Chapter 04. Data Collection and Quality Management
Regulation .01 Responsibilities of MIEMSS.LinkCopy Citation
MIEMSS shall:
A.
Maintain the State trauma registry to collect and analyze data including, but not limited to, data concerning the incidence, severity, and causes of trauma and burns;
B.
Establish criteria to identify patients to be included in the State trauma registry;
C.
Collect data about patients to be included in the State trauma registry from:
(1)
EMS providers;
(2)
Hospitals, both designated and nondesignated including, but not limited to:
(a)
The primary adult resource center;
(b)
Level I trauma centers;
(c)
Level II trauma centers;
(d)
Level III trauma centers; and
(e)
Maryland Trauma Specialty Referral Centers as defined in Health-General Article, §19-130(a)(3), Annotated Code of Maryland;
(3)
Office of Medical Examiner reports; and
(4)
Other sources outside of the trauma and specialty care systems including, but not limited to:
(a)
Death certificates,
(b)
Hospital inpatient discharge data,
(c)
Health care provider and third-party payer billing data, and
(d)
Law enforcement agency records;
D.
Require hospitals to have a case specific patient identifier common to all data sources used in the State trauma registry; and
E.
Establish procedures and specifications for electronic and hard copy submission of data.
Regulation .02 Trauma and Specialty Care Quality Management Plan.LinkCopy Citation
A.
MIEMSS shall design a trauma and specialty care quality management plan for continued monitoring and evaluation of the State trauma and specialty care systems.
B.
The trauma and specialty care quality management plan shall include the establishment, publication, and periodic review of the data required to be submitted to provide information regarding injury, trauma and specialty care, and system operation in the following categories:
(1)
Demography;
(2)
Anatomy;
(3)
Physiology;
(4)
Severity;
(5)
Epidemiology;
(6)
Resource utilization;
(7)
Quality improvement;
(8)
Outcomes; and
(9)
Finance.
C.
MIEMSS shall establish committees for trauma and specialty care quality management as structural units of the Maryland EMS Quality Leadership Council to coordinate the trauma and specialty care systems quality management and quality improvement activities set forth in this subtitle.
D.
MIEMSS shall develop a system and reporting mechanism for quality improvement by:
(1)
Determining the data standards for the State trauma registry;
(2)
Setting forth the data standards for the State trauma registry in:
(a)
The Maryland State Trauma Registry Data Dictionary for Adult Patients for patients 15 years old and older; and
(b)
The Maryland State Trauma Registry Data Dictionary for Pediatric Patients for patients younger than 15 years old.
(3)
Establishing protocols for quality monitoring, consistent with MIEMSS' most current data quality guidelines;
(4)
Conducting studies to assess the completeness and accuracy of case identification and data collection; and
(5)
Ensuring that the data entered in the State trauma registry is complete and accurate.
Regulation .03 Trauma and Specialty Care Quality Management Programs.LinkCopy Citation
A.
A designated trauma or specialty referral center shall have a hospital-wide quality management plan to reflect and demonstrate continuous quality improvement in the delivery of trauma and specialty care.
B.
The quality management program includes, but is not limited to, the requirements for trauma and specialty referral centers in COMAR 30.08.03.
C.
A designated trauma and specialty referral center shall have a system for continuous monitoring and trend analysis of trauma patient bypass status.
D.
Designated trauma and specialty referral centers shall participate in State trauma and specialty care quality management activities sponsored by MIEMSS.
E.
If appropriate for quality assurance purposes, designated trauma and specialty centers shall provide EMS providers licensed or certified by the EMS Board under Education Article §13-516, Annotated Code of Maryland, who have or have had a direct treatment relationship with a patient, follow-up data or information on that patient. Quality assurance information provided under this action is considered to be provided in accordance with COMAR 30.03.04.05.
Regulation .04 Use of State Trauma Registry and Specialty Care Data.LinkCopy Citation
MIEMSS may use State trauma registry and specialty care data to:
A.
Monitor and provide information necessary to evaluate major trauma or specialty patient care, outcome, and cost;
B.
Assess compliance of EMS providers, designated trauma and specialty referral centers, and other hospitals with the trauma and specialty care standards, regulations, and protocols;
C.
Provide information necessary for resource planning and management;
D.
Provide data for injury surveillance, analysis, and prevention programs; and
E.
Provide a data resource for research and education.
Regulation .05 Responsibilities of Emergency Medical Services Providers.LinkCopy Citation
A.
Prehospital services shall provide prehospital MAIS runsheets or EMAIS patient care reports that include trauma or specialty care patient data about:
(1)
Trauma victims dead at the scene of the trauma;
(2)
Patients meeting State trauma or specialty triage criteria who are transported to a hospital;
(3)
Patients transported in accordance with interfacility transfer policies to receive a higher level of care or for special resources; and
(4)
Patients transported to specialty referral centers.
B.
The transporting service is responsible for submitting patient care data designated in the MAIS runsheet or the EMAIS patient care report to the receiving hospital.
C.
Designated trauma or specialty care centers shall use the patient criteria described in Regulation .01B and C of this chapter.
Regulation .06 Access to Trauma Registry and Specialty Care Information.LinkCopy Citation
A.
Data that identifies individual patients, providers, and hospital outcomes is confidential.
B.
MIEMSS may only release confidential information:
(1)
As required by the Health Services Cost Review Commission under Health-General Article, §19-130, Annotated Code of Maryland; or
(2)
In accordance with:
(a)
The provisions of Health Occupations Article, Title 1, Subtitle 4, and §14-506, Annotated Code of Maryland; and
(b)
Other criteria as developed by MIEMSS pertaining to patient confidentiality and quality management records.
C.
MIEMSS may approve requests for data and other information from the State trauma registry and specialty care databases for special studies and analyses in accordance with §B of this regulation.
D.
A person having access to information collected under this subtitle may use the information only for the purposes allowed under Regulation .04 of this chapter.
E.
MIEMSS may require a person who requests data or other information from the State trauma registry and specialty care databases to pay all or part of the reasonable costs associated with special preparation of the request.
F.
MIEMSS may not disclose confidential information to any person, except on request:
(1)
To an approved regional or State quality improvement program if the regional or State quality improvement program is subject to the same confidentiality guidelines as MIEMSS;
(2)
To a scientific research professional associated with a scientific research organization, if:
(a)
MIEMSS has reviewed and approved the research professional's written research proposal with respect to scientific merit and confidentiality safeguards, and
(b)
The data does not identify specific hospitals or patients; and
(3)
MIEMSS shall provide aggregate State trauma registry and specialty care data to hospitals, public or private agencies, and other interested parties for:
(a)
Prevention activities,
(b)
Epidemiological or demographic studies, or
(c)
Education and research projects.
Chapter annotations
Authority: Education Article, §13-509, Annotated Code of Maryland
History: Effective date: March 24, 1997 (24:6 Md. R. 488)
History: Regulations .01—.04 amended effective July 1, 2002 (29:12 Md. R. 932)
History: Regulation .01 amended effective June 4, 2007 (34:11 Md. R. 972)
History: Regulation .02D amended effective June 4, 2007 (34:11 Md. R. 972)
History: Regulation .03E adopted effective December 15, 2003 (30:24 Md. R. 1746)
History: Regulation .05 amended effective June 4, 2007 (34:11 Md. R. 972)
History: Regulation .06 amended effective July 1, 2002 (29:12 Md. R. 932); December 19, 2005 (32:25 Md. R. 1947)