Sec. 4. Emergency medical services

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Title XII of the Public Health Service Act ( 42 U.S.C. 300d et seq. ) is amended by adding at the end the following: In this part: The term ambulance diversion means the practice of hospitals of denying access to an incoming ambulance and requesting that the ambulance proceed to another facility due to a stated lack of capacity at the initial facility, resulting in delayed access to definitive care. The term Director means the Director of the Office of EMS and Trauma established under section 2831.

The term EMS means emergency medical services. The term FICEMS means the Federal Interagency Committee on Emergency Medical Services. The term field EMS means emergency medical services provided to patients (including transport by ground, air, or otherwise) prior to or outside a medical facility or other clinical setting. The term field EMS agency means an organization providing field EMS, including— governmental (including fire-based agencies), nongovernmental (including hospital-based or private agencies), and volunteer organizations; and organizations that provide field EMS by ground, air, or otherwise.

The term emergency medical services or EMS means emergency medical care, trauma care, and related services provided to patients at any point in the continuum of health care services, including emergency medical dispatch and emergency medical care, trauma care, and related services provided in the field, during transport, or in a medical facility or other clinical setting. The term field EMS patient care reports means the information that a field EMS agency typically creates regarding a patient’s medical condition and treatment in the course of providing emergency medical services to that patient.

The term medical oversight means the supervision by a physician of the medical aspects of an EMS system or agency and its providers, including prospective, concurrent, and respective components of field EMS and the education of EMS providers. The term NEMSAC means the National Emergency Medical Services Advisory Council. The term NEMSIS means the National EMS Information System. The term NHTSA means the National Highway Traffic Safety Administration. The term patient parking means the practice by hospitals of refusing to accept transfer of a patient’s care from an ambulance crew until a regular emergency department bed is available, requiring the crew to continue to provide patient care on the ambulance stretcher rather than in a patient bed in the hospital, until hospital staff will accept the transfer of care, resulting in delayed access to definitive care.

The term State EMS Office means an office designated by the State with primary responsibility for oversight of the State’s EMS system, such as responsibility for oversight of EMS coordination, licensing or certifying EMS practitioners, and EMS system improvement. The term STEMI means ST–Segment Elevation Myocardial Infarction. The Director shall establish the an EMS Excellence, Quality, Universal Access, Innovation, and Preparedness grant program, to be referred to as the EQUIP grant program — to promote excellence in all aspects of the provision of field EMS by field EMS agencies; to enhance the quality of emergency medical care provided to patients by field EMS practitioners through evidence-based, medically directed field emergency care; to promote universal access to and availability of high-quality field EMS in all geographic locations of the Nation; to spur innovation in the delivery of field EMS; and to improve EMS agency readiness and preparedness for day-to-day emergency medical response.

To be eligible to receive a grant under this section, an eligible entity shall submit an application to the Director in such form and manner, and containing such agreements, assurances, and information as the Director determines to be necessary to carry out this section. The Director shall ensure that grant application requirements are not unduly burdensome to smaller and volunteer field EMS agencies or other agencies with limited resources. The Director shall ensure that grant applications are consistent with national and relevant State preparedness plans and goals.

Grants may be used by eligible entities— to sustain field EMS practitioners to ensure 24 hours a day, 7 days a week readiness and preparedness at the local level; to develop and implement initiatives related to delivery of medical services, including— innovative clinical practices to improve the cost effectiveness and quality of care delivered to emergency patients in the field that results in improved patient outcomes and cost savings to the health system, including for high prevalence emergency medical conditions such as sudden cardiac arrest, STEMI, stroke, and trauma; and delivery systems to improve patient outcomes, which may include implementing evidence-based protocols, interventions, systems, and technologies to reduce clinically meaningful response times; to purchase and implement— medical equipment and training for using such equipment; communication systems to ensure seamless and interoperable communications with other first responders; and information systems to comply with NEMSIS data collection and integrate field emergency care with electronic medical records; to participate in federally sponsored field EMS research; to establish or enhance comprehensive medical oversight and quality assurance programs that include the active participation by medical directors in field EMS medical direction and educational programs; and for such other uses as the Director determines appropriate.

In establishing and administering the EQUIP grant program, the Director— shall establish a grantmaking process that includes— prioritization for the awarding of grants to eligible entities and consideration of the factors in reviewing grant applications by eligible entities, including— demonstrated financial need for funding; utilization of public and private partnerships; enhanced access to high-quality field EMS in under served geographic areas; unique needs of volunteer and rural field EMS agencies; distribution among a variety of geographic areas, including urban, suburban, and rural; distribution of funds among types of EMS agencies, including governmental, nongovernmental and volunteer; implementation of evidence-based interventions that improve quality of care, patient outcomes, efficiency, or cost effectiveness; and such other factors as the Director determines necessary; a peer-reviewed process to recommend grant allocations in accordance with the prioritization established by the Director, except that final award determinations shall be made by the Director; and the provision of grant awards to eligible entities on an annual basis, except that the Director may reserve not more than 25 percent of the available appropriations for multiyear grants and no grant award may exceed a 2-year period; shall consult with and take into consideration the recommendations of the Assistant Secretary for Preparedness and Response, FICEMS, NEMSAC, and relevant stakeholders; shall ensure that funds used for day-to-day preparedness activities are consistent and aligned with Federal preparedness priorities; and may contract with an independent, third-party, nonprofit organization to administer the grant program if the Director establishes conflict-of-interest requirements as part of any such contractual relationship.

Eligible grant recipients are field EMS agencies that— are licensed by or otherwise authorized in the State in which they operate; and have medical oversight and quality improvement programs as defined by the Director. As a condition on receipt of a grant under this section, the Director shall require the grant recipient to adopt and implement (to the extent applicable) the guidelines promoted, developed, and disseminated under subparagraphs

(B)and

(C)of section 1294(a)(1). The Director shall submit an annual report on the EQUIP grant program under this section to Congress. The Director shall establish a Field EMS System Performance, Integration, and Accountability grant program, to be referred to as the SPIA grant program — to improve field EMS system performance, integration, and accountability; to ensure preparedness for field EMS at the State and local levels; to enhance physician medical oversight of field EMS systems; to improve coordination between regional field EMS systems and integration of such regional field EMS systems into the larger health care system; to enhance data collection and analysis to improve, on a continuing basis, the field EMS system; and to promote standardization of national EMS certification of emergency medical technicians and paramedics. Entities receiving grants under this section may use such grant funds— to enhance EMS system readiness and preparedness for day-to-day emergency medical response; to improve cross-border collaboration and planning among States; and to collect data with regard to— NEMSIS; field EMS education; field EMS workforce; cardiac events, including STEMI and sudden cardiac arrest; stroke; disasters, including injuries and illnesses; ambulance diversion and patient parking; trauma (in a manner that is complementary and not duplicative of other trauma data collection, such as the National Trauma Data Bank); data determined necessary by the State office of EMS for oversight and coordination of the State field EMS system; and any other such data that the Director specifies; to implement and evaluate system-wide quality improvement initiatives, including medical direction at the State, local, and regional levels; to integrate field EMS with other health care services as part of a coordinated system of care provided to patients with emergency medical conditions to help ensure the right patient receives the right care by the right crew in the right vehicle and at the right medical facility in the right amount of time, including by enhancing regional emergency medical dispatch; to incorporate national EMS certification for all levels of emergency medical technicians and paramedics; to improve the State’s planning for ensuring a consistent, available EMS workforce; to fund EMS regional and local oversight and planning organizations or develop regional systems of emergency medical care within the State to further enhance coordination and systemic development throughout the State; and for such other uses as the Director determines appropriate. In establishing and administering the SPIA grant program, the Director shall— establish State EMS system performance standards to serve as guidance to States in improving EMS systems and in applying for grants under this section, taking into consideration— the recommendations of the Assistant Secretary for Preparedness and Response, FICEMS, NEMSAC, and relevant stakeholders; national, evidence-based guidelines; and the needs and resource limitations of volunteer, smaller agencies, and agencies in rural areas; provide technical assistance to State EMS offices in conducting comprehensive EMS planning with regard to evidence-based workforce and development competencies for field EMS management; allocate, within the available funds, SPIA grants to a maximum of one grant per applicant according to a formula based on population and geographic area, as determined by the Director, for a period not to exceed 2 years; and require that States allocate a portion of funds awarded under this section to regional and local oversight and planning EMS organizations within the State for the purpose of field EMS system development, maintenance, and improvement of coordination among regional organizations. To be eligible to receive a grant under this section, an eligible entity shall submit an application to the Director in such form and manner, containing such agreements, assurances, and information as the Director determines to be necessary to carry out this section. The entities eligible for a grant under this section are the State EMS office in each of the several States, Indian tribes, and territories. As a condition on receipt of a grant under this section, the Director shall require the grant recipient to adopt and implement (to the extent applicable) the guidelines promoted, developed, and disseminated under subparagraphs

(B)and

(C)of section 1294(a)(1). The Director shall submit an annual report on the SPIA grant program under this section to Congress. To improve medical oversight of field EMS and ensure continuity and quality for such medical oversight, the Director shall— promote high-quality and comprehensive medical oversight of— all medical care provided by field EMS practitioners; and the education and training of field EMS practitioners; promote the development, adoption, and utilization of national guidelines for the roles of physicians who provide medical oversight for field EMS and other health care providers who support physicians in this role; support efforts of relevant physician stakeholders in developing and disseminating guidelines for use by EMS medical directors and field EMS practitioners on a national basis; and convene a Field EMS Medical Oversight Advisory Committee, comprised of representatives of relevant physician stakeholders, to advise the Director on ways and means to advance and support development and maintenance of quality medical oversight throughout the Nation's systems for field EMS. In carrying out subparagraphs

(B)and

(C)of paragraph (1), the Director shall take into consideration— existing guidelines developed by national professional physician associations, States, and other relevant governmental or nongovernmental entities; the input of other relevant stakeholders, including health care providers who support physicians who provide medical oversight for field EMS; and the unique needs associated with medical oversight of provision of field EMS in rural areas or by volunteers. The guidelines promoted, developed, and disseminated under subparagraphs

(B)and

(C)of paragraph

(1)shall ensure high-quality training, credentialing, and direction in connection with medical oversight of field EMS at the State, regional, and local levels while providing sufficient flexibility to account for historical and legitimate differences in field EMS among States, regions, and localities. The Comptroller General of the United States shall complete a study on— medical and administrative liability issues that may impede— medical direction provided by physicians directly regarding specific patients or medical oversight provided by physicians in establishing medical protocols, procedures, and other activities related to the provision of emergency medical care in field EMS; or the highest quality emergency medical care in field EMS provided by personnel other than physicians such as emergency medical technicians and paramedics; reimbursement for any component of medical oversight; and such other issues as the Comptroller General determines appropriate relating to improving the quality and medical oversight of emergency medical care in field EMS. Not later than 18 months after the date of the enactment of the Field EMS Innovation Act , the Comptroller General shall complete the study under paragraph

(1)and submit a report to Congress on the results of such study, including any recommendations. The Administrator of NHTSA may maintain, improve, and expand the National EMS Information System, including the National EMS Database. The Administrator of NHTSA shall carry out this paragraph in consultation with the Director. In carrying out subparagraph (A), the Administrator of NHTSA shall promote the collection and reporting of data on field EMS in a standardized manner. The Administrator of NHTSA shall ensure that information in the National EMS Database (other than individually identifiable information) is available to Federal and State policymakers, EMS stakeholders, and researchers. In carrying out subparagraph (A), the Administrator of NHTSA may provide technical assistance to State and local agencies, field EMS agencies, and other entities, as the Administrator determines appropriate, to assist in the collection, analysis, and reporting of data. Not later than 1 year after the date of the enactment of the Field EMS Innovation Act , the Secretary of Health and Human Services, acting through the Director, in consultation with the Administrator of NHTSA, shall submit to Congress a report that— identifies gaps in the collection of data related to the provision of field EMS; and includes recommendations for improving the collection, reporting, and analysis of such data. The recommendations required by subparagraph (A)(ii) shall— take into consideration the recommendations of FICEMS and NEMSAC and relevant stakeholders; recommend methods for improving data collection and reporting and analysis without unduly burdening reporting entities and without duplicating existing data sources (such as data collected by the National Trauma Data Bank); address the quality and availability of data, and linkages with existing patient registries, related to the provision of field EMS and utilization of field EMS with respect to a variety of illnesses and injuries (in both the everyday provision of field EMS and catastrophic or disaster response), including— cardiac events such as chest pain, sudden cardiac arrest, and STEMI; stroke; trauma; disaster and catastrophic incidents, such as incidents related to terrorism or natural or manmade disasters; and ambulance diversion and patient parking; and include an analysis of the variety of services provided by field EMS agencies. Not later than 18 months after the date of enactment of the Field EMS Innovation Act , the Secretary, acting through the head of the Office of the National Coordinator for Health Information Technology and the Director, in collaboration with FICEMS and the Administrator of NHTSA as appropriate, and taking into consideration input from relevant stakeholders, shall submit a report (including recommendations) on issues, impediments, and potential solutions pertaining to the following objectives: Incorporation of field EMS patient care reports into patient electronic health records, taking into consideration— the extent to which field EMS patient care reports are created in electronic format and the potential for elements of such reports to be incorporated into patient electronic health records; the data elements of field EMS patient care reports that would promote quality and efficiency of care if incorporated into patient electronic health records; potential modifications to the Medicare and Medicaid programs under titles XVIII and XIX, respectively, of the Social Security Act ( 42 U.S.C. 1395 et seq. , 1396 et seq.) or other Federal health programs (including potential modifications to the HITECH Act (title XIII of division A and title IV of Division B of Public Law 111–5), including modifications to the entities included as eligible for incentive payments under section 1848(o), 1853(l) (to the extent that such section 1848(o) is applied), or 1903(t) of the Social Security Act (42 U.S.C. 1395w–4(o), 1395w–23(l), 1396b(t)), criteria for certified EHR technology for purposes of such sections, and objectives and measures for determining meaningful use of such technology for purposes of such sections) to provide appropriate reimbursement and financial incentives for EMS agencies— to maintain field EMS patient care reports in a structured electronic format; and to otherwise adopt and use electronic health records; and potential modifications to the HITECH Act to provide incentives to eligible hospitals under section 1886(n), 1853(m) (to the extent that such section 1886(n) is applied), or section 1814(l)(3) of the Social Security Act to incorporate appropriate data elements of field EMS patient care reports into patient electronic health records. Incorporation of patient health information created subsequent to the receipt of field EMS emergency care into NEMSIS, taking into consideration— the types of medical information created subsequent to the receipt of field EMS emergency care (such as outcomes information or information regarding subsequent care and treatment) that would, if included in NEMSIS, be potentially useful in evaluating and improving the quality of EMS care; how best to integrate such information into NEMSIS; potential modifications to the HITECH Act to require eligible hospitals, as defined in section 1886(n)(6)(B) of the Social Security Act (42 U.S.C. 1395ww(n)(6)(B)), for purposes of incentive payments under 1886(b)(3)(B)(ix) and 1886(n) of such Act, to develop or report relevant data to NEMSIS or other appropriate State or private registries; and potential modifications to the Medicare and Medicaid programs under titles XVIII and XIX, respectively, of the Social Security Act or other Federal health programs to provide appropriate reimbursement and financial incentives for field EMS agencies to develop or report relevant data to NEMSIS or other appropriate State or private registries. Nothing in HIPAA privacy and security law (as defined in section 3009(a)(2)) shall be construed as prohibiting the exchange of information between field EMS practitioners treating an individual and personnel of a hospital to which the individual is transported for the purposes of relating information on the medical history, treatment, care, and outcome of such individual (including any health care personnel safety issues such as infectious disease). The Secretary shall establish guidelines for exchanges of information between field EMS practitioners treating an individual and personnel of a hospital to which the individual is transported to protect the privacy of the individual while ensuring the ability of such EMS practitioners and hospital personnel to communicate effectively to further the continuity and quality of emergency medical care provided to such individual. Nothing in HIPAA privacy and security law (as defined in section 3009(a)(2)) shall be construed as prohibiting— a field EMS agency from submitting EMS data to the State EMS Office for the purpose of quality improvement and data collection by the State for submission to NEMSIS; or the State EMS Office from submitting aggregated nonindividually identifiable EMS data to the National EMS Database maintained by NHTSA. For the purpose of promoting field EMS as a health profession and ensuring the availability, quality, and capability of field EMS educators, practitioners, and medical directors, the Director may make grants to eligible entities for the development, availability, and dissemination of field EMS education programs and courses that improve the quality and capability of field EMS personnel. In carrying out this section, the Director shall take into consideration recommendations of the Administrators of each of NHTSA, FICEMS, and NEMSAC, the National Health Care Workforce Commission established under section 5101 of the Patient Protection and Affordable Care Act ( 42 U.S.C. 294q ), and relevant stakeholders. In this section, the term eligible entity means an educational organization, an educational institution, a professional association, and any other entity involved with the education of field EMS practitioners. The Director may award a grant to an eligible entity under paragraph

(1)only if the entity agrees to use the grant to— develop and implement education programs that— train field EMS trainers and promote the adoption and implementation of the education standards identified in the Emergency Medical Services Education Agenda for the Future: A Systems Approach including any revisions thereto; bridge the gap in knowledge and skills in field EMS and among field EMS and other allied health professions to develop a larger cadre of educational instructors and build a stronger and more flexible field EMS practitioner corps; or provide training and retraining programs to provide displaced workers the opportunity to enter a field EMS profession; develop and implement educational courses pertaining to— instructor courses; provision of medical direction of field EMS; field EMS practitioners, including physicians, emergency medical technicians, paramedics, nurses, and other relevant clinicians providing emergency medical care in the field; field EMS educational and clinical research; bridge programs among field EMS, nursing, and other allied health professions; field EMS management; national, evidence-based guidelines; and translation of the lessons learned in military medicine to field EMS; evaluate education and training courses and methodologies to identify optimal educational modalities for field EMS practitioners; improve the field EMS education infrastructure by increasing the number of field EMS instructors and the quality of their preparation by improving, enhancing, and modernizing the dissemination of EMS education, including distance learning, and by establishing quality improvement for EMS education programs; enhance the opportunity for medical direction training and for promoting appropriate medical oversight of field emergency medical care; improve systems to design, implement, and evaluate education for prospective and current field EMS providers; or carrying out such other activities as the Director determines appropriate. The Director, in consultation with NHTSA and relevant stakeholders, and taking into consideration the recommendations of FICEMS and NEMSAC, shall establish a system of prioritization in awarding grants under this section to eligible entities. Grants under this section shall be for a period of 1 to 3 years. The Director may not award a grant to an eligible entity under this section unless the entity submits an application to the Director in such form, in such manner, and containing such agreements, assurances, and information as the Director may require. The Director shall ensure that the requirements for submitting an application under this section are not unduly burdensome. Not later than 1 year after the date of the enactment of the Field EMS Innovation Act , the Director, in consultation with the Administrator of the Centers for Medicare & Medicaid Services, and taking into consideration the recommendations of NEMSAC and FICEMS, shall complete an evaluation of— the provision of and reimbursement for alternative delivery models for medical care through field EMS; and the integration of field EMS patients with other medical providers and facilities as medically appropriate. In completing the evaluation under paragraph (1), the Director shall consider each of the following: Alternative dispositions of patients, including— transporting patients by ambulance to destinations other than a hospital such as the office of the patient’s physician, an urgent care center, or the facilities of another health care provider; when medically necessary, the evaluation, treatment, or referral of patients to other medically appropriate health care providers; the provision of medical care regardless of the decision to transport, such as reimbursement models based on readiness rather than transport and shared savings; and the provision of health care using patient centered mobile resources in the out-of-hospital environment, such as mobile integrated health care services and community paramedicine. Issues related to medical liability and the requirements of section 1867 of the Social Security Act ( 42 U.S.C. 1395dd ; commonly referred to as EMTALA ) associated with transport to destinations other than a hospital emergency department. Necessary protections to ensure that patients receive timely and appropriate care in the appropriate setting. Whether there are any barriers to providing alternate dispositions to patients who are not in need of care in hospital emergency departments. Other issues determined by the Director, including, when practicable, issues recommended by FICEMS or NEMSAC for evaluation under this subsection. Beginning not later than 1 year after the date of the enactment of the Field EMS Innovation Act , the Director shall conduct or support at least 10 demonstration projects to— evaluate the implementation and reimbursement of alternative dispositions of field EMS patients, including— transporting patients by ambulance to alternate destinations when medically appropriate and in the patients’ best interests; when medically necessary, evaluating, treating, or referring patients to other medically appropriate providers; and when medically appropriate, treating patients through mobile integrated health care services or community paramedicine. evaluate the implementation of reimbursement models based on readiness rather than transport or shared savings; and determine whether such alternative dispositions and reimbursement models— improve the safety, effectiveness, timeliness, and efficiency of EMS; and reduce overall utilization and expenditures under the Medicare program under title XVIII of the Social Security Act. The Director shall ensure that at least one demonstration project under paragraph

(1)evaluates evidence-based protocols that give guidance on selection of the destination to which patients are transported. The period of a demonstration project under paragraph

(1)shall not exceed 3 years. The Director shall conduct or support further research that the Director determines to be necessary prior to or in conjunction with the demonstration projects under this subsection in order to evaluation the implementation of alternative dispositions of field EMS patients. Of the amount made available to carry out section 1115A of the Social Security Act (42 U.S.C. 1315a) for a fiscal year, the Secretary may transfer such sums as may be necessary to carry out this subsection. Not later than 1 year after the completion of all demonstration projects under subsection (b), the Director shall submit to Congress a report on the results of activities under this section, including recommendations on the efficacy of alternative dispositions of field EMS patients. .

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