Emergency Department Encounter Record

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An outdated Word document of the profile proposal is here: http://wiki.ihe.net/images/0/0e/IHE_Profile_Proposal_%28Detailed%29_ED_Encounter_Record_V1_5.doc.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

  1. Patients frequently leave the ED prior to documentation being finalized. Triggers in workflow vary. How should the Draft vs. Final Status be handled?
  2. Potential for multiple entries.
  3. Timetable for CCD harmonization?
  4. Target systems discussion.
    1. EDIS  CDR  RHIO
    2. EDIS  RHIO  Ambulatory EHR
    3. EDIS  Ambulatory EHR
  5. Potential need for LOINC codes for new elements.
  6. Use of Co-occurrence Constraint [Conditional Restraint] for Disposition elements.
  7. Snomed vs. DEEDS for Disposition?
  8. New LOINC codes for data elements
    • ED Referral Note
    • Prehospital Care Note (EMS Note)
    • ED Triage Note
    • ED Triage Note
    • Procedure Performed

Closed Issues

  1. Content vetted by full Patient_Care_Coordination Technical Committee.
  2. 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

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) http://www.ahrq.gov/research/esi/, and Canadian Triage and Acuity Scale (CTAS). 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.

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

  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 the hospital information system or CDR, perhaps using Query_for_Existing_Data
  4. Imported from an Emergency_Department_Referral (IHE 2006-2007)
  5. 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:

  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.

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

Bindings

TODO: put folder bindings in -- create a list of codes for folder types, EDER? -- in ?section 4.3



IHE Content Modules

IHE PCC Template Identifiers

Editorial Note: The following rows to be added the list of IHE PCC Template Identifiers in PCC TF-2:5.1.2
{{{1}}} IHE PCC Template Identifiers
Extension Description
1.3.6.1.4.1.19376.1.5.3.1.1.X.X ED Nursing Note
1.3.6.1.4.1.19376.1.5.3.1.1.X.X ED Triage Note
1.3.6.1.4.1.19376.1.5.3.1.1.X.X ED Physician Note

Folder Content Specification

{{{1}}} IHE PCC Template Identifiers
Extension Description Opt LOINC
1.3.6.1.4.1.19376.1.5.3.1.1.X.X ED Nursing Note R XXXXX.X NURSING NOTE
1.3.6.1.4.1.19376.1.5.3.1.1.X.X ED Triage Note R XXXXX-X TRIAGE
1.3.6.1.4.1.19376.1.5.3.1.1.X.X ED Physician Note R 28568-4 VISIT NOTE (Physician)
1.3.6.1.4.1.19376.1.5.3.1.1.X.X Lab Report R2
Consultation Notes R2
Imaging and Diagnostic Studies R2

CDA Release 2.0 Content Modules

Data Element Index

Data Element Requirements Other Reference LOINC Section or CDA Element
ED Encounter Record – Data Element Index
Facility Identification Data
Patient Administrative Identifiers
Participating Providers and Roles 18699-9 ED PRACTITIONER CMPLX ATTACH.ED
ED Arrival Data
Referral Source 11293-8 ED REFERRAL SOURCE (DEEDS 4.05)
ED Referral Summary XXXXX-X ED REFERRAL NOTE
Mode of Arrival 11459-5 TRANSPORT MODE
Prehospital Care Report XXXXX-X PREHOSPITAL CARE REPORT
Triage Note XXXXX-X ED TRIAGE NOTE (29753-1 INITIAL EVALUATION NOTE (NURSING) ATTACH.CLINRPT
Acuity Assessment 11283-9 ACUITY ASSESSMENT
Chief Complaint 10154-3 CHIEF COMPLAINT
Vital Signs 34565-2 VITAL SIGNS, WEIGHT & HEIGHT PANEL
Blood Pressure 18684-1 BLOOD PRESSURE ATTACH.ED
Pulse 18708-8 HEART BEAT ATTACH.ED
Temperature 18688-2 BODY TEMPERATURE ATTACH.ED
Oxygen Saturation Need different code, this is method specific for co-oximetry done on blood gas Best option for LOINC is unpublished code 'LP6469' or SNOMED-CT 252465000 30370-1 OXYHEMOGLOBIN/HEMOGLOBIN.TOTAL OxyHgb fr BldCoA
Height 3137-7 BODY HEIGHT MEASURED
Weight 3141-9 BODY WEIGHT MEASURED
ED Nursing Note
Nursing Assessments
Pain Score REPORTED.VISUAL ANALOG SCORE 38214-3 PAIN SEVERITY
Level of Consciousness 28265-7 CONSCIOUSNESS.STATUS OBSERVED.OMAHA
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
Assessment and Plan 18776-5 PLAN OF TREATMENT
ED Course
Medications Administered 18610-6 MEDICATION ADMINISTERED (COMPOSITE)
Intravenous Fluids Administered 8974-8 FLUID INTAKE.INTRAVASCULAR
Procedures Performed LOINC Code for Procedure needed XXXXX-X PROCEDURE 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 (Coded/Description)
ED Disposition 11302-7 ED DISPOSITION (MAY WANT UB-92)
Admission Data
Inpatient Facility THIS IS REALLY LOCATION...
Inpatient Practitioner 18774-0 STAFF PRACTITIONER NAME ???
Discharge Data
Discharge Medications This is different from LOINC in DC summary 18617-1 MEDICATION DISCHARGE 0,n
Discharge Instructions 8653-8 HOSPITAL DISCHARGE INSTRUCTIONS ???
Referral at ED Disposition 11303-5 ED DISPOSITION CONSULT/REFERRAL
ED Referral Practitioner 39266-2 FOLLOW-UP (REFERRED TO) PROVIDER/SPECIALIST CPHS ATTACH.CPHS
Transfer Data 28616-1 TRANSFER SUMMARIZATION NOTE PHYSICIAN ATTACH.CLINRPT (probably wrong)
Facility Receiving ED Patient 11453-8 RECEIVING FACILITY
Accepting Practitioner 11303-5 ED DISPOSITION CONSULT/REFERRAL ???
Consents
Advance Directives 42348-3 ADVANCED DIRECTIVES
Pertinent Insurance Information
Data needed for state and local referral forms, if different than above

Document Specification

Data Element Requirements Opt Section TemplateID Comments
ED Encounter Record – Document Specification
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 5.4.3.4.3 1.3.6.1.4.1.19376.1.5.3.1.9.49  
Blood Pressure R
Pulse R
Temperature R
Oxygen Saturation R2
Pain Score R2
Level of Consciousness R2
Height R2
Weight R2
Physician History R
Chief Complaint R
History Present Illness R 5.4.3.2 1.3.6.1.4.1.19376.1.5.3.1.3.6  
Active Problems R
Current Meds R
Allergies R
List of Surgeries R2
Immunizations R2
Family History R2
Social History R2
History of Pregnancies R2
LMP R2
Pertinent ROS R2
Physical Examination R 5.4.3.4.1 1.3.6.1.4.1.19376.1.5.3.1.1.9.15  
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

Templates Section

Section Template 1

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.X
Parent Template 1.3.6.1.4.1.19376.1.5.3.1.3.Y
General Description This section shall ...
LOINC Code Opt Description
#####-# R Description
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.4.A O Description
Sub-sections Opt Description
1.3.6.1.4.1.19376.1.5.3.1.3.D R Description

CDA Section Example

Development Only

The PCC Wiki Content is used only for development of IHE PCC Content. The Normative content of the PCC Technical Framework and the current supplements can be found at https://www.ihe.net/resources/technical_frameworks/#pcc

Draft.gif Name Section
[[Category:Templates using {{{4}}}]]
Template ID OID1
General Description Description
LOINC Codes Opt Description
{{{4}}} {{{3}}} [[Emergency Department Encounter Record#{{{4}}}|R]]



Sample Name Section 
<component>
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    <id root=' ' extension=' '/>
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    <text>
      Text as described above
    </text>  
       
  </section>
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Uses

See Templates using the Name Section



Development Only

The PCC Wiki Content is used only for development of IHE PCC Content. The Normative content of the PCC Technical Framework and the current supplements can be found at https://www.ihe.net/resources/technical_frameworks/#pcc

Draft.gif Name2 Section
[[Category:Templates using {{{4}}}]] [[Category:Templates using {{{4}}}]] [[Category:Templates using {{{4}}}]]
Template ID OID2
Parent Template {{{ParentName}}} (OID1)
General Description Description2
Entries Opt Description
{{{4}}} {{{3}}} [[Emergency Department Encounter Record#{{{4}}}|O]]
{{{4}}} {{{3}}} [[Emergency Department Encounter Record#{{{4}}}|O2]]
Subsections Opt Description
{{{4}}} {{{3}}} [[Emergency Department Encounter Record#{{{4}}}|O]]



Parent Template

The parent of this template is {{{ParentName}}}.

Sample Name2 Section 
<component>
  <section>
    <templateId root='OID1'/>
    <templateId root='OID2'/>
    <id root=' ' extension=' '/>
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    <entry>
      Required and optional entries as described above
    </entry>

    <component>
      Required and optional subsections as described above
    </component>
       
  </section>
</component>


Uses

See Templates using the Name2 Section


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