Forest Service Region 6 – Request to Develop a Program for Aerial Extraction of Injured Firefighters

HIPAA – The Health Insurance Portability and Accountability Act of 1996 – The Factual Basics – Debunking Myths

Over the last two years, we’ve heard a lot of statements about HIPAA in the fire and EMS services. Some of those statements were factual, while many others were just outright incorrect. When someone writes about HIPAA “as an expert“, but throughout their info calls it “HIPPA“, it should raise a big red flag that they are just spouting off and don’t even have the acronym correct, nor have they done sufficient background research.

Months ago, I tried posting this subject on another well known wildland fire blog, but the owners of that blog thought otherwise. It dumbfounded me that they were letting folks send in stuff that was incorrect, and then preaching it as if it were fact without rebuttal. It reminded me of the “line officer problem” that exists within the Forest Service, basically folks making decisions without the knowledge, skills, abilities, and experience they need for making qualified professional decisions.

In response to the record growth of this blog/website (averaging between 150 to 200 hits per day / 60 to 80 daily return visitors) in just over two months of publication, I think it is about time to hit on another important subject. I know, I’m still a small fish in a big fish tank… but I’ve been a Chief Officer for eight years and it’s all about “baby steps” forward….. and carrying a “big stick“.

In an effort to help clear up some misconceptions about HIPAA, I’m throwing together a little information sheet that might be helpful within the Wildland Firefighting Community. In this information summary, I’ll break HIPAA into it’s most basic parts and provide examples of permitted disclosures that relate to wildland fire. Most of this is cut-and-paste, except for the permitted real world scenarios described below that anyone can “fact check” for accuracy and credibility:

• Summary
• The Standards for Privacy of Individually Identifiable Health Information (“Privacy Rule”) establishes, for the first time, a set of national standards for the protection of certain health information. The U.S. Department of Health and Human Services (“HHS”) issued the Privacy Rule to implement the requirement of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”).1 The Privacy Rule standards address the use and disclosure of individuals’ health information—called “protected health information” by organizations subject to the Privacy Rule — called “covered entities,” as well as standards for individuals’ privacy rights to understand and control how their health information is used. Within HHS, the Office for Civil Rights (“OCR”) has responsibility for implementing and enforcing the Privacy Rule with respect to voluntary compliance activities and civil money penalties.
• Are Fire Departments / EMS Providers Covered by HIPAA? Simple Answer – Yes
• The Privacy Rule, as well as all the Administrative Simplification rules, apply to health plans, health care clearinghouses, and to any health care provider who transmits health information in electronic form in connection with transactions for which the Secretary of HHS has adopted standards under HIPAA (the “covered entities”). For help in determining whether you are covered, use CMS’s decision tool.
• Permitted Disclosures (Verbal or Implied Consent)
• (1) To the Individual. A covered entity may disclose protected health information to the individual who is the subject of the information.
• (2) Treatment, Payment, Health Care Operations. A covered entity may use and disclose protected health information for its own treatment, payment, and health care operations activities. A covered entity also may disclose protected health information for the treatment activities of any health care provider, the payment activities of another covered entity and of any health care provider, or the health care operations of another covered entity involving either quality or competency assurance activities or fraud and abuse detection and compliance activities, if both covered entities have or had a relationship with the individual and the protected health information pertains to the relationship
• (3) Uses and Disclosures with Opportunity to Agree or Object. Informal permission may be obtained by asking the individual outright, or by circumstances that clearly give the individual the opportunity to agree, acquiesce, or object. Where the individual is incapacitated, in an emergency situation, or not available, covered entities generally may make such uses and disclosures, if in the exercise of their professional judgment, the use or disclosure is determined to be in the best interests of the individual.
• For Notification and Other Purposes. A covered entity also may rely on an individual’s informal permission to disclose to the individual’s family, relatives, or friends, or to other persons whom the individual identifies, protected health information directly relevant to that person’s involvement in the individual’s care or payment for care. This provision, for example, allows a pharmacist to dispense filled prescriptions to a person acting on behalf of the patient. Similarly, a covered entity may rely on an individual’s informal permission to use or disclose protected health information for the purpose of notifying (including identifying or locating) family members, personal representatives, or others responsible for the individual’s care of the individual’s location, general condition, or death. In addition, protected health information may be disclosed for notification purposes to public or private entities authorized by law or charter to assist in disaster relief efforts.
• (4) Incidental Use and Disclosure. The Privacy Rule does not require that every risk of an incidental use or disclosure of protected health information be eliminated. A use or disclosure of this information that occurs as a result of, or as “incident to,” an otherwise permitted use or disclosure is permitted as long as the covered entity has adopted reasonable safeguards as required by the Privacy Rule, and the information being shared was limited to the “minimum necessary,” as required by the Privacy Rule. See additional guidance on Incidental Uses and Disclosures.
• (5) Public Interest and Benefit Activities. The Privacy Rule permits use and disclosure of protected health information, without an individual’s authorization or permission, for national priority purposes. These disclosures are permitted, although not required, by the Rule in recognition of the important uses made of health information outside of the health care context. Specific conditions or limitations apply to each public interest purpose, striking the balance between the individual privacy interest and the public interest need for this information.
• Public Health Activities. Covered entities may disclose protected health information to: (1) public health authorities authorized by law to collect or receive such information for preventing or controlling disease, injury, or disability and to public health or other government authorities authorized to receive reports of child abuse and neglect; (2) entities subject to FDA regulation regarding FDA regulated products or activities for purposes such as adverse event reporting, tracking of products, product recalls, and post-marketing surveillance; (3) individuals who may have contracted or been exposed to a communicable disease when notification is authorized by law; and (4) employers, regarding employees, when requested by employers, for information concerning a work-related illness or injury or workplace related medical surveillance, because such information is needed by the employer to comply with the Occupational Safety and Health Administration (OHSA), the Mine Safety and Health Administration (MHSA), or similar state law.

• Authorized Disclosures (Written Consent)
• Authorization. A covered entity must obtain the individual’s written authorization for any use or disclosure of protected health information that is not for treatment, payment or health care operations or otherwise permitted or required by the Privacy Rule. A covered entity may not condition treatment, payment, enrollment, or benefits eligibility on an individual granting an authorization, except in limited circumstances.

Permitted Disclosure Examples:

• A “family liaison” or “advocate” (ie.- A Wildland Firefighter Foundation Advocate or Dept. assigned liaison) who has been informally identified to receive protected health information from a medical facility, physician, IMT, fire or EMS provider.
• In the case of public health and safety: Communications between health care providers, local health departments, and Incident Management Teams when a communicable disease outbreak occurs or has been believed to occur, such a viral, bacterial, or fungal outbreaks in fire camp. 45 CFR 164.512(b)
• An Incident Commander, Safety Officer, or Medical Unit Leader receiving information on injured or ill employees requiring statutory reporting such as a workplace injury. 
• An injured or ill employee gives his/her physician informal consent to give information to an identified representative (ie. – Fire Chief, Forest Supervisor, DFMO, WFF, etc.) for release to the public, or for an informally identified individual to perform advocacy on his/her behalf.

All four examples above are real world, having happened to federal Incident Management Teams during the 2009 Fire Season. Want to know more about these examples? Send an email to comments@RamblingChief.com. We’ll provide generic info/background as to not violate HIPAA or provide any personally identifiable info or “protected health information”. These above incidents are common and repeatable each fire season, but important Lessons Learned for incident managers. Like this post? Click on the small envelope below and mail it to your friends. Don’t let your friends be MUSHROOMS and fed…..

All information obtained from the U.S. Dept. of Health and Human Services website.  

San Bernardino National Forest Offers Emergency Medical Technician Training (EMT)

The San Bernardino National Forest has been authorized as a Basic Life Support (BLS) provider agency since it was first accredited by the Inland Counties Emergency Medical Agency (ICEMA) in 1996. The San Bernardino National Forest BLS program operates under the strict medical direction and program oversight of ICEMA, and participates in a QA/QC program as mandated by California Title 22. As provided for in Title 22, medical direction for BLS programs in California is provided by local EMSA regulation, authorization, and protocols, as well as participation in a QA/QC program.

The San Bernardino National Forest’s BLS program was developed directly in response to a horrific line of duty death that happened during the 1987 fire season. Captain Bruce Visser tragically died after being struck by a motorcycle on the Klamath National Forest. He died after local fire department responders chose to cancel an air ambulance and transport him via ground “since he seemed stable” and the Forest Service folks couldn’t argue. He died of internal hemorrhage enroute to the hospital over 90 minutes away.

Over the next decade, folks started going to EMT classes, and advocating for EMS training and equipment. Unit by unit, folks started buying EMS gear with their limited station budgets.

As time went on, the word spread that the USFS firefighters had trained and equipped fire engines. Soon, local cooperators started requesting them since they were the closest responders. A Duty to Act developed.

Recently, the San Bernardino National Forest has equipped all of their fire engines, crew carriers, and helicopter modules with Automatic External Defibrillators (AEDS) . In addition, each of those modules carry Epi-Pens for employee administration if needed. BOTH of these programs have direct medical direction and authorization in place for their specified use.

In addition to the BLS programs, San Bernardino National Forest instituted a citizen AED program (also authorized by Title 22). In each District Office and the Forest Supervisors Office, AEDS are placed for both the protection of employees as well as the visiting public. Employees receive basic first aid training…. and American Heart Association CPR Training….. both include modules on the use of AEDS.

I’m pretty honored to have been around in the earlier days of EMS in the counties I’ve served… and participate as a “forestry technician” in EMSA QC Reviews… I’ve been even more blessed to help bring a successful program to the agency that I love and see struggling so bad to embrace the future. We have a functioning local model… that can be applied regionally and nationally as needed. It’s not rocket science…. It’s Fire Science.

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Danny Rhynes Interagency Training Center

602 S. Tippecanoe Ave.
San Bernardino, CA 92408
(909) 382-2984 Fax (909) 382-4192
Email: drtc@fs.fed.us
Course Dates: February 13, 2010 – May 22, 2010

Hours: This class will be held one day a week on Saturday from 0800-1800.

Location: Danny Rhynes Interagency Training Center 602 S. Tippecanoe Ave San Bernardino, CA 92408.
Length: Estimated 160 hours of lecture and 72 hours of lab for a total of 9 units.

Nomination deadline: January 15, 2010

Tuition: $300 per student (Upon successful completion of the course, students are eligible for certification as an EMT Basic, and are able to register for the National Registry examination).

Instructor: Provided by Victor Valley College who is affiliated with the San Bernardino National Forest.

Prerequisites: High school Diploma or GED. Student must be 18 years of age to be certified. Current Healthcare provider CPR Card is required. Current negative tuberculosis test is also required.

Course Description: The Emergency Medical Technician course is an intensive 16 week course that will provide training in the recognition of the signs and symptoms of illness and traumatic injuries. The course will consist of classroom lectures, manipulative skills, and clinical internships. The internships require a minimum of four (12) twelve-hour shifts in a local emergency room and transport ambulance. This course is approved by the Inland County Emergency Medical Agency (ICEMA). For orientation information visit the EMT website at www.vvc.edu/academic/emt/

This class meets EMSA regulations and upon successful completion of the course, students are eligible for certification as an EMT Basic, and are able to register for the National Registry examination. The estimated fee associated to sign up for this exam is $90.00 which will need to be paid for by the student.

All Students must be in Uniform

Items to bring to class: Safety Gear full Personal Protective Equipment; nomex shirt, boots, eye protection etc.

Nomination Due Date: Please submit NWCG Nomination Forms through your training officer to the Danny Rhynes Interagency Training Center (DRTC) via email at drtc@fs.fed.us or fax (909) 382-4192.

Coordinator: Questions can be directed to Kristel Johnson (909) 382-2984, or by email at drtc@fs.fed.us.
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Want more info in our participation in such things as:

• Firefighter Burn Treatment Success: Re-Institution of the CDF Burn Treatment Standard and The NWCG Standard Protocols for Wildland Firefighter Burns?
• Firefighter Trauma Treatment Recommendations
• Smoke Exposure and Research?
• Cyanide Exposure and WTF?
• Excellent Knowledge of the Federal OWCP Processes?
• Forest Service Honor Guard?
• Why we support the Wildland Firefighter Foundation?

Email: Comments@ramblingchief.com

An Article from Jim Upchurch, M.D. – Medical Director for the Forest Service, Northern Rockies Region (R-1) Incident Medical Specialist Program

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Have We Taken the ‘Advanced’ out of ACLS?
by Jim Upchurch

For the Article: CLICK HERE

Jim Upchurch MD, MA, NREMT practices in Montana and is board certified in Family Practice with added qualification in Geriatrics. He has a master’s degree in education and human development and is licensed as a paramedic. Dr. Upchurch is a ‘Legacy’ member of the American College of Emergency Physicians. Since 1985 his practice has focused on emergency medicine and EMS while providing the full spectrum of care required in a rural/frontier environment. He provides medical direction for BLS and ALS EMS systems, including critical care interfacility transport; and for the Incident Medical Specialist Program, USDA Forest Service, Northern Region. Dr. Upchurch has served as American Heart Association ACLS Regional and National faculty for Montana and currently represents Montana on the Council of State EMS Medical Directors of the National Association of State EMS Officials. Contact him via e-mail at jim.upchurch@ems1.com.

Other Articles by Dr. Upchurch: CLICK HERE

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Hmm… Contributors on another website seem convinced that the Forest Service lacks medical direction. I disagree. What the Forest Service lacks is visionary leadership who know about what the hell they are trying to make decisions and policies on. The folks in these articles are making a difference and communicating with the folks “in the know” such as Incident Commanders, Operations Section Folks, and the Medical Unit.

Somebody needs to correct many of the posters on that other website… or maybe not. I get a kick out of seeing them try to re-invent the wheel over and over again by doing the same thing. Unfortunately, while it is often entertaining to view the other website, their content often delays or stalls real-world progress being undertaken by real-world experts trying to lead in a real-world of wildland fire complexity… It’s not rocket science… it’s fire science.
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And another article:

11 Burning Questions: Find out everything you’ve always wanted to know about wildfire EMS but were afraid to ask.
By Gene Madden

For the Article: CLICK HERE

Gene Madden is the safety officer of the Atlanta-based National Incident Management Organization (NIMO) for the U.S. Forest Service. Prior to joining the Forest Service, Gene was with the Florida Division of Forestry, for 16+ years. While with the Division of Forestry he was responsible for a number of programs including wildfire safety, driving, EMS and worker compensation programs.

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Additional Reading:

Practice in Context: Emergency and wilderness medicine may differ greatly, but concepts can cross over.
By Tod Schimelpfenig

For the Article: CLICK HERE

Tod Schimelpfenig has been a National Outdoor Leadership School instructor since 1973, has more than 30 years of field experience as an EMT, is a fellow of the Academy of Wilderness Medicine, and is a two-time winner of the Wilderness Medical Society’s Warren Bowman award for contributions to the field of wilderness medicine by a non-physician. Schimelpfenig has served as the NOLS risk-management director and Rocky Mountain School director, and on the board of the Wilderness Medical Society. He is a founder of the Wilderness Risk Manager’s Committee, has taught wilderness medicine since the late 1970s and has written numerous articles on educational program, risk management and wilderness medicine topics. He is the author of NOLS Wilderness Medicine and co-author of Risk Management for Outdoor Leaders. Schimelpfenig is currently the curriculum director of the Wilderness Medicine Institute of NOLS.

Reference:
Wildland Fire Agencies: All Risk or Not?
Chief Donald Duck… Remind You of Anyone?
This Week’s Spotlight Award: The FWFSA
Randy Mantooth (Johnny Gage): Fictional Firefighter, but Still A Fire Family Member and Lifelong Contributor
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Two New Chat Areas Added

The Fire Camp Chatroom is available from the [link] on the top left-side of this blog.


Two new chatroom features have been added:

1.) FIRELINE EMS DISCUSSION (Secondary Password Required)


An area to chat with peers about developments in Fireline EMS being developed by FIRESCOPE, CWCG, CAL CHIEFS, and NWCG (and the problems with four groups trying to create a “consensus standard” at the same time).


2.) DEVELOPING NEWS (Secondary Password Required)


An area to discuss rapidly developing fire situations such as wildfires, earthquakes, or other emergencies. This area will be heavily moderated in times of entrapments or accidents that involve injuries or fatalities.

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In addition to these two new areas, our original three chatrooms are still open and gaining new members every day.

FIRE CAMP CHAT – (General Discussion) – Open only from 15:00 to 24:00 Pacific Time.
Open to all general firefighting, wildland fire, and EMS chat.

CHIEF’S CHAT – (Secondary Password Required) An area for Chiefs and invited guests to discuss things without interruption. An area to put together thoughts and ideas before they are released to the public.

ADMIN/MODERATORS CHAT – An area for the chat moderators and administrators to discuss the functions of the chat service and this blog.