Section 11 - Data and Information Collection and Record Keeping
11.1	Authority
The authority and requirement for data collection is provided in C.R.S. § 25-3.5-501(1), which states, “Each ambulance service shall prepare and transmit copies of uniform and standardized records, as specified by regulation adopted by the department, concerning the transportation and treatment of patients in order to evaluate the performance of the emergency medical services system and to plan systematically for improvements in said system at all levels.”
Additional authority for data collection and analysis is provided in C.R.S. § 25-3.5-307, requiring data collection and reporting by air ambulance agencies, and C.R.S. § 25-3.5-704(2)(h), requiring the establishment of a continuous quality improvement system to evaluate the statewide emergency medical and trauma services system.
11.2	Purpose and Scope
This section consists of rules for the collection and reporting of essential data related to the performance, needs and quality assessment of the statewide emergency medical and trauma services system. These rules focus primarily on the data that ambulance agencies are required to collect and provide to the Department. Rules regarding the collection of data by designated trauma facilities can be found in 6 CCR 1015-4, Chapter 1.	
11.3 	Definitions
1.	Agency or agencies as used in this section 11 means (ground) ambulance services and air ambulance services.  
2.	Air Ambulance means a fixed-wing or rotor-wing aircraft that is equipped to provide air transportation and is specifically designed to accommodate the medical needs of individuals who are ill, injured, or otherwise mentally or physically incapacitated and who require in-flight medical supervision.  
3.	Air Ambulance Service means any governmental or private organization licensed by the department to transport in any aircraft patient(s) who require in-flight medical supervision to a medical facility.
4.	Ambulance means any privately or publicly owned ground vehicle that meets the requirements of C.R.S. § 25-3.5-103(1.5).  
5.	Ambulance service means the furnishing, operating, conducting, maintaining, advertising, or otherwise engaging in or professing to be engaged in the transportation of patients by ambulance. Taken in context, it also means the person so engaged or professing to be so engaged. The person so engaged and the vehicles used for the emergency transportation of persons injured at a mine are excluded from this definition when the personnel utilized in the operation of said vehicles are subject to the mandatory safety standards of the federal mine safety and health administration, or its successor agency.  
6.	Patient means any individual who is sick, injured, or otherwise incapacitated or helpless.
11.4      Reporting Requirements
1.	All ambulance service agencies and air ambulance service agencies licensed in Colorado shall provide the Department with the required data and information as specified in sections 2 and 3 below in a format determined by the Department or in an alternate media acceptable to the Department.
2.	The required data and information for the agency profile shall be based on the Colorado Emergency Medical Services Information System (CEMSIS).
a.	Agency profile data shall include but not be limited to information about licensing, service types and level, agency contact information, agency director and medical director contact information, demographics of the service area, number and types of responding personnel, number of calls by response type, data collection methods, counties served, organizational type, and number and type of vehicles. 
b.	Agencies shall provide agency profile data to the Department using the CEMSIS portal website.  
c.	Agencies shall update agency profile data whenever changes occur and at least annually.
3.	The required data and information on patient care shall be based on the National Emergency Medical Services Information System (NEMSIS).    
a.	These rules incorporate by reference the National Highway Traffic Safety Administration (NHTSA) Uniform Pre-Hospital Emergency Medical Services Dataset, Version 2.2.1, National Elements Subset, published in 2006. Such incorporation does not include later amendments to or editions of the referenced material. The Health Facilities and Emergency Medical Services Division of the Department maintains copies of the complete text of required data elements for public inspection during regular business hours, and shall provide certified copies of any non-copyrighted material to the public at cost upon request. Information regarding how the incorporated materials may be obtained or examined is available from the Division by contacting:
EMTS Section Chief                                                                          Health Facilities and EMS Division                                                             Colorado Department of Public Health and Environment                               4300 Cherry Creek Drive South                                                            Denver, CO 80246-1530
These materials have been submitted to the state publications depository and distribution center and are available for interlibrary loan. The incorporated material may be examined at any state publications depository library. Submission of the National Elements Subset as stated above is required, however, ambulance services may provide additional data as outlined in the complete NEMSIS NHTSA Version 2.2.1 Data Dictionary or as suggested by the Department. 
b.	All agencies licensed in Colorado shall report the required data elements on all responses that resulted in patient contact. Although not required, agencies may also report the required data elements on responses that did not result in patient contact or transport (all calls).  
c.	Agencies shall obtain approval from the Department prior to using third party media to submit the required data.  
d.	Agencies shall provide the data to the Department at least quarterly based on a calendar year or on a schedule submitted to and approved by the Department. The quarterly download must be submitted to the Department within 60 days of the end of the quarter (i.e., data for EMS responses occurring in January through March must be submitted by June 1; for responses in April through June by September 1; for responses in July through September by December 1; for responses in October through December by March 1). The data may be submitted more frequently than quarterly. 
4.	In order to be eligible to apply for funding through the EMTS grants program, agencies shall provide agency profile information as described in section 2 and regularly submit patient care information as described in section 3. 
5.	If an agency fails to comply with these rules, the Department may report this lack of compliance to the county(ies) in which the agency is licensed and/or to the agency’s medical director. 
11.5	Confidentiality of Data and Information on Patient Care
1.	The data and information provided to the Department in accordance with 11.4 section 3 of these rules shall be used to conduct continuing quality improvement of the Emergency Medical and Trauma System, pursuant to C.R.S. § 25-3.5-704 (2)(h)(I). Any data provided to the department that identifies an individual patient’s, provider’s or facility’s care outcomes or is part of the patient’s medical record shall be strictly confidential, whether such data are recorded on paper or electronically. The confidentiality protections provided in C.R.S. § 25-3.5-704 (2)(h)(II) apply to this data.  
2.	Any patient care data in the EMS data system that could potentially identify individual patients or providers shall not be released in any form to any agency, institution, or individual, except as provided in section 11.5,3. 
3. 	An agency may retrieve the patient care data that the agency has submitted via the Department’s web-based data entry utility and that are stored on the Department’s servers.  
4.	Results from any analysis of the data by the Department shall only be presented in aggregate according to established Department policies. 
5.	The Department may establish procedures to allow access by outside agencies, institutions or individuals to information in the EMS data system that does not identify patients, providers or agencies. These procedures are outlined in the Colorado EMS Data System Data Release Policy and other applicable Department data release policies.