Emergency Department Encounter Record

Introduction

This is a draft of the Emergency Department Encounter Record supplement to the Patient Care Coordination Technical Framework. This draft is a work in progress, not the official supplement or profile.

Profile Abstract

The Emergency Department Encounter Record is a summary of the patient’s health status, and a record of care rendered between ED arrival and ED discharge. The ED encounter is an episodic medical summary with a focused scope that fulfills a number of collaborative transfers of care.

Glossary

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.

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Systems

The Emergency Department Information System (EDIS) must be able to produce an emergency department encounter record. Both ambulatory and inpatient EHR-S will need to be able to 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

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.

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)

Volume 1

Add the following bullet to the list of profiles

• Emergency Department Encounter Record (EDER) is a summary of the patient’s health status as well as a record of care rendered in the ED between arrival and ED discharge. The ED encounter is an episodic medical summary with a focused scope that fulfills a number of collaborative transfers of care. The ED encounter record is a multi-authored document, recording the the patient's health status on ED arrival, as well as the assessments and care delivered by the entire ED team, including physicians, nurses, technologists and other providers. The ED encounter record may include links to diagnostic tests performed during the ED encounter, as well as links to an initial ED referral (a 2006 IHE work product), prehospital (EMS) records (IHE roadmap 2008), and the consultations of other providers for patients seen in the ED.

Dependencies

Add the following row(s) to the list of dependencies

Profile Name

Use Case

Emergency Department Visit

This use case presumes the patient is cared for at a hospital facility with an EDIS as well as a hospital information system. Additionally, the patient’s primary care provider is also assumed to posses an interoperable EHR system. This use case begins upon the arrival of the patient to the emergency department. Data including mode of arrival, chief complaint, and other arrival data are manually entered into the EDIS. additional data including past medical problems, medications and allergies, are obtained in one of the following ways:

1. Entered manually into the EDIS by the triage nurse
   
2. Imported from a legacy ED encounter within the EDIS
   
3. Imported from an Emergency Department Referral (Emergency_Department_Referral, IHE 2006-2007)
   
4. imported from a prehospital EMS report (Emergency Medical Services (EMS) to Emergency Dept Data Transfer, PCC_Roadmap)
   

The patient undergoes assessments by a triage nurse, is assigned a triage category (i.e. emergent, urgent, non-urgent). The patient is then registered and demographic data is obtained. One taken to the treatment area, the patient undergoes additional assessments by a primary RN, and seen by an ED physician who performs a history and physical, orders various diagnostic tests, determines a course of therapy, orders medications to be administered in the ED and performs procedures on the patient. Upon completion of ED care, the patient is either admitted to the hospital, discharged from the ED, or transferred to another facility. Hence, the use case can take one of three branches:

1. If admitted, the EDER is sent to the hospital information system where it can be viewed by providers, or read by the EHR system so that medical summary data and details of care rendered in the ED available to inpatient providers.
   
2. If the patient is discharged the EDER is sent to the patients primary care physician as a summary of care rendered during the ED encounter.
   
3. If the patient is transferred to another facility, the EDER is posted to the RHIO and made available for providers at the receiving facility.
   

Actors

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