Texas EMS Trauma Registry - Frequently Asked Questions (FAQs)

questions

What is the Texas EMS and Trauma Registries and its purpose?

The Texas Emergency Medical Services and Trauma Registries (EMS/TR) is an online reporting system that collects legislatively mandated data on all EMS runs, traumatic brain injuries, spinal cord injuries, submersions, and other traumatic injuries based on a specified criterion.

The purpose of the EMS/TR is to monitor and analyze the EMS and trauma care systems. The EMS/TR incorporate national EMS and hospital data standards in addition to Texas custom questions to analyze the EMS and trauma care systems and to benchmark Texas within its22 trauma service areas and between other states. Data is used to perform epidemiological investigations to identify public health issues and support injury prevention projects to ultimately improve the efficiency and quality of care patients receive in Texas.

Who is required to report data to EMS/TR?

As stated in the Texas Administrative Code Title 25, Part 1, Chapter 103, Rule §103.4; the following are the responsible entities required to report to the EMS/TR:

  • EMS Providers
  • Hospitals
  • Acute or Post-Acute Rehabilitation Facilities
  • Justice of the Peace
  • Medical examiners
  • Physicians

If the above-listed professionals or organizations choose to notify a local or regional health authority to respond on their behalf, the local or regional health authority must report to the EMS/TR within ten workdays.

What are the Texas Data reporting requirements and rules?

What reports do entities submit to the EMS/TR? 

EMS
All runs, as defined in the Texas EMS/TR EMS Data Dictionary, must be submitted electronically to the Texas Department of State Health Services (DSHS) online EMS/TR. 

Texas Administrative Code, Title 25, Part 1, Chapter 103, Rule §103.5

A run is a resulting action from a call for assistance where an EMS provider is dispatched to, responds to, provides care to, or transports a person. That includes trauma and medical, emergency and non-emergency, transport and non-transport runs.

Texas Administrative Code, Title 25, Part 1, Chapter 103, Rule §103.2 

Hospitals
Hospitals shall submit all major trauma cases where the patient died or arrived dead, was admitted for more than 48 hours, was transferred into the hospital, or was transferred out to another hospital. Hospitals also submit all traumatic spinal cord injuries, traumatic brain injuries, and submersions. Refer to the definitions on the following link for more details on case inclusion. 

EMS and Trauma Registries Reporting Rules

Texas Administrative Code Title 25, Part 1, Chapter 103, Rule 103.7  

Acute or Post-Acute Rehabilitation Facilities
Traumatic brain injury (TBI): An acquired injury to the brain, including brain injuries caused by anoxia due to submersion incidents. The following International Classification of Diseases 10th Revision Clinical Modification (ICD-10-CM) diagnostic codes are to be used to identify cases of traumatic brain injury: S06 and S02.The ICD-10-CM diagnostic code to be used to identify traumatic brain injury caused by anoxia due to submersion incidents is G93.1 or T75.1XXA. 

Spinal cord injury (SCI): An acute, traumatic lesion of the neural elements in the spinal canal, resulting in any degree of sensory deficit, motor deficits, or bladder/bowel dysfunction. The following International Classification of Diseases 10th Revision Clinical Modification (ICD-10-CM)diagnostic codes are to be used to identify cases of traumatic spinal cord injury: S12, S14, S22, S24, S32, or S34) and S14, S24, or S34.

EMS & Trauma Registries Reporting Rules
Texas Administrative Code, Title 25, Part 1, Chapter 103, Rule §103.8

Justice of the Peace
Submersion injury: The process of experiencing respiratory impairment from submersion or immersion in liquid. 

Traumatic brain injury (TBI): An acquired injury to the brain, including brain injuries caused by anoxia due to submersion incidents. The following International Classification of Diseases10th Revision Clinical Modification (ICD-10-CM) diagnostic codes are to be used to identify cases of traumatic brain injury: S06 and S02. The ICD-10-CMdiagnostic code to be used to identify traumatic brain injury caused by anoxia due to submersion incidents is G93.1 or T75.1XXA. 

Spinal cord injury (SCI): An acute, traumatic lesion of the neural elements in the spinal canal, resulting in any degree of sensory deficit, motor deficits, or bladder/bowel dysfunction. The following International Classification of Diseases 10th Revision Clinical Modification (ICD-10-CM) diagnostic codes are to be used to identify cases of traumatic spinal cord injury: S12, S14, S22, S24, S32, or S34) and S14, S24, or S34. 

EMS & Trauma Registries Reporting Rules
Texas Administrative Code, Title 25, Part 1, Chapter 103, Rule §103.6

Medical Examiners
Submersion injury: The process of experiencing respiratory impairment from submersion or immersion in liquid. 

Traumatic brain injury (TBI): An acquired injury to the brain, including brain injuries caused by anoxia due to submersion incidents. The following International Classification of Diseases10th Revision Clinical Modification (ICD-10-CM) diagnostic codes are to be used to identify cases of traumatic brain injury: S06 and S02. The ICD-10-CMdiagnostic code to be used to identify traumatic brain injury caused by anoxia due to submersion incidents is G93.1 or T75.1XXA. 

Spinal cord injury (SCI): An acute, traumatic lesion of the neural elements in the spinal canal, resulting in any degree of sensory deficit, motor deficits, or bladder/bowel dysfunction. The following International Classification of Diseases 10th Revision Clinical Modification (ICD-10-CM)diagnostic codes are to be used to identify cases of traumatic spinal cord injury: S12, S14, S22, S24, S32, or S34) and S14, S24, or S34. 

EMS & Trauma Registries Reporting Rules
Texas Administrative Code, Title 25, Part 1, Chapter 103, Rule §103.2

Physicians
Submersion injury: The process of experiencing respiratory impairment from submersion or immersion in liquid. 

Traumatic brain injury (TBI): An acquired injury to the brain, including brain injuries caused by anoxia due to submersion incidents. The following International Classification of Diseases10th Revision Clinical Modification (ICD-10-CM) diagnostic codes are to be used to identify cases of traumatic brain injury: S06 and S02. The ICD-10-CMdiagnostic code to be used to identify traumatic brain injury caused by anoxia due to submersion incidents is G93.1 or T75.1XXA. 

Spinal cord injury (SCI): An acute, traumatic lesion of the neural elements in the spinal canal, resulting in any degree of sensory deficit, motor deficits, or bladder/bowel dysfunction. The following International Classification of Diseases 10th Revision Clinical Modification (ICD-10-CM) diagnostic codes are to be used to identify cases of traumatic spinal cord injury: S12, S14, S22, S24, S32, or S34) and S14, S24, or S34. 

Note: A physician shall be exempt from reporting if a hospital or acute or post-acute rehabilitation facility admitted the patient and fulfilled the reporting requirements as stated in §103.7 of this title (relating to Reporting Requirements for Hospitals) or §103.8 of this title (relating to Reporting Requirements for Acute or Post-Acute Rehabilitation Facilities).

The professionals or organizations listed in this section must send all reports of injuries and events listed in this section to the EMS and Trauma Registries. If the above listed professionals or organizations choose to notify a local or regional health authority to respond on their behalf, the local or regional health authority must report to the Registry within ten workdays.

EMS and Trauma Registries Reporting Rules
Texas Administrative Code, Title 25, Part 1, Chapter 103, Rule §103.6

What data does an EMS and hospital provider include in the report? 

EMS
All of the required data fields listed in the EMS Data Dictionary, in the file format described in the data dictionary should be included. The link to the EMS Data dictionary can be found atdshs.texas.gov/injury-prevention/ems-trauma-registries/ems-reporting-requirements. 

Hospital
For trauma hospitalizations, all of the required fields listed in the Hospital Data Dictionary and in the file format described in the data dictionary, should be included. For submersions, all requested fields should be included in the web-data entry. 

dshs.texas.gov/injury-prevention/ems-trauma-registries/hospital

 

How often does an EMS and hospital provider send data? 

EMS
All data should be transmitted at least quarterly; monthly electronic data submissions are recommended. 

EMS providers shall submit data to the Registry within 90 days of the date of call for assistance.

Texas Administrative Code Title 25, Part 1, Chapter 103

Hospital
All data should be transmitted at least quarterly; monthly electronic data submissions are recommended. 

Hospitals shall submit data to EMS/TR within 90 days of a patient's discharge from their facility.

Hospitals must submit No Reportable Data (NRD) to the online system within 90 days of any given month that the hospital did not treat or document a required reportable event.

What is the deadline for data submission for EMS and Hospital?

EMS
Data shall be submitted within 90 days from the date of call for assistance. The EMS/TR recommends EMS providers and Third Parties submit data monthly. 

When there is no data for a month, the EMS provider shall submit a No Reportable Data (NRD) using the online system within 90 days of that month. 

Hospital
Data shall be submitted within 90 days from the date of discharge. The EMS/TR recommends hospitals and Third Parties submit data monthly. 

When there is no data for a month, the hospital shall submit a No Reportable Data (NRD) using the online system within 90 days of that month.

How can entities submit data to EMS/TR?

Data shall be sent electronically via web services, web-data entry, or file upload. Each entity will establish an account with the EMS/TR and use the online system for submitting data. Entities may use their own software or the free online system for entering data. Submersion data shall be sent using the web-data entry method by logging into the EMS/TR.

May an EMS and Hospital provider submit data through a third party (e.g., RAC, billing agency, etc.)?

Yes, EMS and Hospital providers can submit data through a Third Party. However, it is the individual EMS and Hospital providers' responsibility to make sure that its data is reported to the EMS/TR.

How do entities set up an account with EMS/TR?

Once a license has been issued by DSHS Regulatory Licensing Unit and verification of the license has been received by the entity, an email maybe submitted to the Customer Service Team at injury.web@dshs.texas.gov or you may call the toll-free number at 1-800-242-3562. Please provide the entity name, a contact name, a phone number, and reason for request. The toll-free number is a recording to receive messages. The number is not a real person; however, a response will be made to requests received in three to five business days.

How do entities set up the account manager(s) account?

There are two methods in which an account manager account can be created:

1.   The first method is a systematic process through the Registration Portal. Through this process an account manager can be identified and assigned a login name and password. 

2.   The second method is if there is already an existing account manager, the account manager can create and assign a second account manager.

If an account manager has not been established in the EMS/TR for the entity, an administrative representative of the entity may send a request to the EMS/TR customer service email address injury.web@dshs.texas.gov.

How do entities add User(s) to an entity’s account?

The account manager(s) can add a user to an entity’s account. The account manager may send a request to the EMS/TR customer service email address injury.web@dshs.texas.gov.

What is a DSHS ID Number?

Each entity has a system-generated number which is used as the DSHS personal identifier for the EMS/TR. This may or may not match the license number received from regulatory.

What is a License Number (State Provider Number)?

Each entity is issued a license number when they were registering their facility with the DSHS Regulatory Licensing Unit. This number may or may not match the license number received from regulatory. For any questions regarding licensing, please visit the link below.

dshs.texas.gov/online-licensing-help-center-division-consumer-protection

Where do entities get an Entity’s DSHS ID?

For the security of patient data, DSHS IDs are not posted on an open website. An email can be sent to injury.web@dshs.texas.gov requesting your DSHS ID. Your DSHS ID can also be accessed by logging in to your entity’s account and following these steps:

1.   On the main page, click on search for an existing record.

2.   In the “Search Event” section under the Search criteria, look for the “Record Type” drop-down and select the appropriate entity type.

3.   Click on the “Search” button; the name of the entity will be displayed on right side of the Search Event, under the “Search Results”.

4.   Double click on the name of the entity and the “Record Summary” page will be displayed.

5.   The DSHS ID will be seen under the “Basic Information” and subheading “Notifications”.

How do entities request to delete a record (duplicate or invalid record)?

To request deletion of a duplicate or invalid record, submit an email to injury.web@dshs.texas.gov. Specify the data or record ID to be deleted. A three-to-five-day turnaround should be expected.

How do entities request data from the EMS and Trauma Registries?

To request data, send an email to injury.web@dshs.texas.gov providing specifics on the data being sought. DSHS will reach out to discuss the request. To request a Public Use Data File (PUDF), complete the Public Use Data Usage Agreement form on the website (/injury/data/PUDF.doc/) and email it to injury.web@dshs.texas.gov.

How do entities know if the entity’s data has been submitted?

  • For web-data entry, records are submitted the moment the user clicks “save.” To confirm the total number of records submitted for your entity, send an email to injury.web@dshs.texas.gov.
  • For file upload, a submission status display will be shown when the file is uploaded. It will show the status as processed or unprocessed. When the file is processed, a link will be provided. Click the “result” link to see the status. Or check the status in the Question Package by clicking the “Submission Status” line. This method may also be used to verify the records submitted when an entity uses a third-party vendor to submit data.

How do entities request access for a third-party agency?

Please note, the program is currently reviewing the Business Associate Agreement (BAA) process and are drafting an updated policy to allow for the submission of affidavits. When this new policy and affidavit have completed review and are available, stakeholders will be informed, and this FAQ will be updated accordingly. 

A BAA should be uploaded to the entities’ account, and then an email is to be sent to injury.web@dshs.texas.gov to inform DSHS staff that a BAA has been uploaded and ready for review and approval. Once DSHS reviews and approves the BAA, the identified third-party agency will be given access to the entity’s account and will be able to submit data on behalf of the entity. An email will be sent to the entity informing them of the access granted. 

Each entity is responsible for monitoring the submission of its data by their data by their third-party agency.

Sample BAA

What are the current requirements of a valid Business Associate Agreements (BAA)?

  • Name of entity
  • Name of third-party agency
  • Effective date
  • Signatures of both parties (entity and third-party billing agency)

Sample BAA

Who can upload a Business Associate Agreement (BAA)?

Entity account managers must log on to the EMS/TR system and upload their BAA. If having trouble uploading a BAA, contact injury.web@dshs.texas.gov.

How do entities report submersion data?

Submersion data at this time can only be reported via web-data entry. Details on how to do web-data entry can be found in /injury/registry/Training.shtm

What is the difference between an Account Manager and a User?

  • An account manager in the EMS/TR has access to add, edit, and inactivate users; along with permissions to upload Business Associates Agreements (BAA) for all entities they have been granted access. They may also submit data for their entity.
  • A user has permissions to only submit data for their entity.

What is the difference between Required and Mandatory Elements?

  • A Required element can accept Null Values (i.e., Not Applicable or Not Known / Not Recorded).
  • A Mandatory element must be answered with a correct value; if a correct value is not answered for a mandatory field, the record will be rejected from the system (i.e., entering a value for first name).

 

For more information about injury prevention in Texas, please contact us at:

Texas Department of State Health Services
Injury Prevention
PO Box 149347, Mail Code 1922
Austin, TX 78714-9347
Phone number: (800) 242-3562
Fax: (512) 458-7658
injury.web@dshs.texas.gov
tvdrs@dshs.texas.gov
saferiders@dshs.texas.gov
cfrt@dshs.texas.gov

   

External links to other sites are informational and do not have the endorsement of the Texas Department of State Health Services. These external links may not be accessible to persons with disabilities. 

Injury Prevention

Injury Prevention

EMS and Trauma Registries