G uidance on the Collection of Race and Ethnicity Data by Ambulance Services

1. Guidance on the Collection of Race and Ethnicity Databy Ambulance Services Bruce Cohen, Sylvia Hobbs, James West, Georgia Simpson-May Massachusetts Department of Public Health

2. Purpose of this Information Provide instructions on how to collect race and ethnicity data in the prehospital setting Provide tools for responding to questions patients may have and to reduce patient and EMT discomfort Explain why race and ethnicity data are required to meet State and National requirements

3. Question 1, Hispanic Ethnicity 1. Are you Hispanic/Latino/Spanish? ❑ Yes ❑ No

4. If a patient asks “What is meant by Hispanic, Latino or Spanish?” EMT Response: “A person is Hispanic, Latino or Spanish if he or she considers themselves to be of Hispanic or Latino heritage. Usually, but not always people who trace their heritage or family’s heritage to Spain or a country in Latin American can think of themselves as Hispanic.” Record Patient’s Yes or No Response If the response is some, partly, half, or a little, please enter Yes. If a patient declines, enter Not Reporting.

5. If a patient asks “Are you trying to find out if I am a US Citizen?” EMT Response: “No, definitely not. Also, the confidentiality of all patient information if protected by law.” Record Patient’s Yes or No Response If the response is some, partly, half, or a little, please enter Yes. If a patient declines, enter Not Reporting.

6. MATRIS (NEMSIS) Hispanic Ethnicity Data ETHNICITY E06_13 Data Format [combo] single-choice National Element Definition The patient's ethnicity as defined by the OMB (US Office of Management and Budget) XSD Data Typexs:integerXSD Domain (Simple Type)Ethnicity Multiple Entry Configuration No Accepts Null Yes Required in XSD Yes Field Values -25 Not Applicable -15 Not Reporting -20 Not Recorded 690 Hispanic or Latino 695 Not Hispanic or Latino Uses ● A component of the EMS Medical Record: Patient Care Report ● Allows data to be sorted based on ethnicity as required from a state and federal government reporting perspective ● Allows data to describe the ethnicity of the EMS patient population Data Collector ● EMS personnel or electronically through linkage with a pre-existing Patient Care Report or hospital database Other Associated Elements E00 Common Null Values E01_01 Patient Care Report Number E06_01 Last Name References in NHTSA Version 1 Essential Element 43 Race/Ethnicity References to Other Databases ● NFIRS 5.0 EMS Module; Title: Ethnicity; Check-Box: Hispanic = Yes or No

7. Question 2, Race 2. What is your race? (select all that apply) ❑ American Indian/Alaska Native ❑ Asian ❑ Black ❑ Native Hawaiian or other Pacific Islander ❑ White ❑ Other ❑ Unknown/not reporting If a patient declines or does not know, enter Not Reporting.

8. If a patient responds: “We’re all human beings” EMT Response: “We collect this information to make sure everyone gets the best possible care.” If a patient declines or does not know, enter Not Reporting.

9. MATRIS (NEMSIS) Race Data RACE E06_12 Data Format [combo] single-choice National Element Definition The patient's race as defined by the OMB (US Office of Management and Budget) XSD Data Typexs:integerXSD Domain (Simple Type)Race Multiple Entry Configuration No Accepts Null Yes Required in XSD Yes Field Values -25 Not Applicable -20 Not Recorded -15 Not Reporting 660 American Indian or Alaska Native 665 Asian 670 Black or African American 675 Native Hawaiian or Other Pacific Islander 680 White 685 Other Race Uses ● A component of the EMS Medical Record: Patient Care Report ● Allows data to be sorted based on race as required from a state and federal government reporting perspective ● Allows data to describe the race of the EMS patient population Data Collector ● EMS personnel or electronically through linkage with a pre-existing Patient Care Report or hospital database Other Associated Elements E00 Common Null Values E01_01 Patient Care Report Number E06_01 Last Name References in NHTSA Version 1 Essential Element 43 Race/Ethnicity References to Other Databases ● NFIRS 5.0 EMS Module; Title: Race; Pick-List: White = 1, Black = 2, American Indian, Eskimo, Aleut = 3, Asian = 4, Other, Multi-racial = 0, Race Undetermined = U

10. If a patient asks “Why?” EMT Response:There are new state requirements that all ambulance services in Massachusetts collect this information. This information will only be used to guarantee that all patients receive the highest quality of care and to ensure the best services possible.

11. If a patient wants more information… Some patients will want a more detailed explanation about why the data are being collected before responding. In such cases, the EMT should explain that the State will use the data to ensure that we are providing quality care and serving a diverse population. We are collecting this information from all patients. This will help us to see differences in health among different populations. We can reduce those differences by reaching out to people and offering additional services. Although we are required to ask, respondents are NOT required to provide answers. If a patient elects not to answer, the EMT should select the “Not Reporting” box. EMTs should NOT guess or select the category he/she believes best describes the patient.

12. If a patient asks about Privacy EMT Response: “Your privacy is protected.” Who accesses the information: • Hospital Registration personnel • EMS and Hospital Care Providers • EMS Quality Control Personnel Who does not access the information: • Immigration • The general public

13. If the patient refuses EMT Response: “I understand that these questions may be a little sensitive. We are required to ask all patients. This information will be kept private and will only be used to improve the healthcare we provide to all.”

14. If the patient still refuses EMT Response: “That is okay. You have the right to not answer these questions.” RecordPatient’s Response as Not Reporting

15. Why does the State want Race and Ethnicity Data? Collecting race and ethnicity data will help us better address disparities and improve the quality of service delivery. Health Disparities are both a National and State Problem.

16. Added Value OF RACE civil rights infringement: monitors discrimination, equality of opportunity and treatment, and indirectly, institutional racism more routinely collected limited capacity to use alternative data collection processes: (observation, informant, surname) OF ETHNICITY more consistently understood less likely to change over time, less context dependent more useful for program targeting and development measure of cultural practices improved sensitivity to linguistic needs

17. What are Health Disparities? Health disparities are differences in health outcomes and their determinants between segments of the population, as defined by social, demographic, environmental, and geographic attributes. Health inequalities, which is sometimes used interchangeably with the term health disparities, is more often used in the scientific and economic literature to refer to summary measures of population health associated with individual- or group-specific attributes (e.g., income, education, or race/ethnicity). Health inequities are a subset of health inequalities that are modifiable, associated with social disadvantage, and considered ethically unfair. Health disparities, inequalities, and inequities are important indicators of community health and provide information for decision making and intervention implementation to reduce preventable morbidity and mortality. Except in the next section of this report that describes selected health inequalities, this report uses the term health disparities as it is defined in U.S. federal laws and commonly used in the U.S. public health literature to refer to gaps in health between segments of the population. Source: CDC MMWR Rationale for Regular Reporting on Health Disparities and Inequalities--United States, January 14, 2011 / 60(01);3-10

18. What is the Public Health Rationale for Measuring Health Disparities? Increasingly, the research, policy, and public health practice literature report substantial disparities in life expectancy, morbidity, risk factors, and quality of life, as well as persistence of these disparities among segments of the population. In 2007, the CDC’s Healthy People 2010 Midcourse Review revealed progress on certain objectives but less than adequate progress toward eliminating health disparities for the majority of objectives among segments of the U.S. population, defined by race/ethnicity, sex, education, income, geographic location, and disability status. During 1980--2000, the U.S. population became older and more ethnically diverse, and during 1992--2005, household income inequality increased. Although the combined effects of changes in the age structure, racial/ethnic diversity, and income inequality on health disparities are difficult to assess, the nation is likely to continue experiencing substantial racial/ethnic and socioeconomic health disparities, even though overall health outcomes measured by Healthy People 2010 objectives are improving for the nation. Because vulnerable populations are more likely than others to be affected adversely by economic recession, the recent downturn in the global economy might worsen health disparities throughout the United States if the coverage and effectiveness of safety-net and targeted programs do not keep pace with needs . Source: CDC MMWR Rationale for Regular Reporting on Health Disparities and Inequalities--United States, January 14, 2011 / 60(01);3-10

19. The cancer death rate for men was 46% higher than the rate for women Blacks had the highest premature mortality rate, 1.5 times the rate of whites The death rate for those with less education was almost 3 times higher than the rate for those with more education Springfield, Lowell, Fall River, Taunton, Worcester, and New Bedford had the highest premature mortality rates Evidence of Health Disparities in Massachusetts Source: Massachusetts Deaths 2007, Massachusetts Department of Public Health Bureau of Health Information, Statistics, Research, and Evaluation, Division of Research and Epidemiology, Registry of Vital Records and Statistics, April 2009

20. Premature Mortality Rates (PMR) by Community Health Network Area (CHNA) Massachusetts: 2007 Source: Massachusetts Deaths 2007, Massachusetts Department of Public Health Bureau of Health Information, Statistics, Research, and Evaluation, Division of Research and Epidemiology, Registry of Vital Records and Statistics, April 2009

21. Mortality Rates by Education and Race/Ethnicity, Adults 25-64 Years1Massachusetts: 2007 * * * * Statistically higher than those with 13+ yrs of education (p<0..05) Rates are per 100,000 population. Age-adjusted to the 2000 US standard population 1Uses 2000 Population Estimates Source: Massachusetts Deaths 2007, Massachusetts Department of Public Health Bureau of Health Information, Statistics, Research, and Evaluation, Division of Research and Epidemiology, Registry of Vital Records and Statistics, April 2009

22. Premature Mortality Rates by Race and Hispanic EthnicityMassachusetts: 2007 * * (*) Statistically different from State (p ≤.05) Rates are per 100,000 population. Age-adjusted to the 2000 US standard population persons ages 0-74 Source: Massachusetts Deaths 2007, Massachusetts Department of Public Health Bureau of Health Information, Statistics, Research, and Evaluation, Division of Research and Epidemiology, Registry of Vital Records and Statistics, April 2009

23. Diabetes Mortality Rates by Race and EthnicityMassachusetts: 2007 * * * N=1,041 N=96 N=15 N=1,216 N=62 Rates are per 100,000 population. Age-adjusted to the 2000 US standard population * Statistically different than state rate (p<0.05) Source: Massachusetts Deaths 2007, Massachusetts Department of Public Health Bureau of Health Information, Statistics, Research, and Evaluation, Division of Research and Epidemiology, Registry of Vital Records and Statistics, April 2009

24. Mortality Rates for Causes Amenable to Health Care by Race/EthnicityMassachusetts: 2000 and 2007 ** ** ** Statistically lower than 2000 rate (p<0.05) Rates are per 100,000 population. Age-adjusted to the 2000 US standard population persons ages 0-74 Source: Massachusetts Deaths 2007, Massachusetts Department of Public Health Bureau of Health Information, Statistics, Research, and Evaluation, Division of Research and Epidemiology, Registry of Vital Records and Statistics, April 2009

25. Concluding Thoughts Collecting race and ethnicity data will help us better address disparities and improve the quality of service delivery For additional information on health disparities, see: Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care available for free online at: http://www.nap.edu/openbook.php?isbn=030908265X CDC Health Disparities and Inequalities Report — United States, 2011 available for free online at: http://www.cdc.gov/mmwr/pdf/other/su6001.pdf Remember: EMTs should NOT guess or select the category he/she believes best describes the patient.