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.

An outdated Word document of the profile proposal is here: http://wiki.ihe.net/images/0/0e/IHE_Profile_Proposal_%28Detailed%29_ED_Encounter_Record_V1_5.doc.

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.

Issue Log

Open Issues

Patients frequently leave the ED prior to documentation being finalized. Triggers in workflow vary. How should the Draft vs. Final Status be handled?
Potential for multiple entries.
Timetable for CCD harmonization?
Target systems discussion.
1. EDIS  CDR  RHIO
2. EDIS  RHIO  Ambulatory EHR
3. EDIS  Ambulatory EHR
Potential need for LOINC codes for new elements.
Use of Co-occurrence Constraint [Conditional Restraint] for Disposition elements.
Snomed vs. DEEDS for Disposition?

Closed Issues

Content vetted by full Patient_Care_Coordination Technical Committee.
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.

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.

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

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

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:

Entered manually into the EDIS by the triage nurse
Imported from a legacy ED encounter within the EDIS
Imported from an Emergency_Department_Referral (IHE 2006-2007)
Imported from a prehospital EMS report (Emergency Medical Services (EMS) to Emergency Dept Data Transfer, PCC_Roadmap 2008-2009)

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:

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.
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.
If the patient is transferred to another facility, the EDER is posted to the RHIO and made available for providers at the receiving facility.

Real-Life Example

Mr. John Smith, a longstanding patient of Dr. Mark Klein, is 62 year old man with hypertension and diabetes who awoke with acute onset of fever, right-sided chest pain and cough. He presents to the IHE ED via EMS where he is triaged by nurse Karen Ross who collects his past medical history, medications, allergies, mode of arrival, and inputs this data into the EDIS. Mr. Smith is taken directly to the treatment area where he is assigned to nurse Barbara Reiter who obtains vital signs, baseline pulse oximetry, places the patient on oxygen, and obtains IV access. She documents her assessments and interventions in the EDIS. The patient is seen by Dr. William Reed who performs and records a history and physical examination, orders an ECG, chest radiograph, CBC, electrolytes, and blood cultures. The chest radiograph reveals bi-lobar pneumonia and the ECG is slightly abnormal. Ceftriaxone 1gm IV plus Azythromycin 500mg PO are administered. After multiple attempts by Dr. Reed to contact Dr. Klein, Mr. Smith is admitted to a intermediate care bed under the care of Dr. Herman Edwards the IHE hospitalist. Upon hospital admission, a preliminary EDER is posted to the RHIO and also sent to the hospital information system. Using the HIS, the nurse on the intermediate care ward accesses the record and notes the time and administration of antibiotics. At the end of his shift, Dr. Reed completes the record and, as the resposible attending physician, electronically signs the ED chart authenticating the EDER. (The initial ED attending physician to see the patient is by default the legal authenticator, and may only delegate this responsibility to another provider through a formal transfer of care.)

When Dr. Klein reaches the office in the morning, his office EHR-S notifies him that his patient was seen in the IHE ED the previous night, and displays the ED encounter record.

Actors

Volume 2

Data Element Index

ED Encounter Record – Data Element Index
Data Element Requirements	Other Reference	LOINC Section or CDA Element
Facility Identification Data
Patient Administrative Identifiers
Participating Providers and Roles

ED Arrival Data
Referral Source		11293-8 ED REFERRAL SOURCE (DEEDS 4.05)
ED Referral Summary
Mode of Arrival		11459-5 TRANSPORT MODE
Prehospital Care Report

Triage Note
Acuity Assessment		11283-9 ACUITY ASSESSMENT
Chief Complaint		10154-3 CHIEF COMPLAINT

Vital Signs		8716-3 VITAL SIGNS
Blood Pressure		18684-1 BLOOD PRESSURE ATTACH.ED
Pulse		18708-8 HEART BEAT ATTACH.ED
Temperature		18688-2 BODY TEMPERATURE ATTACH.ED
Oxygen Saturation		30370-1 OXYHEMOGLOBIN/HEMOGLOBIN.TOTAL OxyHgb fr BldCoA
Pain Score	REPORTED.VISUAL ANALOG SCORE	38214-3 PAIN SEVERITY
Level of Consciousness		28265-7 CONSCIOUSNESS.STATUS OBSERVED.OMAHA
Height		3137-7 BODY HEIGHT MEASURED
Weight		3141-9 BODY WEIGHT MEASURED

Physician Note
Chief Complaint		10154-3 CHIEF COMPLAINT FIND
History Present Illness		10164-2 HISTORY OF PRESENT ILLNESS
Active Problems		11450-4 PROBLEM LIST
Current Meds		10160-0 HISTORY OF MEDICATION USE
Allergies		10155-0 HISTORY OF ALLERGIES
List of Surgeries		10167-5 HISTORY OF SURGICAL PROCEDURES
Immunizations		11369-6 HISTORY OF IMMUNIZATIONS
Family History		10157-6 HISTORY OF FAMILY MEMBER DISEASES
Social History		29762-2 SOCIAL HISTORY
History of Pregnancies		10162-6 HISTORY OF PREGNANCIES
LMP		8665-2 DATE LAST MENSTRUAL PERIOD
Pertinent ROS		10187-3 REVIEW OF SYSTEMS
Physical Examination		22029-3 PHYSICAL EXAM.TOTAL
General Appearance		10210-3 GENERAL STATUS
Integumentary System		29302-7 INTEGUMENTARY SYSTEM
Head		10199-8 HEAD
Eyes		10197-2 EYE
Ears		10195-6 EAR
Nose		10203-8 NOSE
Mouth, Throat and Teeth		10201-2 MOUTH & THROAT & TEETH
Neck		11411-6 NECK
Endocrine System		29307-6 ENDOCRINE SYSTEM
Thorax and Lungs (may include)		10207-9 THORAX+LUNGS
Chest Wall		11392-8 CHEST WALL
Breasts		10193-1 BREASTS
Heart		10200-4 HEART
Respiratory System		11412-4 RESPIRATORY SYSTEM
Abdomen		10191-5 ABDOMEN
Lymphatic System		11447-0 HEMATOLOGIC+LYMPHATIC+IMMUNOLOGIC SYSTEM
Vessels		10208-7 VESSELS
Musculoskeletal System		11410-8 MUSCULOSKELETAL SYSTEM
Neurologic System		10202-0 NEUROLOGIC SYSTEM
Genitalia		11400-9 GENITALIA
Rectum		10205-3 RECTUM
Assessment and Plan


ED Course
Medications Administered		19011-6 MEDICATION.ADMINISTERED CMPLX - OR - 18610-6 ED MEDICATION ADMINISTERED (COMPOSITE)
Intravenous Fluids Administered		8974-8 FLUID INTAKE.INTRAVASCULAR
Procedures Performed
Test Results (Lab, ECG, Radiology)		11493-4 HOSPITAL DISCHARGE STUDIES SUMMARY (may need revision)
Consultations		11488-4 CONSULTATION NOTE {SETTING} ATTACH.CLINRPT
Progress Note		18733-6 SUBSEQUENT EVALUATION NOTE (ATTENDING PHYSICIAN)

ED Disposition and Diagnosis Data
ED Diagnoses		11301-9 ED DIAGNOSIS
ED Diagnosis Description
ED Disposition		11302-7 ED DISPOSITION (MAY WANT UB-92)

Admission Data
Inpatient Facility
Inpatient Practitioner

Discharge Data
Discharge Medications		10183-2 HOSPITAL DISCHARGE MEDICATIONS ???
Discharge Instructions
Referral at ED Disposition
ED Referral Practitioner

Transfer Data
Facility Receiving ED Patient
Accepting Practitioner

Consents
Advance Directives
Pertinent Insurance Information
Data needed for state and local referral forms, if different than above

Document Specification

ED Encounter Record – Document Specification
Data Element Requirements	Opt	Section	TemplateID	Comments
Facility Identification Data	R
Patient Administrative Identifiers	R
Participating Providers and Roles	R

ED Arrival Data	R
Referral Source	R
ED Referral Summary	R2
Mode of Arrival	R
Prehospital Care Report	R2

Triage Note	R
Acuity Assessment	R
Chief Complaint	R

Vital Signs	R
Blood Pressure	R
Pulse	R
Temperature	R
Oxygen Saturation	R2
Pain Score	R2
Level of Consciousness	R2
Height	R2
Weight	R2

Physician History	R

Physical Examination	R

Assessment and Plan	R2

ED Course
Medications Administered	R
Intravenous Fluids Administered	R
Procedures Performed	R
Test Results (Lab, ECG, Radiology)	R2
Consultations	R2
Progress Note	R2

ED Disposition and Diagnosis Data	R
ED Diagnoses	R
ED Diagnosis Description	R
ED Disposition	R

Admission Data	C ¹
Inpatient Facility	R
Inpatient Practitioner	R

Discharge Data	C ²
Discharge Medications	R
Discharge Instructions	R
Referral at ED Disposition	R2
ED Referral Practitioner	R2

Transfer Data	C ³
Facility Receiving ED Patient	R
Accepting Practitioner	R

Consents	O
Advance Directives	R
Pertinent Insurance Information	O
Data needed for state and local referral forms, if different than above	O

Emergency Department Encounter Record

Contents