ASTM E1744 - 04(2010) Standard Practice for View of Emergency Medical Care in the Electronic Health Record (Withdrawn 2017).pdf

1、Designation: E1744 04 (Reapproved 2010) An American National StandardStandard Practice forView of Emergency Medical Care in the Electronic HealthRecord1This standard is issued under the fixed designation E1744; the number immediately following the designation indicates the year oforiginal adoption o

2、r, in the case of revision, the year of last revision. A number in parentheses indicates the year of last reapproval. Asuperscript epsilon () indicates an editorial change since the last revision or reapproval.1. Scope1.1 This practice covers the identification of the informationthat is necessary to

3、 document emergency medical care in anelectronic, paperless patient record system that is designed toimprove efficiency and cost-effectiveness.1.2 This practice is a view of the data elements to documentthe types of emergency medical information that should beincluded in the electronic health record

4、.1.2.1 The patients summary record and derived data setswill be described separately from this practice.1.2.2 As a view of the electronic health record, the infor-mation presented will conform to the structure defined in otherASTM standards for the electronic health record.1.3 This practice is inten

5、ded to amplify Guides E1239 andF1629 and the formalisms described in Practices E1384 andE1715.1.3.1 This practice details the use of data elements alreadyestablished in these standards and other national guidelines foruse during documentation of emergency care in the field or ina treatment facility

6、and places them in the context of the objectmodels for health care in Practice E1384 that will be thevehicle for communication standards for health care data.1.3.1.1 The data elements and the attributes referred to inthis practice are based on national guidelines whenever avail-able.1.3.1.2 The EMS

7、definitions are based on those generatedfrom the previous EMS consensus conference sponsored byNHTSA and from ASTM task group F 30.03.03 on EMSManagement Information Systems.1.3.1.3 The Emergency Department (ED) definitions arebased on the Data Elements for Emergency Department Sys-tems (DEEDS) dist

8、ributed by the Centers for Disease Controlin June 1997.1.3.1.4 The hospital discharge definitions are based onrecommendations from the Centers for Medicare and MedicaidServices (CMS) for Medicare and Medicaid payment and fromthe Department of Health and Human Services for the UniformHospital Dischar

9、ge Data Set.1.3.1.5 Because the current trend is to store data as text, thecodes for the attribute values have been determined as unnec-essary and thus are eliminated from this document.1.3.1.6 The ASTM process allows for the data elements tobe updated as the national consensus changes. When nationa

10、lor professional guides do not exist, or whenever there is aconflict in the existing EMS, ED, hospital or other guides, thecommittee will recommend a process for resolving the conflictor an explanation of the conflict within each guide.1.3.2 This practice reinforces the concepts set forth in GuideE1

11、239 and Practice E1384 that documentation of care in allsettings shall be seamless and be conducted under a commonset of precepts using a common logical record structure andcommon terminology.1.4 The electronic health record focuses on the patient.1.4.1 In particular, the computerbased patient recor

12、d setsout to ensure that the data document includes:1.4.1.1 The occurrence of the emergency,1.4.1.2 The symptoms requiring emergency medicaltreatment, and potential complications resulting from preexist-ing conditions,1.4.1.3 The medical/mental assessment/diagnosesestablished,1.4.1.4 The treatment r

13、endered, and1.4.1.5 The outcome and disposition of the patient afteremergency treatment.1.4.2 The electronic health record consists of subsets of datafor the emergency patient that have been captured by differentcare providers at the time of treatment at the scene and enroute, in the emergency depar

14、tment, and in the hospital or otheremergency health care settings.1.4.3 The electronic record focuses on the documentation ofinformation that is necessary to support patient care but doesnot define appropriate care.1This practice is under the jurisdiction of ASTM Committee E31 on HealthcareInformati

15、cs and is the direct responsibility of Subcommittee E31.25 on HealthcareData Management, Security, Confidentiality, and Privacy.Current edition approved March 1, 2010. Published August 2010. Originallyapproved in 1995. Last previous edition approved in 2004 as E174404. DOI:10.1520/E1744-04R10.Copyri

16、ght ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, PA 19428-2959. United StatesNOTICE: This standard has either been superseded and replaced by a new version or withdrawn.Contact ASTM International (www.astm.org) for the latest information12. Referenced Documents2.1 ASTM

17、Standards:2E1239 Practice for Description of Reservation/Registration-Admission, Discharge, Transfer (R-ADT) Systems forElectronic Health Record (EHR) SystemsE1384 Practice for Content and Structure of the ElectronicHealth Record (EHR)E1633 Specification for Coded Values Used in the ElectronicHealth

18、 RecordE1715 Practice for An Object-Oriented Model forRegistration, Admitting, Discharge, and Transfer (RADT)Functions in Computer-Based Patient Record SystemsE1869 Guide for Confidentiality, Privacy, Access, and DataSecurity Principles for Health Information Including Elec-tronic Health RecordsE198

19、5 Guide for User Authentication and AuthorizationE2084 Specification for Authentication of Healthcare Infor-mation Using Digital Signatures (Withdrawn 2009)3F1177 Terminology Relating to Emergency Medical Ser-vicesF1288 Guide for Planning for and Response to a MultipleCasualty IncidentF1629 Guide fo

20、r Establishing Operating Emergency Medi-cal Services and Management Information Systems, orBoth (Withdrawn 2015)32.2 ANSI Standard:X3.172 American National Dictionary for Information Sys-tems 199042.3 Institute of Electrical Electronic Engineers Standards:610.12 Standard Glossary of Software Enginee

21、ring Termi-nology53. Terminology3.1 For definitions of terms used in this specifcation, refer toANSI X3.172 and IEEE 610.123.2 Definitions of Terms Specific to This Standard:3.2.1 emergency conditionchange(s) in the patientshealth status perceived to require immediate medical attentionto prevent unn

22、ecessary death or disability (See also GuideF1177).3.2.2 emergency department (ED) data setthat set of dataelements collected in the emergency outpatient treatmentfacility prior to admission as an inpatient.3.2.3 emergency encountera single event of health carefor an emergency, such as care at the s

23、cene, or at the emergencyoutpatient setting. It concludes when the patient proceeds to thenext phase of care for the emergency.3.2.4 emergency episodea series of encounters relating toan emergency condition that may lead either to death, fullrecovery, or a clinical steady state.3.2.5 emergency episo

24、de documentationthose recordedobservations that describe the care rendered during the periodof an emergency episode, whether brief or extended.3.2.6 other emergency outpatient facilityemergency facil-ity that is not a licensed emergency department connected to anacute care hospital but which provide

25、s emergency stabilizationand treatment upon demand. Such facilities may includeclinic/health centers, freestanding ambulatory surgery center,physicians office, etc.3.2.7 pre-hospital EMS data setthat set of data elementscollected at onset and en route prior to arrival at the firsttreatment facility.

26、4. Significance and Use4.1 The Emergency Medical Service System (EMSS) in theUnited States has largely arisen since 1945 and has drawn to agreat degree from the experience gained in military conflictsduring and since World War II. The documentation of care,however, has remained largely paper recordb

27、ased until re-cently.4.1.1 Beginning in the 1970s both civilian and militaryagencies have closely examined electronic means of storingand managing patient data about emergency medical care.4.1.2 The report of the Institute of Medicine on theComputer-Based Patient Record has emphasized the use ofinfo

28、rmation technology in patient care in general and emer-gency care data in particular.4.1.3 During this period ASTM has documented the logicalstructure of the electronic health record in Guide E1239 andPractice E1384, while Guides F1288 and F1629 has defined thepatient care data, to be gathered in th

29、e pre-hospital record, andthe outcome data, relative to the pre-hospital phase of theemergency, which are collected in the emergency departmentand after inpatient admission.4.1.3.1 Specifications for the logical model are also pre-sented in Practice E1715.4.2 This practice shows how the data gathere

30、d for EMSoperations and management merge smoothly into thecomputer-based patient record, consistent with the recognitionthat these data are part of the primary record of care. Severalstates6have formalized that recognition in state law.4.2.1 This practice does not instruct physicians how tocollect d

31、ata for patient care.4.2.2 This practice does not indicate what information needsto be collected at the time of patient care.4.3 The task now is to document, using standardconventions, the means by which this integration occurs inorder to set the stage for the capture and transfer of such2For refere

32、nced ASTM standards, visit the ASTM website, www.astm.org, orcontact ASTM Customer Service at serviceastm.org. For Annual Book of ASTMStandards volume information, refer to the standards Document Summary page onthe ASTM website.3The last approved version of this historical standard is referenced onw

33、ww.astm.org.4Available from American National Standards Institute (ANSI), 25 W. 43rd St.,4th Floor, New York, NY 10036, http:/www.ansi.org.5Available from Institute of Electrical and Electronics Engineers, Inc. (IEEE),445 Hoes Ln., P.O. Box 1331, Piscataway, NJ 08854-1331, http:/www.ieee.org.6State

34、of Washington: Revised Code of Washington 76.168 and WashingtonAdministrative Code 246-976-380.E1744 04 (2010)2emergency care data using information technology and tele-communications in a standardized way consistent with all othersettings of care while protecting the privacy and confidentialityof t

35、hat data.4.3.1 The electronic health record has the potential to reducehealth care costs by optimizing case management and support-ing effective post ED follow-up.4.3.2 Systematizing the data also enhances its ability to beused consistently, with proper protection, for research into andfor managemen

36、t of EMSS operations within the variousjurisdictional boundaries.4.4 The electronic form of the emergency episode documen-tation utilizes the same logical data model as the electronichealth record, but it focuses on data collected during thedifferent phases of the emergency.4.4.1 These data sets do

37、not limit what may be recorded, orby whom, but they do identify those data considered essential,when they exist. These data sets include all those data recordedto document instances of emergency medical care.4.4.2 Data organized to enhance flexible and efficient man-agement of information.4.4.2.1 Id

38、entifications of practitioners and facilities will becoded, when necessary, to protect confidentiality and to makeprovider data comparable. Names will be included when theyare necessary to support patient care. Privacy and confidenti-ality of patient data should be handled according to GuideE1869.4.

39、4.2.2 Provider identification numbers will be maintainedon master data files which also include additional informationsuch as specialty, license level, and the like.4.4.2.3 Provider identification numbers recorded in the elec-tronic health record will automatically link to the master datafiles to el

40、iminate the need for duplicate data entry of referencematerial in the patient record.4.4.2.4 Coding systems for emergency reporting (ICD-9-CM, CPT,7HCPCS,8SNOMED9) will be referenced in themaster data files for Practice E1384 as appropriate.4.4.2.5 The efficient arrangement of the logical model ofPr

41、actice E1384 permits output to be generated and identified tomirror the paper record, such as nurse-specific or physician-specific notes.4.4.2.6 The arrangement of the logical model permits mul-tiple entries of assessment data, using a small group ofvariables, that can then be used to generate outpu

42、t. Forexample, sequence of diagnoses by date-time.5. Phases of Emergency Medical Care5.1 Patient data are collected during the different phases ofthe emergency by different care providers, the number and typedepend on the severity of the emergency.5.1.1 Fig. 1 presents the different phases of emerge

43、ncy fromonset until final disposition, at which point the patient is nolonger the responsibility of emergency care.5.1.2 In some instances, emergency patients are transportedfrom the location of onset to an emergency department andthen later transferred to specialty tertiary care centers to receivet

44、reatment for life-threatening medical problems.5.1.3 Records completed for the emergency patient at dif-ferent points in time are unique to the type of emergencyresponse and the phase of the emergency.5.1.4 This practice does not include rehabilitation andoutpatient follow-up as part of emergency me

45、dical care sincethis information is recorded elsewhere in the RHR and is notwithin the scope of this practice.5.2 Documentation of emergency care is more efficient ifthe data are captured at the time of collection so that thisinformation can be incorporated simultaneously into the elec-tronic health

46、 record at the time of data entry.5.3 A core of patient identification information (age/date ofbirth, sex/gender, facility identification, times, etc.) is commonto all of the medical records.5.3.1 Other data elements exist that are unique to theemergency event, and still others exist that are unique

47、 to aspecific care site.5.3.2 Although many different records may be completedfor a single emergency patient, not all of the data collected areincorporated into the electronic health record.5.3.2.1 Except for times (see 6.14.4 and 6.14.14), adminis-trative data which are useful for ambulance service

48、 manage-ment information, such as the use of lights and sirens andmileage, the EMS agencys response number, the type of EMSvehicle, and environmental factors affecting EMS care, havebeen excluded from the electronic health record, which focuseson the patient.5.4 The electronic health record has the

49、potential to improvedata quality as follows.5.4.1 Time and date entries will not be subject to theidiosyncrasies of the clock at hand, or the memory of theperson entering the data but may be automatically recorded bythe computer; however, when data are entered retrospectively,the system should allow a manual override to record actualtime.5.4.2 Direct data entry, by voice, dictation, touch, etc., bythe care provider will eliminate the need to interpret the careproviders handwriting.5.5 Each segment of emergency care is cumulative, thoughnot necessarily sequen