Legislature(1993 - 1994)
04/07/1993 03:00 PM HES
* first hearing in first committee of referral
= bill was previously heard/scheduled
= bill was previously heard/scheduled
HOUSE HEALTH, EDUCATION AND SOCIAL SERVICES STANDING COMMITTEE April 7, 1993 3:00 p.m. MEMBERS PRESENT Rep. Cynthia Toohey, Co-Chair Rep. Con Bunde, Co-Chair Rep. Al Vezey Rep. Bettye Davis Rep. Irene Nicholia Rep. Tom Brice MEMBERS ABSENT Rep. Gary Davis, Vice Chair Rep. Pete Kott Rep. Harley Olberg COMMITTEE CALENDAR HB 30: "An Act amending the definition of `municipality' for the purposes of the human services community matching grant program." PASSED WITH INDIVIDUAL RECOMMENDATIONS SB 71: "An Act relating to emergency medical service; and repealing obsolete references to the Statewide Health Coordinating Council and health systems agencies." HEARD AND HELD - NO ACTION TAKEN WITNESS REGISTER ANNETTE KREITZER Legislative Assistant Sen. Loren Leman Alaska State Legislature State Capitol, Room 113 Juneau, Alaska 99801-1182 Phone: (907) 465-2095 Position statement: Testified in support of SB 71 MARK JOHNSON, Chief Emergency Medical Services Section Division of Public Health Department of Health and Social Services P.O. Box H Juneau, Alaska 99811-0616 Phone: (907) 465-3027 work Phone: (907) 463-5807 home Position statement: Testified in support of SB 71 MATT ANDERSON, Training Coordinator Emergency Medical Services Section Division of Public Health Department of Health and Social Services P.O. Box 110616 Juneau, Alaska 99811-0616 Phone: (907) 465-3141 work Phone: (907) 789-1549 home Position statement: Testified in support of SB 71 LARRY FANNING, Fire Chief Capitol City Fire & Rescue Alaska State Fire Chiefs Association 820 Glacier Ave. Juneau, Alaska 99811-0616 Phone: (907) 586-5322 Position statement: Testified in support of SB 71 ELMER LINDSTROM Special Assistant to the Commissioner Department of Health and Social Services P.O. Box 110601 Juneau, Alaska 99811-0601 Phone: (907) 465-3030 Position statement: Answered questions on SB 71 TODD HUTTENLOCHER, M.D. Co-Medical Director Emergency Medical Services Section Division of Public Health Department of Health and Social Services P.O. Box 3739 Juneau, Alaska 99801 Phone: (907) 586-8447 work Phone: (907) 789-4919 home Position statement: Testified in support of SB 71 PREVIOUS ACTION BILL: HB 30 SHORT TITLE: HUMAN SERVICES MATCHING GRANTS BILL VERSION: SPONSOR(S): REPRESENTATIVE(S) BRICE,Sitton,Therriault, Davies,James TITLE: "An Act amending the definition of `municipality' for purposes of the human services community matching grant program." JRN-DATE JRN-PG ACTION 01/04/93 32 (H) PREFILE RELEASED 01/11/93 32 (H) READ THE FIRST TIME/REFERRAL(S) 01/11/93 32 (H) CRA, HES, FINANCE 01/15/93 92 (H) COSPONSOR(S): DAVIES, JAMES 02/09/93 (H) CRA AT 01:00 PM CAPITOL 124 02/09/93 (H) MINUTE(CRA) 02/10/93 284 (H) CRA RPT CS(CRA) 5DP 2NR 02/10/93 284 (H) DP: BUNDE, DAVIES, WILLIS, TOOHEY, OLBERG 02/10/93 284 (H) NR: SANDERS, WILLIAMS 02/10/93 284 (H) -2 ZERO FNS (DCRA, DHSS) 2/10/93 02/22/93 (H) HES AT 03:00 PM CAPITOL 106 03/15/93 (H) HES AT 03:00 PM CAPITOL 106 03/15/93 (H) MINUTE(HES) 03/16/93 (H) HES AT 03:30 PM CAPITOL 106 03/17/93 (H) HES AT 03:00 PM CAPITOL 106 03/17/93 (H) MINUTE(HES) 04/02/93 (H) HES AT 03:00 PM CAPITOL 106 BILL: SB 71 SHORT TITLE: EMERGENCY MEDICAL SERVICES SYSTEM BILL VERSION: CSSSSB 71(FIN) AM SPONSOR(S): SENATOR(S) LEMAN,Ellis,Taylor,Duncan,Donley, Kerttula,Little,Zharoff,Lincoln TITLE: "An Act relating to emergency medical services; and repealing obsolete references to the Statewide Health Coordinating Council and health systems agencies." JRN-DATE JRN-PG ACTION 01/27/93 170 (S) READ THE FIRST TIME/REFERRAL(S) 01/27/93 171 (S) HES,LABOR & COMMERCE,FINANCE 02/26/93 503 (S) SPONSOR SUBSTITUTE INTRODUCED-REFERRALS 02/26/93 503 (S) HES, LABOR & COMMERCE, FINANCE 03/08/93 (S) HES AT 02:15 PM BUTROVICH ROOM 205 03/09/93 688 (S) HES RPT 3DP 2NR 03/09/93 688 (S) FISCAL NOTE (DHSS) 03/09/93 688 (S) ZERO FISCAL NOTE (DCED) 03/10/93 723 (S) L&C REFERRAL WAIVED 03/15/93 (S) FIN AT 08:30 AM SENATE FIN 518 03/22/93 (S) RLS AT 12:00 PM FAHRENKAMP ROOM 203 03/22/93 895 (S) FIN RPT CS 7DP SAME TITLE 03/22/93 895 (S) LETTER OF INTENT WITH FIN REPORT 03/22/93 895 (S) ZERO FISCAL NOTE TO CS (S.FIN/DHSS) 03/22/93 895 (S) PREVIOUS ZERO FN APPLIES (DCED) 03/23/93 912 (S) RULES 2 CALENDAR 1NR 3/23/93 03/23/93 913 (S) READ THE SECOND TIME 03/23/93 913 (S) FIN CS ADOPTED UNAN CONSENT 03/23/93 914 (S) ADVANCE TO 3RD RDG FAILED Y11 N9 03/23/93 914 (S) THIRD READING 3/24/93 CALENDAR 03/23/93 916 (S) COSPONSOR(S): TAYLOR, DUNCAN, DONLEY, 03/23/93 916 (S) KERTTULA, LITTLE, ZHAROFF 03/24/93 929 (S) READ THE THIRD TIME CSSSSB 71(FIN) 03/24/93 929 (S) RETURN TO SECOND FOR AM 1 UNAN CONSENT 03/24/93 930 (S) AM NO 1 ADOPTED UNAN CONSENT 03/24/93 930 (S) AUTOMATICALLY IN THIRD READING 03/24/93 930 (S) (S) ADOPTED FIN LETTER OF INTENT 03/24/93 933 (S) COSPONSOR(S): LINCOLN 03/24/93 931 (S) PASSED Y20 N- CSSSSB 71(FIN) AM 03/24/93 934 (S) TRANSMITTED TO (H) 03/26/93 775 (H) READ THE FIRST TIME/REFERRAL(S) 03/26/93 775 (H) HES, FINANCE 04/07/93 (H) HES AT 03:00 PM CAPITOL 106 ACTION NARRATIVE TAPE 93-60, SIDE A Number 000 CHAIR TOOHEY called the meeting to order at 3:11 p.m., noted members present, and announced the calendar. She then brought HB 30 to the table. HB 30: HUMAN SERVICES MATCHING GRANTS Number 023 REP. NICHOLIA MOVED passage of HB 30 from the committee with individual recommendations. Number 030 REP. VEZEY OBJECTED. CHAIR TOOHEY called for a roll call vote. Those voting yes were Reps. Toohey, Bunde, B. Davis, Nicholia and Brice; voting no was Rep. Vezey. The motion PASSED 5-1. She declared that HB 30 WAS PASSED FROM THE COMMITTEE WITH INDIVIDUAL RECOMMENDATIONS. SB 71: EMERGENCY MEDICAL SERVICES SYSTEM CHAIR TOOHEY brought SB 71 to the table. Number 144 CHAIR TOOHEY announced her intention not to pass SB 71 that day, but to take it up again on Thursday, April 8, 1993. Number 146 ANNETTE KREITZER, LEGISLATIVE ASSISTANT TO SEN. LOREN LEMAN, PRIME SPONSOR OF SB 71, read a sponsor statement. In summary, the statement said that since trauma was the state's top killer, a statewide trauma system was essential. She stated that SB 71 would allow the Department of Health and Social Services (DHSS) to regulate voluntary compliance for trauma care centers. It would also establish a patient care information system and allow paramedic training inside Alaska instead of elsewhere. She said there was broad support for the bill. She then proceeded to give a detailed sectional analysis of the bill. Section 1-8 eliminates language limiting the bill's application to physician-trained paramedics, as paramedics are trained by others as well as by physicians. Section 9 allows DHSS to establish criteria to designate hospitals as voluntary trauma centers. Section 10 was amended in the Senate Finance Committee to allow paramedics to collect patient information data, but not to compel them to do so. Most such data is already collected voluntarily. MS. KREITZER explained that the patient information system involves contracts with emergency room nurses who abstract data for DHSS, at a cost of about $40,000 per year. She said Sen. Leman wanted to return the $40,000 to the fiscal note under contractual services, instead of under grants. Number 114 MS. KREITZER noted a letter of intent from the Senate Finance Committee requiring DHSS to streamline its computerized data collection, a letter the sponsor supported, she said. She noted that the Finance Committee had deleted two positions in the bill, and asked that the two positions, a computer specialist and a clerk typist, be returned to the bill, as the data they would gather was valuable and other users could pay for it when the federal grant expired on September 30, 1993. Ms. Kreitzer continued the sectional analysis. Section 11 changes the name of the advisory council on emergency medical services to reflect its extended membership and purpose. Section 12 was amended to require that one member of the advisory council be from an area not on the state road system. MS. KREITZER noted that the bill packets contained recommendations that no two of the three consumer members of the advisory council be selected from the same one of the state's four judicial districts, to ensure representation from all over the state. She said she had prepared an amendment to effect that request. Section 13 expands the authority of the DHSS to adopt regulations to charge fees for certification and licensing of organizations such as trauma care centers. Section 14 allows for certification of emergency medical dispatchers (EMDs), and allows the department to set standards for paramedic training programs, and prevents people without such training from claiming to be certified. Section 16 prevents trauma centers from advertising their services unless they are certified as trauma centers. Number 165 CHAIR TOOHEY interrupted to ask Ms. Kreitzer if any committee members had questions for her. She then asked if SB 71 addressed medical dispatchers from just trauma centers or ambulance dispatchers also. MS. KREITZER said SB 71 dealt just with dispatchers of emergency medical technicians (EMTs), paramedics, or ambulances. Number 175 CHAIR TOOHEY said it was therefore primarily for larger cities. She asked how such dispatchers were to be trained, if they were going to be trained. Number 185 MARK JOHNSON, CHIEF, EMERGENCY MEDICAL SERVICES, DIVISION OF PUBLIC HEALTH, DEPARTMENT OF HEALTH AND SOCIAL SERVICES, testified in Juneau in support of SB 71. He said many Alaska EMDs had taken courses in other states who believed that being certified would carry the advantage of some immunity from liability enjoyed by some EMTs. He said he would not require such training for ambulance dispatchers. REP. BUNDE asked if Juneau 911 service used certified EMDs. MR. JOHNSON said no, but Anchorage did. Number 211 REP. BUNDE asked if the bill would require non-EMD certified dispatchers to take the additional training or face the loss of their jobs. MR. JOHNSON answered no, the training was not a requirement, but an incentive to avoid legal liability for giving advice to callers. Number 215 REP. BUNDE repeated his question. MR. JOHNSON repeated his answer. He said much emergency service can be administered before an ambulance arrives, and a national standard of care was developing for such service. Number 223 MS. KREITZER said she was from a rural area and had been concerned that her local dispatchers who give pre-arrival instructions would be hurt by the regulation. She said that the bill actually standardizes the level of dispatch, but does not obligate current dispatchers to receive the training. REP. BUNDE asked who paid for the training. MS. KREITZER said the sponsor recommended that the legislature should consider giving $100,000 for training. Number 246 CHAIR TOOHEY expressed concern that the bill ignored those emergency medical services organizations that operated in the Bush. MR. JOHNSON stated that a woman in Ketchikan had developed and tested a training program for Bush emergency medical service workers that might be used as a pilot program for training of those in the Bush. CHAIR TOOHEY said it was important to provide all such workers with training before giving more training to one group of people. Number 264 MS. KREITZER said she used the term local to refer to emergency medical service squads in Nome, Bethel, Tanana, Soldotna and other smaller areas, as differentiated from regional centers such as Anchorage. She said the $100,000 would be administered by regional councils, but would go directly to the local squads to pay for training. Number 274 REP. BUNDE said such training would provide the benefit of decreased legal liability for emergency medical service workers. He asked if there was any provision to require such people to pay part of the cost for such training themselves. MS. KREITZER said she believed that, as EMTs volunteered their own time, money, and equipment, providing them training to reduce their legal liability was merely recognition of their contributions. Number 293 REP. BUNDE noted that if he phoned 911, he would be speaking with paid dispatchers, and it was not unreasonable to ask such people wanting additional certification to protect them from liability to pay part of the cost. MS. KREITZER said such questions would be up to local and state authorities to decide, but she said that unpaid workers in rural areas might deserve more consideration for training. Number 308 CHAIR TOOHEY asked whether volunteer emergency medical service workers who had been trained were automatically protected for liability if they were working within that system. MR. JOHNSON answered that they were covered for the scope of the practice for which they had been trained. CHAIR TOOHEY asked whether it was reasonable to assume that anyone acting as a dispatcher in a 911 service had been trained. Number 316 MR. JOHNSON answered that not all dispatchers were EMTs. CHAIR TOOHEY noted that not all EMTs were dispatchers, either. Number 319 MR. JOHNSON said that all dispatchers he had spoken to, including those in Anchorage, had told him the bill's aims were desirable. CHAIR TOOHEY agreed that the bill's goals were desirable, but she was concerned about the fiscal note. She noted that she was a former EMT-3 and ambulance driver, but said that it was important to be realistic. MR. JOHNSON acknowledged her point and added that he was proud of the economy with which emergency medical service workers operated, which included finding creative ways to provide training, such as an annual EMT symposium at which training is available at no cost to the state. Number 335 CHAIR TOOHEY said she hesitated to make training requirements so strict that they barred volunteers from the system. Number 340 MR. JOHNSON said his philosophy was to provide options, and he described different classifications of EMTs and the training required: an ETT first responder required 40 hours of training; an EMT-1, 110 hours; an EMT-2, 160 hours; and an EMT-3, 210 hours. He said he wanted to let local communities choose the level of training they wanted in their emergency medical service workers. He said those who get some experience desire additional training so that they can feel more comfortable with their skills. Number 358 REP. NICHOLIA noted that Tanana had EMTs and ETTs which were essential to local medical services. She said the squad members were very enthusiastic about their work and training and the legislature should do what it could to improve the system. Number 364 MS. KREITZER resumed her section-by-section discussion of SB 71. Section 14 gave EMTs the option of becoming EMDs. While the section did not mandate current dispatchers become certified EMDs, it did give departments the ability to establish paramedic training programs or to require such certification. Section 15 barred people from calling themselves certified EMDs without such state certification. Section 16 prevented trauma centers from advertising themselves as being state-certified unless they were, and required state certification of paramedic trainers. Section 17 limited the liability for providing pre- arrival instructions, with the exceptions of gross negligence or intentional misconduct. Section 18 granted liability immunity to state- certified EMT-1s (unintelligible) EMT instructors. She said the section was added because the University of Alaska-Fairbanks had asked for its EMT instructors to carry malpractice insurance, which she said was unfeasible. Section 19 was amended on the Senate floor to specify those people able to disclose patient information to EMTS, specifically, physicians, advanced nurse practitioners, and physicians' assistants. The section bars EMTs from revealing such information, and the section is aimed at improving EMT education. Sections 20-22 added several definitions into current law. Sections 23, 26 and 27 deleted references to an obsolete statewide health coordinating council. Sections 24 and 25 amended the law to make wording consistent. Section 28 assures the transition of membership for the advisory council on EMS to the new Alaska Council on EMS established by the bill, and assures that state- licensed paramedics would not be affected by the establishment of new training programs. Number 416 CHAIR TOOHEY said Anchorage once had a paramedic training course at the University of Alaska-Anchorage (UAA), but it was dropped in the mid-1970s because it was felt there were not enough jobs for the graduates. She asked if the year long training course would be offered by the state. Number 420 MR. JOHNSON replied that the Emergency Medical Services Section of the Division of Public Health proposed to set standards for training and then allow communities to decide if they wanted to have a course. He said some long-time EMT-3s who might want to upgrade to paramedics would otherwise have to leave Alaska for training and there begin training at the basic level. He said there was no money for the state to set up the actual training. CHAIR TOOHEY asked if the standards would be set by an accredited paramedic school. Number 435 MR. JOHNSON answered that there were national standards, which the state would try to follow closely, but the state would also try to meet the special needs of Alaska citizens. Number 441 MATT ANDERSON, TRAINING COORDINATOR, EMERGENCY MEDICAL SERVICES, DIVISION OF PUBLIC HEALTH, DEPARTMENT OF HEALTH AND SOCIAL SERVICES, testified in support of SB 71. He said that, in response to interest around the state in putting on paramedic training programs, the division assembled some boilerplate regulations concerning how such training programs could assess whether they would be up to standards. He said the state attorney general's office informed them that the state medical board lacked the statutory authority to promulgate regulations authorizing paramedic training programs, and that provisions for that authority were therefore included in SB 71. He stated there was interest in innovative and creative training programs on the Kenai Peninsula, in Juneau, and other areas and the division should take advantage of those courses. He said there were paramedic bridge courses, and the division has spoken to people in Tacoma, Washington about the possibility of an EMT-3 and paramedic bridge course. He said he wanted the authority to develop standards for training that any organization wanting to establish its own training program could follow. Number 457 CHAIR TOOHEY asked if the division was hoping that graduates of such courses would be state certified. MR. ANDERSON said graduates would be eligible to be licensed as a paramedic in the state. Number 467 CHAIR TOOHEY asked if certification in another state would win someone certification as a paramedic in Alaska. MR. ANDERSON said the program would allow people to meet national standards for EMTs and paramedics, which would allow them to become licensed in Alaska after passing examinations. He said other states would recognize Alaska's training program, but would likely still require people to pass examinations before becoming licensed in that state. The training would not have to be repeated, he said. CHAIR TOOHEY asked if Alaska recognized training or paramedic certification from other states or cities. MR. ANDERSON pointed out that the state medical board licensed paramedics, and the state will evaluate out-of- state application for paramedic licensing. CHAIR TOOHEY repeated her question. Number 473 MR. ANDERSON answered yes, as long as the paramedic was state licensed in his or her home state and had successfully completed national paramedic examinations. REP. BUNDE asked whether the training and certification program was for current volunteer or paid emergency medical service workers, or whether it was aimed at training up those without prior experience. Number 487 MR. JOHNSON said at first, most of those taking the training would already be involved in the EMS system, but communities which wanted to do so could train novices. He said the standards would merely establish the training standards. REP. BUNDE asked whether people would already have to be accepted as volunteer or paid emergency medical service workers before they could begin the training. Number 497 MS. KREITZER said it depended on where the paramedic would serve. Some Native corporations will send a novice away from Alaska to be trained as an emergency medical service worker, while in other cases, such as in Anchorage, those already involved in the EMT system as a volunteer or paid will seek additional training as a paramedic. She said there was nothing that would keep novices out, but common sense indicated that most of those taking the training would have already been involved in the EMT system, at least at first. She said she understood Rep. Bunde's concerns about funding the training program, and said the question was for whom the trainees would be working or volunteering. REP. BUNDE said he did not oppose the EMT program, but it was important for the state, with finite resources, to offer those with prior training a priority for further training. However, he said it was also important to write statutes to avoid ambiguity and embrace clarity and specificity. Number 518 MS. KREITZER asked Rep. Bunde if he wanted to see the program restricted to avoid too many people from being trained as paramedics. REP. BUNDE answered no, but said it needed to be made clear who could gain access to the training and how. He said he understood her to say that whoever ran a training program could write their own rules in their own little kingdom, and that it was not appropriate for state government to operate in such a manner. Number 525 CHAIR TOOHEY said she agreed with Rep. Bunde. She noted that UAA had a waiting list of people to take its paramedic program, but the program was eliminated because there were not enough jobs. She said she could not understand the logic of that move, as the job of a school was education, not the guarantee of employment upon graduation. She asked if the emergency medical service workers training programs would be restricted to those already in the system and how much would it cost. Number 534 MR. JOHNSON said the division had not meant to set limits, but just to outline and offer training that would meet a national standard. He said he did not envision dictating to local communities who they should train or not. He said that, as it would be up to the local community or organization to fund their training programs, it would be appropriate for them to establish their own entrance criteria, as long as they met the minimum state standard. Number 546 MS. KREITZER said EMT and ETT qualifications are clearly laid out in state statute, and SB 71 just carried those current training programs further. She said that the way the EMT system was set up, needs were filled as they came up because local communities or public safety organizations do not pay to train people they can not use. REP. BUNDE commented that it sounded like excessive demand for paramedic training would be a local problem, and that the state would certify any qualified trainees. He said he feared that training slots in local programs might be allocated according to local politics. He expressed a desire to keep access to state-funded training available on a fair basis. He observed that allowing people to pay for their own training would resolve his concerns. Number 566 MR. ANDERSON said there were no regulations regarding paramedic training programs in the state, and the state had no authority to say any one training program was good or bad. He said applicants for paramedic licenses were evaluated after their training. He stated the division wanted to develop guidelines to provide a framework so that public safety departments or other organizations wishing to bring their personnel up to paramedic level could have a standard. He noted that the division consulted experts around the state in specific subject areas when it first began work on draft regulations. He stated it was dangerous to go ahead with designing training guidelines without such oversight. He observed that UAA had considered reviving its paramedic training program, but had declined because of funding limitations. He commented that whenever a training program was established it would benefit from guidelines. Number 600 REP. BUNDE said he did not believe there were any private paramedic training institutions in Alaska. TAPE 93-60, SIDE B Number 015 MR. JOHNSON said the laws under which his division operated were 15 years old. He said a national team of experts had, at his invitation, evaluated Alaska's statewide system and produced a report, "State of Alaska: An Assessment of Emergency Medical Services." (copies are on file in the committee room) The report's recommendation that Alaska update its statutes led to SB 71. He spoke in favor of SB 71 and the state EMS system. He spoke of the patient information system, whose grant funding from the Centers for Disease Control will expire. He said the system has grown from its start five years ago with seven Southcentral Alaska hospitals to include all hospitals in the state. The system provides good data on all cases of trauma in the state, whether treated at hospitals or not, he said. Number 061 CHAIR TOOHEY asked if it included Bush hospitals. MR. JOHNSON answered yes. CHAIR TOOHEY asked whether those statistics were reflected in the division's budget. Number 066 ELMER LINDSTROM, SPECIAL ASSISTANT TO THE COMMISSIONER, DEPARTMENT OF HEALTH AND SOCIAL SERVICES, said he did not understand Rep. Toohey's question. CHAIR TOOHEY said the division was gathering statistics from across the state. Number 070 MR. JOHNSON noted that the Senate had passed a fiscal note. He said the division was asking for money mostly to continue the data system, which was important, but which would not be continued without funding. He described the data system's two main purposes as helping review the quality of care provided by the emergency medical services system and identifying the causes and severity of injuries, so as to point to better prevention. He commented on trauma centers, saying national standards exist for level one, level two and level three trauma centers. While Alaska would likely not have a level one center any time soon, he said, a level two trauma center is feasible in Anchorage, and level three centers were feasible in other communities. He said a state task force had received a federal grant to set optional standards for trauma care for facilities ranging from hospitals to small clinics. Number 145 CHAIR TOOHEY asked if Mr. Johnson had included Anchorage hospitals in its discussion of trauma centers. MR. JOHNSON answered yes. CHAIR TOOHEY asked if ambulances from outside of Anchorage would bring patients only to designated trauma centers in Anchorage. MR. JOHNSON answered no, all hospitals would treat trauma patients. He said the current system of referral patterns works well 99 percent of the time, but it could still be improved. He repeated that the bill wanted to establish standards toward which providers should aspire, but it could be done without adverse impact on cost through such strategies as preparing a trauma team to treat a patient whose condition fell inside certain parameters even before that patient arrived at the trauma center. CHAIR TOOHEY observed that such a practice was already being done. MR. JOHNSON countered that it was done sometimes, but not always. He said he relied on doctors, nurses and other professionals to set standards and make recommendations. Number 189 REP. BUNDE said he did not oppose improvements in the paramedic program, but observed that voluntary compliance standards might not be binding. He said he liked local options, too, but asked if there was any mechanism in the bill to enforce compliance with the standards. MR. JOHNSON answered no. He said his division had tried to use small grants to encourage hospitals by providing training in a partnership arrangement. He said the department had tried to encourage "truth in labeling" of what services hospitals could offer. Number 244 CHAIR TOOHEY asked Mr. Johnson whether the bill barred hospitals from describing themselves as trauma centers. MR. JOHNSON said no Alaska hospitals advertised themselves as trauma centers, probably because they know that there are American College of Surgeons standards for such centers that they might not meet. He added, however, that Anchorage hospitals were considering consulting soon with the College representatives to obtain recommendations. Number 241 MR. LINDSTROM offered to answer whether the funds were represented in the fiscal note for SB 71 in the state House or Senate versions of the budget, and answered no, they were not. He asked Mr. Johnson to address the fiscal notes and associated documents to clear up any confusion. MR. JOHNSON said the division was following its April 6, 1993, position paper because the division found a mistake in the first revised position paper which did not reflect some changes made to the bill in the Senate. He said the division was using the March 30, 1993, fiscal note, which reflected the cost to continue the patient information system and to pay for a team from the American College of Surgeons to verify whether any Alaska health care facilities met trauma center criteria. He said the amount was an estimate, based on the number of hospitals that might apply for such certification, a cost which the state would ask the hospitals to pay back. He said that some of the requests that Ms. Kreitzer had expressed were not reflected in the fiscal note, and his division believed the fiscal note was very conservative. Number 276 TODD HUTTENLOCHER, M.D., CO-MEDICAL DIRECTOR, EMERGENCY MEDICAL SERVICES SECTION, DIVISION OF PUBLIC HEALTH, DEPARTMENT OF HEALTH AND SOCIAL SERVICES, testified on SB 71. He said he had practiced in Alaska for 15 years both in several cities and in the Bush. He said he had also been medical director of the Yukon-Kuskokwim Delta Regional Hospital, chief of staff of Bartlett Memorial Hospital, and medical director of the Southeast region EMS, and was currently the co-medical director for the state EMS in Juneau. He said the state needed SB 71. He said it would cut across jurisdictional lines. He said the lack of observed resistance from the medical-industrial complex indicated that the state had done a good job tailoring the bill to meet Alaska's needs. Number 300 MR. HUTTENLOCHER said it was important to balance the need for high emergency medical service standards in Alaska's large cities with the need not to make it too complicated to provide emergency medical service in smaller communities, or through Native corporation health aide programs. He stated SB 71 would ease up some patient confidentiality restrictions and make it easier for doctors to give feedback to EMTs and paramedics on how well they were handling trauma patients. He said that no state laws barred any hospital or clinic from advertising itself as a trauma center, and the bill would encourage trauma centers to adhere to standards. Number 328 REP. BUNDE asked if SB 71 would set required standards for emergency medical service training in Alaska. Number 330 DR. HUTTENLOCHER said the bill specifically said that the state would approve training courses in some way. He said that current practice in Juneau, which does not have provisions for full paramedic service, was to train EMT-3s to a level half-way between EMT-3 and paramedic. He said the bill would allow the EMS office to provide guidance, direction and certification for local needs, which he said vary from community to community. CHAIR TOOHEY agreed that the state needed flexibility in EMT training for different communities. She asked Mr. Anderson who provided insurance to those trained to the mid-level between EMT-3 and paramedic, and to what degree they were covered. Number 355 MR. ANDERSON answered that the division used certificates to endorse the skills of such people, and the division presumed that immunity from liability granted to some emergency medical service workers covered the application of those extra skills. He said malpractice insurance was generally paid for by the organization employing the person. CHAIR TOOHEY asked how such skills were identified on the certificate. Number 361 MR. ANDERSON said the information was recorded both in the application for service, where all the skills were listed, and also on the individual's certificate. MR. JOHNSON added that the division did not allow anyone to use advanced-level skills without having a medical director approve those skills. He said no emergency medical service worker in Alaska could start intravenous therapy, or use a defibrillator, or use drugs or intubation, or other such treatments unless they had been licensed for such treatment and had received a doctor's approval. Number 379 REP. VEZEY asked Dr. Huttenlocher to describe his position in Juneau. DR. HUTTENLOCHER said he wore a lot of hats. He said he was also the medical director for the Capitol City Rescue unit, which provides pre-hospital EMS support. REP. VEZEY asked if he was the physician for the fire-rescue unit in Juneau. DR. HUTTENLOCHER said that was correct. REP. VEZEY asked a clarifying question, whether anything in state law would prevent Dr. Huttenlocher, as a licensed physician, from setting himself up in business as a trauma center. He said he did not believe in licensing for its own sake and he believed there needed to be a valid public purpose for regulation and licensing. DR. HUTTENLOCHER said hospitals had a problem with jumping through hoops to prove that what they did was for the public good. He said that trauma was a special disease, deserving special care, and medicine and the EMS system had helped significantly lower the rate of death from trauma in the past 20 years. Number 395 REP. VEZEY said he was not disputing that fact. But he asked what was wrong with a doctor establishing a trauma center. DR. HUTTENLOCHER said that there was a need for a well thought-out, organized system of dispatch and pre-hospital treatment of trauma. He said the state had an interest in maintaining minimum standards for its emergency medical service system. He said he could not establish himself as a hospital and bill Medicare without meeting minimum requirements, because the state had a right to establish standards and make sure that such centers were operated right. He asserted that the Alaska State Hospital and Nursing Home Association had reviewed the bill and had expressed no major objections. Number 418 REP. VEZEY questioned whether issuance of a license to operate as a trauma center did not under other state law make the center a utility, and subject to many other regulations under the Alaska Public Utilities Commission. He acknowledged, though, that there were many things he did not know about the issue. He said that he saw nothing wrong with competing systems, and asked whether it were appropriate for the state to deny the public a choice of medical service. Number 426 REP. BUNDE observed that the state might want to take steps to ensure that only the appropriate physicians, and not for example proctologists, were allowed to advertise services as a trauma center. REP. VEZEY said that he did not know if proctology was a specialty licensed by the American Medical Association, though he acknowledged it was possible he might be wrong. REP. BUNDE said he believed it was. Number 437 REP. VEZEY asked if the state was making it more difficult or expensive to provide that degree of medical services. DR. HUTTENLOCHER said that trauma center designation was an issue nation-wide, for many reasons. He said that in Alaska, and specifically Anchorage, there had been problems with hospitals acknowledging how trauma centers should be established. He said he and others in the state saw SB 71 as a help, not a hindrance, which would ultimately bring about a more streamlined system that will help health care practitioners design a system that would save money. Number 450 CHAIR TOOHEY asked whether a doctor practicing in a trauma center would need special certification, or if being an emergency room doctor would suffice. She predicted that certifying trauma centers would lead to certifying trauma doctors. DR. HUTTENLOCHER said that surgeons have been the major players in the trauma game and have directed the care for other health care providers. He said that was most of what was necessary for level two, and level three trauma centers was already available in Alaska. He said that, to his knowledge, there was no American College of Surgeons "traumatologist" sub-specialty. Number 462 MR. JOHNSON said there were none to his knowledge, either. DR. HUTTENLOCHER said surgeons were not the main feature of trauma care; it was an entire system involving other specialists, lots of money, and much sophisticated equipment and facilities. Number 467 MS. KREITZER said she understood Rep. Vezey's concerns, and said that the sponsor did not want over-regulation, either. But she said it was beneficial to encourage those treating trauma patients to meet certain standards. She said SB 71 encouraged hospitals to meet American College of Surgeons standards for trauma care, and several hospitals already possessed from 80 percent to 85 percent of what they would need to qualify for certification as trauma centers. She stated the report said trauma center designation demonstrated commitment to an entire chain of trauma care. Number 489 CHAIR TOOHEY announced her intention to take one more question, and that, if no one else wanted to ask a question, the committee would take up the bill the next day. MR. JOHNSON referred to an article from the American Medical Association, which said fewer than half of the states had trauma care systems. He said major trauma included internal bleeding requiring surgical attention. He said standards for trauma care extend beyond the hospital facility to the emergency medical service delivery system. He predicted some Alaska hospitals could meet the trauma center standards without much effort. He stated it was better not to designate one hospital as an area's sole trauma center, and instead to establish care standards and allow hospitals to decide for themselves if they wanted to seek such certification. Number 515 CHAIR TOOHEY commented she was scared that the state would enact regulations that would effectively designate one trauma center and limit the doctors or nurses that could be identified as trauma doctors and trauma nurses. Number 524 LARRY FANNING, FIRE CHIEF, CAPITOL CITY FIRE & RESCUE, AND REPRESENTATIVE OF THE ALASKA STATE FIRE CHIEFS ASSOCIATION, testified in favor of SB 71, saying the Fire Chiefs Association endorsed the bill. He said that a paramedic in Juneau once took personal leave to go to Seattle for training because such training was unavailable in Juneau. He said it might be possible to license paramedics in Alaska if the state were to adopt its own rules and regulations for paramedic certification, allowing training both locally and in other training centers outside the state. He referred to the Seattle Medic One program as a privately-owned program which certified its own paramedics without relying on state certification. He said graduates could take the national registry paramedic examination, though it was not a requirement for graduation. He said the association also endorses SB 71's provisions concerning EMDs, saying that consistent training provided under a certification program would ensure that dispatchers relayed information accurately in a medical emergency, which could result in better patient treatment. Number 544 CHAIR TOOHEY said, "Where do you see this dispatcher ... dispatching?" MR. FANNING responded, "Wherever a 911 call comes into what we call the PSAP, or public safety answering point. And so if I'm injured, you call, it goes into a PSAP. It's at that point when a person picks up the receiver to see what kind of emergency do you have, and there is the opportunity there for a computer screen or a log book to come up on the line and say that you've got a broken leg, we'll do this and this (unintelligible)." CHAIR TOOHEY stated, "But this is a person employed by a municipality or a city or a borough." MR. FANNING remarked that this was not necessarily true. He noted that Ketchikan used volunteer dispatchers at the fire station, people who took regular tours of overnight duty without pay. CHAIR TOOHEY asked how many cities had volunteer dispatchers. MR. FANNING answered that most cities did. He continued with his testimony, saying that he supported SB 71 for those two reasons, and also because it would support the patient information system. He said that system helped emergency responders by letting them know how their patients responded to their treatment. He said the $40,000 requested for the trauma data register also would help emergency medical service workers study their trauma service delivery to look for ways to improve. He asked the committee to endorse the bill. TAPE 93-61, SIDE A Number 000 REP. BUNDE said he was impressed that dedicated citizens would volunteer to act not only as EMTs, which had the fun of going out on rescue runs, but also as dispatchers sitting by the telephone. Number 008 REP. VEZEY said he had a hard time visualizing the program proposed by SB 71 as a state-wide program. He said he did not see why it was necessary for small clinics in remote locations to meet trauma center standards. MR. FANNING observed that the program was voluntary, not obligatory. He said that by setting a standard, people could train to that standard and advertise that they met that standard and could provide a certain level of care to patients. He said the state should encourage as many 911 centers as possible to get the EMT training necessary to provide quality care to those they serve. Number 038 MS. KREITZER said she had experience as an EMT in Cold Bay, and said that proper training of dispatchers can prevent unnecessary and costly medivac flights in rural areas. CHAIR TOOHEY ADJOURNED the meeting at 4:40 p.m.