSA's own CEMSIS system. The author asserts
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that this bill will both facilitate the adoption and
integration of electronic pre-hospital care reports for EMS,
and improve the consistency and quality of data collection at
the state level for EMS. As LEMSA providers transition to
electronic patient records, it will be essential that data
collection is consistent across various platforms, that LEMSA
providers have clear guidelines for system components and data
points, that any electronic platform has the ability to
securely integrate with hospital records to track outcome
data, and that statewide and local standards take into account
system limitations, including the ability to use electronic
records and transmission in rural areas.
2)BACKGROUND . According to information provided by the author,
California's 33 LEMSAs typically subcontract with different
EMS providers (ambulance, fire, helicopter services), with
each provider using some version of a patient care record.
Several LEMSA providers have started or finished the process
of converting to an electronic patient care record. While the
electronic record may be completed while the patient is being
treated, or during transport, the EMS electronic report is
generally not compatible with the hospital's electronic health
record, and a paper record is completed as well. A December
2013 report by Lumetra Healthcare Solutions indicates that
even the paper record often fails to make it into the
hospital's patient record.
The Lumetra report covers a survey done by EMSA to examine
disconnect between the documentation of EMS, and the transfer
and receipt of that information by the hospital. The survey
covered the readiness of local agencies and providers and gaps
in the readiness for health information exchange. The survey
and report concluded that while the electronic patient record
systems and health information exchange have made significant
progress, more work needs to be done, particularly with the
standardization of data collection and coordination with
hospitals to integrate records and document measureable
patient outcomes.
In 2012, EMSA received a grant from the California HealthCare
Foundation (CHCF) to increase the accessibility and accuracy
of pre-hospital data for public, policy, academic and research
purposes to facilitate system evaluation and improvement. The
grant included a review of EMSA's existing CEMSIS system, the
development of a core measures program, and engagement with
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local EMS agencies 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 CEMSIS
system had a number of weaknesses that made it difficult for
EMSA to validate EMS information for reporting, impacting it's
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
CEMSIS system was also assessed by the Health Services
Advisory Group 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 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)NATIONAL EMERGENCY MEDICAL SERVICES INFORMATION SYSTEM . The
National Emergency Medical Services Information System
(NEMSIS) is the national repository that will be used to
potentially store EMS data from every state in the nation.
The purpose of NEMSIS is to facilitate EMS data sharing and
provide guidance to states to create an EMS data collection
system. Local EMS data will be reported to state EMS
databases, then that data reported to the national EMS
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database in order to generate and produce reports on different
areas of interest to EMS. Many statewide data systems have
been created, however, these EMS systems vary in their ability
to collect patient and systems data and allow analysis at a
local, state, and national level. For this reason, the NEMSIS
project was developed to help states collect more standardized
elements and eventually submit the data to a national EMS
database. NEMSIS includes a data dictionary which has over
400 elements split into two datasets. Currently NEMSIS is on
its third version with numerous revisions in each version and
the data dictionary is also evolving.
5)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.
6)SUPPORT . The American Federation of State, County and
Municipal Employees writes in support of this bill because it
would provide important statewide data on the quality and
effectiveness of EMS services in California, allow
policymakers, EMS providers, and the public to access this
information and adjust laws and regulations to reflect best
practices, ultimately improve patient care. American Medical
Response (AMR), also in support, states this bill will provide
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important data needed to assess existing systems and establish
performance indicators and quality initiatives across the
state. AMR also states that measuring quality in EMS systems
is increasingly important as EMS scope and types of
prehospital procedures have expanded. The California Hospital
Association (CHA) states in support of this bill that EMS
providers must be prepared at all times for the unexpected and
patient handoff communication from the ambulances to the
emergency departments is one of the most critical
information-dependent components of the process. CHA furthers
that advances in technology bring new opportunities to improve
communication and transfer of patient data and that health
information technology among California's EMS providers is of
critical importance in day-to-day operations, as well as in
the event of disasters and other unforeseen occurrences.
7)OPPOSITION . The Emergency Medical Services Administrators
Association of California, California State Association of
Counties, and County Health Executives Association of
California all write in opposition to this bill. The
opposition is supportive of expanding the use of electronic
EMS data, but not the costly regulatory mandate on counties
and EMS providers. The American Civil Liberties Union (ACLU),
Electronic Frontier Foundation, and the Consumer Federation of
California all write that they are opposed to this bill,
unless it is amended to include crucial language about privacy
and security of sensitive medical data. According to the
ACLU, it is unclear if the authority in charge of SEMSDIS and
LEMSAs are entities covered under HIPAA or CMIA and that this
bill should explicitly clarify that EMSA is subject to at
least as strong as the patient privacy and security rules as a
hospital is under CMIA.
8)RELATED LEGISLATION . AB 1975 (Roger Hern�ndez) requires
LEMSAs to contract with the American College of Surgeons every
five years to conduct a comprehensive assessment of the county
trauma system. AB 1975 is pending in the Assembly Health
Committee.
REGISTERED SUPPORT / OPPOSITION :
Support
American Federation of State, County and Municipal Employees,
AFL-CIO
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American Medical Response
California Association of Air Medical Services
California Hospital Association
Opposition
American Civil Liberties Union of California (unless amended)
California State Association of Counties
Consumer Federation of California (unless amended)
County Health Executives Association of California
Electronic Frontier Foundation (unless amended)
Emergency Medical Services Administrators Association of
California
Analysis Prepared by : Patty Rodgers / HEALTH / (916) 319-2097