ASTM E1744-04(2010)
(Practice)Standard Practice for View of Emergency Medical Care in the Electronic Health Record (Withdrawn 2017)
Standard Practice for View of Emergency Medical Care in the Electronic Health Record (Withdrawn 2017)
SIGNIFICANCE AND USE
The Emergency Medical Service System (EMSS) in the United States has largely arisen since 1945 and has drawn to a great degree from the experience gained in military conflicts during and since World War II. The documentation of care, however, has remained largely paper record–based until recently.
Beginning in the 1970s both civilian and military agencies have closely examined electronic means of storing and managing patient data about emergency medical care.
The report of the Institute of Medicine on the Computer-Based Patient Record has emphasized the use of information technology in patient care in general and emergency care data in particular.
During this period ASTM has documented the logical structure of the electronic health record in Guide E1239 and Practice E1384, while Guides F1288 and F1629 has defined the patient care data, to be gathered in the pre-hospital record, and the outcome data, relative to the pre-hospital phase of the emergency, which are collected in the emergency department and after inpatient admission.
Specifications for the logical model are also presented in Practice E1715.
This practice shows how the data gathered for EMS operations and management merge smoothly into the computer-based patient record, consistent with the recognition that these data are part of the primary record of care. Several states have formalized that recognition in state law.
This practice does not instruct physicians how to collect data for patient care.
This practice does not indicate what information needs to be collected at the time of patient care.
The task now is to document, using standard conventions, the means by which this integration occurs in order to set the stage for the capture and transfer of such emergency care data using information technology and telecommunications in a standardized way consistent with all other settings of care while protecting the privacy and confidentiality of that data.
The electronic health record has the ...
SCOPE
1.1 This practice covers the identification of the information that is necessary to document emergency medical care in an electronic, paperless patient record system that is designed to improve efficiency and cost-effectiveness.
1.2 This practice is a view of the data elements to document the types of emergency medical information that should be included in the electronic health record.
1.2.1 The patient's summary record and derived data sets will be described separately from this practice.
1.2.2 As a view of the electronic health record, the information presented will conform to the structure defined in other ASTM standards for the electronic health record.
1.3 This practice is intended to amplify Guides E1239 and F1629 and the formalisms described in Practices E1384 and E1715.
1.3.1 This practice details the use of data elements already established in these standards and other national guidelines for use during documentation of emergency care in the field or in a treatment facility and places them in the context of the object models for health care in Practice E1384 that will be the vehicle for communication standards for health care data.
1.3.1.1 The data elements and the attributes referred to in this practice are based on national guidelines whenever available.
1.3.1.2 The EMS definitions are based on those generated from the previous EMS consensus conference sponsored by NHTSA and from ASTM task group F 30.03.03 on EMS Management Information Systems.
1.3.1.3 The Emergency Department (ED) definitions are based on the Data Elements for Emergency Department Systems (DEEDS) distributed by the Centers for Disease Control in June 1997.
1.3.1.4 The hospital discharge definitions are based on recommendations from the Centers for Medicare and Medicaid Services (CMS) for Medicare and Medicaid payment and from the Department of Health and Human Services for the Uniform Hospital Discharge Data Set.
1.3.1.5 ...
General Information
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Standards Content (Sample)
NOTICE: This standard has either been superseded and replaced by a new version or withdrawn.
Contact ASTM International (www.astm.org) for the latest information
Designation: E1744 − 04 (Reapproved 2010) An American National Standard
Standard Practice for
View of Emergency Medical Care in the Electronic Health
Record
This standard is issued under the fixed designation E1744; the number immediately following the designation indicates the year of
original adoption or, in the case of revision, the year of last revision. A number in parentheses indicates the year of last reapproval. A
superscript epsilon (´) indicates an editorial change since the last revision or reapproval.
1. Scope 1.3.1.4 The hospital discharge definitions are based on
recommendations from the Centers for Medicare and Medicaid
1.1 This practice covers the identification of the information
Services (CMS) for Medicare and Medicaid payment and from
that is necessary to document emergency medical care in an
the Department of Health and Human Services for the Uniform
electronic, paperless patient record system that is designed to
Hospital Discharge Data Set.
improve efficiency and cost-effectiveness.
1.3.1.5 Because the current trend is to store data as text, the
1.2 This practice is a view of the data elements to document
codes for the attribute values have been determined as unnec-
the types of emergency medical information that should be
essary and thus are eliminated from this document.
included in the electronic health record.
1.3.1.6 The ASTM process allows for the data elements to
1.2.1 The patient’s summary record and derived data sets
be updated as the national consensus changes. When national
will be described separately from this practice.
or professional guides do not exist, or whenever there is a
1.2.2 As a view of the electronic health record, the infor-
conflict in the existing EMS, ED, hospital or other guides, the
mation presented will conform to the structure defined in other
committee will recommend a process for resolving the conflict
ASTM standards for the electronic health record.
or an explanation of the conflict within each guide.
1.3 This practice is intended to amplify Guides E1239 and
1.3.2 ThispracticereinforcestheconceptssetforthinGuide
F1629 and the formalisms described in Practices E1384 and
E1239 and Practice E1384 that documentation of care in all
E1715.
settings shall be seamless and be conducted under a common
1.3.1 This practice details the use of data elements already
set of precepts using a common logical record structure and
established in these standards and other national guidelines for
common terminology.
use during documentation of emergency care in the field or in
1.4 The electronic health record focuses on the patient.
a treatment facility and places them in the context of the object
1.4.1 In particular, the computer–based patient record sets
models for health care in Practice E1384 that will be the
out to ensure that the data document includes:
vehicle for communication standards for health care data.
1.4.1.1 The occurrence of the emergency,
1.3.1.1 The data elements and the attributes referred to in
1.4.1.2 The symptoms requiring emergency medical
this practice are based on national guidelines whenever avail-
treatment, and potential complications resulting from preexist-
able.
ing conditions,
1.3.1.2 The EMS definitions are based on those generated
1.4.1.3 The medical/mental assessment/diagnoses
from the previous EMS consensus conference sponsored by
established,
NHTSA and from ASTM task group F 30.03.03 on EMS
1.4.1.4 The treatment rendered, and
Management Information Systems.
1.4.1.5 The outcome and disposition of the patient after
1.3.1.3 The Emergency Department (ED) definitions are
emergency treatment.
based on the Data Elements for Emergency Department Sys-
1.4.2 Theelectronichealthrecordconsistsofsubsetsofdata
tems (DEEDS) distributed by the Centers for Disease Control
for the emergency patient that have been captured by different
in June 1997.
care providers at the time of treatment at the scene and en
route,intheemergencydepartment,andinthehospitalorother
This practice is under the jurisdiction ofASTM Committee E31 on Healthcare
Informatics and is the direct responsibility of Subcommittee E31.25 on Healthcare
emergency health care settings.
Data Management, Security, Confidentiality, and Privacy.
1.4.3 The electronic record focuses on the documentation of
Current edition approved March 1, 2010. Published August 2010. Originally
information that is necessary to support patient care but does
approved in 1995. Last previous edition approved in 2004 as E1744–04. DOI:
not define appropriate care.
10.1520/E1744-04R10.
Copyright © ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, PA 19428-2959. United States
E1744 − 04 (2010)
2. Referenced Documents 3.2.4 emergency episode—a series of encounters relating to
2 an emergency condition that may lead either to death, full
2.1 ASTM Standards:
recovery, or a clinical steady state.
E1239 Practice for Description of Reservation/Registration-
Admission, Discharge, Transfer (R-ADT) Systems for 3.2.5 emergency episode documentation—those recorded
Electronic Health Record (EHR) Systems
observations that describe the care rendered during the period
E1384 Practice for Content and Structure of the Electronic of an emergency episode, whether brief or extended.
Health Record (EHR)
3.2.6 other emergency outpatient facility—emergency facil-
E1633 SpecificationforCodedValuesUsedintheElectronic
itythatisnotalicensedemergencydepartmentconnectedtoan
Health Record
acute care hospital but which provides emergency stabilization
E1715 Practice for An Object-Oriented Model for
and treatment upon demand. Such facilities may include
Registration,Admitting, Discharge, and Transfer (RADT)
clinic/health centers, freestanding ambulatory surgery center,
Functions in Computer-Based Patient Record Systems
physician’s office, etc.
E1869 Guide for Confidentiality, Privacy, Access, and Data
3.2.7 pre-hospital EMS data set—that set of data elements
SecurityPrinciplesforHealthInformationIncludingElec-
collected at onset and en route prior to arrival at the first
tronic Health Records
treatment facility.
E1985 Guide for User Authentication and Authorization
E2084 Specification for Authentication of Healthcare Infor-
4. Significance and Use
mation Using Digital Signatures (Withdrawn 2009)
F1177 Terminology Relating to Emergency Medical Ser-
4.1 The Emergency Medical Service System (EMSS) in the
vices
United States has largely arisen since 1945 and has drawn to a
F1288 Guide for Planning for and Response to a Multiple
great degree from the experience gained in military conflicts
Casualty Incident
during and since World War II. The documentation of care,
F1629 Guide for Establishing Operating Emergency Medi-
however, has remained largely paper record–based until re-
cal Services and Management Information Systems, or
cently.
Both (Withdrawn 2015)
4.1.1 Beginning in the 1970s both civilian and military
2.2 ANSI Standard:
agencies have closely examined electronic means of storing
X3.172 American National Dictionary for Information Sys-
and managing patient data about emergency medical care.
tems 1990
4.1.2 The report of the Institute of Medicine on the
2.3 Institute of Electrical Electronic Engineers Standards:
Computer-Based Patient Record has emphasized the use of
610.12 Standard Glossary of Software Engineering Termi-
information technology in patient care in general and emer-
nology
gency care data in particular.
4.1.3 During this periodASTM has documented the logical
3. Terminology
structure of the electronic health record in Guide E1239 and
3.1 Fordefinitionsoftermsusedinthisspecifcation,referto
PracticeE1384,whileGuidesF1288andF1629hasdefinedthe
ANSI X3.172 and IEEE 610.12
patient care data, to be gathered in the pre-hospital record, and
the outcome data, relative to the pre-hospital phase of the
3.2 Definitions of Terms Specific to This Standard:
emergency, which are collected in the emergency department
3.2.1 emergency condition—change(s) in the patient’s
and after inpatient admission.
health status perceived to require immediate medical attention
to prevent unnecessary death or disability (See also Guide 4.1.3.1 Specifications for the logical model are also pre-
F1177). sented in Practice E1715.
3.2.2 emergency department (ED) data set—that set of data
4.2 This practice shows how the data gathered for EMS
elements collected in the emergency outpatient treatment
operations and management merge smoothly into the
facility prior to admission as an inpatient.
computer-based patient record, consistent with the recognition
3.2.3 emergency encounter—a single event of health care that these data are part of the primary record of care. Several
foranemergency,suchascareatthescene,orattheemergency states have formalized that recognition in state law.
outpatientsetting.Itconcludeswhenthepatientproceedstothe
4.2.1 This practice does not instruct physicians how to
next phase of care for the emergency.
collect data for patient care.
4.2.2 Thispracticedoesnotindicatewhatinformationneeds
to be collected at the time of patient care.
For referenced ASTM standards, visit the ASTM website, www.astm.org, or
contact ASTM Customer Service at service@astm.org. For Annual Book of ASTM
4.3 The task now is to document, using standard
Standards volume information, refer to the standard’s Document Summary page on
conventions, the means by which this integration occurs in
the ASTM website.
3 order to set the stage for the capture and transfer of such
The last approved version of this historical standard is referenced on
www.astm.org.
Available from American National Standards Institute (ANSI), 25 W. 43rd St.,
4th Floor, New York, NY 10036, http://www.ansi.org.
5 6
Available from Institute of Electrical and Electronics Engineers, Inc. (IEEE), State of Washington: Revised Code of Washington 76.168 and Washington
445 Hoes Ln., P.O. Box 1331, Piscataway, NJ 08854-1331, http://www.ieee.org. Administrative Code 246-976-380.
E1744 − 04 (2010)
emergency care data using information technology and tele- 4.4.2.6 The arrangement of the logical model permits mul-
communicationsinastandardizedwayconsistentwithallother tiple entries of assessment data, using a small group of
settings of care while protecting the privacy and confidentiality variables, that can then be used to generate output. For
of that data. example, sequence of diagnoses by date-time.
4.3.1 Theelectronichealthrecordhasthepotentialtoreduce
health care costs by optimizing case management and support- 5. Phases of Emergency Medical Care
ing effective post ED follow-up.
5.1 Patient data are collected during the different phases of
4.3.2 Systematizing the data also enhances its ability to be
theemergencybydifferentcareproviders,thenumberandtype
used consistently, with proper protection, for research into and
depend on the severity of the emergency.
for management of EMSS operations within the various
5.1.1 Fig. 1 presents the different phases of emergency from
jurisdictional boundaries.
onset until final disposition, at which point the patient is no
4.4 Theelectronicformoftheemergencyepisodedocumen-
longer the responsibility of emergency care.
tation utilizes the same logical data model as the electronic
5.1.2 In some instances, emergency patients are transported
health record, but it focuses on data collected during the
from the location of onset to an emergency department and
different phases of the emergency.
thenlatertransferredtospecialtytertiarycarecenterstoreceive
4.4.1 These data sets do not limit what may be recorded, or
treatment for life-threatening medical problems.
by whom, but they do identify those data considered essential,
5.1.3 Records completed for the emergency patient at dif-
when they exist.These data sets include all those data recorded
ferent points in time are unique to the type of emergency
to document instances of emergency medical care.
response and the phase of the emergency.
4.4.2 Data organized to enhance flexible and efficient man-
5.1.4 This practice does not include rehabilitation and
agement of information.
outpatient follow-up as part of emergency medical care since
4.4.2.1 Identifications of practitioners and facilities will be
this information is recorded elsewhere in the RHR and is not
coded, when necessary, to protect confidentiality and to make
within the scope of this practice.
provider data comparable. Names will be included when they
5.2 Documentation of emergency care is more efficient if
are necessary to support patient care. Privacy and confidenti-
the data are captured at the time of collection so that this
ality of patient data should be handled according to Guide
information can be incorporated simultaneously into the elec-
E1869.
tronic health record at the time of data entry.
4.4.2.2 Provider identification numbers will be maintained
on master data files which also include additional information
5.3 A core of patient identification information (age/date of
such as specialty, license level, and the like.
birth, sex/gender, facility identification, times, etc.) is common
4.4.2.3 Provideridentificationnumbersrecordedintheelec-
to all of the medical records.
tronic health record will automatically link to the master data
5.3.1 Other data elements exist that are unique to the
files to eliminate the need for duplicate data entry of reference
emergency event, and still others exist that are unique to a
material in the patient record.
specific care site.
4.4.2.4 Coding systems for emergency reporting (ICD-9-
5.3.2 Although many different records may be completed
7 8 9
CM, CPT, HCPCS, SNOMED ) will be referenced in the
for a single emergency patient, not all of the data collected are
master data files for Practice E1384 as appropriate.
incorporated into the electronic health record.
4.4.2.5 The efficient arrangement of the logical model of
5.3.2.1 Except for times (see 6.14.4 and 6.14.14), adminis-
Practice E1384 permits output to be generated and identified to
trative data which are useful for ambulance service manage-
mirror the paper record, such as nurse-specific or physician-
ment information, such as the use of lights and sirens and
specific notes.
mileage, the EMS agency’s response number, the type of EMS
vehicle, and environmental factors affecting EMS care, have
been excluded from the electronic health record, which focuses
on the patient.
Current Procedure Terminology for Physician Services.
5.4 Theelectronichealthrecordhasthepotentialtoimprove
HCFA (Health Care Financing Administration) Common Procedure Coding
System.
data quality as follows.
Systematized Nomenclature of Medicine.
5.4.1 Time and date entries will not be subject to the
idiosyncrasies of the clock at hand, or the memory of th
...
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