Talk:PCC TF-1/EDES

Profile Abstract

An Emergency Department "chart" is the entire collection of (multi-authored) documents and reports recording the assessments and care delivered by the entire ED team (including physicians, nurses, technologists and other providers) in response to an ED visit.

For the purposes of this integration profile, we define the Emergency Department Encounter Record (EDER) as a summary of the patient’s current health status and care rendered in the ED between arrival and ED departure. The EDER is not intended to replace the ED Chart as a complete, legal document of care, but is a collection of medical summaries with focused scope that are produced to fulfill a number of collaborative transfers of care.

Issue Log

Open Issues

1. New LOINC codes for data elements
   
   • ED REFERRAL NOTE
     
   • PRE-HOSPITAL CARE NOTE (EMS Note)
     
   • ED TRIAGE NOTE
     
   • XASSES-X NURSING ASSESSMENTS PANEL
     
   • NURIN-T NURSING INTERVENTIONS PANEL
     
   • XIVFLU-X INTRAVENOUS FLUID ADMINISTERED (COMPOSITE)
     

Closed Issues

1. The EDER is a multi-authored (but singly attested?) document. How should this best be implemented/reflected: Document to be attested to by ED attending physician.
   
2. Patients frequently leave the ED prior to documentation being finalized. Triggers in workflow vary. How should the Draft vs. Final Status be handled: Only final documents will be posted to XDS.
   
3. Potential for multiple entries: using folders, multiple sections do not occur.
   
4. Timetable for CCD harmonization: done
   
5. Target systems discussion: use case defined as EDIS posts to XDS.
   
6. Use of Co-occurrence Constraint [Conditional Restraint] for Disposition elements: Yes.
   
7. Snomed vs. DEEDS for Disposition: DEEDS
   

Glossary

Acuity Assessment

Also known as triage category, this is the acuity of the patient assigned during the process of ED triage. A number of evidenced based triage scales exist, including the Emergency Severity Index (ESI), Canadian Triage and Acuity Scale (CTAS), the Australasian Triage Scale (ATS), and the Manchester Triage System. In many emergency departments, patients may simply be classified as emergent, urgent or non-urgent.

EDIS

An Emergency Department Information System (EDIS) is an extended EHR system used to manage data in support of Emergency Department patient care and operations. The functions of an EDIS may be provided by a single application or multiple applications.

Mode of Arrival

The method of transportation used to transport the patient to the Emergency Department.

Referral Source

An individual, group, or agency that determined the patient should seek care at the ED. Referral source may be used to determine appropriate discharge referrals and services, or to provide surveillance data for program and service planning, or to examine referral patterns.

Systems

• The Emergency Department Information System (EDIS) will produce an emergency department encounter record.

• Both ambulatory and inpatient EHR-S will read and display this data.

Data Standards

• Data Elements for Emergency Department Systems (DEEDS) 1.0
• HL7 Version 3
• HL7 CDA Release 2
• HL7 CDA CCD
• XML 1.0
• IHE - Primary Care to ED Referral Request (2006)
• IHE - Acute Care Discharge to Ambulatory Care Environment (2005)
• IHE - Pre-procedure History and Physical (2006)

Technical Approach

The ED Encounter Record is a folder in XDS that defines a collection of documents. Separate content profiles must be created for the various kinds of documents that might be generated during an ED encounter. These content profiles include (existing and new):

• Triage Note
• Nursing Note
• ED Physician Note
• Pre-hospital Care Report
• Diagnostic Imaging Reports
• Laboratory Reports
• Consultation Reports
• Patient Consents for Treatment and Procedures
• Transfer Summary
• Summary of Death

As of this IHE cycle, we propose and define content profiles for Physician and Nursing documents within EDER.

It is expected that the transfers of care referred to in the use cases will occur in an environment where the EDIS, HIS, and Primary Care Physician EHR are coordinated within a Regional Health Information Organization (RHIO) environment or local community of care setting. As such a repository-based, or a peer-to-peer transfer of information is needed. It is expected that the XDS profile specified in the ITI Infrastructure domain would be the vehicle for transferring the EDER. HL7 CDA for creating XML-based extractions of the EMR will be constrained appropriately to reflect the inclusion of the sections/elements denoted in this use case. To ensure persistence of “care context” following the information transfer, an appropriate transformation Style Sheet (XSLT) will be described and included with the document. The subsequent care provider will use this transformed document as the default presentation option for the referral.

Risks

Both small and large EDIS product vendors must easily implement the solution defined. Simplified, iterative implementation approaches may need to be considered when identifying the technical solution. The solution must be able to accommodate multiple levels of “consumers” of these transfers of care documents. EHR-S or HIS vendors may choose not to engineer the ability to consume all elements in the EDER, but constrain machine readability to elements considered pertinent to their customers practice, such as new diagnoses, new prescriptions, medications administered during the visit, procedures performed, and disposition. Finally, time to implementation may constrain scope and or quality. The healthcare industry and Congress actively promote both EMR utilization and interoperability by its care practitioners and healthcare facilities. ONC through HITSP are currently This translates to numerous community-wide and medical societal-wide initiatives for the introduction of healthcare technology solutions by their constituents. As a side effect, expediency of action is important in order to be out ahead of these initiatives as much as possible to lead them in their decision/selection process. Care must be taken to ensure that the technical solution is able to be implemented expediently and engineered for change as feedback from these early initiatives is absorbed and reacted to by the healthcare industry. This work partially positions IHE to address the most recent AHIC challenge to ONC/HITSP for the development of an emergency response use case for EHR adoption, as the ED (and hence the ED encounter) figure prominently in the chain of information transfer outlined in the first drafts of this use case: http://www.hhs.gov/healthit/erehr.html.

Summary

Data released by the Centers for Disease Control and Prevention (CDC) estimates that there were over 110 million emergency department visits in 2004, making the emergency department (ED) chart (hereafter called encounter record) one of the most common medical summaries in use today. Currently, the ED encounter record remains largely a paper based artifact, and when produced by an Emergency Department information system (EDIS) is almost exclusively delivered as unstructured or loosely structured text. The ED chart is used to communicate the details of an emergency department visit in a variety of ways. The chart is most frequently faxed or mailed to primary care providers, and is increasingly archived electronically to hospital clinical data repositories. The original (or a copy) must accompany the patient to the ward upon hospital admission where is can be reviewed by hospital providers, or a copy may be sent with the patient on transfer from ED to ED or from ED to other medical treatment facilities. Unfortunately, these frequently become lost or misplaced. ED encounter records have no standardized format, and may be frequently be difficult to read by users unfamiliar with their formatting. None yet carry any semantic meaning that could be consumed by a receiving EHR system (EHR-S).

The production and delivery of the ED encounter record solves a number of problems, including:

• Communication with and transfer of care back to the patient’s primary care physician.
• Communication with care providers in the inpatient setting for patients admitted to the hospital from the emergency department.

The ED encounter record could also be employed in:

• Transfer of information to hospital and provider billing systems.
• Transfer of information to regulatory and public health agencies requesting data from emergency department encounters.

References

1. Emergency Care Special Interest Group, Health Level 7:Emergency Department Information Systems (EDIS) Functional Profile. Draft Version 1.04 (3/2/2007)