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HIV-infected health care providers: Legal rights and protections
EDITORIALS Emergency Care Guidelines Emergency
Care G u i d e l i n e s
(ECGs) is a cornerstone document of the American College of Emergency Physicians. The guidelines detail the resources needed to evaluate and treat any patient who presents to the emergency department. Included are the requirements for the physical plant, the administration and organization of the department, the qualifications and responsibilities of the staff, and the equipment and supplies necessary to deliver this care. In addition, the guidelines detail the relationship between the ED and other providers and entities with which it must interact. See related article, p 1389. Since the last revision in 1985, numerous and significant regulatory and legal changes have affected the
practice of emergency medicine. In 1989, the P r a c t i c e M a n a g e m e n t Committee was charged with revising t h e E C G s to a d d r e s s t h e s e changes. These periodic revisions of this document ensure that the guidelines are consistent with changes in the health care environment. This 1991 edition, for example, has added references to on-call physicians, patient transfer legislation, observation units, and follow-up responsibilities. The following are other significant additions included in the 1991 revision: • Appendix of suggested radiologic, imaging, and other diagnostic services • Appendix of suggested laboratory capabilities • A description of the ED's relationship with prehospital care providers and resources
• Inclusion of the main points of ACEP's previous policy statement,
Guidelines for Emergency Department Physician Staffing • Recognition of the COBRA/OBRA requirements for hospital, medical staff, and ED responsibilities for medical screening and stabilization of patients In adopting the Emergency Care Guidelines, the College's goal is to improve patient care by offering information and guidance to planners, administrators, and health care providers on the capabilities needed to deliver emergency care.
Alexander R Lampone, MD, FACEP Chairman, ACEP Practice Management Committee, 1989-91 E Jackson Allison, Jr, MD, MPH, FACEP ACEP President
HIV-Infected Health Care Providers: Legal Rights and Protections Hysteria over the potential menace posed by HIV-infected health care workers threatens to destroy the web of legal principles crafted to prevent precisely such scapegoating. Perhaps only the commitment of the American College of Emergency Physicians and other professional organizations to humane and reasoned science will preserve the decency contained in these principles. The cornerstones of a just and prudent public health policy are based on the fair and equal treatment of all members of society. Legal protections against discrimination and disclosure combined with more rigorous workplace safety standards ensure that HW-infected persons - patients and health care workers alike - are not relegated to pariah status. Because of the fear and panic produced by the Florida AIDS dental cases, all of these principles are in jeopardy. 142/1379
The United States Supreme Court case that supports the employment rights of HIV-infected persons is School Board v Arline. ] A tubercular schoolteacher (ironically, also from Florida) c l a i m e d that the school board had fired her unfairly. The Court upheld her claim that persons with infectious diseases were entitled to the same legal protections as other disabled persons. The Court issued a two-part test for determining when an otherwise qualified person may be disqualified because his or her infection posed an unreasonable risk to others. First, the risk of infection must be reasonably accommodated. Second, the risk that remains must be significant before an infectious person may be barred from the workplace. The Court knew that its opinion would have a great impact on AIDS policy. The issue of AIDS had been Annals of Emergency Medicine
heavily briefed, and the case was heard just six mouths after the US Justice Department released a notorious memorandum arguing that fear and ignorance about contagiousness were permissible grounds for discrimination against an infected person. The Court repudiated the Justice Department's position, saying, "Few aspects of a handicap give rise to the same level of public fear and misapprehension as contagiousness . . . . Complex and often pernicious mythologies about the nature, cause, and transmission of illness ''2 may not deprive infected persons of fair and just treatment under the law. Yet the Arline test has scarcely been part of the debate about the risk HIV-infected health care workers pose to their patients. Instead, HIVinfected health care providers have been abandoned to the kind of fear 20:12 December 1991
EDITORIALS
and misapprobation ArIine intended to prohibit. In January of this year, a scant two days after the Centers for Disease Control's a n n o u n c e m e n t that two more infected patients of the Florida dentist with AIDS had been found, the American Medical and American Dental Associations hastily reversed long-standing policy about infected health care providers to declare that they had an absolute ethical duty to disclose their status to their patients. Even as sensitive an observer as Larry Gostin, executive director of the American Society of Law and Medicine, discounted the hysteria faced by HIV-infected people in his evaluation of Arline's significant risk test. "I prefer to emphasize patient confidence and patient safety" in determining "who ought to bear the burden of scientific uncertainty. ''3 Privacy, too, has been trampled by the reactions unleashed by the Florida AIDS cases, despite a growing judicial understanding of the importance of privacy protections for HIVinfected people. "IT]here are few matters of a more personal nature, and there are few decisions over which a person could have a greater desire to exercise control, than the manner in which he reveals ... [an AIDS] diagnosis to others," one federal district court has noted. "IT]he decision of whether, or how, or when to risk familial and communal opprobrium and even ostracism is one of fundamental importance. ''4 A line of state s and federal 6 cases has emerged that recognizes that disclosure of an individual's HIV status requires heightened scrutiny. Constitutional issues of privacy can be involved, particularly in the health care setting. Yet in the wake of the hysteria over HIV-infected health care providers, health care institutions' decisions to disclose the status of caregivers have been driven by fears of liability rather than sufficient regard for staff privacy. Institutionalized zeal to search out and r e m o v e i n f e c t e d h e a l t h care workers is on a roll. Considerably less zeal has been devoted to upgrading workplace safety conditions in 20:12 Decem ber 1991
which health care workers risk becoming infected. By the late 1970s, occupational safety specialists had concluded from hepatitis B seroprevalence studies that an individualized approach to blood-borne infection control was outdated. What was needed was replacement of the case-by-case model with a universal strategy. The emergence of HIV in the early 1980s only underscored the need for such a change, but its implementation is still being delayed. Two and a half years after a federal rule requiring universal precautions in all occupational settings was first proposed, 7 the Senate was forced last September to amend an appropriations bills to require the rule to be issued by December l, 1991. There is virtually no dispute over the essential concept of universal precautions. Issuance of the rule has been held up by technical concerns about s h o r t - t e r m i m p l e m e n t a t i o n costs.
Had the rule been issued shortly after the official c o m m e n t period ended, the firestorm created by the Florida AIDS dental cases m i g h t never have taken place. The required one-year comment period ended May 29, 1990. The CDC released its first Florida AIDS dental case report July 27, 9 eight weeks later) Firm and aggressive enforcement of an infection control rule was precisely what a frightened public needed to be reassured that government and the health care industry took the issue of safety seriously. Instead, we have witnessed one more incident of failed leadership, one more instance of the breakdown of trust and respect that has marked the history of the epidemic in this country. Continued lack of national leadership was the National Commission on AIDS' main point in last September's annual report lo to the President and Congress. By the late 1980s, most Americans had come to believe that the epidemic was happening to " t h e m , " marginal groups like gays and IV drug users, n o t " u s . " Suddenly, through their identification with the Florida dental patients, those who Annals of Emergency Medicine
were at no risk believed they were at some risk. For some, no discussion about statistical remoteness could overcome that q u a n t u m leap. But for m a n y others, decent and responsible leadership would have headed off calls for m e a s u r e s that treat HIV-infected health care workers with disrespect. To protect themselves, HIV-infected care providers must consult lawyers before they disclose their status to anyone. Binding guarantees of confidentiality and nondiscrimination should be negotiated with employing institutions. Disability and workers compensation rights must be determined. Whenever possible, attorneys should undertake such negotiations without disclosing their clients' identities. This is ugly advice, for people need community to cope with illness. But like other HIV-infected people, infected care providers must learn to protect themselves against abuse and abandonment. In Camus' The Plague, the doctor says that "there's no question of hero i s m " in combatting an epidemic. "It's a matter of common decency. T h a t ' s an idea w h i c h m a y m a k e some people smile, but the only means of fighting a plague is - common decency. ''ll The triad of nondiscrimination, respect for privacy, and aggressive workplace safety is the basis for comm o n decency amidst the HIV epidemic. The eclipse of those principles by recent events reminds us of the fragility of the web that separates us from indecent behavior.
David I Schulman, JD Supervising Attorney AIDS/HIV Discrimination Unit Los Angeles City Attorney's Office Los Angeles, California
L School Board of Nassau County vArline, 480 US 273 (I987). 2. Arline, 480 US at 284, and at note 12. 3. Gostin L: CDC Guidelines on HIV or HBV-Positive Health Care Professionals Performing Exposure-Prone Invasive Procedures. Law, Medicine & Health Care 1991 (Spring, Summer);19:140-143. For a counterpoint, see C Feldblum, A Response to Gostin, The HIV-Infected
1380/143
EDITORIALS
Health Care Professional: Public Policy, Discrimination, and Patient Safety. Law, Medicine & Health Care 1991 (Spring, Summer)19:134-139.
6. Doe v Borough of Barrington, 729 F Supp 376 (D NJ 1990); Doe v Coughlan, 697 ]~ Supp 1234 [ND NY 1988)~ Woods v White, 689 F Supp 874 (WD Wis 1988}.
4. Doe v Coughlin, 687 F Supp 1234, 1237-1238 [ND NY 1988).
7. Occupational Exposure to Bloodborne Pathogens; Proposed Rule and Notice of Hearing. 54 Fed Reg 23042-139 (May 30, 1989).
5. Urbaniak v Newton, 226 Cal App 3d 1128 (1991}; Estate of Behringer v Medical Center, No. 188-2550 {NJ Super Ct Law Div, April 25, 1991).
8. HR 2707, amended September 11, 1991. 9. Possible transmission of human immunodeficiency
virus to a patient during an invasive dental procedure. MMWR 1990;39:489-493. 10. National Commission on Acquired Immune Deficiency Syndrome: America Living With AIDS: Transforming Anger, Fear and Indifference into Action. Washington, DC, US Government Printing Office, 199l. 11. Camus A: The Plague. New York, Vintage Books, 1972 ed, p 154.
EMS Data Collection: Filling in the Dots Among the 15 mandatory components of an effective emergency medical services system (EMSS) identified in the EMSS Act of 1973 was "standardized record keeping. ''l However, the collection of administrative, demographic, clinical, and epidemiological information on EMS has been hit and miss. Many investigators have commented on the difficulty of making intersystem comparisons due to the lack of standardization in EMS data collection. 2,3 See related article, p 1325. The specific system (microcomputer, optical m a r k reader, machinescannable first-care forms, and software) described in this issue of Annals by Joyce and Brown, and now p r o v i d e d c o m m e r c i a l l y b y Mr Brown's firm, was developed by them in southeastern Arizona where Dr Joyce was a member of the faculty of Emergency Medicine at the University of Arizona College of Medicine and Mr Brown was executive director of the Southeastern Arizona Emergency Medical Services Coordinating Council. Our experience with the system is therefore likely to be of some interest to readers of their article. The Office of Emergency Medical Services of the Arizona Department of Health Services sponsored some of the early work on this data collection system and encouraged its use by EMS p r o v i d e r s around the state. However, the system has never been adopted by the largest EMS providers in Arizona (the municipal fire departments of the cities of Phoenix and Tucson), and several smaller EMS organizations that initially tried the system have abandoned it. Joyce and 144/1381
Brown, in their discussion, touch on many of the issues that have figured in Arizona discussions of their optically scanned reporting system. The methodology of selecting data elements for inclusion in an optically scannable form represents no great scientific advance. Polling EMS services for data elements may merely document how widespread the misconception is that some data elements are useful. The authors' alternative criteria for data element select i o n ( e s t a b l i s h m e n t of a list of "essential" elements based on EMS literature review, personal experience, and local EMS practices) are no more or less scientifically valid than the suggestions of others experienced in the study and provision of prehospital emergency medical services.4, 5 We agree t h a t data b a s e d e s i g n should be v a l i d a t e d by o u t c o m e studies, an approach that has been significantly advanced by such investigators as Cobb, Copass, Cummins, Eisenberg, and Weaver. 3,6 In our experience, the optically scanned format is excellent for collection of n o m i n a l (eg, m o t o r c y c l e helmet use: yes or no) and ordinal (eg, Glasgow Coma Score) data. Continuous variables (eg, blood pressure) are less wieldy and require considerable space on the "fill in the dots" t y p e f o r m u s e d in an o p t i c a l l y scanned system, thus limiting the number of continuous variables that m a y be collected (unless, of course, one is willing to entertain a multipaged form). Other types of data are more problematic. For example, the current Arizona Department of Health Services optically scanned EMS First Care Form asks the EMS provider to document the intervals from collapse to Annals of Emergency Medicine
CPR, advanced life support care, and initial defibrillation for victims of nontraumatic cardiac arrest. The reliability of provider estimates, made in the heat of the resuscitation, for parameters such as these has been questioned - it has certainly never been established. 7 Moreover, the Arizona EMS provider has only four choices of dot to fill in: four minutes, four to eight minutes, eight to 15 minutes, or more than 15 minutes. Annals readers who have considered even the basic "Utstein" data set (intended for use in nonresearchoriented EMS systems) 8 will recognize the limited utility of the Arizona optically scanned EMS form for monitoring EMS system performance in this most-studied of prehospital medical problems. Thus, the Tucson Fire Department did not adopt this system at the time of its introduction because it had just embarked, in cooperation with the University of Arizona College of Medicine, on a citywide epidemiological study of sudden cardiac death. The detailed information required by the study was not available from the specific form and software to be used in this state. The Arizona experience with optically scanned EMS reporting also has raised wider p r e h o s p i t a l care questions. What is the purpose of collecting such data? Who should collect it? Statewide, centralized EMS data collection has a "morn and apple p i e " a t t r a c t i v e n e s s . However, data do not become information, a useful c o m m o d i t y , until t h e y are studied and interpreted by knowledgeable people. The Arizona state agency charged with overseeing EMS and that operates the aforementioned centralized reporting system in Ari20:12 December 1991
Care G u i d e l i n e s
(ECGs) is a cornerstone document of the American College of Emergency Physicians. The guidelines detail the resources needed to evaluate and treat any patient who presents to the emergency department. Included are the requirements for the physical plant, the administration and organization of the department, the qualifications and responsibilities of the staff, and the equipment and supplies necessary to deliver this care. In addition, the guidelines detail the relationship between the ED and other providers and entities with which it must interact. See related article, p 1389. Since the last revision in 1985, numerous and significant regulatory and legal changes have affected the
practice of emergency medicine. In 1989, the P r a c t i c e M a n a g e m e n t Committee was charged with revising t h e E C G s to a d d r e s s t h e s e changes. These periodic revisions of this document ensure that the guidelines are consistent with changes in the health care environment. This 1991 edition, for example, has added references to on-call physicians, patient transfer legislation, observation units, and follow-up responsibilities. The following are other significant additions included in the 1991 revision: • Appendix of suggested radiologic, imaging, and other diagnostic services • Appendix of suggested laboratory capabilities • A description of the ED's relationship with prehospital care providers and resources
• Inclusion of the main points of ACEP's previous policy statement,
Guidelines for Emergency Department Physician Staffing • Recognition of the COBRA/OBRA requirements for hospital, medical staff, and ED responsibilities for medical screening and stabilization of patients In adopting the Emergency Care Guidelines, the College's goal is to improve patient care by offering information and guidance to planners, administrators, and health care providers on the capabilities needed to deliver emergency care.
Alexander R Lampone, MD, FACEP Chairman, ACEP Practice Management Committee, 1989-91 E Jackson Allison, Jr, MD, MPH, FACEP ACEP President
HIV-Infected Health Care Providers: Legal Rights and Protections Hysteria over the potential menace posed by HIV-infected health care workers threatens to destroy the web of legal principles crafted to prevent precisely such scapegoating. Perhaps only the commitment of the American College of Emergency Physicians and other professional organizations to humane and reasoned science will preserve the decency contained in these principles. The cornerstones of a just and prudent public health policy are based on the fair and equal treatment of all members of society. Legal protections against discrimination and disclosure combined with more rigorous workplace safety standards ensure that HW-infected persons - patients and health care workers alike - are not relegated to pariah status. Because of the fear and panic produced by the Florida AIDS dental cases, all of these principles are in jeopardy. 142/1379
The United States Supreme Court case that supports the employment rights of HIV-infected persons is School Board v Arline. ] A tubercular schoolteacher (ironically, also from Florida) c l a i m e d that the school board had fired her unfairly. The Court upheld her claim that persons with infectious diseases were entitled to the same legal protections as other disabled persons. The Court issued a two-part test for determining when an otherwise qualified person may be disqualified because his or her infection posed an unreasonable risk to others. First, the risk of infection must be reasonably accommodated. Second, the risk that remains must be significant before an infectious person may be barred from the workplace. The Court knew that its opinion would have a great impact on AIDS policy. The issue of AIDS had been Annals of Emergency Medicine
heavily briefed, and the case was heard just six mouths after the US Justice Department released a notorious memorandum arguing that fear and ignorance about contagiousness were permissible grounds for discrimination against an infected person. The Court repudiated the Justice Department's position, saying, "Few aspects of a handicap give rise to the same level of public fear and misapprehension as contagiousness . . . . Complex and often pernicious mythologies about the nature, cause, and transmission of illness ''2 may not deprive infected persons of fair and just treatment under the law. Yet the Arline test has scarcely been part of the debate about the risk HIV-infected health care workers pose to their patients. Instead, HIVinfected health care providers have been abandoned to the kind of fear 20:12 December 1991
EDITORIALS
and misapprobation ArIine intended to prohibit. In January of this year, a scant two days after the Centers for Disease Control's a n n o u n c e m e n t that two more infected patients of the Florida dentist with AIDS had been found, the American Medical and American Dental Associations hastily reversed long-standing policy about infected health care providers to declare that they had an absolute ethical duty to disclose their status to their patients. Even as sensitive an observer as Larry Gostin, executive director of the American Society of Law and Medicine, discounted the hysteria faced by HIV-infected people in his evaluation of Arline's significant risk test. "I prefer to emphasize patient confidence and patient safety" in determining "who ought to bear the burden of scientific uncertainty. ''3 Privacy, too, has been trampled by the reactions unleashed by the Florida AIDS cases, despite a growing judicial understanding of the importance of privacy protections for HIVinfected people. "IT]here are few matters of a more personal nature, and there are few decisions over which a person could have a greater desire to exercise control, than the manner in which he reveals ... [an AIDS] diagnosis to others," one federal district court has noted. "IT]he decision of whether, or how, or when to risk familial and communal opprobrium and even ostracism is one of fundamental importance. ''4 A line of state s and federal 6 cases has emerged that recognizes that disclosure of an individual's HIV status requires heightened scrutiny. Constitutional issues of privacy can be involved, particularly in the health care setting. Yet in the wake of the hysteria over HIV-infected health care providers, health care institutions' decisions to disclose the status of caregivers have been driven by fears of liability rather than sufficient regard for staff privacy. Institutionalized zeal to search out and r e m o v e i n f e c t e d h e a l t h care workers is on a roll. Considerably less zeal has been devoted to upgrading workplace safety conditions in 20:12 Decem ber 1991
which health care workers risk becoming infected. By the late 1970s, occupational safety specialists had concluded from hepatitis B seroprevalence studies that an individualized approach to blood-borne infection control was outdated. What was needed was replacement of the case-by-case model with a universal strategy. The emergence of HIV in the early 1980s only underscored the need for such a change, but its implementation is still being delayed. Two and a half years after a federal rule requiring universal precautions in all occupational settings was first proposed, 7 the Senate was forced last September to amend an appropriations bills to require the rule to be issued by December l, 1991. There is virtually no dispute over the essential concept of universal precautions. Issuance of the rule has been held up by technical concerns about s h o r t - t e r m i m p l e m e n t a t i o n costs.
Had the rule been issued shortly after the official c o m m e n t period ended, the firestorm created by the Florida AIDS dental cases m i g h t never have taken place. The required one-year comment period ended May 29, 1990. The CDC released its first Florida AIDS dental case report July 27, 9 eight weeks later) Firm and aggressive enforcement of an infection control rule was precisely what a frightened public needed to be reassured that government and the health care industry took the issue of safety seriously. Instead, we have witnessed one more incident of failed leadership, one more instance of the breakdown of trust and respect that has marked the history of the epidemic in this country. Continued lack of national leadership was the National Commission on AIDS' main point in last September's annual report lo to the President and Congress. By the late 1980s, most Americans had come to believe that the epidemic was happening to " t h e m , " marginal groups like gays and IV drug users, n o t " u s . " Suddenly, through their identification with the Florida dental patients, those who Annals of Emergency Medicine
were at no risk believed they were at some risk. For some, no discussion about statistical remoteness could overcome that q u a n t u m leap. But for m a n y others, decent and responsible leadership would have headed off calls for m e a s u r e s that treat HIV-infected health care workers with disrespect. To protect themselves, HIV-infected care providers must consult lawyers before they disclose their status to anyone. Binding guarantees of confidentiality and nondiscrimination should be negotiated with employing institutions. Disability and workers compensation rights must be determined. Whenever possible, attorneys should undertake such negotiations without disclosing their clients' identities. This is ugly advice, for people need community to cope with illness. But like other HIV-infected people, infected care providers must learn to protect themselves against abuse and abandonment. In Camus' The Plague, the doctor says that "there's no question of hero i s m " in combatting an epidemic. "It's a matter of common decency. T h a t ' s an idea w h i c h m a y m a k e some people smile, but the only means of fighting a plague is - common decency. ''ll The triad of nondiscrimination, respect for privacy, and aggressive workplace safety is the basis for comm o n decency amidst the HIV epidemic. The eclipse of those principles by recent events reminds us of the fragility of the web that separates us from indecent behavior.
David I Schulman, JD Supervising Attorney AIDS/HIV Discrimination Unit Los Angeles City Attorney's Office Los Angeles, California
L School Board of Nassau County vArline, 480 US 273 (I987). 2. Arline, 480 US at 284, and at note 12. 3. Gostin L: CDC Guidelines on HIV or HBV-Positive Health Care Professionals Performing Exposure-Prone Invasive Procedures. Law, Medicine & Health Care 1991 (Spring, Summer);19:140-143. For a counterpoint, see C Feldblum, A Response to Gostin, The HIV-Infected
1380/143
EDITORIALS
Health Care Professional: Public Policy, Discrimination, and Patient Safety. Law, Medicine & Health Care 1991 (Spring, Summer)19:134-139.
6. Doe v Borough of Barrington, 729 F Supp 376 (D NJ 1990); Doe v Coughlan, 697 ]~ Supp 1234 [ND NY 1988)~ Woods v White, 689 F Supp 874 (WD Wis 1988}.
4. Doe v Coughlin, 687 F Supp 1234, 1237-1238 [ND NY 1988).
7. Occupational Exposure to Bloodborne Pathogens; Proposed Rule and Notice of Hearing. 54 Fed Reg 23042-139 (May 30, 1989).
5. Urbaniak v Newton, 226 Cal App 3d 1128 (1991}; Estate of Behringer v Medical Center, No. 188-2550 {NJ Super Ct Law Div, April 25, 1991).
8. HR 2707, amended September 11, 1991. 9. Possible transmission of human immunodeficiency
virus to a patient during an invasive dental procedure. MMWR 1990;39:489-493. 10. National Commission on Acquired Immune Deficiency Syndrome: America Living With AIDS: Transforming Anger, Fear and Indifference into Action. Washington, DC, US Government Printing Office, 199l. 11. Camus A: The Plague. New York, Vintage Books, 1972 ed, p 154.
EMS Data Collection: Filling in the Dots Among the 15 mandatory components of an effective emergency medical services system (EMSS) identified in the EMSS Act of 1973 was "standardized record keeping. ''l However, the collection of administrative, demographic, clinical, and epidemiological information on EMS has been hit and miss. Many investigators have commented on the difficulty of making intersystem comparisons due to the lack of standardization in EMS data collection. 2,3 See related article, p 1325. The specific system (microcomputer, optical m a r k reader, machinescannable first-care forms, and software) described in this issue of Annals by Joyce and Brown, and now p r o v i d e d c o m m e r c i a l l y b y Mr Brown's firm, was developed by them in southeastern Arizona where Dr Joyce was a member of the faculty of Emergency Medicine at the University of Arizona College of Medicine and Mr Brown was executive director of the Southeastern Arizona Emergency Medical Services Coordinating Council. Our experience with the system is therefore likely to be of some interest to readers of their article. The Office of Emergency Medical Services of the Arizona Department of Health Services sponsored some of the early work on this data collection system and encouraged its use by EMS p r o v i d e r s around the state. However, the system has never been adopted by the largest EMS providers in Arizona (the municipal fire departments of the cities of Phoenix and Tucson), and several smaller EMS organizations that initially tried the system have abandoned it. Joyce and 144/1381
Brown, in their discussion, touch on many of the issues that have figured in Arizona discussions of their optically scanned reporting system. The methodology of selecting data elements for inclusion in an optically scannable form represents no great scientific advance. Polling EMS services for data elements may merely document how widespread the misconception is that some data elements are useful. The authors' alternative criteria for data element select i o n ( e s t a b l i s h m e n t of a list of "essential" elements based on EMS literature review, personal experience, and local EMS practices) are no more or less scientifically valid than the suggestions of others experienced in the study and provision of prehospital emergency medical services.4, 5 We agree t h a t data b a s e d e s i g n should be v a l i d a t e d by o u t c o m e studies, an approach that has been significantly advanced by such investigators as Cobb, Copass, Cummins, Eisenberg, and Weaver. 3,6 In our experience, the optically scanned format is excellent for collection of n o m i n a l (eg, m o t o r c y c l e helmet use: yes or no) and ordinal (eg, Glasgow Coma Score) data. Continuous variables (eg, blood pressure) are less wieldy and require considerable space on the "fill in the dots" t y p e f o r m u s e d in an o p t i c a l l y scanned system, thus limiting the number of continuous variables that m a y be collected (unless, of course, one is willing to entertain a multipaged form). Other types of data are more problematic. For example, the current Arizona Department of Health Services optically scanned EMS First Care Form asks the EMS provider to document the intervals from collapse to Annals of Emergency Medicine
CPR, advanced life support care, and initial defibrillation for victims of nontraumatic cardiac arrest. The reliability of provider estimates, made in the heat of the resuscitation, for parameters such as these has been questioned - it has certainly never been established. 7 Moreover, the Arizona EMS provider has only four choices of dot to fill in: four minutes, four to eight minutes, eight to 15 minutes, or more than 15 minutes. Annals readers who have considered even the basic "Utstein" data set (intended for use in nonresearchoriented EMS systems) 8 will recognize the limited utility of the Arizona optically scanned EMS form for monitoring EMS system performance in this most-studied of prehospital medical problems. Thus, the Tucson Fire Department did not adopt this system at the time of its introduction because it had just embarked, in cooperation with the University of Arizona College of Medicine, on a citywide epidemiological study of sudden cardiac death. The detailed information required by the study was not available from the specific form and software to be used in this state. The Arizona experience with optically scanned EMS reporting also has raised wider p r e h o s p i t a l care questions. What is the purpose of collecting such data? Who should collect it? Statewide, centralized EMS data collection has a "morn and apple p i e " a t t r a c t i v e n e s s . However, data do not become information, a useful c o m m o d i t y , until t h e y are studied and interpreted by knowledgeable people. The Arizona state agency charged with overseeing EMS and that operates the aforementioned centralized reporting system in Ari20:12 December 1991