Electrophysiology Report Content

Summary

This profile specifies the content structure for a clinical report of an electrophysiology procedure recorded in an EP Lab. Such procedures include Implantable Cardioverter Defibrillator (ICD) Implant, Permanent Pacemaker (PPM)/Implantable Pulse Generator (IPG) Implant, Implantable Cardiac Monitor Implant, Lead Implant, ICD Explant, Generator Change, Lead Explant, Lead Abandonment, and Imaging associated with Implant/Explant (e.g., Venogram).

Benefits

This content profile is motivated by EP physicians, who face an increasing demand from patient-care, data-quality and legislative perspectives to increase the usefulness of (discrete) clinical data across the various care-settings and stakeholders.

The aim is to enable collection and distribution of the most clinically-relevant discrete data on the EP Implant/Explant procedures common in cardiology.

The usage of the discrete data is three-fold:

• To enable individual Implant/Explant procedure related information to be more easily shared and used between care givers and systems
• To enable population-based outcomes-based research on procedure effectiveness
• To provide the ability to interact with data registries for data exchange.

Details

This profile provides an HL7 CDA Implementation Guide for an Electrophysiology Implant/Explant Procedure Report, derived from the Procedure Note specifications as defined in the IHE Health Story Consolidation, Release 1. The content is based on the ACC NCDR ICD Registry version 1.2 data set.

This profile specifies the use of an HL7 Clinical Document Architecture (CDA) format for the EP physician clinical report. This format supports both the human readable narrative historically used for clinical reports, as well as a substantial set of discrete data elements that may be used for longitudinal or population analysis or other computer processing. It provides the framework of high level section titles and a set of discrete data elements. Within that framework reports can be created with the clinical content desired by their authors, including additional discrete data elements.

This profile codifies representative areas of procedure indications, procedures, medications, observations, complications and findings for electrophysiology procedures and specifies how this discrete data can be organized to be used by both care-providers and automated data processing systems.

Systems Affected

The EPRC profile is a content profile, which defines the content of a Cardiac Electrophysiology Report. The means of interchanging the report is not detailed in this profile but addressed in other profiles like DRPT, XDS or PDI. In general two types of systems would be relevant: A reporting workstation, Cardiovascular Information System or an EP Analysis workstation which creates a report and distributes it via one of the mechanism mentioned above. A workstation or system which is receiving and displaying the report. This could be an EMR/EHR System or any type of reporting workstation.

Actors & Transactions:

Specification

Profile Status: Trial Implementation

Documents:

• EPRC Supplement

Underlying Standards:

• HL7 CDA Release 2.0
• HL7 Implementation Guide for CDA® Release 2: IHE Health Story Consolidation, Release 1.1 - US Realm
• Systematized Nomenclature of Medicine – Clinical Terms
• Logical Observation Identifiers Names and Codes
• NCDR ICD Registry v1.2 Coder’s Data Dictionary

See Also

Related Profiles

As a content integration profile EPRC provides the payload for any of the exchange mechanisms of the following profiles

• Displayable Reports (DRPT) for the creation, exchange and management of cardiac imaging reports within an enterprise
• Portable Data for Imaging (PDI) for storage and exchange of cardiac imaging Reports on exchangeable media
• Cross Enterprise Document Sharing (XDS) for storage and retrieval of cardiac imaging reports in a cross enterprise setting

This page is based on the Profile Overview Template