Minutes for November 19, 2018

Facilitator Chris Thomas opened with introductions around the room. Chris asked if any attendee had corrections to propose for the draft meeting minutes from the November 5th meeting of the group and none were proposed.

Chris introduced the first of the three scheduled speakers, Deputy Chief Ted Peterson of Southern Marin Fire Protection District.

Ted spoke about government sources of revenue beyond traditional ambulance billing available to transport providers. Ted went through the Federal programs that have been created to reimburse local government healthcare providers for costs of providing care to uninsured. Ted explained the federal government recognizes these costs local jurisdictions are incurring on the behalf of the federal government. The funding is provided through the CPE program, which funds fee-for-service Medi-Cal participants, and through the Inter- Governmental Transfer (IGT) program, which addresses managed care enrollees. Hospital Districts and public hospitals account for the majority of funding distributed via these programs. Until a few years ago, EMS providers were not included in the distribution. Ted went on to talk about the efforts his agency and others, along with the California Association of Fire Chiefs, made to educate the state and federal managers of such programs that fire districts are providers of health care to Medi-Cal beneficiaries and are expending local tax dollars serving them without compensatory federal funding. The result was an adaption of the use of federal block grants through the CPE and IGT programs that will reimburses public EMS providers serving Medi-Cal patients at a loss up to fifty cents on each dollar. The breakdown of funding for Medi-Cal patients covered via the CPE program is around 20% of the total compared to the 80% covered by IGT due to Managed Medi-Cal enrollment statistics.

A new source of funding in California is the Quality Assurance Fee (QAF) modeled after a similar funding source created to support Skilled Nursing Facilities serving the same population. The QAF will be available to all EMS provider agencies, public or private.

The premise of the funding sources is the same; agencies must show on paper there is a loss from providing the services. Entities applying for IGT funding are required to put 50% of the requested funds up to the state as the fiscal agent of the federal program. The funds are returned with a match from the federal government. The program has resulted in over
$200,000 in revenue for CA fire services (annually) for the 90 CA departments that participate out of 180 eligible statewide. Ted mentioned there is an expense in administering the program locally and the “up front” 50 % that is sent to the state is not available to the department until such time as the funds are dispersed at the end of the year. Ted pointed out the cost of readiness for resources that serve patients is eligible for reimbursement. New efforts are underway by Fire Service to enable cost of first response engine companies to be reimbursed along with transport personnel.

Steve Akre (Sonoma Valley Fire Rescue Authority) asked about the timeline for the 1st responder component. Ted thought there was (a meeting scheduled) in a couple weeks with State of California Department of Healthcare Services (DHCS) looking at language used from other states to be approved by the Federal authorities. The per-agency cost was recognized as specific to the entity providing services. This concept was discussed in the context of a single county-wide rate structure as considered in a previous group meeting. Could that rate be a factor considered in reimbursement calculations? Ted felt rates were not relevant to the reimbursement calculations; only cost. Mark Heine (Windsor/Rincon Valley Fire Protection Districts) related a previous experience with another agency in aligning cost with rates amid the complexity of reimbursement realities that face healthcare billing.

Ted Peterson was asked if the outlook for these programs was solid, or are they going away? Ted opined that in comparison with other healthcare entitlement programs, reimbursement is really small in the scope of health care costs. Ted asked the State program managers if they had heard that the programs were at risk, and was told DHCS hasn’t heard this from the federal government.

Chris thanked Ted Peterson for the information and presentation and introduced the next speaker, Beyond Lucid Technology’s Jonathon Feit.

Jonathon began with a disclaimer that although his company is a technology firm, he was not speaking from a sales perspective; rather he was present to speak about data and technology and what could be accomplished with the tools at hand or available now.
Jonathon spoke in support of data used to improve delivery of service rather than data used “as a weapon” to intimidate. Jonathon opined that EMS is about 5 years behind the rest of the health care business, but the lag has the advantage of allowing for perspective on the impact of information technology changes on healthcare.

Jonathon presented on some areas of concern his firm had found with the data set and indicators developed to arrive at the California Core Measures as indicators of system quality. He went on to point out areas where he feels there are mathematical errors impacting the way the results are arrived at due to the construction of the indicators.

Jonathon related a conversation with a customer who expressed frustration with data system technologists not connecting with the needs of customers because the customers don’t know themselves what the need really is. Jonathon talked about the public perception, from his perspective, that EMS is still “scoop and run” in contrast to the ever-more connected reality of the modern system. Jonathan feels information needs to flow to keep track of patients and help with real-time decision-making. Data and technology should enable access to healthcare services in the same manner other sectors have been enhanced such as airlines

and hotels. Hospital awareness of patient condition prior to arrival should be supported, as should destination changes based on hospital impacts such as wall times. Jonathan talked about the perception that hospital Electronic Health Records (EHRs) do not interface well. Jonathan spoke about the inherent conflict between NEMSIS (pre-hospital) and HL7 (hospital) datasets due to different federal oversight entities creating standards and resulting in conflict between hospital providers, and pre-hospital providers, each users of different standard based data sets. He did note a Meaningful Use funded effort to create a single standard that could work with both. The funding for the current Healthcare Information Exchange (HIE) project underway in California is coming from the HL7 standard setting body. Jonathon spoke about the different standards for EHR output, and the fact that to date, all of them include more information than is appropriate from a HIPPA point of view for pre-hospital agencies or providers which led to reluctance to make such data available without some method of narrowing down the data provided to HIPPA-appropriate subsets. Johnathon spoke of a new standard, Fast Healthcare Interoperability Resources (FHIR), that allows for selective access to healthcare information and this may address the HIPPA concern and may facilitate hospitals to more readily share information with EMS partners.

Jonathon spoke about the ability of EHR systems in hospitals to adapt to data sharing more readily that is generally understood, He used the example of hospitals sharing data with pharmacies. He went on to advocate for a standards based philosophy when considering pre-hospital electronic Patient Care Reporting (ePCR) systems rather than solving interoperability with a single product solution. Jonathon felt all systems should “play well together” as a requirement.

Jonathon was asked to talk about the different between an HIE (Health Information Exchange) and an HIH (Health Information Hub). He described an HIH as a proprietary (ImageTrend) version of a Health Information Exchange. He stated that ImageTrend did not accept outside systems’ information into their product as a business decision which he attributed to the size of the organization.

Jonathon was asked to summarize the advice he had for the group in their process going further regarding data technology products and the companies that provide the services and Chris Thomas boiled it down as:

Know what you want, tell them what you expect and make them show you they can provide it.

Jonathon also suggested the possibility of using an RFP to learn more about what is available so that the group could be better informed as they decided what they wanted.

Chris next introduced Lucinda Gardner, Staff Epidemiologist with Sonoma County Department of Health Services Administration.

Lucinda provided her background and history with the Department and the scope of her regular work. She also talked about use of the ImageTrend data set in support of DHS monitoring of suicide and opiate overdose issues in the community as well as in tracking patients evacuated in the October 2017 Sonoma Complex fires.

Lucinda shared some working draft information regarding the response of EMS Paramedic Ambulances within the established service zones and in support of neighboring zones.
Lucinda examined a year (2017) of CAD system response data, excepting October 2017 due to atypical response patterns from the fires. Cloverdale Ambulance reported numbers

separately as they are not dispatched directly by REDCOM and response data are not part of the CAD record.

Upfront Lucinda provided a disclaimer that the data shared represented her first time working with REDCOM data, and therefore all information shared was to be considered draft and subject to change. Stakeholder agencies present had a number of questions and concerns they would like answered based on the information presented.

Some follow up questions were:

• What are “external units” noted in a few tables?
• Can we include ALS and BLS first response when those resources arrive prior to ambulances? How long are they on scene, and what is the gap between first resource on scene and ALS on scene.
• Can we identify when a request for mutual aid in a zone is driven by that zone’s resources being unavailable as a result of responding to a mutual aid request from someone else?
• Can we add BLS ambulances as CLSD and Petaluma have some limited participation of those resources?
• Can we show “hand offs” to another ALS unit? How many events are handed off and to which agency?
• Need to find total CLSD volume including Mendocino calls. Some of these are in Mendocino and come to Sonoma Hospitals.
• Responses to another zone; dispatched but canceled prior to arrival are not included, but agencies want to see those numbers to know how many times units are assigned to calls out of their zone and then cancelled.
• Steve Akre asked about ALS units posted or moved up; how many times and for how long?
• Add SRFP ALS first response to data set

Chris wound down the discussion due to the meeting time coming to an end. He asked the group to consider what needs to be in the ordinance directly related to this topic? What might be helpful for RFP planning or other system improvement action? Write up your ideas and send them to James Salvante for collection. Also, should a group be established to dig deeper and help Lucinda Gardner with subject matter expertise and if so, who is interested in participating?

Who wants to participate: James, Nicole, Steve H, Dean, Jason Clopton, and Steve S.

Steve Herzberg (BBFPD, 5th Dist. EMCC) felt getting data and raising system capacity so as to prevent rural, outlying providers from being pulled into core system coverage was important. He also felt another pass at the information was needed prior to finishing the RFP. A last thought was to make sure resources sent routinely out-of-county or from out-of-county providers were considered; Novato and Bodega Bay were cited as examples of cross-county provider agencies.

Meeting adjourned. Next meeting will be December 3th 2018 at Sonoma County Water Agency 404 Aviation Blvd from 9:30 AM-12:00 PM in the Redwood Conference Rooms.

Project Website:

https://www.coastalvalleysems.org/about-us/committees/sonoma-county-ems-systems-workgroup.html