Regulation of Emergency Medical Services:II Ch 3

· Since 1975, the statutes have required that a data system be put in place -- 25 years later there is no data collection system

· Absent a system, there are no basic descriptive information on Connecticut’s system, and no data to evaluate the system

· Lack of consensus within EMS community appears to have stymied the implementation of a system

· Several attempts were made at initiating a system but they have been piecemeal approaches, and largely unsuccessful

· Connecticut is one of a minority of states without a comprehensive data collection system

· Costs have been an obstacle in the past, but DPH may not have looked for the most cost effective methods to implement a system

· A substantial number of other states still rely on paper transmission for part of its data collection efforts

Require DPH to collect, maintain and report on data contained on ambulance run forms. Annually, DPH would report on the data by town and grouped by urban, suburban and rural categories.

One of the biggest gaps in the EMS system in Connecticut is the lack of a data collection system to measure how the system is performing. Since 1975, the statutes have required (through P.A. 75-112) that there be a data collection system in place. However, almost 25 years later there are no comprehensive data on the system, including key performance indicators like types of calls, passed calls (i.e., where the responder cannot take the call), response times, or patient outcomes. Even basic information like the number of emergency and non-emergency calls and the services that respond are not routinely collected or reported. There are a number of reasons for the continuing lack of an EMS data collection. They are explained below.

Unclear statutes and regulations. The statutes call for the commissioner of DPH to “develop or cause to be developed a data collection system which shall include a method of uniform patient record keeping. . .” (C.G.S.§ 19a-177(8)). However, the statutes do not indicate where or how the data should be kept. The EMS regulations specify that records on each request for emergency medical service be maintained at the provider’s location for at least seven years. The records, which the regulations specify contain at least 10 pieces of information, including response time and patient treatment, must be available for OEMS inspection. However, the records are not required to be sent to DPH nor are the providers required to report on them.

Data not examined. While the regulations give DPH authority to inspect provider records, there was no state effort to examine those data until recently. Beginning in March 1999, a DPH staff person assigned to conduct vehicle safety inspections began examining the provider records. The results are being included as part of the vehicle inspection reports, but one staff person is able to review only a small sample of records. Further, site inspection of records is an inefficient way to examine data, and comprehensive results are not systematically recorded or maintained.

No consensus exists. The EMS system is comprised of many players – DPH, commercial ambulance companies, volunteer and nonprofit companies, towns, hospitals, physicians, and dispatch centers. The EMS community appears to strive for decisions by consensus. But there has been -- and still is -- no consensus among the parties on how a data collection system should be implemented. What might be a good method for one segment of the EMS community might be too costly or time-consuming for another. Thus, in an attempt to find a method that suits everyone, nothing is accomplished.

Even among EMS regional councils, there is no agreement. Table III-1 on the following page illustrates the variation in proposals dealing with data collection. While most regions followed the state EMS plan, which called for a full-time data systems manager, there continue to be differences in the regional plans dealing with implementation, method and time frame.

Prior attempts. There have been several attempts through the years to initiate a data collection system but none have been successful and were subsequently abandoned. For example, just last year a pilot program was initiated where computers were installed at two rural hospitals with the aim of having individual emergency medical technicians (EMTs) enter the data at the hospital site. However, the project was terminated because it was too time-consuming and EMTs had not been trained in entering data into the computer, and, therefore, did not use the system.

Securing adequate resources to finance and staff a data collection system has been cited as a problem. However, some of the proposals for data collection may not have been reasonable in terms of costs. For example, the fiscal note attached to the 1999 proposed legislation, based on DPH information, estimated costs of about $4 million, with $2.5 to be borne by providers and towns for computer equipment on individual vehicles, an expensive approach.

DPH has diverted its focus for establishing a comprehensive EMS data system to other data mandates, but in a piecemeal fashion and without oversight on outcomes. For example, in 1992, in response to NHTSA findings, a Commissioner’s Committee on Trauma (CCT) was appointed and charged the committee with developing trauma regulations.

The trauma regulations, which became effective in 1995, call for specific data elements to be collected on EMS but only related to trauma cases. After federal funding supporting the trauma data system expired, the data collection collapsed. The Connecticut Hospital Association, which had been maintaining the data, indicates it cannot continue the system without continued funding. More than $500,000 has been spent on the trauma registry, and while a couple of reports were produced, EMS participants questioned the validity of data contained in the reports. No reports on the trauma data have been issued since 1998.

Parties involved in the system indicate that some providers question the need for a data collection system. The failure to date to produce any data useful to providers reinforces that negative response.

Why Data Collection is Necessary

Reasons for a data collection system were listed in phase one of the study. In summary, they are:

· Connecticut does not collect the data needed to provide even basic descriptive information of the system, such as the number of 9-1-1 calls requiring EMS, what towns they were in, what types of calls, or what treatment was required

· Commitment is needed from the towns that they will be monitoring their providers; towns cannot adequately monitor without data

· Accountability cannot improve system without measuring and evaluating provider performance; bad performance will not come as a surprise to towns if monitoring is ongoing

· Providers may not have the data they need to examine their own performance and work toward improvement

· Need to evaluate what works in EMS and what does not. For example, if data show no difference in outcomes of a certain category of patients using BLS versus those where ALS was sent, the need for ALS for that type of call should be considered

Flexibility in Approach

In phase one of the EMS report, the program review committee recommended that towns be responsible for collecting data from EMS providers and to report annually to the Department of Public Health. The recommendation was drafted into proposed legislation, but faced intense opposition. The bill was amended to have the providers furnish the data, with towns using dispatch centers, known as public safety answering points (PSAPs), where that was mutually agreeable. Some parties still objected and the bill did pass.

Since the 1999 session, and the failed proposal, program review has consulted many parties to determine the best way to collect, maintain and report on EMS data. The main thrust of their comments follows:

· The pieces of data collected have to be uniform (all providers must report the same pieces of information). The “run form” used for each ambulance call may be best way to do this;

· The purpose of data collection cannot be seen as punitive; but there must be an evaluation component to it;

· There has to be expected compliance and consequences if providers don’t comply;

Taking these factors into consideration, the program review committee recommends the following:

By January 1, 2001, the Department of Public Health shall collect and maintain data from the ambulance run form. Data points required to be submitted to DPH shall be uniform by all EMS providers. Providers shall submit copies of the run form information monthly via a method that accommodates needs of both providers and the department. The trauma reporting requirements shall be consolidated on this run form to satisfy both general EMS and specific trauma data fields.

By March 2002, and annually thereafter, DPH shall report on the following information which shall include, but not limited to:

· fractile response times for each level of the EMS system -- dispatch, first response, basic life support, and advanced life support – using common definitions of response times established by the Department of Public Health. Data may be subject to audit by DPH, as the department deems necessary.

The report shall compile the information and report it in an aggregated format by town – with towns grouped according to urban, suburban, and rural categories – and make the information publicly available, including through DPH’s web site. The department shall notify the Public Health Committee of the report’s availability.

If a provider does not comply with the submission of required data for a period of six months, or if DPH has cause to believe the provider knowingly and intentionally submitted incomplete or false information, DPH shall notify the provider and the towns served by the provider that compliance is mandatory. If full compliance is not achieved within the following quarter, DPH shall hold a hearing at which the provider would be required to demonstrate why the Primary Service Area assignment should not be removed.

In addition to EMS providers, each public safety answering point (PSAP) shall, beginning January 1, 2001, submit quarterly aggregated data on its EMS calls to the Office of Statewide Emergency Telecommunications (OSET), within the Department of Public Safety. The data submitted from PSAPS shall include all 9-1-1 calls where a medical emergency is involved. The aggregated data shall report elapsed time for dispatch -- from the time the call was received to the time the call was dispatched or transferred -- and shall be reported in fractile response times.

Rationale and Implementation

The program review committee believes responsibility for EMS data collection should be at the state level for a number of reasons. Designating EMS data collection and reporting as a state level function offers the best opportunity for quality assurance of the data, and the most effective use of staffing and equipment resources necessary to perform the duties. Further, if the data collection function for EMS is assigned to a single place, an implementation date of January 1, 2001 is more easily accomplished. Finally, since DPH has overall regulatory responsibility for the state’s EMS system and more specifically a statutory mandate for developing a uniform data system, it is logical to conclude DPH carry it out.

Other state experience. The majority of states receive some type of EMS performance data; Connecticut is one of a minority of states that still does not. Program review surveyed all 50 states on their EMS systems. The results of the states responses regarding data collection are illustrated in Figure III-1. Thirty-eight states answered the question, and 26 states – more than two-thirds of respondents -- indicated they received EMS performance data. Thus, most states have seen the value in being able to monitor their systems; Connecticut must do the same.

DPH as designated agency. In Connecticut, the Department of Public Health is the most appropriate state agency to collect and compile EMS data since it has regulatory authority over the EMS system. However, before any data collection system can be initiated, DPH must ensure that all areas of the state have a designated responders as required by regulation. (See findings and recommendations in Chapter V).

The committee considered requiring public safety answering points to collect and report EMS data, but decided against that option for several reasons. First, in response to the program review survey of public safety answering points, the committee found that:

· 62 percent of PSAPS said they dispatched the ambulance, but more than one-third did not;

· only 54 percent of responding PSAPs indicated they dispatched paramedic level services; and

· even lower percentages could report when ambulances or paramedics arrived on the scene.

Thus, a substantial percentage of PSAPs would not have data needed to fulfill complete EMS reporting. Of the PSAPs not currently collecting response time information, 93 percent indicated they would not have the capability to collect and compile that data. To require PSAPs to collect and report complete data for all EMS providers is likely to be seen as an unfunded mandate for dispatch centers.

Dispatch centers. Requiring PSAPs to collect and report data for the entire EMS system, as discussed above, seems an unworkable proposal. However, the program review committee believes it is necessary to collect performance data on the dispatch segment of the EMS system. This is an area where no data are collected now, and excludes an important time element – from the time a call is received until dispatch or transfer.5

The committee concluded PSAP data should be collected by the state Department of Public Safety (DPS). Because of agency jurisdiction -- public safety answering points are under the purview of DPS, Office of Statewide Emergency Telecommunications (OSET) -- it makes administrative and organizational sense to have PSAP data reported to OSET. Data on fire responses are already required to be submitted by local fire departments to the Department of Public Safety, Office of the State Fire Marshal, but those data do not measure dispatch information either.

Further supporting dispatch center reporting is a regulatory mandate (§28-27-10) that all 9-1-1 calls be answered at the PSAPs within 10 seconds. The committee determined that performance data should be collected to assess how well dispatch centers comply with this mandate as well as report on how quickly the centers dispatched the appropriate responders. While not part of the recommendation, program review believes the PSAPs should use the same number on the data form as the responders use on the run form. If a unique identifier is used for each call, there will be a way to track the entire call if necessary.

The mandate that dispatch centers begin reporting by July 1, 2001, would apply only to EMS calls, because of the limits in the committee’s scope of study. However, if OSET and the centers agreed, dispatch data could also be collected for fire and police.

Data transmission. Many states still rely on paper for some transmission of data. Of the 26 states who collect data at the state level, 14 states responded to the committee survey that they rely on paper (including scannable bubble sheets) as the primary source of transmitting data, while five states responded they use electronic methods primarily. Seven states indicated they used both methods.

In light of the number of states still using a primarily paper-based system, the committee determined there should be no mandate, or even expectation, that all providers transmit data electronically immediately. Many Connecticut providers already use computerized data from the run form for their own reports and/or for billing purposes. A growing number are obtaining computers with Internet access. Electronic transfer by all providers will be likely in the near future, but a mandate for that is premature now. The important element is that the data reported are uniform, comprehensive for all types of calls, and reported by all providers and segments of the system.

In keeping with the recommendation, the program review committee concludes that the collection of trauma data should be consolidated with the data collected on the entire pre-hospital system so that all EMS cases can be evaluated. Attempts to revive the trauma registry or maintain the data separately will only divert resources and attention away from establishing an overall data collection system.

Equipment and staffing. There will be start-up and equipment costs with any data collection system. Program review estimates those to be no more than $250,000, including the first year of staffing.6 The one-time costs include:

· About $50,000 for a consultant to assist DPH in determining equipment and software needs as well as designing a form that captures uniform data. The committee contacted a vendor that has established EMS data systems in 35 states or counties, and a preliminary, informal cost estimate for developing Connecticut’s system was well under $50,000. The committee believes this would be money well spent. Contracting with an expert experienced in designing EMS systems in many other jurisdictions might avoid both design pitfalls and expenditures on unnecessary equipment or methods, and help parties in the system reach a decision on data needs quickly.

· Approximately $15,000 for a high volume, high speed scanner to scan transfer the data on the paper run form to a computerized format. Program review estimates the scanner will need to scan about 1,000 documents a week, and therefore a heavy duty scanner should be purchased. DPH has developed specifications on a request for proposal (RFP) but the RFP was issued late in 1999, and DPH did not know what the bid amounts would be. The cost figure used here is an estimate from the same national EMS vendor cited above.

· The committee estimates no additional costs for the purchase of computers. DPH should already have an adequate number computers to use for the data collection efforts. DPH now has possession of the computers that had been placed at the hospitals for the pilot program last year, when that program failed. DPH will be responsible for maintaining state computer access to providers to submit their data electronically, but providers must provide their own computers at their site, or submit their forms via paper.

· Approximately $25,000 for initial purchase (and $25,000 a year after that) for paper run forms. Approximately 75,000 forms a year should be purchased, although it is likely that at most only 50,000 will be needed.

Staffing. The committee believes EMS data collection functions can be performed well with two additional personnel hired at DPH. Staffing costs for the first year are estimated at approximately $110,000. Yearly increases should be limited to raises in salary and fringe awarded through state employment contracts. The positions, associated cost estimates, and proposed functions are outlined below:

EMS Data Collection Project Manager (hired at the mid-range salary for EMS Field Training Coordinator)

Data Entry Operator (hired at the mid-range salary level for Data Entry Operator 1)

Program review proposes functions to be performed by the project manager include:

· Ensuring the run forms are sent in monthly by each EMS ambulance provider in the state. DPH should probably set a staggered schedule for submissions so that not all forms (especially those needing scanning) will come in at the same time.

· Ensuring the data on the forms appear complete, correct, and valid. Where problems appear, the project manager must work with the providers to ensure completeness, and validity.

· Conducting audits to ensure the validity of the data. Outside sources, such as the PSAP data, should be used to verify.

· Compiling data into an annual report (by March 2002) by town and provider so that performance of EMS providers may be evaluated.

· Coordinating with OSET to obtain and consolidate the data from the PSAPs in order to ensure the report incorporates data on all segments of the pre-hospital care system -- from time the 9-1-1 call is answered to the time the patient is delivered to the emergency room.

Program review envisions this position in the EMS systems development area of DPH, and not in the regulatory bureau. The committee believes the assignment of the position is important because it will signal to the EMS community that emphasis will be on development and assistance rather than immediate compliance and enforcement. Until providers, towns and the public see the benefits -- and not just the anticipated burden -- of an EMS data system and the information it can furnish, provider compliance may be a problem.

In order to obtain compliance, DPH must demonstrate a willingness to work with providers whose data show that improvement in service is needed. The DPH project manager will have to work with providers and towns to prove that cooperative corrective action can occur over a realistic period of time.

At the same time, the recommendation makes clear that data collection is a requirement, and gives DPH authority to take punitive measures if a provider does not report data or submits incomplete or false records. The ultimate purpose of the data is to evaluate provider performance. At some point towns must be able to use the data for establishing contracts, improving service, and/or terminating providers who cannot correct poor performance. To construct the foundation for such an evaluation system, there must be universal and honest reporting. It will be the project manager’s duty to ensure this.

Financing. The program review committee believes the approach to data collection outlined above impose realistic cost and staffing demands. However, the proposal will still require funding not allocated currently.

Therefore, the Legislative Program Review Committee recommends that, beginning July 1, 2000, an allocation of no more than $250,000 annually from the surcharge on phone lines that cover the 9-1-1 system be made to finance data collection, maintenance and reporting for the emergency medical system.

· A dedicated funding stream already exists through the surcharge on phone bills for the state’s 9-1-1 system.

· There is more than adequate funding available through the 9-1-1 surcharge. Each penny of the individual assessment generates about $300,000 annually. Thus, the recommendation will use less than one cent of the surcharge.

· The surcharge produces more than what can be spent on its original purpose – hardware for the 9-1-1 centers; grants to regionalize dispatch centers; training for dispatchers; and operations at the Office of State Emergency Telecommunications.

· It is logical that a surcharge that pays for the state’s 9-1-1 system should be used to finance data collected on EMS services generated from the system.

· Establishing another dedicated source of funding, such as a “Dollar for Life”-- which adds a $1 fee onto a driver’s license or car registration fee and which some have suggested as a financing mechanism -- would require new or added administrative functions to implement such a fee.

The recommendation calls for a cap on the amount that may be allocated from the 9-1-1 surcharge that would go to EMS data collection. In order to safeguard the integrity of the 9-1-1 financing, a more formal mechanism may be necessary. For example, the public safety department (which oversees OSET) and DPH (which would administer the EMS data collection system) could sign a memorandum of agreement regarding how the funding will be used. The memorandum of agreement could be approved by the Department of Public Utility Control (DPUC), which oversees the assessment and expenditures of the 9-1-1 surcharge. This would provide written assurances that allocations will be spent on purposes that DPH and DPS agree to and DPUC approves as appropriate.

5 Even with data from the PSAPs and the EMS providers there will be an incomplete EMS time picture for those towns where the PSAPs transfer an EMS call to another dispatch center (like a local fire or police department) rather than dispatching the EMS call directly.

6 This is a far more reasonable estimate than the $3 million start-up figure contained in the fiscal note for the data collection proposal contained in the EMS bill during the 1999 legislative session. These high costs were associated with electronic recorders or computers that were to be placed in every vehicle for recording times. The hefty expense note associated with the bill contributed to its demise.

Table III-1. Data Collection Recommendations Contained in Regional EMS Plans
Region	Implementation	Method	Time frame
Northwest	Manager to work with data committee. Develop an RFP to design and implement an EMS data system at state level	No recommendation; Suggests the bubble form at a certain cost or electronic at higher cost	Five years for an electronic system; two years for the bubble sheet
Eastern	Regional approach: This region states a clerical person is needed in each region ($45K a region) plus $10k in equipment for each region	Suggest $3 million for hardware, software and training. No “method” suggested	No time frame established
South Central	No recommendations on implementation Regional plan indicates “support state efforts”	“support state efforts”	No time frame
Southwestern	No implementation recommendations –continue to send representatives to task forces, working groups	Work with DPH and EMS Advisory Board during FY 99-00 to identify funding source	No time frame
North Central	Change statutes to require EMS providers to submit data to DPH in format the agency prescribes	Allocation of up to $3 million with “carry-over” authority	No time frame
Source of Data: Regional EMS Plans

Table III-1. Data Collection Recommendations Contained in Regional EMS Plans

Why Data Collection is Necessary

Flexibility in Approach

Rationale and Implementation