BLS First Response | Paper PCR Portal | ALS First Response ~ ePCR and pPCR Electronic Availability at Receiving Hospitals
The Bureau of Emergency Medical Services Data and Informatics Unit has been collaborating with EMS agencies and Regional Program Agencies to ensure the electronic delivery of ePCRs to the hospital implementing consistent standards for the entire EMS system regardless of location and documentation methodology. The following updates have been implemented on the NYS Elite Site and the updated documentation standard allowing for the changes announced previously will be issued in the near future. At this time we are distributing clarification of how this type of service shall be documented, how the chart will be delivered to the receiving hospital and changes made to the BLS First Response Documentation Standard and the Paper PCR Portal.
Regions with Hospital Hub available and deployed are already quite accustomed to transporting ePCR charts already appearing in Hospital Hub; hospitals in regions not utilizing Hospital Hub (Adirondack-Appalachian, Finger Lakes, Hudson-Mohawk, Hudson Valley, Nassau, New York City, Mountain Lakes, Southern Tier, Suffolk, Westchester) are being oriented and provided access to Elite Viewer so that all hospitals in those regions will have access to first response, intercepting and transporting pre-hospital care reports ~ all contributing to the continuity of care. Any hospital who has not attended the information session should email emsdata@health.ny.gov to arrange for a demonstration and orientation.
ePCR software vendors must ensure the entire narrative sets entered into the ePCR are transmitted to NYS as all ePCRs are now being transmitted to the receiving hospital thus necessitating quality documentation. We have received notice that some software vendors are not submitting the entirety of the narrative sections and each EMS agency should contact their ePCR vendor to confirm the entirety of the chart is being transmitted to NYS as the chart provided to the hospital.
ALS Intercept Documentation (ALS Intercepting Agency)
This process is implemented for ground transport and for helicopter transport regardless of whether the ground ALS agency is involved in the final transport or not.
eResponse.07 Primary Role of the Unit is one of the following
2207005 Non-Transport Administrative (e.g. Supervisor)
2207009 Non-Transport Rescue
2207003 Ground Transport (if, and only if, the response vehicle is an ambulance)
EMS Agencies that are first response only, must use 2207005 or 2207009
EMS Agencies that provide ambulance transport and are driving an ambulance should list the unit (vehicle) as 2207003
EMS Agencies that provide ambulance transport and are driving an emergency ambulance service vehicle (EASV) shall list the unit as 2207009 or 2207005
eDisposition.12 Incident / Patient Disposition (for the non-transporting ALS intercepting agency accompanying the transporting agency to the receiving hospital) is one of the following
4212031 Patient Treated, Transferred Care to Another EMS Unit (may also be used when the patient is not transported to the hospital with the ALS Intercepting agency on board)
4212013 Patient Dead at Scene-No Resuscitation Attempted (with transport)
4212017 Patient Dead at Scene-Resuscitation Attempted (with transport)
4212023 Patient Refused Evaluation/Care (with transport)
eDisposition.02 Destination/Transferred To, Code (using the eDisposition.02 codes distributed to ePCR software vendors for the 06/01/2021 NYS Documentation Standard Update and posted on the NYS NEMSIS resource page https://nemsis.org/state-data-managers/state-map-v3/new-york)
This field is now required with the above-listed dispositions which will allow for the ePCR | pPCR to be available to the hospital via Elite Viewer or Hospital Hub
BLS First Response Documentation
An additional set of fields will be added to the ImageTrend Elite BLS FR Platform and an additional validation rule set to allow for the intended receiving facility to be documented thus allowing the chart to be received by the intended destination hospital in much the same fashion as an ALS Intercept shall be received. This will also allow BLS FR ePCRs to be contained in the patient’s electronic health record at the destination hospital.
eResponse.07 Primary Role of the Unit is equal to
2207005 Non-Transport Assistance
eResponse.15 Level of Care of this Unit is one of the following
2215001 NYS Certified First Response (CFR)
2215003 NYS Emergency Medical Technician (EMT)
eDisposition.12 Incident / Patient Disposition (when an assessment is completed by the BLS FR agency and turned over to a transporting agency)
4212031 Patient Treated, Transferred Care to Another EMS Unit
4212013 Patient Dead at Scene-No Resuscitation Attempted (with transport)
4212017 Patient Dead at Scene-Resuscitation Attempted (with transport)
4212023 Patient Refused Evaluation/Care (with transport)
eDisposition.02 Destination/Transferred To, Code (using the eDisposition.02 codes distributed to ePCR software vendors for the 06/01/2021 NYS Documentation Standard Update and posted on the NYS NEMSIS resource page)
This field is now required with the above-listed dispositions which will allow for the ePCR | pPCR to be available to the hospital via Elite Viewer or Hospital Hub
Paper PCR Portal
The same concepts apply except that the Paper PCR Portal now has a Destination page that opens and is expected for completion when the patient is transported by the documenting agency or by a transporting agency.
eDisposition.12 Incident / Patient Disposition
4212031 Patient Treated, Transferred Care to Another EMS Unit
4212013 Patient Dead at Scene-No Resuscitation Attempted (with transport)
4212017 Patient Dead at Scene-Resuscitation Attempted (with transport)
4212023 Patient Refused Evaluation/Care (with transport)
When one of the above-listed dispositions is selected, the Destination section is required and is highlighted in red.
These changes are possible with the amazing collaboration of EMS agency leadership, regional program agency leaders and feedback from trauma and stroke program hospitals. The EMS system has made incredible steps forward in including EMS patient care documentation as part of the initial hospital receiving electronic health record. Patients with a higher acuity of illness being transferred will still need the original receiving hospital’s ePCR and pPCR to be sent to the higher acuity hospital.
If you have any questions or wish to discuss these changes further, please send an email to emsdata@health.ny.gov. A member of the DI team will respond as efficiently as possible.
Thank you for all that you do!
Stay safe!
Peter
Peter L. Brodie, BS, AEMT
Deputy Chief, Data and Informatics Unit
EMS Data Manager
Bureau of Emergency Medical Services and Trauma Systems
New York State Department of Health
875 Central Avenue
Albany, New York 12206
The Data and Informatics Unit in the Bureau of Emergency Medical Services and Trauma Systems is dedicated to exceeding the expectations of EMS Agencies, ePCR Software Vendors, EMS Providers, Regional Program Agencies and the greater public we serve.
ph: 518.474.7245 (d) | ph: 518.694.6368 (m) | peter.brodie@health.ny.gov
http://www.health.ny.gov
