NOTICES
DEPARTMENT OF HEALTH
Emergency Medical Services Patient Care Report Data Elements, Confidential and Nonconfidential Data Elements and Essential Patient Information for Transmission at Patient Transfer
[49 Pa.B. 1606]
[Saturday, March 30, 2019]Under 28 Pa. Code § 1021.41 (relating to EMS patient care reports) the Department of Health (Department) is publishing the following: (a) a list of data elements and form specifications for the emergency medical services (EMS) patient care report (PCR); (b) requirements that a prospective vendor must satisfy to secure endorsement of the vendor's software by the Bureau of Emergency Medical Services (Bureau); and (c) a designation of data items for the PCR that are confidential.
(A) Data Elements and Form Specifications. The following standards must be met for an EMS data collection software program to satisfy the requirements for electronic PCR reporting:
1. A prospective or currently approved vendor software must be capable of collecting and reporting data in the format detailed in the National Emergency Medical Services Information System (NEMSIS) Data Dictionary at the most current version, as published by the National Highway Traffic Safety Administration. Information on NEMSIS is published at www.nemsis.org. Prospective vendors and approved vendors are encouraged to contact the NEMSIS Technical Assistance Center (TAC) for issues regarding the NEMSIS reporting requirements. Software marketed to Commonwealth EMS agencies must be capable of collecting and reporting all NEMSIS elements. Prospective vendors and currently approved vendors must use the Commonwealth specific data files as published on the NEMSIS web site. The Bureau will maintain a list of required fields, codes and resources on the NEMSIS webpage.
2. A PCR data collection software program must satisfy the following:
i. It must be capable of recording all data elements identified in the Pennsylvania Data Dictionary, which can be found on the NEMSIS web site. Additionally, the software must have the ability to error check PCRs using the NEMSIS Data Dictionary published on the NEMSIS web site.
ii. It must connect and transmit to the State data bridge through approved formats that align with NEMSIS versioning standards at the date of connection.
iii. It must be able to collect and print narrative.
iv. It must allow for the ambulance service to make corrections when data elements are omitted or when an error occurred when the form was initially completed.
v. It must annotate additions and corrections made to the PCR by identifying what data element was added or changed, the date of change and who made the change.
vi. It must assign a specific PCR Number (NEMSIS Field eRecord.01 or the most current identifier for the PCR Number) to each PCR and prevent duplication of this identifier.
3. A prospective vendor must assist EMS agencies in setting up software and validate that PCR data created by the software being proposed will be compliant with the ''Required Data Elements'' on the EMS PCR Data and Information Chart.
4. A prospective vendor must coordinate with a regional EMS council that is willing to conduct a test of the software program using ten PCRs previously submitted to the NEMSIS TAC.
The test will include:
i. Printing of the ten PCRs.
ii. Printing a list of the data elements collected.
iii. Printing reports that identify unit utilization for:
a. Response outcome, hour/day of week.
b. Fractal time.
c. Municipal response for the test site.
iv. Printing the following reports:
a. Incident location/type report with number of calls and percentage of calls.
b. Trauma summary.
c. Revised trauma scores.
d. Glasgow coma scale.
e. Medical summary.
f. EKG.
g. Treatment summary.
h. Admission summary.
i. BLS and ALS skills report for each practitioner.
j. BLS and ALS skills report for each beta test site.
k. Demographics summary (age, gender, total).
l. Vital signs summary (ranges, systolic, diastolic, pulse, respiration).
m. Attendant activity.
v. Printing output files of data elements to include:
a. Field number.
b. Field name.
c. Number of fields for each field name.
d. Type of field (that is, numeric, blanks stored as ''0,'' mm/dd/yyyy, character and acceptable field values).
5. A prospective vendor must request and secure a determination of software compliance from the Bureau. Upon receipt of this request, the Bureau will notify the prospective vendor of reports and information that the prospective vendor must submit to the Bureau to secure a determination of compliance.
(B) Bureau Endorsement of Software. To secure endorsement of the software by the Bureau, in addition to securing a determination of compliance from the Bureau, a prospective vendor must do the following:
1. Agree, in writing, to make changes to the software program at no cost to the EMS agency if the change is the addition of additional data elements included in the most current NEMSIS Data Dictionary version.
2. Agree, in writing, to provide to the Bureau and to Commonwealth licensed EMS agencies using the vendor's software, 30-days advance notice before selling the program source code or company or going out of business. The prospective vendor must further agree, in writing, that if circumstances prevent the prospective vendor from meeting the 30-day notice requirement, the vendor will provide input specifications and the source code for the software program to the Bureau at no cost.
(C) Confidential PCR Data Elements. Under 28 Pa. Code§ 1021.42 (relating to dissemination of information) the release of the PCR, disclosure of confidential information in the PCR or a report or record thereof, is pro- hibited except as authorized under 28 Pa. Code § 1021.42(a)(1)—(8). The Department has the authority under 28 Pa. Code § 1021.42(b) to designate some of the information in the PCR as nonconfidential but has chosen not to do so at this time. Consequently, the PCR is confidential in its entirety, and all information in the PCR is subject to the disclosure restrictions in 28 Pa. Code § 1021.42(a). The Bureau and the regional EMS councils will, however, release aggregate data extracted from PCRs.
(D) Patient Information Required to be Transmitted to Hospital at Time of Patient Delivery. Under 28 Pa. Code § 1021.41(c) an EMS agency is to provide to the individual at the hospital assuming responsibility for the patient the patient information designated in the PCR as essential for immediate transmission to personnel for patient care. The Bureau encourages EMS agencies to transmit immediately to the facility all information solicited by the PCR, including the narrative section. If the EMS agency does not provide all the information solicited by the PCR at the time the hospital or facility assumes care, essential information that must be transmitted are the items listed on the EMS PCR Data and Information Chart. The information shall be transmitted verbally, and in writing, or electronically in a format (developed by the hospital or other entity) that the hospital finds acceptable to ensure the confidentiality of information designated as confidential in the PCR form.
Persons with a disability who require an alternate format of this notice (for example, large print, audiotape or Braille) should contact Aaron M. Rhone, Department of Health, Bureau of Emergency Medical Services, 1130 Elmerton Avenue, Harrisburg, PA 17110, (717) 787-8740 or for speech or hearing impaired persons call the Pennsylvania AT&T Relay Service at (800) 654-5984 (TDD users) or (800) 654-5988 (voice users).
RACHEL L. LEVINE, MD,
Secretary
[Pa.B. Doc. No. 19-464. Filed for public inspection March 29, 2019, 9:00 a.m.]
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