I 113th CONGRESS 1st Session H. R. 809 IN THE HOUSE OF REPRESENTATIVES February 25, 2013 Mr. Bucshon introduced the following bill; which was referred to the Committee on Energy and Commerce , and in addition to the Committee on Ways and Means , for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned A BILL To provide for improvement of field emergency medical services, and for other purposes.

1. Short title; table of contents (a) Short title This Act may be cited as the Field EMS Quality, Innovation, and Cost Effectiveness Improvements Act of 2013 . (b) Table of contents The table of contents of this Act is as follows: Sec. 1. Short title; table of contents. Sec. 2. Findings. Sec. 3. Definitions. Sec. 4. Recognition of HHS as primary Federal agency for emergency medical services and trauma care. Sec. 5. Field EMS Excellence, Quality, Universal Access, Innovation, and Preparedness. Sec. 6. Field EMS System Performance, Integration, and Accountability. Sec. 7. Field EMS quality. Sec. 8. Field EMS education grants. Sec. 9. Evaluating innovative models for access and delivery of field EMS for patients. Sec. 10. Enhancing research in field EMS. Sec. 11. Emergency Medical Services Trust Fund. Sec. 12. Authorization of appropriations. 2. Findings The Congress finds the following: (1) All persons throughout the country should have access to and receive high-quality emergency medical care as part of a coordinated emergency medical services system. (2) Properly functioning emergency medical services (EMS) systems, 24 hours per day, 7 days per week, are essential to ensure access to emergency medical care and transport for all patients with emergency medical conditions. Such coordinated EMS systems are also necessary for response to catastrophic incidents. (3) Ensuring high-quality and cost-effective EMS systems requires readiness, preparedness, medical direction, oversight, and innovation throughout the continuum of emergency medical care through Federal, State, and local multijurisdictional collaboration and sufficient resources for EMS agencies and providers. (4) At the Federal level, EMS responsibilities and resources of several Federal agencies consistent with their expertise and authority must emphasize the critical importance of Federal agency collaboration and coordination for all emergency medical services. (5) At the State and local level, EMS systems and agencies require the coordination and improved capabilities of multiple and diverse stakeholders. (6) Emergency medical services encompass the provision of care provided to patients with emergency medical conditions throughout the continuum, including emergency medical care and trauma care provided in the field, hospital, and rehabilitation settings. (7) Field EMS comprises essential emergency medical services, including medical care or medical transport provided to patients prior to or outside medical facilities and other clinical settings. The primary purpose of field emergency medical services is to ensure that emergency medical patients receive the right care at the right place in the right amount of time. (8) Coordinated and high-quality field EMS is essential to the Nation’s security. Field EMS is an essential public service provided by governmental and nongovernmental agencies and practitioners 24 hours a day, 7 days a week, and during catastrophic incidents. To ensure disaster and all-hazards preparedness for EMS operations as part of the Nation’s comprehensive disaster preparedness, Federal funding for preparedness activities, including catastrophic training and drills, must be provided to governmental and nongovernmental EMS agencies so as to ensure a greater capability within each of these areas. (9) Numerous recommendations from several significant national reports and documents have demonstrated the need in multiple areas for substantial improvement of emergency medical services provided in the field, including recommendations in the EMS Agenda for the Future, the Institute of Medicine report The Future of Emergency Care in the United Health System , and the National EMS Education Agenda for the Future: A Systems Approach and recommendations by the National EMS Workforce Injury and Illness Surveillance Program, the Department of Transportation’s National EMS Advisory Council (NEMSAC), and the Federal Interagency Committee on Emergency Medical Services (FICEMS). (10) To substantially improve field EMS, advancements must be made in several essential areas including readiness, innovation, preparedness, education and workforce development, safety, financing, quality, standards, and research. (11) The recognition of a primary programmatic Federal agency for emergency medical services within the Department of Health and Human Services was recommended by the Institute of Medicine and is necessary to provide a more streamlined, cost-efficient, and comprehensive approach for field EMS and a focal point for practitioners and agencies to interface with the Federal Government. (12) The essential role of field EMS in disaster preparedness and response must be incorporated into the national preparedness and response strategy and implementation as provided and overseen by the Department of Homeland Security and the Department of Health and Human Services pursuant to their respective jurisdictions. (13) The essential role of NHTSA in the continued development of NEMSIS and in overseeing transportation issues related to field EMS such as EMS and ambulance vehicle safety standards should be maintained. (14) FICEMS must continue in its essential role in coordinating the Federal activities related to the full spectrum of EMS. 3. Definitions In this Act: (1) The term ambulance diversion means the practice by hospitals of denying access to an incoming ambulance by requesting it to proceed to another facility due to a stated lack of capacity at the initial facility, resulting in delayed access to definitive care. (2) The term EMS means emergency medical services. (3) The term FICEMS means the Federal Interagency Committee on Emergency Medical Services. (4) 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. (5) The term field EMS agency means an organization providing field EMS, regardless of— (A) whether such organization is governmental, nongovernmental, or volunteer; and (B) whether such organization provides field EMS by ground, air, or otherwise. (6) 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. (7) 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. (8) 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. (9) The term NEMSAC means the National Emergency Medical Services Advisory Council. (10) The term NEMSIS means the National EMS Information System. (11) The term NHTSA means the National Highway Traffic Safety Administration. (12) 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 other than a patient bed in the hospital until hospital staff will accept the transfer of care, resulting in delayed access to definitive care. (13) 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. (14) The term STEMI means ST–Segment Elevation Myocardial Infarction. 4. Recognition of HHS as primary Federal agency for emergency medical services and trauma care (a) Primary Federal agency The Department of Health and Human Services shall serve as the primary Federal agency with responsibility for programs and activities relating to emergency medical services and trauma care. (b) Office of EMS and Trauma (1) Establishment There is established an Office of Emergency Medical Services and Trauma, to be known as the Office of EMS and Trauma, within the Department of Health and Human Services. The Office of EMS and Trauma shall be headed by a director appointed by the Secretary of Health and Human Services. (2) Role of Office within HHS (A) In general The Office of EMS and Trauma shall have— (i) the responsibilities delegated to the Office of EMS and Trauma pursuant to paragraph (3); (ii) the responsibilities and authorities vested in the Office of EMS and Trauma by other provisions of this Act; and (iii) such responsibilities and authorities as may be delegated or transferred to the Office of EMS and Trauma pursuant to subparagraph (B). (B) Additional responsibilities and authorities In addition to the responsibilities and authorities specified in clauses (i) and (ii) of subparagraph (A), the Secretary of Health and Human Services may delegate or transfer to the Office of EMS and Trauma any other responsibility or authority of the Department of Health and Human Services relating to emergency medical services and trauma care, including such services and care relating to— (i) the full continuum of emergency medical services, including field EMS and trauma and hospital emergency medical care; or (ii) improving the quality, innovation, or cost effectiveness of emergency medical services. (C) Location of office in HHS The Secretary shall locate the Office of EMS and Trauma within the organizational structure of the Department of Health and Human Services in a manner that achieves each of the following: (i) Recognition of the importance and unique life-saving services associated with field EMS, trauma care, and hospital emergency care as a significant Federal priority. (ii) Integration of these essential services with the larger health care system and within the disaster preparedness system, including through regionalization of such services and by enhancing daily readiness capabilities to ensure adequate disaster readiness capabilities, consistent with the National Health Security Strategy. (iii) Consolidation, co-location, and cost efficiencies in administering programs and activities related to field EMS, trauma care, and hospital emergency medical care. (iv) Establishment of a Federal focal point for leadership and improved coordination, support, and oversight of field EMS, trauma care and hospital emergency medical care. (v) Sufficient level and stature such that— (I) such Office is able to fulfill its role, responsibilities, and authorities; and (II) the Director of such Office reports directly to the Secretary or an official within the Department who reports directly to the Secretary. (vi) Establishment of a visible and identifiable point of contact with which the public; EMS agencies and practitioners; State and local government agencies; EMS educational institutions; EMS, trauma, and hospital emergency care professional associations; and all other parties may interact. (3) Responsibilities The Secretary of Health and Human Services shall, at a minimum, delegate responsibility to the Office of EMS and Trauma to carry out— (A) sections 5 and 6 (relating to the EQUIP and SPIA grant programs, respectively); (B) section 330J of the Public Health Service Act ( 42 U.S.C. 254c–15 ; relating to rural emergency service training and equipment assistance program); (C) part A ( 42 U.S.C. 300d et seq. ), part B (42 U.S.C. 300d–11 et seq.), part C ( 42 U.S.C. 300d–31 et seq. ), part D (42 U.S.C. 300d–41 et seq.), and part H ( 42 U.S.C. 300d–81 et seq. ) of title XII of the Public Health Service Act (relating to trauma care); (D) section 8 (relating to the field EMS education grant program); and (E) section 9 (relating to evaluating innovative models for access and delivery of field EMS for patients). (c) National EMS strategy The Secretary of Health and Human Services, acting through the Director of the Office of EMS and Trauma, and in consultation with the Assistant Secretary for Preparedness and Response and the Administrator of the Health Resources and Services Administration, shall develop and implement a cohesive national EMS strategy to strengthen the development of the full continuum of EMS at the Federal, State, and local levels. In establishing such a strategy, the Secretary shall— (1) solicit and consider the recommendations of the NEMSAC as well as relevant stakeholders; (2) consult and collaborate with FICEMS to ensure consistency of such national EMS strategy within the larger Federal strategy regarding all of emergency medical services and national preparedness and response; (3) address issues related to EMS patient and practitioner safety, standardization of EMS practitioner licensing and credentialing, field EMS quality and medical oversight, regionalization of field EMS and trauma and emergency care services, availability of field EMS and trauma care and emergency medical services throughout the Nation, and integration of field EMS practitioners into the broader health care system, including— (A) promotion of the adoption by States of the education standards identified in the Emergency Medical Services Education Agenda for the Future: A Systems Approach and any revisions thereto, including the standardization of licensing and credentialing of field EMS practitioners and standards of care, based on best practices and evidence-based medicine, including by— (i) the identification of differences in the levels of care, scope of practice, and licensure and credentialing requirements among the States; and (ii) the adoption by the States of national standards for such levels of care, scope of practice and licensure and credentialing requirements; (B) promotion of a culture of safety, including— (i) the adoption of an anonymous error reporting system designed to identify systemic problems in field EMS patient and practitioner safety and ensure a single means of collecting and reporting relevant error data by field EMS agencies and States; (ii) the establishment of field EMS patient and practitioner safety goals and the specific means to improve field EMS practitioner and patient safety to achieve such goals; and (iii) the adoption of more uniform national ambulance vehicle safety and manufacturing standards as developed by the National Fire Protection Administration or coordinated by NHTSA; (C) the integration and utilization of field EMS practitioners as part of the larger health care system including— (i) the potential utilization of field EMS practitioners for the provision of care to patients with nonemergent medical conditions; and (ii) strategies to implement the recommendations provided by the National Health Care Workforce Commission, pursuant to section 5101(d)(2) of the Patient Protection and Affordable Care Act ( 42 U.S.C. 294q(d)(2) ; and (D) such other issues as the Secretary considers appropriate; (4) incorporate into such strategy the preparedness and response objectives identified by the Secretary of Homeland Security and the Assistant Secretary for Preparedness and Response in order— (A) to ensure the capability and capacity of the full spectrum of EMS to respond to terrorist attacks, disasters, catastrophic events, and mass casualty events; and (B) to coordinate with the Secretary of Homeland Security accordingly; (5) complete the development of such strategy not later than 18 months after the date of enactment of this Act; (6) communicate such strategy to the relevant congressional committees of jurisdiction; (7) implement such strategy to the extent practical not later than 3 years after the date of enactment of this Act; and (8) update such strategy not less than every 3 years. (d) Statutory construction Nothing in this Act shall be construed to supercede any statutory authority of any Federal agency that is not within the Department of Health and Human Services. 5. Field EMS Excellence, Quality, Universal Access, Innovation, and Preparedness (a) In general The Director of the Office of EMS and Trauma (in this section referred to as the Director ), shall establish the EQUIP grant program— (1) to promote excellence in all aspects of the provision of field EMS by field EMS agencies; (2) to enhance the quality of emergency medical care provided to patients by field EMS practitioners through evidence-based, medically directed field emergency care; (3) to promote universal access to and availability of high-quality field EMS in all geographic locations of the Nation; (4) to spur innovation in the delivery of field EMS; and (5) to improve EMS agency readiness and preparedness for day-to-day emergency medical response. (b) Application (1) In general 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, that contains such agreements, assurances, and information as the Director determines to be reasonably necessary to carry out this section. (2) Simple form 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. (3) Consistency with preparation goals The Director shall ensure that grant applications are consistent with national and relevant State preparedness plans and goals. (c) Use of funds Grants may be used by eligible entities to— (1) sustain field EMS practitioners to ensure 24 hours a day, 7 days a week readiness and preparedness at the local level; (2) develop and implement initiatives related to delivery of medical services, including— (A) 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 (B) delivery systems to improve patient outcomes, which may include implementing evidence-based protocols, interventions, systems, and technologies to reduce clinically meaningful response times; (3) purchase and implement— (A) medical equipment and training for using such equipment; (B) communication systems to ensure seamless and interoperable communications with other first responders; and (C) information systems to comply with NEMSIS data collection and integrate field emergency care with electronic medical records; (4) participate in federally sponsored field EMS research; (5) 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 (6) such other uses as the Director may establish. (d) Administration of grants In establishing and administering the EQUIP grant program, the Director— (1) shall establish a grantmaking process that includes— (A) prioritization for the awarding of grants to eligible entities and consideration of the factors in reviewing grant applications by eligible entities including— (i) demonstrated financial need for funding; (ii) utilization of public and private partnerships; (iii) enhanced access to high-quality field EMS in under served geographic areas; (iv) unique needs of volunteer and rural field EMS agencies; (v) distribution among a variety of geographic areas, including urban, suburban, and rural; (vi) distribution of funds among types of EMS agencies, including governmental, nongovernmental and volunteer; (vii) implementation of evidence-based interventions that improve quality of care, patient outcomes, efficiency, or cost effectiveness; and (viii) such other factors as the Director considers necessary; (B) 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 (C) 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; (2) shall consult with and take into consideration the recommendations of the Assistant Secretary for Preparedness and Response, FICEMS, NEMSAC and relevant stakeholders; (3) shall ensure that funds used for day-to-day preparedness activities are consistent and aligned with Federal preparedness priorities; and (4) 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. (e) Eligibility Eligible grant recipients are field EMS agencies that— (1) are licensed by or otherwise authorized in the State in which they operate; and (2) have medical oversight and quality improvement programs as defined by the Director. (f) Annual report The Director shall submit an annual report on the EQUIP grant program under this section to the Congress. 6. Field EMS System Performance, Integration, and Accountability (a) In general The Director of the Office of EMS and Trauma (in this section referred to as the Director ) shall establish the SPIA grant program— (1) to improve field EMS system performance, integration and accountability; (2) to ensure preparedness for field EMS at the State and local levels; (3) to enhance physician medical oversight of field EMS systems; (4) to improve coordination between regional field EMS systems and integration of such regional field EMS systems into the larger health care system; (5) to enhance data collection and analysis to improve, on a continuing basis, the field EMS system; and (6) to promote standardization of national EMS certification of emergency medical technicians and paramedics. (b) Use of funds Grants may be used by eligible entities— (1) to enhance EMS system readiness and preparedness for day-to-day emergency medical response; (2) to improve cross-border collaboration and planning among States; and (3) to collect data with regard to— (A) NEMSIS; (B) field EMS education; (C) field EMS workforce; (D) cardiac events, including STEMI and sudden cardiac arrest; (E) stroke; (F) disasters, including injuries and illnesses; (G) ambulance diversion and patient parking; (H) trauma (in a manner that is complementary and not duplicative of other trauma data collection such as the National Trauma Data Bank); (I) data determined necessary by the State office of EMS for oversight and coordination of the State field EMS system; and (J) any other such data that the Director specifies; (4) to implement and evaluate system-wide quality improvement initiatives, including medical direction at the State, local, and regional levels; (5) 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; (6) to incorporate national EMS certification for all levels of emergency medical technicians and paramedics; (7) to improve the State’s planning for ensuring a consistent, available EMS workforce; (8) 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 (9) for such other uses as the Director may establish. (c) Administration of grants In establishing and administering the SPIA grant program, the Director shall— (1) establish State EMS system performance standards to serve as guidance to States in improving their EMS systems and in applying for grants under this subsection. In establishing such standards, the Director shall— (A) take into the consideration the recommendations of the Assistant Secretary for Preparedness and Response, FICEMS, NEMSAC, and relevant stakeholders; (B) include national, evidence-based guidelines; and (C) take into account the needs and resource limitations of volunteer, smaller agencies, and agencies in rural areas. (2) 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; (3) 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 (4) require that States allocate a portion of their grant funds 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. (d) Application 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, that contains such agreements, assurances, and information as the Director determines to be reasonably necessary to carry out this section. (e) Eligibility The eligible entities for a grant under this section are the State EMS office in each of the several States, tribes, and territories. (f) Annual report The Director shall submit an annual report on the SPIA grant program under this section to the Congress. 7. Field EMS quality (a) Medical oversight (1) In general To improve medical oversight of field EMS and ensure continuity and quality for such medical oversight, the Director of the Office of EMS and Trauma (in this section referred to as the Director ) shall— (A) promote high-quality and comprehensive medical oversight of— (i) all medical care provided by field EMS practitioners; and (ii) the education and training of field EMS practitioners; (B) 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; (C) 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 (D) 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. (2) Additional considerations In carrying out subparagraphs (B) and (C) of paragraph (1) (relating to supporting guidelines), the Director shall take into consideration— (A) existing guidelines developed by national professional physician associations, States, and other relevant governmental or nongovernmental entities; (B) the input of other relevant stakeholders, including health care providers who support physicians who provide medical oversight for field EMS; and (C) the unique needs associated with medical oversight of provision of field EMS in rural areas or by volunteers. (3) Flexibility The guidelines promoted 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. (4) Required use of guidelines As a condition on receipt of a grant under section 5 or 6, the Director shall require the grant recipient to adopt and implement (to the extent applicable) the guidelines promoted under subparagraphs (B) and (C) of paragraph (1). (b) GAO study and report (1) In general The Comptroller General of the United States shall complete a study on— (A) medical and administrative liability issues that may impede— (i) 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 (ii) the highest quality emergency medical care in field EMS provided by personnel other than physicians such as emergency medical technicians and paramedics; (B) reimbursement for any component of medical oversight; and (C) such other issues as the Comptroller General deems appropriate relating to improving the quality and medical oversight of emergency medical care in field EMS. (2) Report to Congress Not later than 18 months after the date of the enactment of this Act, the Comptroller General shall complete the study under paragraph (1) and submit a report to the Congress on the results of such study, including any recommendations. (c) Data collection and exchange (1) National EMS information system (A) In general The Administrator of NHTSA may maintain, improve, and expand the National EMS Information System, including the National EMS Database. (B) Consultation The Administrator of NHTSA shall carry out this paragraph in consultation with the Director. (C) Standardization In carrying out subparagraph (A), the Administrator of NHTSA shall promote the collection and reporting of data on field EMS in a standardized manner. (D) Availability of data 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. (E) Technical assistance In carrying out subparagraph (A), the Administrator of NHTSA may provide technical assistance to State and local agencies, field EMS agencies, and other entities deemed appropriate by the Administrator to assist in the collection, analysis, and reporting of data. (2) Report on data gaps (A) In general Not later than 12 months after the date of the enactment of this Act, the Secretary of Health and Human Services, acting through the Director, in consultation with the Administrator of NHTSA, shall submit to the Congress a report that— (i) identifies gaps in the collection of data related to the provision of field EMS; and (ii) includes recommendations for improving the collection, reporting, and analysis of such data. (B) Recommendations The recommendations required by subparagraph (A)(ii) shall— (i) take into consideration the recommendations of FICEMS and NEMSAC and relevant stakeholders; (ii) 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); (iii) 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— (I) cardiac events such as chest pain, sudden cardiac arrest, and STEMI; (II) stroke; (III) trauma; (IV) disaster and catastrophic incidents, such as incidents related to terrorism or natural or manmade disasters; and (V) ambulance diversion and patient parking; and (iv) include an analysis of the variety of services provided by field EMS agencies. (3) Report on data integration to promote quality of care Not later than 18 months after the date of the enactment of this Act, the Secretary of Health and Human Services, acting through the head of the Office of the National Coordinator for Health Information Technology, in collaboration with the Director of the Office of EMS and Trauma, 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: (A) Incorporation of field EMS patient care reports into patient electronic health records, taking into consideration— (i) the extent to which field EMS patient care reports are presently created in electronic format and the potential for elements of such reports to be incorporated into patient electronic health records; (ii) the data elements of field EMS patient care reports that would promote quality and efficiency of care if incorporated into patient electronic health records; (iii) potential modifications to the Medicare and Medicaid programs under titles XVIII and XIX, respectively, of the Social Security Act or other Federal health programs (including potential modifications to the HITECH Act (title XIII of division A 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, 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— (I) to maintain field EMS patient care reports in a structured electronic format; and (II) to otherwise adopt and use electronic health records; and (iv) 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. (B) Incorporation of patient health information created subsequent to the receipt of field EMS emergency care into NEMSIS, taking into consideration— (i) what 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) would, if included in NEMSIS, be potentially useful in evaluating and improving the quality of EMS care; (ii) how best to integrate such information into NEMSIS; (iii) potential modifications to the HITECH Act to require eligible hospitals, as defined in section 1886(n)(6)(B) of the Social Security Act, 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 (iv) 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. (d) Clarification of HIPAA (1) Exchange of information related to the treatment of patients (A) In general Nothing in HIPAA privacy and security law (as defined in section 3009(a)(2) of the Public Health Service Act ( 42 U.S.C. 300jj–19(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). (B) Guidelines The Secretary of Health and Human Services 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. (2) NEMSIS data Nothing in HIPAA privacy and security law (as defined in section 3009(a)(2) of the Public Health Service Act ( 42 U.S.C. 300jj–19(a)(2) ) shall be construed as prohibiting— (A) 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 (B) the State EMS Office from submitting aggregated nonindividually identifiable EMS data to the National EMS Database maintained by NHTSA. 8. Field EMS education grants (a) In general 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 of the Office of EMS and Trauma (in this section referred to as 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 input from the Administrator of NHTSA, FICEMS, 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. (b) Eligibility 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. (c) Use of funds The Director may award a grant to an eligible entity under paragraph (1) only if the entity agrees to use the grant to— (1) develop and implement education programs that— (A) 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; (B) 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 (C) provide training and retraining programs to provide displaced workers the opportunity to enter a field EMS profession; (2) develop and implement educational courses pertaining to— (A) instructor courses; (B) provision of medical direction of field EMS; (C) field EMS practitioners, including physicians, emergency medical technicians, paramedics, nurses, and other relevant clinicians providing emergency medical care in the field; (D) field EMS educational and clinical research; (E) bridge programs among field EMS, nursing, and other allied health professions; (F) field EMS management; (G) national, evidence-based guidelines; and (H) translation of the lessons learned in military medicine to field EMS; (3) evaluate education and training courses and methodologies to identify optimal educational modalities for field EMS practitioners; (4) 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; (5) enhance the opportunity for medical direction training and for promoting appropriate medical oversight of field emergency medical care; (6) improve systems to design, implement, and evaluate education for prospective and current field EMS providers; or (7) carrying out such other activities as the Director may identify. (d) Priority 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. (e) Duration of grants Grants under this section shall be for a period of 1 to 3 years. (f) Application 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. 9. Evaluating innovative models for access and delivery of field EMS for patients (a) Evaluation (1) In general Not later than 1 year after the date of the enactment of this Act, the Director of the Office of EMS and Trauma, in consultation with the Administrator of the Centers for Medicare & Medicaid Services (in this section referred to as the Director ), and taking into consideration the recommendations of NEMSAC and FICEMS, shall complete an evaluation of— (A) the provision of and reimbursement for alternative delivery models for medical care through field EMS; and (B) the integration of field EMS patients with other medical providers and facilities as medically appropriate. (2) Specific issues The evaluation under paragraph (1) shall consider each of the following: (A) Alternative dispositions of patients, including— (i) 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; (ii) when medically necessary, the evaluation, treatment, or referral of patients to other medically appropriate health care providers; and (iii) the funding of the provision of medical care regardless of the decision to transport such as reimbursement models based on readiness rather than transport and shared savings. (B) 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. (C) Necessary protections to ensure that patients receive timely and appropriate care in the appropriate setting. (D) Whether there are any barriers to providing alternate dispositions to patients who are not in need of care in hospital emergency departments. (E) Other issues determined by the Director, including, when possible, issues recommended by FICEMS or NEMSAC for evaluation under this subsection. (b) Demonstration projects (1) In general Beginning not later than 1 year after the date of the enactment of this Act, the Director shall conduct or support at least 10 demonstration projects to— (A) evaluate the implementation and reimbursement of alternative dispositions of field EMS patients, including— (i) transporting patients by ambulance to alternate destinations when medically appropriate and in the patients’ best interests; and (ii) when medically necessary, evaluating, treating, or referring patients to other medically appropriate providers; (B) evaluate the implementation of reimbursement models based on readiness rather than transport or shared savings; and (C) determine whether such alternative dispositions and reimbursement models— (i) improve the safety, effectiveness, timeliness, and efficiency of EMS; and (ii) reduce overall utilization and expenditures under the Medicare program under title XVIII of the Social Security Act. (2) Evidence-based protocols 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. (3) Duration The period of a demonstration project under paragraph (1) shall not exceed 36 months. (4) Research If the Director determines that further research is 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, the Director shall conduct or support such research. (5) Authorization of appropriations Of the amount made available to carry out section 1115A of the Social Security Act (42 U.S.C. 1315a) for a fiscal year, there are authorized to be appropriated such sums as may be necessary to carry out this subsection. (c) Report to Congress Not later than 1 year after the completion of all demonstration projects under subsection (b), the Director shall submit to the Congress a report on the results of activities under this section, including recommendations on the efficacy of alternative dispositions of field EMS patients. 10. Enhancing research in field EMS (a) Models To be tested by Center for Medicare and Medicaid Innovation Section 1115A(b)(2)(B) of title XI of the Social Security Act ( 42 U.S.C. 1315a(b)(2)(B) ) is amended by adding at the end the following: (xxi) Enhancing health outcomes for patients receiving field emergency medical services and improving timely and efficient delivery of high-quality field emergency medical services, such as through— (I) regionalization of emergency care; (II) medical transport to alternate destinations; or (III) when medically necessary, the evaluation, treatment, or referral of patients to other medically appropriate health providers. . (b) Emergency medical research Section 498D of the Public Health Service Act ( 42 U.S.C. 289g–4 ) is amended— (1) by redesignating subsections (c) and (d) as subsections (d) and (e), respectively; and (2) by inserting after subsection (b) the following: (c) Field EMS emergency medical research The Secretary shall conduct research and evaluation relating to field EMS through the Agency for Healthcare Research and Quality and the Center for Medicare and Medicaid Innovation. . (c) Field EMS practice center Subpart II of part D of title IX of the Public Health Service Act ( 42 U.S.C. 299b–33 et seq. ) is amended by adding at the end the following: 938. Field EMS practice center (a) Establishment For the purpose described in subsection (b), the Director shall establish within the Office of Research and Evaluation a Field EMS Evidence-Based Practice Center. (b) Purpose The purpose of the Center is to conduct or support research to promote the highest quality of emergency medical care in field EMS and the most effective delivery system for the provision of such care. Research conducted or supported pursuant to the preceding sentence shall include— (1) comparative safety and effectiveness research; (2) other appropriate clinical or systems research; and (3) research addressing— (A) critical care transport; (B) off-shore operations; (C) tactical emergency medical services; (D) air medical services; and (E) the application of lessons learned in military field medicine in the delivery of emergency medical care in field EMS. (c) Definition In this section: (1) The term Center means the Field EMS Evidence-Based Practice Center established under subsection (a). (2) The term field EMS has the meaning given to such term in section 3 of the Field EMS Quality, Innovation, and Cost Effectiveness Improvements Act of 2013 . . (d) Limitations on certain uses of research Section 1182 of the Social Security Act ( 42 U.S.C. 1320e–1 ) is amended by striking section 1181 each place it appears and inserting section 1181 of this Act or section 498D(c) or 938 of the Public Health Service Act . (e) Regulatory barriers For the purposes of research conducted pursuant to this section or any other research funded by the Department of Health and Human Services related to emergency medical services in the field in which informed consent is required but may not be attainable, the Secretary of Health and Human Services shall— (1) evaluate and consider the patient and research issues involved; and (2) address regulatory barriers to such research related to the need for informed consent in a manner that ensures adequate patient safety and notification, and submit recommendations to Congress for any changes to Federal statutes necessary to address such barriers. 11. Emergency Medical Services Trust Fund (a) Designation of income tax overpayments and additional contributions for emergency medical services Subchapter A of chapter 61 of the Internal Revenue Code of 1986 (relating to returns and records) is amended by adding at the end the following new part: IX Designation of income tax overpayments and additional contributions for emergency medical services 6097. Designation by individuals (a) In general Every individual (other than a nonresident alien)— (1) may designate that a specified portion of any overpayment of tax for a taxable year, and (2) may designate that an amount in addition to any payment of tax for such taxable year and any designation under paragraph (1), shall be used to fund the Emergency Medical Services Trust Fund. Designations under the preceding sentence shall be in an amount not less than $1 and the Secretary shall provide for elections in amounts of $1, $5, $10, or such other amount as the taxpayer designates. (b) Adjusted income tax liability For purposes of this section, the term adjusted income tax liability means income tax liability (as defined in section 6096(b)) reduced by any amount designated under section 6096 (relating to designation of income tax payments to Presidential Election Campaign Fund). (c) Overpayments Treated as Refunded For purposes of this title, any portion of an overpayment of tax designated under subsection (a) shall be treated as— (1) being refunded to the taxpayer as of the last date prescribed for filing the return of tax imposed by chapter 1 (determined without regard to extensions) or, if later, the date the return is filed, and (2) a contribution made by such taxpayer on such date to the United States. (d) Manner and time of designation A designation under subsection (a) may be made with respect to any taxable year— (1) at the time of filing the return of the tax imposed by chapter 1 for such taxable year, or (2) at any other time (after the time of filing the return of the tax imposed by chapter 1 for such taxable year) specified in regulations prescribed by the Secretary. Such designation shall be made in such manner as the Secretary prescribes by regulations except that, if such designation is made at the time of filing the return of the tax imposed by chapter 1 for such taxable year, such designation shall be made either on the first page of the return or on the page bearing the signature of the taxpayer. . (b) Emergency Medical Services Trust Fund Subchapter A of chapter 98 of the Internal Revenue Code of 1986 is amended by adding at the end the following new section: 9512. Emergency Medical Services Trust Fund (a) Creation of trust fund There is established in the Treasury of the United States a trust fund to be known as the Emergency Medical Services Trust Fund , consisting of such amounts as may be credited or paid to such trust fund as provided in section 6097. (b) Transfers to trust fund There are hereby appropriated to the Emergency Medical Services Trust Fund amounts equivalent to the amounts of the overpayments of tax to which designations under section 6097 apply. (c) Expenditures from trust fund Amounts in the Emergency Medical Services Trust Fund shall be available, as provided in appropriation Acts, only for carrying out the provisions for which amounts are authorized to be appropriated under subsections (a) and (b) of section 12 of the Field EMS Quality, Innovation, and Cost Effectiveness Improvements Act of 2013 . . (c) Clerical amendments (1) Clerical amendment The table of parts for subchapter A of chapter 61 of the Internal Revenue Code of 1986 is amended by adding at the end the following new item: Part IX. Designation of income tax overpayments and additional contributions for emergency medical services. . (2) The table of sections for subchapter A of chapter 98 of such Code is amended by adding at the end the following new item: Sec. 9512. Emergency Medical Services Trust Fund. . (d) Effective date The amendments made by this section shall apply to taxable years beginning after December 31, 2013. 12. Authorization of appropriations (a) In general Out of amounts in the Emergency Medical Services Trust Fund, there are authorized to be appropriated— (1) $12,000,000 shall be for carrying out sections 4 (excluding the provisions of law listed in subsection (b)(3) of such section), 7, 9(a), 9(c), and 11 of this Act for each of fiscal years 2014 through 2017; (2) $200,000,000 shall be for carrying out section 5 of this Act for each of fiscal years 2014 through 2017; (3) $50,000,000 shall be for carrying out section 6 of this Act for each of fiscal years 2014 through 2017; (4) $4,000,000 shall be for carrying out section 7(c)(1) of this Act for each of fiscal years 2014 through 2017; (5) $15,000,000 shall be for carrying out section 8 of this Act for each of fiscal years 2014 through 2017; and (6) $40,000,000 shall be for carrying out sections 498D(c) and 938 of the Public Health Service Act, as added by subsections (b) and (c) of section 10 of this Act, for each of fiscal years 2014 through 2017. (b) Excess amounts If, for any fiscal year, amounts in the Emergency Medical Services Trust Fund exceed the maximum amount authorized to be appropriated under subsection (a), such excess amounts are authorized to be appropriated to carry out section 330J, section 498D, and parts A, B, C, D, and H of title XII of the Public Health Service Act (42 U.S.C. 254c–15, 289g–4, 300d et seq., 300d–11 et seq., 300d–31 et seq., and 300d–81 et seq.). (c) Start-Up funding (1) In general Out of the discretionary funds available to the Secretary of Health and Human Services for each of fiscal years 2014 and 2015, $40,000,000 shall be for carrying out the provisions listed in subsection (a) or (b). (2) Relation to other funds The amount of discretionary funds allocated under paragraph (1) for the purpose of carrying out the provisions listed in subsection (a) or (b) shall be in addition to, not in lieu of, the amount of discretionary funds that would otherwise be available for such purpose. (d) Administrative expenses Of the amounts made available under subsection (a), (b), or (c) to carry out each of the provisions listed in subsection (a), not more than 5 percent of each such amount may be used for Federal administrative expenses.