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					                                                      D53T00
         Maryland Institute for Emergency Medical Services Systems

Operating Budget Data
                                                ($ in Thousands)


                                              FY 10           FY 11         FY 12      FY 11-12    % Change
                                              Actual         Working      Allowance     Change     Prior Year

 Special Fund                                    $11,984       $12,244       $12,503       $259          2.1%
 Contingent & Back of Bill Reductions                  0             0           -80        -80
 Adjusted Special Fund                           $11,984       $12,244       $12,423       $179          1.5%

 Federal Fund                                          111          610          129        -481       -78.8%
 Contingent & Back of Bill Reductions                    0            0            0           0
 Adjusted Federal Fund                                $111         $610         $129       -$481       -78.8%

 Reimbursable Fund                                     924       1,126           646        -480       -42.6%
 Contingent & Back of Bill Reductions                    0           0            -1          -1
 Adjusted Reimbursable Fund                           $924      $1,126          $645       -$481       -42.7%

 Adjusted Grand Total                            $13,019       $13,980       $13,197       -$783        -5.6%



       The Governor’s fiscal 2012 allowance for the Maryland Institute for Emergency Medical
        Services Systems (MIEMSS) decreases by $0.8 million, or 5.6%, from the fiscal 2011
        working appropriation.

       The Department of Legislative Services estimates Back of the Bill reductions for MIEMSS for
        health insurance, prescription drug benefits, and retirement contributions to decrease the
        budget by $80,553.

       Reimbursable fund support from other State agencies and federal fund support account for the
        majority of the decrease due to grants and projects budgeted in prior fiscal years.




Note: Numbers may not sum to total due to rounding.
For further information contact: Kathleen K. Wunderlich                                   Phone: (410) 946-5530

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    Personnel Data
                                               FY 10             FY 11             FY 12        FY 11-12
                                               Actual           Working          Allowance       Change

    Regular Positions                                94.10             94.10            94.10         0.00
    Contractual FTEs                                 10.90              7.30             7.30         0.00
    Total Personnel                                 105.00            101.40           101.40         0.00

    Vacancy Data: Regular Positions

    Turnover and Necessary Vacancies, Excluding New
    Positions                                                            3.75          3.99%
    Positions and Percentage Vacant as of 12/31/10                       5.00          5.31%


         There are no changes to staffing at MIEMSS in the fiscal 2012 allowance.

         As of December 31, 2010, there were 5 vacant positions, accounting for 5.31% of its
          workforce. The vacancy rate is slightly higher than the agency’s budgeted turnover rate.




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Analysis in Brief
Major Trends
Maryland Trauma Care Exceeds the National Norm: Maryland continues to demonstrate consistent
outcomes above the national norm as measured by the survivability rate of trauma care center
admissions.

Medevac Transport Trends:           Following a Maryland Medevac helicopter crash in late
September 2008, MIEMSS issued revised guidelines for emergency triage protocol directing that all
Medevac requests for trauma patients with certain injuries to consult with the receiving trauma center
before requesting a helicopter to be dispatched. In the years since the crash, the number of Medevac
flights taken has decreased by 51% due to a number of factors, including protocol changes.


Issues
Communications System in Jeopardy: MIEMSS emergency medical communications system
connects emergency response vehicles, dispatch centers, and hospital emergency departments. The
system handles nearly 400,000 radio and phone calls each year with emergency medical services
(EMS) providers who are providing emergency care in the field. The hub of this system is located at
the MIEMSS headquarters in downtown Baltimore. The operability of this system is critical to the
success of the EMS system in Maryland and the safety and health of Marylanders. Multiple factors
put the security and operability of the system at risk.


Recommended Actions


1.   Concur with Governor’s allowance.



Updates
Upgrade to the Maryland EMS Data System: As part of its oversight of Maryland’s EMS system,
MIEMSS licenses and certifies EMS providers, develops the protocol under which EMS providers
deliver prehospital care, and monitors trauma and specialty hospitals. In order to determine how well
the Maryland EMS system is functioning, MIEMSS must gather and analyze appropriate data. To
that end, MIEMSS is moving forward with an information technology project that will create a new
electronic medical records system aimed at improving the quality of data and data sharing by EMS
providers.




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Response to Independent Findings Regarding Triage Protocols, Helicopter Utilization, and
Helicopter Safety: The 2009 Joint Chairmen’s Report requested that MIEMSS and the Maryland
State Police (MSP) jointly prepare and submit a status report on the implementation of each of the
findings and recommendations of the National Transportation Safety Board and the Expert Panel,
which convened to review and make recommendations regarding Maryland’s emergency transport
protocol following the September 2008 helicopter crash. This update summarizes the report from
MIEMSS and MSP.




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        Maryland Institute for Emergency Medical Services Systems
Operating Budget Analysis
Program Description
       The Maryland Institute for Emergency Medical Services Systems (MIEMSS) was established
as a State agency under legislation that became effective July 1, 1993. MIEMSS had been in
existence for 20 years prior to that – first under the Department of Health and Mental Hygiene
(DHMH) and then the University of Maryland, Baltimore.
       Under the 1993 law, MIEMSS became a State agency under the direction of an Emergency
Medical Services (EMS) Board appointed by, and directly responsible to, the Governor. The EMS
Board is tasked with developing, adopting, and monitoring a statewide plan to ensure effective
coordination and evaluation of emergency medical services. As structured, the EMS law established
a system that encourages statewide participation and feedback through membership on the EMS
Board and its advisory body, the State EMS Advisory Council. The EMS Board appoints the
Executive Director of MIEMSS, who serves as the administrative head of the State’s emergency
medical services and of the operations of MIEMSS. Funding for MIEMSS comes primarily from the
Maryland Emergency Medical System Operations Fund (MEMSOF), created by the 1992 General
Assembly. Support for the fund comes from a surcharge on motor vehicle registrations, which was
increased from $8 to $11 by Chapter 33 of 2001.
       MIEMSS’ mission is to provide the resources, leadership, and oversight necessary for
Maryland’s EMS system to function optimally and to provide effective care to patients by reducing
preventable deaths, disability, and discomfort. MIEMSS develops a Maryland EMS Plan that is
periodically updated and that is designed to enable MIEMSS to fulfill this mission.

        MIEMSS coordinates a statewide emergency medical services system that includes over
30,000 licensed or certified EMS providers and works to integrate the delivery of prehospital
emergency care with the State’s 48 hospital emergency departments; nine adult and two pediatric
trauma centers; as well as specialty referral centers, primary stroke centers, and perinatal centers.
MIEMSS regulated the dispatch of 2,044 Medevac helicopter transports from accident scenes in
fiscal 2010, primarily transported by the Maryland State Police (MSP) Medevac helicopter system
and supplemented by U.S. Park Police helicopters, Delaware State Police helicopters, and private
carriers. The number of flights dispatched in recent years has been reduced significantly due to a
number of factors, including field triage protocol changes. In addition to the commercial air transport
services, MIEMSS also regulates commercial ground ambulance services.

        The Emergency Medical Resource Center (EMRC), responsible for coordinating medical
consultation between emergency personnel at the scene and hospital physicians, handled over
360,000 telephone and radio calls in fiscal 2010; the System Communications Center (SYSCOM),
responsible for helicopter dispatch and monitoring of the transport of critically ill or injured patients
by helicopter to area hospitals, handled almost 30,000 telephone and radio calls.


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       Operationally, the EMS system is divided into five regions:

      Region I: Allegany and Garrett counties;

      Region II: Frederick and Washington counties;

      Region III: Central Maryland, including Baltimore City;

      Region IV: the Eastern Shore; and

      Region V: Metropolitan Washington.

       The MIEMSS mission addresses the need to:

      provide high-quality medical care to individuals receiving emergency medical services; and

      maintain a well-functioning EMS system.


Performance Analysis: Managing for Results
       MIEMSS collects a wide array of data concerning the State’s EMS system. The Managing for
Results measures reflect the various roles of MIEMSS:

      as promulgator of standards for EMS personnel and emergency departments with a measure
       monitoring compliance with those standards;

      as a facilitator/communications center for EMS services with measures about handling of calls
       for assistance by EMRC/SYSCOM for appropriate transportation of seriously injured patients;
       and

      as the leader of the EMS system with outcome measures related to overall system
       performance.

        The first goal of MIEMSS is to provide high-quality, systematic medical care to individuals
receiving emergency medical services. The agency measures the achievement of this goal by
maintaining the system’s trauma patient care performance above the national norm and monitoring
the survivability rate of patients that are admitted to a trauma center, as shown in Exhibit 1.




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                                                   Exhibit 1
                             Program Measurement Data
              Maryland Institute for Emergency Medical Services Systems
                                             Calendar 2004-2010

                                        2004        2005        2006        2007     2008         2009     2010

Maryland Trauma Patient Care
   Exceeds National Norm                    Yes         Yes          Yes       Yes          Yes      Yes      Yes
Survivability Rate for Trauma
   Center Admissions (%)                  94.7%       94.3%         96.0%    96.4%     96.6%       96.5%    96.5%


Source: Maryland Institute for Emergency Medical Services Systems



        Maryland’s nine adult- and two pediatric-designated trauma centers maintain electronic
registry data on all patients transported for trauma care services. Patients are coded according to a
Trauma and Injury Severity Score (TRISS). TRISS data is used to run reports to show
mortality/morbidity among trauma center patients. These reports are reviewed by both the hospitals
and MIEMSS to monitor trends in outcomes and to identify any deviations. Notable deviations are
flagged and reviewed with the respective trauma center.

        Emergency Department Overcrowding
       The County Hospital Alert Tracking System (CHATS) is a real-time computerized monitoring
system of emergency department status throughout Maryland. Hospital emergency departments that
are temporarily unable to accept ambulance-transported patients due to overcrowding or hospital
overload are identified so that ambulances can be diverted to other, less crowded emergency
department facilities.

        MIEMSS utilizes CHATS to determine hospital bed availability, and while participation is not
mandatory, the reporting system aids MIEMSS in diverting ambulances to hospitals with adequate
capacity. MIEMSS tracks “yellow” alerts when an emergency room requests to receive absolutely no
patients in need of urgent medical care by ambulance with the exception of certain priority cases and
“red” alerts when a hospital has no inpatient electrocardiogram monitored beds available.

         Exhibit 2 shows the total number of hours of yellow and red alerts across the State from
calendar 2008 through 2010. Emergency department overcrowding, as measured by yellow and red
alerts, appears to be steadily decreasing. Hospitals in Washington, DC are not included in this chart,
even though Maryland residents utilize those hospitals. Region III and Region V make up the vast
majority of yellow and red alert hours. In calendar 2010, Region III contributed 75% of the


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                                                       Exhibit 2
                                           Yellow and Red Alerts
                                                   Fiscal 2008-2010

                          30,000

                          25,000

                          20,000
                  Hours




                          15,000

                          10,000

                           5,000

                              0
                                          2008                   2009               2010

                                                 Yellow Alerts   Red Alerts


Source: Maryland Institute for Emergency Medical Services Systems



yellow alerts and 46% of the red alerts for the entire State. Region V constituted 18% of yellow
alerts and 45% of red alerts for the entire State in calendar 2010.

       The number of yellow alert hours for emergency room requests decreases significantly
between fiscal 2009 and 2010, as shown in Exhibit 2. In general, the decrease is due to improvement
in hospital procedures to facilitate the movement of patients from emergency rooms to other parts of
the hospital in order to keep space available for new patients that need emergency room care.

        Triage Protocols
       A key responsibility of MIEMSS is the development and distribution of Maryland Medical
Protocols for EMS providers. These triage protocols provide a system of determining priority and
appropriateness of medical treatment, transportation, and place of care in emergent situations. The
protocols guide the actions of EMS field providers as they respond to emergency transport calls and
promote uniformity of care throughout the State. All State-licensed and certified EMS providers,
whether public or commercial, are required to function within the scope of practice defined by the
protocols.

        In a regional system of care such as Maryland’s, field protocols provide that more acutely
injured patients are transported quickly to designated trauma centers. In Maryland, the most severely

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injured patients are transported to the State’s Primary Adult Resource Center, the R Adams Cowley
Shock Trauma Center or to the State’s Level I trauma center, the Johns Hopkins Hospital Adult
Trauma Center. Less critically injured patients are transported to Level II or III trauma centers, and
some patients are directed to specialty centers based on the etiology of their injury (e.g., burn victims
to specialty burn centers).

       Prior to the crash of Trooper 2 in 2008, MIEMSS was engaged in a comprehensive review of
the protocols for determining when a patient should be transported by Medevac helicopter. The
review included an internal review of data from within the State and an external review of protocols
and processes used in other states. However, as a direct result of the crash, effective October 9, 2008,
MIEMSS changed the protocol for helicopter transport of Category C and D patients to require
consultation with the receiving trauma center before requesting helicopter transport.

        In the years following the protocol change, there has been a marked reduction in helicopter
scene transport. Exhibit 3 shows Medevac transports between fiscal 2000 and 2012. The number of
Medevac flights taken in fiscal 2010 decreased by 51% below the number flown in fiscal 2008. Even
before this precipitous change, the number of Medevac flights flown annually had been steadily
declining between fiscal 2004 and 2008. The agency expects the utilization rate to stabilize in
fiscal 2011 and 2012.


                                                    Exhibit 3
                                           Medevac Transports
                                               Fiscal 2000-2012


                       6,000



                       4,000



                       2,000



                           0
                                                                                                2011 2012
                               2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
                                                                                                Est. Est.
           Medevac Transports 4,921 5,113 5,384 5,011 5,428 5,409 5,093 4,730 4,199 2,414 2,044 2,400 2,400



Source: Maryland Institute for Emergency Medical Services Systems




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Proposed Budget
       The fiscal 2012 allowance as proposed by the Governor decreases by $0.8 million, or 5.6%, as
shown in Exhibit 4. Special fund support increases by $0.2 million, or 1.5%; federal fund support
decreases by $0.5 million, or 78.8%; and reimbursable fund support decreases by $0.5 million or
42.7%.


                                                                    Exhibit 4
                                                           Proposed Budget
                        Maryland Institute for Emergency Medical Services Systems
                                             ($ in Thousands)

                                                            Special              Federal               Reimb.
  How Much It Grows:                                         Fund                  Fund                 Fund                    Total
  2011 Working Appropriation                               $12,244                   $610                $1,126             $13,980
  2012 Allowance                                             12,503                    129                   646              13,277
      Amount Change                                             $259                -$481                 -$480                 -$702
      Percent Change                                           2.1%               -78.8%                -42.6%                  -5.0%

  Contingent Reductions                                         -$80                     $0                   -$1                 -$81
      Adjusted Change                                           $179                -$481                 -$481                 -$783
      Adjusted Percent Change                                  1.5%               -78.8%                -42.7%                  -5.6%

Where It Goes:
    Personnel Expenses
        Increased salaries, including restoration of furlough reductions ................................................... $211
        Employee retirement contributions ...............................................................................................             103
        Overtime earnings .........................................................................................................................    42
        Employee and retiree health insurance (as reduced by Sections 18, 19, and 20) ..........................                                       25
        Turnover adjustments ....................................................................................................................       -6
        Other fringe benefit adjustments ...................................................................................................            6
    Other Changes
        Special fund grants to health care providers .................................................................................                133
        Metropolitan Medical Response System grant in fiscal 2011 .......................................................                             -480
        Reimbursable fund grants to health care providers for bioterrorism and highway safety.............                                            -372
        PSIC grant fiscal 2009-2011 .........................................................................................................         -342

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Where It Goes:
         EMEDS project in fiscal 2011 ......................................................................................................                    -135
         Other .............................................................................................................................................     32
    Total                                                                                                                                                      -$783


EMEDS: Electronic Maryland Emergency Medical Services Data System
PSIC: Public Safety Interoperable Communications

Note: Numbers may not sum to total due to rounding.



        Impact of Cost Containment
       The fiscal 2012 budget reflects several across-the-board actions. In fiscal 2012, this agency’s
share of the reduction is $65,582 in special funds and $698 in reimbursable funds for changes in
employee health insurance. Reductions contingent upon statutory changes include $14,123 in special
funds and $150 in reimbursable funds for retiree prescription drug benefits. To the extent that
MIEMSS has positions abolished under the Voluntary Separation Program, additional reductions will
be implemented by the Administration.

        Personnel Expenses
       Personnel expenses increase by $0.4 million compared to the fiscal 2011 working
appropriation, as shown in Exhibit 4. Increased salaries, including restoration of furlough reductions
increase the budget by $0.2 million. Also, employee retirement contributions increase by
$0.1 million. Overtime earnings increase by $42,000 to reflect actual expenditures for overtime.
Employee and retiree health insurance expenses, including prescription drug benefits increase by
$25,000. This includes Back of the Bill reductions mentioned above.

        Operating Expenses
       Operating expenses for MIEMSS decrease collectively by $1.2 million, as shown in Exhibit 4.
The majority of the decrease is due to projects and grants budgeted in prior fiscal years. First,
MIEMSS received $0.5 million in federal funds in fiscal 2011 to improve the disaster response
system in Region V, Montgomery County, using the Metropolitan Medical Response System
(MMRS). The funds were available from a federal grant from the Homeland Security Grant
program’s Urban Areas Security Initiative and enabled the agency to move from a traditional
response system into an integrated response system capable of responding to all-hazards events,
including weapons of mass destruction, PanFlu preparedness, catastrophic natural disaster response
capability, and response preparedness for all other hazards events.

      Second, MIEMSS received reimbursable funds from the Department of Health and Mental
Hygiene and the Maryland Department of Transportation for bioterrorism activities and highway

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safety initiatives in the fiscal 2011 budget that are not continued in fiscal 2012. These grants account
for a decrease of $0.4 million.

        MIEMSS also received funding for a Public Safety Interoperable Communications (PSIC)
project to connect hospitals, public health facilities, and 9-1-1 call centers to the State
communications network. The funding for this program was available through a federal grant
awarded to the Maryland Emergency Management Agency and totaled $0.3 million in the fiscal 2011
budget.

       Finally, the agency is also finishing the upgrades to the Electronic Maryland EMS Data
System (EMEDS) for which the agency received funding in fiscal 2011. The budget decreases by
$0.1 million, even though there are still funds in the fiscal 2012 allowance to complete the upgrade.
The new system will comply with data requirements approved by the National Highway Traffic and
Safety Administration and will be compatible with all jurisdictions in Maryland to allow for more
complete and accurate EMS data reporting.

       The increases to the budget result from accounting changes to accurately reflect expenditures.
For instance, MIEMSS disburses grants to counties, hospitals, and other health care providers and
provides for the purchase of EMS equipment, training, and emergency dispatch program using special
funds from MEMSOF. The budget increases by $0.1 million in the fiscal 2012 allowance to more
accurately reflect these grants.




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Issues
1.     Communications System in Jeopardy
        MIEMSS coordinates a statewide emergency medical services system to integrate the delivery
of prehospital emergency care with the State’s 48 hospital emergency departments; nine adult and
two pediatric trauma centers; as well as specialty referral centers, primary stroke centers, and
perinatal centers. The agency relies on two primary communications systems to coordinate care in
Maryland – EMRC, which is responsible for coordinating medical consultation between emergency
personnel at the scene and hospital physicians; and SYSCOM, which is responsible for helicopter
dispatch and monitoring of the transport of critically ill or injured patients by helicopter to area
hospitals.

         The MIEMSS communications systems handle nearly 400,000 radio and phone calls each
year with EMS providers who are providing emergency care in the field. The hub of this system is
located at the MIEMSS headquarters in downtown Baltimore. The operability of this system is
critical to the success of the EMS system in Maryland and the safety and health of Marylanders.

       Immediate Problems
       The MIEMSS staff identified several problems such as outdated communications equipment
no longer being manufactured and systems that are not compatible with other communications
systems in the State and region, as well as vulnerable cable and wiring that keep the system operable.
In order to properly mitigate these problems, MIEMSS is employing a communications systems
consultant to do a complete evaluation of the system and equipment currently used by the agency.

        The consultant is tasked with identifying problems that MIEMSS will have to address in
future years that do not compromise the integrity of the system in the immediate future, as well as any
acute problems that represent a single point of failure for the communications systems that needs
immediate attention. An internal vulnerability document identified multiple areas of risk with the
single greatest area of risk being the vulnerability of the copper lines that support the statewide EMS
communications systems and run adjacent to water lines, high-pressure steam lines, gas lines, and
sewage lines. Running parallel to the copper cable is the fiber cable providing internet connectivity
for MIEMSS which handles all data traffic. Failure of any of those lines or damage by utilities
working on those lines, threatens the loss of emergency medical communications throughout the
State. Additionally, new construction or street repair in Baltimore City also poses a threat to the
safety of the lines if construction workers are not properly aware of their presence.

        Damage or destruction of the cable lines that carry all MIEMSS voice and data
communications to the hub in the Bressler Building on the University of Maryland, Baltimore campus
could result in a breach of service for the State’s EMS system. If the lines were to be compromised,
the State would lose all field communications with EMS providers. Additionally, critical programs
that confer information about the status of area hospitals and patients being delivered to hospitals


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such as EMEDS, CHATS, and the Facilities Resource Emergency Database would be inaccessible.
Finally, coordination and tracking of MSP Medevac missions would be unavailable.

      The agency should comment on the immediacy of this problem and plans to address this
vulnerability.

       Potential Problems
        In addition to the acute problem presented by the vulnerability of the communications lines,
other problems were identified that pose long-term threats to the system. First, the primary telephone
interface in the MIEMSS Communications Center is only partially supported with vendor assistance.
Replacement parts are not available for many of the key components. The loss of telephone interface
would prevent MIEMSS from receiving telephone calls from EMS, first responders, and public
citizens, and from coordinating helicopter missions with MSP. Second, the core patching equipment
and sub-systems technology that allow EMS providers to receive life-saving medical consultations
and directions from physicians and specialty hospitals is over 20 years old and is past the end of its
useful life. Repair/replacement parts for the system are not available. Finally, the primary console
interface with the MIEMSS radio communications system is outdated and no longer supported by the
manufacturer. The system also cannot operate directly on the new State 700 MHz radio system.

       The agency should comment on plans to address these communications issues including
whether or not a system can be devised that will be wireless and run on the State 700 MHz
radio system.




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Recommended Actions

1.   Concur with Governor’s allowance.




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Updates
1.     Upgrade to the Maryland EMS Data System
       MIEMSS is responsible for the coordination and public health oversight of the Maryland EMS
system. As part of its duties, MIEMSS licenses and certifies EMS providers, develops the protocol
under which EMS providers deliver prehospital care, and monitors trauma and specialty hospitals. In
order to determine how well the Maryland EMS system is functioning, MIEMSS must gather and
analyze appropriate data. To that end, MIEMSS began an update of its EMS Data System to create a
new electronic medical records system that improves the quality of data and data sharing by EMS
providers. The project supports the strategic goals of MIEMSS through:

      collecting statewide EMS call data for the purposes of patient care reporting;

      gathering data for continually monitoring and improving the centralized statewide system;

      providing for surveillance, including patient tracking;

      providing for simple data entry for EMS providers and easy data export for appropriate
       analysis; and

      allowing for eventual interface with other patient care and system databases.

        The new EMEDS is a software system that Maryland jurisdictions can access in order to more
efficiently and fully report prehospital patient care data. Prior to the upgrade, jurisdictions used
differing systems to report this data. A uniform data set will improve the ability of MIEMSS and the
jurisdictions to effectively evaluate and improve services provided by the Maryland EMS.

       Background
        Maryland regulations (COMAR 30.03.04.04) requires EMS providers to deliver pre-hospital
data to MIEMSS monthly via electronic or paper submission. Public Safety Article § 8-103 requires
counties to participate in pre-hospital data reporting as a condition of receiving certain public
funding. However, the old system that MIEMSS operated, called the Electronic Maryland
Ambulance Information System (EMAIS) , did not comply with the new standard data requirements
approved by the National Highway Traffic Safety Administration (NHTSA) through its National
Emergency Medical Services Information System (NEMSIS) standards. Additionally, EMAIS was
incompatible with the data systems that some jurisdictions in Maryland use, making the data collected
by MIEMSS incomplete in some cases. There are three factors that are driving the new system:

        Interoperability: The new system should comply with data standards established by NHTSA
and NEMSIS and interface with the existing prehospital certification and licensure database to be
able to link between multiple sources and provide measurable outcome data for the system.

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        Centralization: The new system should create a centralized reporting system for patient care
reports for the purpose of oversight of the Maryland EMS system and to improve the quality of care
rendered.

       Functionality: The new system should provide reliable, user-friendly data entry for EMS
providers and data retrieval by the individual jurisdictions and by MIEMSS.

       Leveraging Federal Funds
       The new system will comply with NHTSA and NEMSIS standards, a requirement for
obtaining certain federal funding. Total project funding from fiscal 2009 through 2013 totals
approximately $1.1 million, of which approximately $560,000 is projected to be federal funds
received by the Maryland Highway Safety Office within the Maryland Department of Transportation
(MDOT). The remainder will be covered by special funds from the agency’s operating budget.

       Status
        MIEMSS established a project team in 2009 to identify the needs of the Maryland EMS
community in regard to the new reporting system. The project team held stakeholder meetings and
identified and refined the needs, requirements, and limitations of what is needed for a
NEMSIS-compliant data collection system. The Department of Information Technology approved
the project and funds were included in the fiscal 2011 budget to move forward to secure a vendor to
administer the new system. It is currently deployed in three counties on a pilot basis – Cecil, Harford,
and Queen Anne’s counties.


2.     Response to Independent Findings Regarding Triage Protocols, Helicopter
       Utilization, and Helicopter Safety
       The 2009 Joint Chairmen’s Report requested that MIEMSS and MSP jointly prepare and
submit a status report on the implementation of each of the findings and recommendations of the
National Transportation Safety Board (NTSB) and the Expert Panel, which convened to review and
make recommendations regarding Maryland’s emergency transport protocol following the
September 2008 helicopter crash.

       MSP Aviation Command concurred with all of the recommendations made by NTSB and the
Expert Panel that reviewed helicopter utilization protocols in Maryland. The following sections
provide an update on the progress to implement the recommendations.

       NTSB Safety Recommendations
       NTSB made 12 primary recommendations to improve the safety of helicopter medical
transport. The recommendations and corresponding State actions are as follows:



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   Comply with Federal Aviation Administration Part 135 regulations. The Aviation
    Command has applied for and is in the process of obtaining Federal Aviation Administration
    (FAA) Part 135 certification. It has already adopted and complied with many of the mandates
    required for Part 135 certification including pilot currency requirements, personnel additions,
    weather minimums, obstacle clearance pre-flight checks, and crew rest requirements.

   Conduct scenario-based training for helicopter emergency medical services pilots on a
    regular basis to ensure proficiency. The Aviation Command has modified its pilot training
    program to include scenario-based training for conditions and hazards unique to helicopter
    emergency medical services (HEMS) operations. Also, the Aviation Command is working
    with MDOT to lease or procure flight simulator or flight training devices.

   Implement a safety management system program that includes risk management
    practices. As part of its FAA Part 135 certification, the Aviation Command will expand on
    the safety management program already in use.

   Install flight data recording devices and establish a structured flight data monitoring
    program. The specifications for the new helicopters mandate that they must be equipped
    with flight data recording devices and cockpit video recording devices. Also, a monitoring
    program that incorporates routine reviews of the information from these devices will be used
    to identify deviations from established norms and procedures and other potential safety issues.

   Install and require the use of night vision imaging systems for operations at night. The
    specifications for the new helicopters also mandate that they must be equipped with night
    vision imaging systems. Until the new helicopters are purchased, Aviation Command has
    purchased night vision goggles.

   Equip helicopters with autopilots and train pilots to use the autopilot if a second pilot is
    not available. All Aviation Command helicopters are equipped with autopilots and all
    Command pilots are trained and proficient in using the autopilot systems. Additionally, the
    new helicopters will also be equipped with autopilots.

   Develop and implement flight risk evaluation program. The Aviation Command has
    developed and utilizes a computer-based Risk Assessment Tool that includes procedures that
    support the systematic evaluation of flight risks, and consultation with others trained in EMS
    flight operations if the risks reach a predefined level. Policy was developed that requires
    flight crews to consider both the “static” and “dynamic” operational variables that have been
    known to increase and/or mitigate operational risk. Crews are required to complete the Risk
    Assessment Tool at the beginning of each shift and throughout the shift as conditions change.

   Use formalized dispatch and flight-following procedures that include up-to-date weather
    information and assistance for in-flight risk assessment decisions. SYSCOM serves as the
    Aviation Command’s formalized dispatch and flight-following center. Aviation Command


                 Analysis of the FY 2012 Maryland Executive Budget, 2011
                                           18
                   D53T00 – Maryland Institute for Emergency Medical Services Systems

      duty officers stationed at SYSCOM have been trained to a nationally accepted standard of
      Certified Flight Communicator or higher, using a curriculum and accreditation process
      promulgated by the National Association of Air Communication Specialists. Real-time
      weather information is available to officers on duty around the clock, including the HEMS
      weather tool and the Digital Weather product at the Shock Trauma Center.

     Install terrain awareness and warning systems on aircraft and provide adequate training
      for staff. Specifications for the new helicopters mandate that they must be equipped with
      integrated terrain awareness and warning systems. Until the new aircraft are purchased,
      Aviation Command has purchased new portable Garmin 696 systems for each existing
      helicopter. The systems come with terrain and obstacles databases. With information from
      these databases, the systems monitor current position in relation to surrounding terrain to
      provide alerts.

     Implement a program to screen and treat pilots for obstructive sleep apnea. The
      Aviation Command concurred with this recommendation and is currently exploring ways to
      screen and, if necessary, treat pilots for this disorder.

     Revise policy regarding incident commanders to specify that, in any event involving a
      missing or overdue aircraft, an Aviation Command trooper will serve as the incident
      commander. The Aviation Command has created a policy in which an Aviation Command
      pilot will respond to a Command Post and provide expert consultation to incident
      commanders in any event involving a missing or overdue aircraft.

     Provide additional training to dispatchers on the use of cell phone “pinging.” MSP has
      trained investigators on the use of cell phone pinging how to integrate the data obtained from
      cell phone pinging into an overall search and rescue plan.

      Expert Panel Recommendations
      The Expert Panel made six primary recommendations to improve the safety of helicopter
medical transport. The recommendations and corresponding State actions are as follows:

     The EMS Board should establish a multidisciplinary task force to determine the optimal
      number and distribution of HEMS assets based on population needs, geography and
      current location, and capabilities of existing hospitals. MSP and MIEMSS submitted a
      report on December 1, 2010, that recommended operating seven bases and 10 helicopters with
      Trooper 1 located at Aberdeen Proving Grounds.

     The Maryland HEMS program should take the necessary steps to achieve accreditation
      by the Commission for the Accreditation of Medical Transport Systems. The
      Commission for the Accreditation of Medical Transport Systems accreditation requires
      Part 135 certification and the staffing of a second medical provider on each medical flight.


                   Analysis of the FY 2012 Maryland Executive Budget, 2011
                                             19
                 D53T00 – Maryland Institute for Emergency Medical Services Systems

    While the Aviation Command has taken steps to be certified according to Part 135, it has yet
    to hire additional flight paramedics due to cost constraints.

   MIEMSS should continue their comprehensive and prospective evaluation of the recent
    modifications to the triage process examining over-triage, under-triage, secondary
    triage, time-to-definitive care, and patient outcome. MIEMSS is responsible for modifying
    statewide EMS provider protocols, tracking helicopter utilization, collecting data on patient
    transfers which indicate whether or not the patient was initially transported to the facility best
    able to treat the patient’s injuries, and tracking trends in patient mortality.

   MIEMSS should perform rigorous and regular utilization review on pre-hosptial
    transport to ensure compliance with established triage process and criteria. In 2009,
    MIEMSS started development of a Helicopter Utilization Database to provide each
    jurisdiction with the ability to conduct retrospective quality improvement reviews of patients
    transported by helicopter. As of June 2010, of the 1,232 cases that have been entered and
    reviewed, 90% of the transports met the protocol requirements.

   The current indicators for the appropriateness of HEMS transport being collected and
    used by MIEMSS are appropriate and should be comparatively analyzed on an ongoing
    basis to monitor system performance. MIEMSS uses this information to track patient
    outcomes by modes of transport.

   The Maryland HEMS program should evolve to a program which emphasizes time-drive
    critical care goals. This recommendation has implications for crew configuration,
    education, and expansion of the mission profile to include provision of direct scene
    response for ST segment elevation myocardial infarction and stroke intervention to
    underserved areas of the State. In 2007, MIEMSS began implementation of a statewide
    stroke system to ensure that patients who have suffered a stroke are quickly identified in the
    field and transported to a designated primary stroke center.




                 Analysis of the FY 2012 Maryland Executive Budget, 2011
                                           20
                     D53T00 – Maryland Institute for Emergency Medical Services Systems

                                                                                             Appendix 1


Current and Prior Year Budgets

                              Current and Prior Year Budgets
                  Maryland Institute for Emergency Medical Services System
                                       ($ in Thousands)

                       General           Special          Federal           Reimb.
                        Fund              Fund             Fund              Fund           Total
     Fiscal 2010
Legislative
Appropriation               $0          $12,325             $100              $771        $13,197
Deficiency
Appropriation                0                60               30                 0            90

Budget
Amendments                   0                 0                0              400            400
Cost
Containment                  0              -193                0                 0          -193

Reversions and
Cancellations                0              -208              -19              -248          -475
Actual
Expenditures                $0         $11,984              $111             $924         $13,019

     Fiscal 2011
Legislative
Appropriation               $0          $12,244             $130            $1,126        $13,500
Budget
Amendments                   0                 0              480                 0           480
Working
Appropriation               $0         $12,244              $610           $1,126         $13,980

Note: Numbers may not sum to total due to rounding.




                      Analysis of the FY 2012 Maryland Executive Budget, 2011
                                                21
                    D53T00 – Maryland Institute for Emergency Medical Services Systems

Fiscal 2010
        In fiscal 2010, the budget for MIEMSS closed at $13.0 million, a decrease of $0.2 million
below the legislative appropriation. A deficiency appropriation for the agency increased the budget
by $60,000 in special funds for increased revenue from the licensure and inspection of commercial
ambulances and by $30,000 in federal funds for an increase in EMS-C revenue. Cost containment
actions taken by the Board of Public Works reduced the special fund appropriation by $0.2 million
for personnel expenses and furloughs.

      Reimbursable funds increased by $0.4 million, due to an amendment transferring funds from
the Maryland Emergency Management Agency to cover the cost of implementing the PSIC project.
The project will connect hospitals, 9-1-1 centers, and emergency operations centers to the State
communications network.

       At the end of the year, MIEMSS cancelled $0.5 million in appropriations as follows:

      $208,226 special funds cancelled due to lower than expected expenditures for certain
       sub-objects that can only be used for their intended purpose and for other miscellaneous
       revenues not realized;

      $18,690 federal funds cancelled due to lower than anticipated expenditures in the EMS-C
       program; and

      $247,621 reimbursable funds cancelled due to lower than anticipated expenditures for the
       PSIC project.


Fiscal 2011
       The fiscal 2011 working appropriation for MIEMSS is $14.0 million, an increase of
$0.5 million over the original legislative appropriation. The increase is due to a budget amendment to
improve the disaster response system in Region V, Montgomery County, using MMRS. The funds
were available from a federal grant from the Homeland Security Grant program’s Urban Areas
Security Initiative.




                    Analysis of the FY 2012 Maryland Executive Budget, 2011
                                              22
                                                          Major Information Technology Projects
                                                                                                 Maryland Institute for Emergency Medical Services Systems
                                                                               Maryland Emergency Medical Services Pre-hospital Data Management Enhancement
                                                          Project Description:                   Upgrade to the Maryland Emergency Medical Services Data System.




                                                                                                                                                                                                                             D53T00 – Maryland Institute for Emergency Medical Services Systems
                                                          Project Business Goals:                Improve the quality of data and data sharing by Emergency Medical Service providers.
                                                          Estimated Total Project Cost:          $975,000                                                   New/Ongoing Project: Ongoing.
Analysis of the FY 2012 Maryland Executive Budget, 2011




                                                          Project Start Date:                    June 2009                               Projected Completion Data:     December 2011
                                                          Schedule Status:
                                                          Cost Status:
                                                          Scope Status:
                                                          Project Management Oversight Status:   The project has been approved by the Department of Information Technology.
                                                          Identifiable Risks:
                                                          Additional Comments:                   This project will be jointly funded with Maryland Emergency Medical System Operation Funds and funding from
                                                                                                 a federal grant.
                                                                                                                                                                                     Balance to
                                                          Fiscal Year Funding (000)              Prior Years FY 2012             FY 2013     FY 2014     FY 2015       FY 2016       Complete        Total
                          23




                                                          Personnel Services                            $0.334          $0.0          $0.0        $0.0         $0.0          $0.0           $0.0      $0.334
                                                          Professional and Outside Services              0.400         0.065           0.0         0.0          0.0           0.0            0.0        0.465
                                                          Other Expenditures                            0.096          0.0        0.80           0.0           0.0             0.0           0.0       0.176
                                                          Total Funding                                $0.830      $0.065        $0.80          $0.0          $0.0            $0.0          $0.0      $0.975




                                                                                                                                                                                                                Appendix 2
                                                                                                                 Object/Fund Difference Report
                                                                                                    Maryland Institute for Emergency Medical Services Systems

                                                                                                                                     FY 11
                                                                                                                   FY 10            Working              FY 12           FY 11 - FY 12           Percent
                                                                             Object/Fund                           Actual         Appropriation        Allowance        Amount Change            Change




                                                                                                                                                                                                                             D53T00 – Maryland Institute for Emergency Medical Services Systems
                                                          Positions
                                                          01 Regular                                                     94.10               94.10              94.10                0.00                  0%
Analysis of the FY 2012 Maryland Executive Budget, 2011




                                                          02 Contractual                                                 10.90                7.30               7.30                0.00                  0%
                                                          Total Positions                                               105.00              101.40             101.40                0.00                  0%

                                                          Objects
                                                          01 Salaries and Wages                                    $ 7,645,049         $ 7,692,632        $ 8,154,534           $ 461,902               6.0%
                                                          02 Technical and Spec. Fees                                  608,201             339,693            341,927               2,234               0.7%
                                                          03 Communication                                           1,523,329           1,432,368          1,106,791            -325,577            -22.7%
                                                          04 Travel                                                     73,626              98,940             96,122              -2,818              -2.8%
                                                          06 Fuel and Utilities                                        117,938             131,000            128,000              -3,000              -2.3%
                                                          07 Motor Vehicles                                            178,932             201,978            226,329              24,351             12.1%
                                                          08 Contractual Services                                    1,533,502           1,936,043          1,325,733            -610,310            -31.5%
                          24




                                                          09 Supplies and Materials                                    208,355             168,060            158,520              -9,540              -5.7%
                                                          10 Equipment – Replacement                                   177,376              58,500            101,500              43,000             73.5%
                                                          11 Equipment – Additional                                     53,333              86,100             44,000             -42,100            -48.9%
                                                          12 Grants, Subsidies, and Contributions                      815,380           1,754,864          1,515,868            -238,996            -13.6%
                                                          13 Fixed Charges                                              83,441              79,334             78,163              -1,171              -1.5%
                                                          14 Land and Structures                                           260                   0                  0                   0               0.0%
                                                          Total Objects                                           $ 13,018,722        $ 13,979,512       $ 13,277,487          -$ 702,025             -5.0%

                                                          Funds
                                                          03 Special Fund                                         $ 11,983,724        $ 12,243,808       $ 12,502,631           $ 258,823              2.1%
                                                          05 Federal Fund                                              111,210             610,000            129,136            -480,864            -78.8%
                                                          09 Reimbursable Fund                                         923,788           1,125,704            645,720            -479,984            -42.6%
                                                          Total Funds                                             $ 13,018,722        $ 13,979,512       $ 13,277,487          -$ 702,025             -5.0%

                                                          Note: The fiscal 2011 appropriation does not include deficiencies. The fiscal 2012 allowance does not include contingent reductions.




                                                                                                                                                                                                                Appendix 3
                                                                                                                      Fiscal Summary
                                                                                                Maryland Institute for Emergency Medical Services Systems

                                                                                                                   FY 10            FY 11              FY 12                          FY 11 - FY 12
                                                                            Program/Unit                           Actual         Wrk Approp         Allowance          Change         % Change

                                                          01 General Administration                               $ 13,018,722      $ 13,779,512     $ 13,212,127        -$ 567,385                -4.1%




                                                                                                                                                                                                                        D53T00 – Maryland Institute for Emergency Medical Services Systems
                                                          02 Information Technology Project                                  0           200,000           65,360          -134,640              -67.3%
                                                          Total Expenditures                                      $ 13,018,722      $ 13,979,512     $ 13,277,487        -$ 702,025               -5.0%
Analysis of the FY 2012 Maryland Executive Budget, 2011




                                                          Special Fund                                            $ 11,983,724      $ 12,243,808     $ 12,502,631         $ 258,823                2.1%
                                                          Federal Fund                                                 111,210           610,000          129,136          -480,864              -78.8%
                                                          Total Appropriations                                    $ 12,094,934      $ 12,853,808     $ 12,631,767        -$ 222,041               -1.7%

                                                          Reimbursable Fund                                          $ 923,788       $ 1,125,704        $ 645,720        -$ 479,984              -42.6%
                                                          Total Funds                                             $ 13,018,722      $ 13,979,512     $ 13,277,487        -$ 702,025               -5.0%

                                                          Note: The fiscal 2011 appropriation does not include deficiencies. The fiscal 2012 allowance does not include contingent reductions.
                          25




                                                                                                                                                                                                           Appendix 4

				
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