Electronic PCR Data Submission

Bureau of EMS Policy Statement
Policy Statement # 12-03
Date January 23, 2012
Subject Electronic PCR Data Submission
Supercedes/Updates 04-05, 08-01

The New York State Department of Health, Bureau of Emergency Medical Services is responsible, pursuant to Article 30 of the Public Health Law (PHL) for the collection of prehospital patient documentation data. The paper Prehospital Care Report (PCR) has been the primary instrument used for patient care and EMS event documentation. The primary purpose of the PCR/ePCR is to document all prehospital care and pertinent patient information for medical and legal purposes, as well as serving as a data collection tool for local and statewide quality improvement, protocol development and when approved, research.

The Department collects and compiles raw data into quantitative and summary data as a retrospective review of EMS activity throughout the state. Recently, links were made to match out-of-hospital PCR/ePCR data with in-hospital data from the NYS Trauma Registry and the Statewide Planning and Research Cooperative System (SPARCS) Emergency Department data sets to create a more complete and inclusive patient care record. The PCR information is provided to the State and Regional EMS Councils and the State and Regional Emergency Medical Advisory Committees.

PHL Article 30 requires that all ambulance and advanced life support first response services (ALS-FR) submit all call reporting documentation to the Department, in a format approved by the Department. The NYS EMS Code, 10NYCRR Part 800.15, requires that every person certified as an EMS provider, at any level, must complete a PCR/ePCR for each request for EMS response received by his/her agency, in accordance with the Department's established policy.

Article 30 § 3053 Reporting

Advance life support first response services and ambulance services registered or certified pursuant to article thirty of this chapter shall submit detailed individual call reports on a form to be provided by the department, or may submit data electronically in a format approved by the department. The state emergency medical services council, with the approval of the commissioner, may adopt rules and regulations permitting or requiring ambulance services whose volume exceeds twenty thousand calls per year to submit call report data electronically. Such rules shall define the data elements to be submitted, and may include requirements that assure availability of data to the regional emergency medical advisory committee.

Part 800.15 Required Conduct

Every person certified at any level pursuant to these regulations shall:

  • (a) at all times maintain the confidentiality of information about the names, treatment, and conditions of patients treated except:
  • (1) a prehospital care report shall be completed for each patient treated when acting as part of an organized prehospital emergency medical service, and a copy shall be provided to the hospital receiving the patient and to the authorized agent of the department for use in the State's quality assurance program;

As more regions and EMS agencies look toward the implementation of an electronic patient documentation platform, it is the Department's intention to continue to collect patient care data through regionally based systems and/or through the State EMS Bridge.

The National EMS Information System (NEMSIS)

NEMSIS is a national effort to standardize the prehospital data collected by EMS agencies. NEMSIS is the national repository that will be used to potentially store EMS data from every state in the nation. Since the 1970s, the need for EMS information systems and databases has been well established, and 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.

Electronic Data Submission in New York State

As the federal government continues coordinating the national EMS data set, called National EMS Information System (NEMSIS), New York State has updated its method for collecting the prehospital patient care data. In consultation with the NYS EMS Council, the Department has published a NEMSIS compliant data dictionary. The additional information will provide a vast new look at the EMS picture in NYS and allow for an improved evaluation of the system at the local, regional and state levels. The New York State EMS Data Dictionary is available at the following URL:

Policy

The Department works with Regional EMS Councils, ambulance and first response services in an effort to facilitate the submission of the required data elements through an electronic medium. In an effort to insure an acceptable format, prior to implementing an electronic data collection product for the submission of ePCR data, the EMS agency MUST RECEIVE WRITTEN APPROVAL FROM THE DEPARTMENT and the applicable Regional EMS Council(s). This policy statement is intended to define the criteria necessary for an EMS Agency to convert its paper PCR system to the electronic submission of patient care report data.

In order to be considered for approval by the Department to submit PCR data electronically, EMS agencies MUST adhere to all of the following:

  1. Be in compliance with all applicable sections of Article 30 and Part 800.
  2. Be submitting paper PCRs to the Regional Program Agency on a routine and on-going basis.
  3. Contact the Department, in writing, to determine electronic reporting requirements and request approval for electronic submission.
  4. For EMS services that receive one-time, start up funding (i.e., grant funds) to purchase ePCR software/hardware, the written request for approval will need to include a plan of funding sustainability of the software/hardware after the initial funding stream has been depleted.
  5. If the software being considered for purchase is not currently mapped and submitting to the NY state data repository, testing of the data compliance must occur to insure proper format and electronic transmission to the satisfaction of the Department and the Regional Program Agency.
  6. Submit PCR data to the Department in the specified data file format at predetermined and scheduled intervals.
  7. Receive approval from the appropriate Regional Emergency Medical Services Council(s) (REMSCO) and Regional Emergency Medical Advisory Committee(s) (REMAC) in writing.
  8. All EMS services must submit the standard NYS data file to the Regional Program Agency in a compatible format on a regular and routine schedule determined by the program agency.
  9. Apply for, and receive an account with the Department's Health Commerce System (HCS). This may be done with assistance from the Regional Program Agency.
  10. If any changes or interruptions are made to the electronic patient record system that may affect data submission, the EMS service must notify the Department, in writing, ten (10) business days in advance of implementation. It is the Department's expectation that once a service converts to an electronic data collection (ePCR) system, that service will maintain the electronic system and NOT revert back to a paper-based system.

Additional Requirements

EMS agencies considering the submittal of patient care data through an electronic medium are also required to maintain records in accordance with established policies, laws and regulations. This must include, but may not be limited to:

  • Strict written confidentiality policies, including a written statement, addressing the electronic transmission, storage and security.
  • Be in compliance with the Federal Regulations pertaining to the transfer of electronic patient information and HIPPA.
  • Use an electronic data collection product that meets or exceeds the National EMS Information System (NEMSIS) data set and includes minimum statewide required data fields.
  • Records retention policies which must include, but not be limited to:
    • If maintaining original records, they must be secured and available for retrieval within 24 hours of request.
    • Patient records may be stored electronically, however a hardcopy of the like image must be readily available upon appropriate request.
    • Federal Law (HIPPA) requires that medical records be retained for six years (6). If the call involves the treatment of persons under age 18, the PCR must be retained for three years after the child reaches age 18.
  • Records must be made available for review by the Department upon request as required by regulation.
  • Provide the REMAC or its designee, with additional data elements as requested for use with quality improvement programs, specific studies or approved research projects.
  • The maintenance of patient records in a readable format and be capable, upon request by patient or designee, of providing the patient record.
  • The patient records have to be provided to the receiving hospital at the time the patient care is transferred or a predetermined written plan with the hospital must be in place.
  • EMS services are required to leave a paper copy or transfer the electronic PCR information to the hospital prior to the EMS service leaving the hospital. This document must minimally include, patient demographics, presenting problem, assessment findings, vital signs, and treatment rendered.
  • Failure to leave patient information with the emergency department upon the delivery of the patient may compromise medical treatment and interrupt the continuity of patient care.
  • All electronic patient records should be completed and closed prior to the end of the shift during which the patient was treated. There should be no access to patient records on personally owned computers. Agencies should have policies restricting the use of personally owned computers for completing ePCRs.

Other Important Considerations

There are many details surrounding electronic patient record systems. It is the Department's expectation that every EMS agency choosing to implement an electronic patient documentation system will carefully examine these details and while this list may not be comprehensive, consider the following issues:

  • Understand and adhere to the applicable HIPAA regulations.
  • Have an appropriate secure method of data transmission.
  • Have the necessary technical staff support to the electronic program.
  • Have appropriate infrastructure, security and back up for the system.
  • Have the funding available to maintain the hardware and software associated with the system.
  • Researched the product and vendor to ensure that all of the state, local and legal requirements are met by the product to be utilized.

The Review Process

Once the Department receives a written request to submit patient data electronically, it will review the request, and require the EMS service through a Memorandum of Understanding, to agree to the conditions set forth by the Department.

The conditions may include, but not be limited to:

  1. The provision of a confidentiality statement.
  2. Description of system infrastructure.
  3. Proof of system back up or redundancy.
  4. Proof of contracts for technical support, maintenance, upgrading and trouble- shooting.
  5. Information about the hardware and software products chosen for the system.
  6. Proof of REMSCO/REMAC approvals.
  7. Proof of continuous transmission of data to the Department, REMSCO/REMAC and the EMS service(s).
  8. Proof that patient care records are provided to the receiving hospital, long term care facility or alternative destination, as appropriate, at the time the patient is delivered or a written agreement with the hospital for the delivery of the patient record at an alternative time or method.
  9. Proof of compliance with PHL Article 30 requirements for service level Quality Improvement Committee.
  10. Proof that there is a regular and routine process for providing data to the applicable REMSCOs, REMACs and Program Agencies.
  11. The Department has the ability to amend the data collection method or elements as may be required by any future changes to the New York State data set.

Notice

In accordance with section 3053 of the PHL, the Department may immediately revoke the authority to submit data electronically from an agency or regional program upon written notice. If the authority is revoked, the agency will be mandated to submit paper PCRs through the Regional Program Agency.