Inventory of Health Care Information Standards. E1744-95, Standard Guide for a View of Emergency Medical Care in the Computerized Patient Record

01/01/1997

Contact For More Information

Manager - Committee E31, ASTM

Barr Harbor Drive

West Conshohocken, PA 19373

Ph: 610-832-9500

Fax: 610-832-9666

Description of Standard

This guide covers the identification of the information that is necessary to document emergency medical care in a computerized patient record that is part of a paperless patient record system designed to improve efficiency and cost-effectiveness. It details the use of data elements already established for emergency care in the field or in a treatment facility and places them in the context of the object models for health care that will be the vehicle for communication standards for health care data. The codes for the data elements referred to in the document will be developed in consideration of national or professional guidelines whenever available. The EMS definitions are based on those generated from the national consensus conference sponsored by NHTSA and from ASTM F30.03.03 on EMS management information systems. The Emergency Department (ED) definitions will consider those recommended by the Data Elements for Emergency Department Systems workshop sponsored by CDC, NHTSA, and other public and private organizations. The hospital discharge definitions will be developed in consideration of existing requirements for Medicare and Medicaid payment. The ASTM process allows for the definitions to be updated as the national consensus changes. When national or professional definitions do not exist, or whenever there is a conflict in the definitions, the committee will recommend a process for resolving the conflict or present the various definitions within the document along with an explanation for the purpose of each definition.

This view reinforces the concepts set forth in E-1239 and E-1384 that documentation of care in all settings must be seamless and be conducted under a common set of precepts using a common logical record structure and common terminology. The computerized patient record focuses on the patient and includes information about the occurrence of the emergency, symptoms requiring emergency medical treatment, medical/mental assessment/diagnoses established, treatment rendered, outcome and disposition of the patient after emergency treatment. It consists of subsets of the data computerized by multiple care providers at the time of onset/scene and enroute, in the emergency department, in the hospital or other emergency health care settings. The computerized patient record focuses on the documentation of information that is necessary to support patient care but does not define appropriate care.

Readiness of Standard

This guide is a "view" of the data elements to document the types of emergency medical information that would be valuable if available in the computerized patient record. As a view of the computerized patient record, the information presented will conform to the structure defined in other ASTM standards for the computerized patient record. This guide is intended to amplify Guides E 1239, E 1384, and F 1629 and the formalisms described in Practice E 1715. It is implementable in that it consists of a list of data elements important to emergency medical care that vendors can include in their data systems. The guide does not include attribute values for each of the data elements. However, most of these data elements are already defined in the other documents as indicated in Section VI. (The EMS definitions are based on those generated from the national consensus conference sponsored by NHTSA and from ASTM F30.03.03 on EMS management information systems. The Emergency Department (ED) definitions will consider those recommended by the Data Elements for Emergency Departments Workshop sponsored by CDC, NHTSA, and other public and private organizations. The hospital discharge definitions will be developed in consideration of existing requirements for Medicare and Medicaid payment.) The guide is currently being revised to include the attribute values. The guide may be obtained for a fee from ASTM.

The standard is published and is an American National Standard. How can the standard be obtained? ASTM standards are available through the ASTM Customer Service Department by calling 610-832-9585. Standards can also be ordered through the ASTM Web Site at www.astm.org

Indicators of Market Acceptance

Approximately 2300 copies of the E31 standards have been distributed.

The Guide will be incorporated into the overall standards for the computerized patient record and is not designed to stand alone.

Level of Specificity

Same as information under VII.

Relationships with other Standards

There are no other similar Standards related to emergency medical care that have been developed by an authorized SDO. Defacto standards developed by the organizations listed in VI include data sets that have been developed during a formal consensus process (EMS), through broad participation by all stakeholders (ED) or through the payment of public funds (hospital). The definitions developed during these efforts will be incorporated into the next revision of E-1744.