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Emergency Department Information Systems Functional Profile EDIS Functional Profile Working Group Emergency Care Special Interest Group Health Level 7 Co-Chairs Todd C. Rothenhaus, MD FACEP Donald Kamens, MD FACEP FAAEM James McClay, MD, MS Kevin Coonan, MD Version 0.6 (8/1/2006) EDIS - Functional Profile Emergency Care Special Interest Group – HL7 EDIS Functional Profile Working Group EC-SIG Co-chairs Todd C. Rothenhaus, MD FACEP Donald R. Kamens, MD FACEP FAAEM James McClay, MD MS Kevin Coonan, MD Boston University School of Medicine XPress Technologies University of Nebraska Medical Center University of Utah School of Medicine EDIS Functional Profile Working Group Randy Case Dennis G. Cochrane MD FACEP John Epler JT Finnel M. Catherine Glenz RN, BSN John R. Griffith Mark Jaben Richard Hartl MD Laura Heermann Langford, RN, PhD. Daniel Myung JA Magnusun Dan Pollack Uhri Randhas Eric Rock John Santmann MD Bharat Sutariya Chris Thompson, MD, FACEP Siemens Morristown Memorial Hospital, Morristown, NJ Picis Regenstrief Institute Alert Life Sciences Computing, Inc. MEDHOST, Inc. Haywood Regional Medical Center Wellsoft, Inc Intermountain Healthcare Boston University Oregon Department of Human Services Centers for Disease Control MEDHOST, Inc. MEDHOST, Inc. Wellsoft, Inc. Cerner, Inc. Touch Medix, LLC 2 EDIS - Functional Profile Emergency Care Special Interest Group – HL7 3 Emergency Department Information Systems (EDIS) - Functional Profile Emergency Care Special Interest Group – HL7 VERSION 0.6 08/1/2006 Welcome to the EDIS Functional Profile (EDIS-FP) project of the HL7 Emergency Care SIG (EC-SIG). The project is aimed at developing an HL7 Informative Functional Profile for emergency department information systems (EDIS), conforming to the HL7 EHR Functional Model, under the auspices and direction of the EHR Technical Committee. By creating a robust and usable functional profile that includes specific and relevant conformance criteria, we hope to develop an open and objective standard for development, refinement, and comparisons between ED information systems. In 2003, the EHR TC (then a special interest group) began development of a functional model for electronic health record systems (EHR-S). Subsequently, a number of organizations approached HL7 to accelerate development of a consensus standard to define the necessary functions of an EHR. The EHR SIG was promoted to a full technical Committee and in 2004 published the EHR-S Functional model as a Draft Standard for Trail Use (DSTU). The EHR Functional Model remains in development. The EHR-TC intends that unique functional profiles will be developed by subject matter experts in various care settings or domains (i.e. ambulatory, inpatient, anesthesia, long-term care). These functional profiles will serve to inform developers, purchasers, and other stakeholders of the functional requirements of systems developed for these domains. Recently, the Certification Commission on Health Information Technology (CCHIT) adopted the EHR FM as a tool for evaluation of ambulatory and inpatient EHR systems. The EC-SIG has been in communication with the leadership of CCHIT and intends to advance the EDIS-FP as the standard for evaluation of emergency department information systems. The EC-SIG was founded last year to inform the HL7 and other standards development organizations (SDOs) of the unique HIT requirements and workflows of emergency care. The EC-SIG co-chairs solicited input and membership from domestic an international specialty societies, including but not limited to, ACEP, SAEM, AAEM, ENA, and the Canadian and Australasian Emergency Medicine Societies. Participation was also thoroughly solicited from the vendor community through invitations and presentations. In 2005, American College of Emergency Physicians (ACEP) joined HL7 and sponsored membership in the EC-SIG in the form of 4 memberships and 2 funded awards for travel and expenses. Sufficient infrastructure was secured from an unrestricted grant from X-press Technologies to set up an intranet site and weekly teleconferences to supplement thrice yearly face to face meetings at HL7 workgroup meetings. Members of the EDIS-FP include physicians, nurses, medical informatics experts, EDIS developers, engineers, and other representatives from the vendor community. We began the EDIS-FP project by taking a broad look at the functions required of ED systems and without particular reference to the EHR FM, which faces open ballot in HL7 in 2006. Using this methodology, we have discovered at least a few functions that the EHR-TC may have not yet considered in the FM. It has also permitted us to tackle the project in a manner recognizable to most people working in emergency medicine. Ultimately, harmonization between the workgroup product and the FM will need to occur for the product to become an HL7 Informative Functional Profile. We anticipate publication of the workgroup document in a format suitable for practicing emergency department providers and managers to use as a guide to system evaluation and selection. It is also expected that the EDIS-FP will defines conformance for both EHR systems and for any subsequent profiles subsequently developed from the FP itself. The project was planned in four phases: 1. Organization – solicitation of participants, determination of scope and care setting of profile, and development of project plan and overview (completed). 2. Formalization – step by step development of EDIS functions and conformance criteria (largely completed). 3. Harmonization –comparison with, incorporation into, and alignment with the EHR FM (in process). a. Incorporate defined EDIS functions through alignment with EHR-FM. b. Accept or reject other functions from FM. c. Solicit input from EHR TC for possible new functions. d. Define priority timeframes (i.e. essential now, essential future) for functions. e. Incorporate and modify conformance criteria. 4. Finalization – attention to detail, wording, language, conformance and preparation for final EHR – TC approval and external publication. The development of the EDIS FP uses the HL7 approach. That is to say that everyone’s contribution or concern needs to be addressed. Your input is welcome. EDIS - Functional Profile Emergency Care Special Interest Group – HL7 4 Reading this Document The EDIS FP like the EHR FM, is divided into three broad sections: Direct Care, Supportive Functions and Information Infrastructure. Each section defines a broad category of functions applicable to Direct Care Supportive Functions Information Infrastructure We began with a scope of ED care that begins with a “heads-up” and moves through patient arrival, triage, nursing and physician assessment, orders, results, procedures and ongoing assessments, and finally admit/transfer/discharge planning. However, many of these traditional concepts or tasks are interspersed throughout the document, depending upon whether aspects constitute patient tracking, administrative functions, clinical workflow, tasks/orders, clinical documentation, or clinical decision support, etc. For instance, the triage process can be found in both clinical workflow and clinical documentation. If a particular aspect of the profile do not make sense, look for pointers to other areas included in the document. Functional Priorities The EHR TC and EC-SIG recognize that clinical computing is an evolving field, and that many of the desired functions of an EHR-S may not be available at this time. Certain functions, for instance access to regional health information, may not be feasible or essential now because widespread adoption of RHIOs has yet to occur. Nevertheless, it is important for functional profiles to outline major trends and articulate a vision for functionality (especially interoperability) for the future. Furthermore, the delineation of potential functions for future implementation and adoption should guide vendors in development, and help purchasers develop and articulate to vendors a strategic vision for future functional requirements. Each function in the EDIS FP is assigned a single priority as follows: Essential Now Essential Future Optional The function is readily available and the users can implement it. In assigning this priority, the committee believes that the function is critical to helping an EDIS: • Support Delivery of Effective Healthcare • Improve Patient Safety • Facilitate management of chronic conditions • Improve efficiency • Facilitate self-health management The function should be feasible to implement and readily available to users within the prescribed period of time. The function is important or desirable but not a critical component of an EDIS. Conformance Criteria Conformance criteria have been developed in accordance with the standards set forth by the EHR technical committee. In order to ensure consistent, unambiguous understanding and application of the functional profile, the use of a consistent set of keywords (normative verbs) have been employed to describe conformance requirements. SHALL – indicates a mandatory, required action. Synonymous with ‘is required’. SHOULD – indicates an optional, recommended action that is particularly suitable, without mentioning or excluding other actions. Synonymous with ‘is permitted and recommended’. MAY – indicates an optional, permissible action. Synonymous with ‘is permitted’ In addition, clarification is necessary to understand the standardized nomenclature used to describe the functions of a system. The following chart, adapted from the EHR FM, illustrates the hierarchy of nomenclature. For example, “capture” is used to describe a function that includes both direct entry “create” and indirect entry through another device “input”. Similarly, “maintain” is used to describe a function that entails reading, updating, or removal of data. EDIS - Functional Profile Emergency Care Special Interest Group – HL7 5 MANAGE Capture Input Device (Ext.) Maintain Create (Int.) Read (Present) View Report Display Access Update Edit Correct Amend Augment Remove Access Obsolete Inactivate Destroy Nullify Purge ID T y p e Name Statement Description Rationale/Citations Comments Proposed Conformance Criteria Proposed Comments or Changes Direct Care EDC.1 EDC.1.1 (See: DC.3, S.1.4.2) H H Care Management Patient Location Tracking EDC.1.1.1 F Track inbound patients Track patient physical location through all phases of visit, from pre-arrival through disposition. In emergency medicine, the concept of tracking within and EDIS connotes multiple concepts. This section refers to tracking physical location only. Tracking the status of care is covered in Clinical Workflow Tracking and Task Management Track inbound The system shall provide a means to track Most often begins with patients a telephone call made patients who have been referred to the ED. from referring actor to The system shall capture and display the Log information receiving ED. Often, Source of Referral. about incoming the information gets referrals from: haphazardly recorded. The system shall provide a means to document physicians offices, Data must be easily clinical data on patients who have been referred clinics, EMS, accessible, central, transfers from other retrievable, updatable, to the ED. hospitals or EDs, AND transportable. The system shall note the patient who has been nursing homes, Clinical data from referred to the ED as a referral throughout the others. provider to provider is essential to quality ED stay. coordinated care for The system should provide a means to track patients referred to the ED. Knowledge of patients who are en route to the ED via the EMS patients who are system. expected to arrive helps both ED and hospital administrative staff plan resource use in real time. For EMS transports, advanced notification is common, but not the rule. This data is most often taken during a radio call. Hence, patient demographic data is frequently omitted for privacy concerns. The system must allow users to Identify incoming ambulances and be able to reserve bed and assign human resources to incoming patients. EDIS - Functional Profile Emergency Care Special Interest Group – HL7 ID T y p e Name Statement EDC.1.1.2 F Track ED patients Manually (i.e. actively) or automatically (i.e. passively) track patient physical location throughout ED visit. EDC.1.2 H Clinical Workflow EDC.1.2.1 H Arrival Tasks EDC.1.2.1.1 H Patient Registration EDC.1.2.1.1.1 F Enter patient into EDIS 7 Description Rationale/Citations Comments EMS arrivals frequently require inroom registration. Notification to registration of incoming ambulance can target registration staff to be available at time of patient arrival. Identify the current location of patient and the history of movement throughout ED visit. Benchmarks of ED stay (i.e. triage, registration, in-room, disposition, departure) should be automatically captured based on business logic behind location and room types. Proposed Conformance Criteria Proposed Comments or Changes The system shall provide a means to identify the current physical location of a patient in the ED. The system shall provide a means to update the current location of a patient. The system shall record and archive the movement of patients through the ED. The system should provide a means to display the prior location of a patient while still in the ED. Consider adding the term “tracking” to this function name for clarity. The interval from patient arrival to delivery of care ordinarily involves multiple steps. In an EDIS, administrative functions need to be de-coupled from patient care functions. ED patients frequently require evaluation and treatment prior to ADT registration. The ability to provide care before formal registration is essential. In addition, many patients are brought directly to patient care areas. The system shall provide for means for The system shall Enter patient into Sometimes triage EDIS personnel can obtain registration of patients. permit clinical demographic documentation The system shall allow registration of patients information. Other and order entry times, the volume of before, during, and after, provision of care. prior to formal incoming patients is registration. The system should allow a sequential too great, and triage must concentrate on accumulation of registration data,, so that clinical information registration does not interfere with the delivery of only. care. Capture demographics at bedside for patients brought directly to The system should provide a means to obtain demographic data and document consent for treatment in the triage area. EDIS - Functional Profile Emergency Care Special Interest Group – HL7 ID T y p e EDC.1.2.1.1.2 Name Statement John Doe Registration Enter patient without demographic data into EDIS. (See DSTU. ”anonymous registration”) EDC.1.2.1.1.3 Quick Registration Identify patient in EDIS and create a new visit. EDC.1.2.1.1.4 Merge Registrations Merge Registrations EDC.1.2.1.2 EDC.1.2.1.2.1 F Triage Manage triage acuity rating Provide a means to capture and maintain a triage acuity rating (level) to the patient. 8 Description Rationale/Citations Comments treatment areas. Patients may present who are unable to provide any demographic data. Anonymous registration (John Doe) also allows RN to pass entire work of obtaining and entering demographics to registration staff. To maximize usability, identification of patients with prior visits should be possible to aid in triage by recovering prior medications, allergies, problems. Time can be spent verifying, updating, and correcting data, as well as minimize data entry. This is called “quick registration” by a number of vendors. Formal registration may occur in EDIS or hospital ADT system. A means must be provided to register patient in hospital ADT system and merge data with EDIS via an inbound ADT feed, or alternatively capture entire demographic data into EDIS and send that data to the hospital ADT system. Ref: Five-Level Triage: A Report from the ACEP/ENA Five-Level Triage Task Force. Proposed Conformance Criteria Proposed Comments or Changes The system should provide for John Doe registration The system should allow for quick registration. The system shall provide a means for merger of registrations. The system shall provide a means to assign a triage acuity rating to a patient. The system shall permit the use of standardized This requires additional conformance akin to a longitudinal care record. EDIS - Functional Profile Emergency Care Special Interest Group – HL7 ID EDC.1.2.1.2.2 EDC.1.2.1.2.3. EDC.1.2.1.3 EDC.1.2.1.3.1 T y p e F F H F Name Capture Initial Vital signs Manage/Prioritize/Sort/ Triage List EMS Arrival Tasks Manage EMS data Statement 9 Description Rationale/Citations Comments Journal of Emergency Nursing, Volume 31: 39-50, 2005. Capture Initial vital signs Identify priorities within the triage list. Re-prioritize when necessary, communicate these to other care areas in the ED. Triage lists are dynamic, with changing priorities, and the necessity for continued communication with other parts of the ED. Capture and display EMS data. Consider future interoperability features with EMS Information Systems (i.e. automatically capture data, telemetry collected electronically prior to patient arrival). Capture EMS Data Information, Tests Proposed Conformance Criteria Proposed Comments or Changes ED triage scales The system shall permit triage acuity rating to be customized according to locally derived rules. The system shall provide a means to record initial vital signs. The system may provide a means for automated capture and recording of vital signs via external devices. The system shall provide a mechanism to display patients who are waiting to be seen. Question as to what this means? The system should provide a means to sort or display patients who are waiting to be seen by various criteria. This may be better moved to EDC.1.5.1 Capture ED Arrival Data The system should provide a mechanism for recording and retrieval of pre-hospital information. The system shall provide a mechanism for the capture of electronic EMS data (i.e. EKG, telemetry, defibrillator data). When available, the system should electronically capture EMS Data, EMS Telemetry, and display alarms and concerns. When electronic capture is not available to EMS, the system may allow EMS personnel to easily input EMS data, telemetry, and other information into the system. EDIS - Functional Profile Emergency Care Special Interest Group – HL7 ID T y p e EDC.1.2.2 H Name Clinical Workflow Task Management: Creation, Display, Prioritization, and Notification See: EHR-FM: Clinical workflow tasking (DC 3.1) Clinical task assignment and routing (DC 3.1.1) Clinical task linking (DC 3.1.2) Clinical task tracking (DC.3.1.3) Clinical task timeliness tracking (DC.3.1.3.1) 10 Description Proposed Rationale/Citations Proposed Conformance Criteria Comments or Comments Changes In the ED, there exists a critical need for distributed communication of the status of workflow tasks. An essential EDIS function is the management and display of tasks to be accomplished. In the pre-EHR era, this was accomplished by “artifacts” (grease boards, chart racks, etc.). Systems in the ED, therefore must seek to achieve the a level of embedded buy-in and participation as have home-grown artifacts. Statement Communication of priorities is difficult in the ED. Work to be done is constantly changing. For instance, a critically ill patient has the immediate effect of re-prioritizing all workflow. In the ED, shifting of priorities is the norm, not the exception. Tasks in the ED are usually assigned to at least one member (or department) of the healthcare team. Tasks are generally linked to a particular patient, or occasionally to infrastructure in the ED (i.e. bed needs cleaning). The EDIS should be extensible enough to accommodate the complexity of clinical task routing according to local needs. For instance, in one ED, the assignment of a task “Chest Radiograph” may be assigned to the patient’s primary RN alone (sub-optimal), who carries out the task of ordering the study in the RIS and contacting transport to take the patient to the radiology department. In another ED, the same task might entail the creation of multiple sub-tasks to: Alert the primary RN that the patient requires transport out of the department Alert the radiology technologist to perform the study Alert the transporter to transport the patient to radiology Send an HL7 message to the RIS ordering the study. The tracking and display of tasks takes two major forms: The status and display of tasks for a particular member of the healthcare team (i.e. MD, RN or Tech) or an external department (i.e. Radiology, Laboratory, Admitting) The status and display of tasks for an individual patient In an EDIS, the optimal display of clinical tasks is visible, and communicates at a distance. EDC.1.2.2.1 F Task Management Manage ED tasks with the EDIS See: Clinical workflow tasking (DC 3.1) EDC.1.2.2.2 F Task assignment and routing See: Clinical task assignment and routing (DC 3.1.1) Assign tasks to ED providers or ancillary departments. Provide a means to identify tasks in the EDIS. Examples include: Tests/X-Ray/Lab Clinical Tasks Consultations ADT (placed in disposition section) The system shall maintain a list of tasks. The system shall permit the creation of new tasks. The system shall permit prioritization of tasks according to patient severity, LOS, or other criteria. The system shall permit the delegation of tasks to one or multiple providers. The system shall permit the provider to reprioritize tasks. The system shall notify the clinicians when tests and laboratory results have been returned for review. EDIS - Functional Profile Emergency Care Special Interest Group – HL7 ID T y p e EDC.1.2.2.3 EDC.1.2.2.4 11 Description Rationale/Citations Comments Name Statement F See: Clinical task linking (DC 3.1.2) F Display/Notify Status of Care Link clinical tasks to a particular patient, an object, or a place in the ED chart. Display those tasks which have been ordered or initiated, but have not been completed. The system shall link each clinical task to a patient, an object in the department (i.e. bed to be cleaned), or a place on the patient’s ED chart (i.e. interpretation of ECG). The system shall track creation, acknowledgment, and completion of tasks. Display and notify providers about tasks which have returned results that are awaiting review. The system shall display an up to date list of tasks to be done by patient. See: Clinical task tracking (DC.3.1.3) Proposed Conformance Criteria The system shall display an up to date list of tasks to be done by provider. This system shall display tests and radiological studies that have been ordered. The system shall notify the clinician when clinical tasks are complete. The system shall display consultations which are pending. The system should notify of the completion of consultations. EDC.1.2.2.5 F Display overdue tasks or results. See: Clinical task timeliness tracking (DC.3.1.3.1) Display and notify providers of tasks which are overdue. The system may display ETA of consultations. The system shall display tasks which are overdue. The system shall flag tasks that have not been completed at the time of disposition. The system should flag results that have been received but have not been reviewed. The system should flag tasks that are not complete but not expected to be complete as requiring follow up. Proposed Comments or Changes EDIS - Functional Profile Emergency Care Special Interest Group – HL7 ID T y p e Name Statement EDC.1.3 H Orders Provide means to order laboratory, radiology, medications, nursing tasks, and materials management through the EHR application. EDC.1.3.1 F Manage Orders Maintain a master list of orders. 12 Description Rationale/Citations Proposed Conformance Criteria Comments Orders are a unique subset of clinical tasks that possess certain qualities. An individual order may actually comprise a number of bundled tasks. For instance, an order for a complete blood count may comprise a number of sub-tasks, including: Draw the blood specimen Transport the specimen to the lab Initiate the order in the laboratory system Create a task to review and document results It should be recognized that for success, orders must be highly specific and customizable by personnel role, physical location, and other patient specific factors (i.e. major trauma patient). The system must be sufficiently extensible to support institutional variations and preferences. For instance, the order for an ECG may be carried out by an ED RN in one institution, and a person from heart station in another. Aerosol therapy may be the purview of nursing in one ED and respiratory care in another. The system shall provide a means to maintain a Each institution is different. The EDIS list of orders. serves as an interface The system should provide a means for the to that institution. Hence a customized creation of both role-based and location-based list of potential orders orders. is required. The system should provide a means to define a workflow of related tasks. The system should provide a means to create groupings of tasks. The system should provide a means to name orders according to a local taxonomy. The system shall provide a means to flag and allow the treating physician to co-sign or countersign non-physician orders. The system may provide a means for subclassification of order types based upon local interoperability needs. EDC.1.3.2 F Manage Order Sets See: DC.1.4.3 Provide order sets based on provider input or system prompt. Proposed Comments or Changes Order sets, which may include medication orders, allow a care provider to choose common orders for a particular circumstance or disease state The system shall provide a means for the creation of order sets. The system should permit the inclusion of all order types relevant to a particular problem (i.e. laboratory, radiology, medications, nursing tasks, and materials management). EDIS - Functional Profile Emergency Care Special Interest Group – HL7 ID T y p e Name Statement 13 Description Rationale/Citations Comments according to best practice or other criteria. Recommended order sets may be presented based on patient data or other contexts. EDC.1.3.3 F Manage diagnostic orders See: Order diagnostic tests (DC.1.4.2) Submit diagnostic test orders Provide a means for providers to order diagnostic tests including, but not limited to, laboratory, radiology, and special procedures. Proposed Conformance Criteria Proposed Comments or Changes The system should allow for the update of order sets. The system should allow for the customization of order sets by provider type. The system should allow for the customization and/or presentation of order sets by patient age, sex, or other patient factors. The system may allow for the customization of order sets by physician. The system shall maintain a list of laboratory and radiological studies available to the clinician. The system shall provide a means for clinicians to order laboratory tests. The system shall provide a means for clinicians to order radiological studies. The system shall prompt the clinician to provide the necessary information to transmit a complete order for any orderable item. The system should, for each orderable item, automatically provide as much data as possible to transmit the order. EDC.1.3.4 F Manage therapeutic orders See: Medication ordering and management (DC.1.3), RN documentation and Prescription writing in EDC.1.5.1 The system should provide a flag of certain diagnostic studies that are being repeated within a proscribed period of time. The system shall provide a means to create ED medication orders with detail adequate for correct filling and administration. The system should support institution specific formularies. The system shall provide drug-drug, and drug allergy interaction checking. The system shall provide a list of medications to search from, including both generic and brand name. The system shall interface with systems of blood banks or other sources to EDIS - Functional Profile Emergency Care Special Interest Group – HL7 ID T y p e Name Statement 14 Description Rationale/Citations Comments Proposed Conformance Criteria Proposed Comments or Changes manage orders for blood products or other biologics. The system shall provide a means to institute cosignatures for therapeutic orders based upon roles (i.e. medical student, consulting physician). EDC.1.3.5 F Manage patient care orders Provide a means to order care provided wound care, diet, monitoring and other care. The system shall provide a means to order intravenous catheter placement and fluid therapy. The system shall provide a means to order dressings and wound care The system shall provide a means to order a diet for the patient, including NPO status. The system shall provide a means to order cardiopulmonary monitoring. The system shall provide a means to order an ECG. EDC.1.3.6 F Manage patient education orders Provide a means to order patient education. The system shall provide a means to order ventilator therapy. The system shall provide a means to order specific patient education tasks. EDIS - Functional Profile Emergency Care Special Interest Group – HL7 ID T y p e EDC.1.4 H EDC1.4.1 F Name Manage Diagnostic Test Results Display Diagnostic Results Statement Provide means to view results of diagnostic studies. 15 Description Rationale/Citations Comments Proposed Conformance Criteria Proposed Comments or Changes The system shall provide means to view results of diagnostic studies ordered during the ED visit. The system should provide a means to view laboratory results in trend view. The system should provide a means to view results of diagnostic studies ordered during prior ED visits. F Notify Clinician of Abnormal Results/Panic values and results. The system may provide a means to view prior diagnostic studies ordered within the same institution. The system may provide a means for notifying clinicians of abnormal results. The Laboratory usually handles this. However. We need to recognize that this may be an EDIS function. Other ways of notification of significantly abnormal results may be developed in the future. The system should provide a mechanism for review of diagnostic test results ordered that have not returned before completion of the ED visit. EDIS - Functional Profile Emergency Care Special Interest Group – HL7 ID T y p e EDC.1.5 H EDC.1.5.1 F Name Clinical Documentation Merge Pre-Arrival Data 16 Statement Description Rationale/Citations Comments Merge inbound (EMS, telephone, transfer) data with record being created for visit. Merge data collected prior to patient arrival with record created to provide means to access data in record. Proposed Conformance Criteria The system shall provide a means to display pre-arrival data during triage. The system shall provide a means to merge data collected prior to patient arrival with the record begun at the time of arrival. Proposed Comments or Changes The system shall provide a mechanism to merge inbound data with the patient’s record. See: EDC.1.1.1 The system may provide a means to import the EMS run sheet. (Consider moving to interoperability section) EDC.1.5.1 F F ED Arrival Data Focused Triage Assessment F Comprehensive Triage Assessment. F Patient Medical History Capture ED Arrival Data Capture Focused Triage Assessment Capture data pertinent to ED visit including, but not limited to: Mode of arrival Referral source Arrival time (See: DEEDS 1.0 and National Emergency Encounter Registry) Also called “quick triage” for patients who arrive when triage is delayed, or for patients who may undergo a multi-step triage process. For patients who arrive and are non critical or will undergo a single triage assessment. The system shall provide a means to capture ED arrival data. The system shall capture and display time of arrival. The system should provide a mechanism to vary the information taken at triage, depending on local practice. The system should provide a mechanism to vary the information taken at triage, depending on patient circumstances. The system shall provide a means to document a focused triage assessment. The system shall provide a means to capture chief complaint. The system shall provide a means to document a comprehensive triage assessment. The system shall provide a means to document past medical history, medications, and allergies. The system should provide a means to manage allergies and medications as coded data. The system should provide a means to capture family history and social history. The system shall provide a means to record past immunizations. EDIS - Functional Profile Emergency Care Special Interest Group – HL7 ID T y p e EDC.1.5.2 EDC.1.5.3 Name Statement F Manage Nursing Documentation F Medication Administration Record (MAR) Provide means for nurses to document care provided to patients. Medication Administration Record (MAR) 17 Description Rationale/Citations Comments Proposed Conformance Criteria Proposed Comments or Changes The system shall provide a means for nurses to document assessments and care delivered to a patient The system shall provide a means to document medications and other therapeutic agents administered in the ED. The system shall present a list of medications to be administered. The system shall unambiguously display the timing route and dose of all medications on the list. The system may provide a means for barcode recognition verification of patients. Others from DC.1.8.2 EDC.1.5.3 H Manage Physician Documentation Provide a means to capture and maintain physician documentation. ED patient commonly receive care, and care must be documented, before registration is completed. The system shall provide a means of clinical documentation for all ED providers. Care and documentation frequently occur in a non-linear temporal sequence. However, clinical summaries created by the EDIS should re-create a traditional or standard type of record flow. The system shall reconcile documentation made in a non-linear temporal sequence. The system shall permit clinical documentation before the patient is registered. The system shall provide a means to distinguish between time of observation and time of data entry. The system should provide multiple levels of data display (log view versus readable view) vs. not display at all. Needs to be moved or deleted. Needs to be moved. EDIS - Functional Profile Emergency Care Special Interest Group – HL7 ID T y p e Name Statement EDC.1.5.3.1 F Manage patient history Provide a means to capture and maintain HPI, PMH, Meds, Allergies and ROS. 18 Description Rationale/Citations Comments Proposed Conformance Criteria The system shall provide a mechanism for incorporation of the patient’s history. The system should provide a means for the system to incorporate the HPI as narrative and/or story. The system may provide a means to incorporate the HPI as data elements. EDC.1.5.3.2 F Manage physical examination EDC.1.5.3.3 F Manage lab, radiology, other diagnostic tests interpretation Provide a means to capture and maintain physical examination. Provide a means to capture and maintain lab, radiology, other diagnostic tests interpretation. Proposed Comments or Changes This may be quite controversial. Discussion regarding narrative vs. template based styles. Should conformance weight narrative and template styles equally? Should narrative style be a backup for complicated or subtle presentations? Do we need granularity conformance as above? The system shall provide a means to record ECG interpretations by the emergency physician. The system shall provide a means to record laboratory test interpretations by the emergency physician. The system shall provide a means to record plain radiograph interpretations by the emergency physician. The system shall provide a means to record initial (“wet”) and final radiograph interpretations by the radiology department. The system should provide a means to document and reconcile discrepancies between initial and final radiographic interpretations. The system should integrate with RIS or PACS system for ED, wet reads and final radiologist interpretations. EDIS - Functional Profile Emergency Care Special Interest Group – HL7 ID EDC.1.5.3.4 T y p e F Name Manage consultation requests and responses Statement Provide a means to capture and maintain requests for consultation and responses. 19 Description Rationale/Citations Comments The EHR should have easily referenced means to document and note calls made to consultants, as well as their responses. Proposed Conformance Criteria The system may integrate with RIS or PACS system for viewing images obtained during ED visit. The system shall provide a means to record consultations by providers other than the emergency physician. Proposed Comments or Changes See DC.1.9.5 It is even conceivable to initiate calls from a dropdown, and verify returns in a similar manner. Must document time paged, responded, arrived and final recommendation. EDC.1.5.3.5 F Manage medical decision making F Manage progress notes F Manage transfers of care EDC.1.5.3.8 F Document procedures EDC.1.5.3.9 F Document patient and family education EDC.1.5.3.6 Including development of differential diagnosis and process used to exclude lifethreatening diagnoses. The system shall provide a means for physicians to document medical decision making including development of differential diagnosis and process used to exclude lifethreatening diagnoses. Should include medico-legal and billing aspects. The system should provide a mechanism to incorporate narrative interpretation of the physician’s decision making process Provide a means to capture and maintain progress notes or ongoing evaluations. Provide a means to capture and maintain transfers of care between ED providers Provide Mechanism for Documentation of Procedures Include Documentation of Events, Deteriorations, Arrests The system shall provide a means to record progress notes by providers. Provide a mechanism for documentation of patient and family A Function allowing for entry/retrieval of a description of the counseling given to the Provide a means to capture and maintain medical decision making The system shall provide a means to record procedures performed on the patient. The system shall provide a means to document patient education, counseling, and communication with the patient’s family by the emergency physician. The system should provide a means to record sufficient data for billing. The EHR should show not only the thinking about a patient's condition, EDIS - Functional Profile Emergency Care Special Interest Group – HL7 ID T y p e Name Statement communications, counseling, and education. EDC.1.5.5.2.2 F Manage Advanced Directives EDC.1.5.5.2.3 F Flag Patient with Special Needs 20 Description Rationale/Citations Comments Patient/Family regarding the condition (for which the patient was seen in the ED) Provide mechanism to retrieve and flag advanced directives. Provide a means to note special needs of patient as they may pertain to the ED visit. People with special needs include: wheel chairs, people who are blind or visually impaired, people who are deaf or severely hard of hearing, people with severe emotional impairments, people with severe intellectual impairments, people with medically related needs such as diabetics, individuals with seizure Proposed Conformance Criteria The system shall provide a means to document patient education provided to the patient or family. Note: “Management of Advance Directives dropped from EDIS FM in deference to EHR-FM DC.1.11 (Preferences, Directives, Consents, Authorizations). There are however, some CC for DC.1.11.3 (Manage Consents and Authorizations) that might be elevated to “shall” in the EDIS profile. Proposed Comments or Changes but also what was communicated to patient/family, so that subsequent physicians to whom the patient is referred have a grasp of conversations that have already taken place. Submitted by Neal Handly: See DSTU DC.3.2.1|| Inter-provider Communication and DC.3.2.3 || Provider and patient or family communication and DC.3.2.4 Patient, family and care giver education. EDIS - Functional Profile Emergency Care Special Interest Group – HL7 ID T y p e Name Statement 21 Description Rationale/Citations Comments Proposed Conformance Criteria Proposed Comments or Changes disorders, and many others that require unique assistance. Individuals with disabilities are defined as persons who have physical or mental impairment that limit major life activities, have an ongoing or chronic condition, or even if they don’t have such a condition, are regarded by the community as being disabled. And this doesn’t necessarily include the ever-enlarging group of senior citizens who have a greater number of special needs including Alzheimer’s and related memory disorders" EDC.1.5.5.3 H Verify InterPractitioner correctness Acknowledge/Amend Other Provider Documentation (may be best function name for this header). An important aspect of ED documentation is the cross-check during clinical time for pieces of information that are sometimes gleaned from one practitioner (say a nurse), and must be reflected in the documentation of other key care givers (say physician). Sometimes this means commenting on findings that are not duplicated, sometimes it means verification of findings, but in all cases it means not having discrepancies which can be of severe medical and medical-legal consequence. The system shall provide a means to mark the Assistants (Physician, Rank of Nursing) documentation as read by another provider. observations (i.e. Attending vs. The system shall provide a means to mark Ancillary Care resident vs. RN (Technicians, etc) documentation by another provider as agreed vs. student.) Other care givers (RT, with. PT, etc). Agree to disagree vs. reconciliation Can this be made a conformance? The system should permit the physician to agree or disagree with other provider documentation. Amended, vs. wiped out vs. corrected. EDIS - Functional Profile Emergency Care Special Interest Group – HL7 ID T y p e Name Statement EDC.1.5.5.3.1 F Review nurses notes Scan/review nurses notes, annotate for disparities, import when desired. EDC.1.5.5.3.2 F Review other care giver notes EDC.1.5.6 F Attending Attestation Scan/review notes, annotate for disparities, import when desired. Enable focused annotation of a supervisee’s note by the attending ED physician. EDC.1.5.7 F Allow Other Provider Documentation 22 Description Rationale/Citations Comments This is a key function of any coherent ED EHR system. Making this happen easily and smoothly will be a matter of implementation. But making it at least happen, in my mind, should be a minimum function. Summarize any annotations at the digital signature level for attestation of supervision note. EHR which masters this function will be welcome. Again, smooth implementation is one issue. But a minimum requirement (or option) for teaching institutions...makes sense. Enable capture of documentation created by providers other than primary caregivers in the ED. Consultants generally do not use the EDIS to document care. A method should be available to capture or link these documents to the ED visit. Proposed Conformance Criteria The system shall provide a means for the attending ED physician to attest to supervising care. CMS 100.1.1 Proposed Comments or Changes EDIS - Functional Profile Emergency Care Special Interest Group – HL7 ID T y p e EDC.1.5.8 H Name Manage Record Completion 23 Description Proposed Rationale/Citations Proposed Conformance Criteria Comments or Comments Changes Delineate the timing, means, and circumstances by which ED records are created and completed. While ED records are ideally completed by the time a patient leaves the department, this is not always possible. Moreover, ED records are often created discontinuously, and systems need to consider provisions for permitting staggered, delayed, and offsite completion of records as well as monitoring and reporting their completion. Furthermore, EDIS systems should consider the process of authorship (one or more providers), signature, authentication, completion and addendum of ED records. Statement Provide means to scan and view patient records needing attention or completion. Needing additions after signature. Legally restricted. Completions of chart in sequence…say one doctor, then another. Completion of a chart by multiple care givers at one time. After provider leaves premises, but before signature (reported incidence with some EHRs by underground reports. may be a habit holdover from dictation). Simultaneous holding of multiple, partially completed charts, on different patients. ED Physicians sometime do not get documentation completed at the end of each shift. Although some stay afterward to complete the work, others take the work home, and complete the medical record over the next 24-36 hours. It is conceivable in a busy shift that a physician may want to look over his/her clinical documentation before signage. Although this is not ideal, facilities should have the option to add this feature, when the workflow demands it? Completion of parts of chart on any one patient, out of sequence, later synthesized… Because of the commonly irregular, sometimes chaotic, and piecemeal acquisition of information in the ED, documentation is often accomplished in fragments, and sometimes outside of the sequencing used in other care spaces. Documentation should be able to be done in any order, with good perspectives of what has and has not been completed, as well as what remains to be completed. After patient care… ED clinicians sometimes must wait until the end or stay after an assigned shift, to find time to complete records. EDC.1.5.8.2.1 F Record Completion The system shall allow for discontinuous completion of ED records. The system should keep clinicians informed of the state of completion of each record. The system should enable the clinician to choose which section of the record to edit. The system shall provide a means to move between incomplete patient records without loss of work. The system shall permit the delayed completion of records. The system should display a list of records that EDIS - Functional Profile Emergency Care Special Interest Group – HL7 ID T y p e Name Statement 24 Description Rationale/Citations Comments Proposed Conformance Criteria Proposed Comments or Changes remain to be completed. The system may allow for completion of records offsite. The system shall allow each facility to determine use, or non-use of this function, according to medical staff, hospital, or other rules. The system should enable the facility to determine who is authorized to use offsite completion. The system should allow the facility to determine the time limits under which completion must be accomplished. EDC.1.6 H EDC.1.5.3.7 F Disposition Management Manage disposition EDC.1.6.1 H Manage discharge EDC.1.6.1.1 F Manage prescriptions Provide Mechanism for Documentation of Disposition, Disposition Status, Follow up Provide means to create a complete and tailored discharge package for patients discharged from the ED. Includes instructions, prescriptions, and follow up information. Provide a means to create prescriptions for patients discharged from the ED. The system shall provide careful monitoring and reporting related to use of this function, according to operative rules. The system should display patients ready for disposition. The system shall provide a means to record the final disposition of the patient from the emergency department. Final dispositions should be coded in DEEDS. The system shall create a record of the materials provided to the patient at discharge. The system shall provide a means to create outpatient prescriptions with detail adequate for correct filling and administration. The system may provide a means to create and securely transmit electronic prescriptions in compliance with current regulations. The system should provide a means to calculate doses based on weight. The system may provide a means EDIS - Functional Profile Emergency Care Special Interest Group – HL7 ID EDC.1.6.1.2 T y p e F Name Statement 25 Description Rationale/Citations Comments Proposed Conformance Criteria The system should provide the ability to tailor formularies by institution, insurance or other local rules. The system shall provide a means to manage discharge instructions. Manage discharge instructions The system may provide the ability for individual providers to manage their discharge instructions. The system shall provide a means to edit discharge instructions for a particular patient. The system should provide a means to create patient discharge instructions in multiple languages. The system may provide a list of appropriate discharge instructions based on age. The system may provide a list of appropriate discharge instructions based on sex. The system may provide a list of appropriate discharge instructions based on diagnosis. The system may provide a list of appropriate discharge instructions based on reading level. The system shall provide a means to document that instructions were given. The system may provide a means to capture via digitized signature that instructions were given. EDC.1.6.1.3 EDC.1.6.1.4 F F Manage follow-up care Manage custom forms Scheduled vs. unscheduled follow up. Provide means to produce school or work notes and document occupational recommendations. The system shall provide a means to provide scheduled or intended follow up for patients discharged from the ED. The system shall provide the ability to manage a list of follow up physicians, offices, or clinics. The system shall provide a means to manage work, school, or other custom forms. Proposed Comments or Changes to calculate doses based on renal function. EDIS - Functional Profile Emergency Care Special Interest Group – HL7 ID T y p e Name EDC.1.6.2 H Manage Admission Statement 26 Description Rationale/Citations Comments Proposed Conformance Criteria The system should clearly display the time between disposition initiation and disposition achieved. Proposed Comments or Changes The system should notify when disposition is complete. The system should provide a means to notify admitting that a bed request. The system should provide a means to specify sufficient detail to request a particular bed. The system should capture when a bed becomes available The system should capture when a patient is ready for transport to inpatient bed. H Manage Transfers The system should capture when the patient leaves the ED. The system shall provide a means to create legal transfer documentation. The system shall capture the name of the accepting physician. EDC.1.6 H Post-Disposition Management The system shall capture the name of the accepting facility. The system needs to provide a means to track all flavors of outstanding patient issues after the ED visit is completed. For example, the system should allow providers to identify patients with outstanding laboratory, radiological, or other diagnostic study issues, or to arrange follow-up care that could not be adjudicated prior to discharge. These tasks may be delegated to a particular person or may be displayed to entire ED staff. In addition, the system needs to track patients requiring administrative action after discharge (i.e. patient satisfaction or other non-clinical follow-up). Furthermore, the system need to provide a means to reconcile preliminary diagnostic test results with the final interpretations of the services requested (i.e. reconcile ED interpretation with ultimate radiologist dictation). Hence, interoperability with radiology information system and ECG system (not traditional interfaces) becomes desirable (see interoperability). EDC.1.6.1 F Manage discharged patients Note: the EHR FM seems to have a series of related functions but no specific function for this critical activity of assuring that the care sequence has been followed. The system shall provide a mechanism for the Provide a means to The system should provide a capture and maintain management of radiological follow-up for outstanding patient discharged patients. means to flag issues after the ED discrepancies The system shall provide a mechanism for the visit is completed. between ED management of administrative follow up for physician EDIS - Functional Profile Emergency Care Special Interest Group – HL7 ID T y p e Name Statement 27 Description Rationale/Citations Comments Proposed Conformance Criteria discharged patients. The system shall provide a mechanism for the management of clinical follow-up for discharged patients. Proposed Comments or Changes interpretation, radiology wet reads, and final interpretations of radiographic studies. The system should provide a means to flag discrepancies between ED physician interpretation cardiologist interpretations of ECGs. EDIS - Functional Profile Emergency Care Special Interest Group – HL7 28 EDC.2 H Clinical Decision Support The concept of decision support encompasses a large number of potential applications and functions. EDC.2.1 F Evidence Based Triage Provide a means for triage staff to assign triage categories. From EDC.3.1 F Waiting Room Management Provide a means to view and prioritize patients based upon acuity, waiting time, and practitioner load. Offer prompts to support the adherence to care plans, guidelines, and protocols at the point of information capture. Support for standard assessments Support for Patient Context-enabled Assessments Offer prompts based on patient-specific data at the point of information capture. This is the CDS analog to the triage lists. When a clinician fills out an assessment, data entered triggers the system to prompt the assessor to consider issues that would help assure a complete/accurate assessment. A simple demographic value or presenting problem (or combination) could provide a template for data gathering that represents best practice in this situation, e.g. Type II diabetic review, fall and 70+, rectal bleeding etcetera. As another example, to appropriately manage the use of restraints, an online alert is presented defining the requirements for a behavioral health restraint when it is selected. When a clinician fills out an assessment, data entered is matched against data already in the system 1. The system SHALL access the standard assessment in the patient record and related to the patient specific problem list. 2. The system SHALL enable access to standards and practices related to age, gender, normal growth and development and medical conditions. 3. The system SHOULD enable comparisons between elements of assessments captured by the clinician and those prevalent in the best available practices relevant to age, gender, development and medical conditions 4. The system MAY derive supplemental assessment data from evidence based standard assessments, practice standards, or other generally accepted, verifiable, and regularly updated standard clinical sources. 5. The system SHOULD provide prompts based on practice standards to recommend additional assessment functions. 6. The system SHOULD enable updating of the problem list by activating new problems and deactivating old problems (DC 1.5) as identified by conduct of standard assessments. The system SHALL access the standard assessment in the patient record and related to the patient specific problem list. (DC 1.4) The system SHALL enable data EDIS - Functional Profile Emergency Care Special Interest Group – HL7 29 to identify potential linkages. For example, the system could scan the medication list and the knowledge base to see if any of the symptoms are side effects of medication already prescribed. Important but rare diagnoses could be brought to the doctor’s attention, for instance ectopic pregnancy in a woman of child bearing age who has abdominal pain. Support for identification of potential problems and trends Identify trends that may lead to significant problems, and provide prompts for consideration. When personal health information is collected directly during a patient visit input by the patient, or acquired from an external ource (lab results), it is important to be able to identify potential problems and trends that may be patient specific, given the individual's personal health profile, or changes warranting further assessment. For example: significant trends (lab results, weight); a decrease in creatinine clearance for a patient on metformin, or an capture to a very small scale for unique situations, such as premature infants as well as patient context assessment features relevant to presenting medical conditions 3. The system SHALL enable access to standards and practices for age, gender, developmental stage, and medical condition presenting at the time of the encounter. 4. The system SHALL enable comparisons between additional assessment data entered during the encounter and the accessed standards and practices. 5. The system SHOULD enable messages to prompt providers to conduct additional assessments or testing based on differences between the current assessment and the accessed practice standards 6. The system SHOULD enable comparisons of medical data and patient context assessments to the accessed practice standards to prompt additional testing, possible diagnoses, or adjunctive treatment. 1. The system SHALL access the standard assessment in the patient record. (DC.1.4) 2. The system SHALL relate the standard assessment to the patient specific problem list. (DC 1.5) 3. The system SHOULD enable access to standards for age, gender, developmental stage, and medical condition presenting at the time of the encounter. 4. The system SHOULD compare patient context assessments and additional medical information to best available practices to identify patient specific growth and development patterns, health trends and potential health problems 5. The system SHOULD enable configuration rules for abnormal trends 6. The system SHOULD prompt with EDIS - Functional Profile Emergency Care Special Interest Group – HL7 30 abnormal increase in INR for a patient on warfarin. abnormal trends 7. The system SHOULD prompt for additional assessments, testing or adjunctive treatment 8. The system SHOULD enable entry of decisions regarding prompts or override of prompts. 9. The system MAY integrate with appropriate teaching materials 1. The system SHALL provide access to standard care plans, protocols and guidelines when requested within the context of a clinical encounter. These documents may reside within the system or be provided through links to external sources. 2. The system MAY support the creation and use of site-specific care plans, protocols, and guidelines. 3. The system MAY support site-specific modifications to standard care plans, protocols, and guidelines obtained from outside sources. 1. The system SHALL support access to resources for care plans that are context sensitive to patient specific data and assessment, and are appropriate to the age, gender, developmental stage and medical condition of the patient (DC 1.3.1, DC 1.4, DC 1.5, DC 1.6) 2. The system SHOULD suggest context specific care plan(s) appropriate to the presenting problem(s) of the patient 3. The system MAY capture care process across the continuum of care 4. The system MAY display care processes across the continuum of care 5. The system MAY enable and document the choice of action in response to care plan suggestions. Support for standard care plans, guidelines, protocols Support the use of appropriate standard care plans, guidelines and/or protocols for the management of specific conditions. At the time of the clinical encounter, standard care protocols are presented. These may include sitespecific considerations. Support for context sensitive care plans, guidelines, protocols Identify and present the appropriate care plans, guidelines and/or protocols for the management of specific conditions that are patientspecific. At the time of the clinical encounter (problem identification), recommendations for tests, treatments, medications, immunizations, referrals and evaluations are presented based on evaluation of patient specific data, their health profile and any site-specific considerations. These may be modified on the basis of new clinical data at subsequent encounters. Support consistent management of patient groups or populations Support for research Probably not Provide support for The clinician is 1. The system SHALL support EDIS - Functional Profile Emergency Care Special Interest Group – HL7 31 protocols relative to individual patient care. the management of patients enrolled in research protocols presented with appropriate protocols for patients participating in research studies, and is supported in the management and tracking of study participants. Support for drug interaction checking Identify drug interaction warnings at the point of medication ordering The clinician is alerted to drugdrug, drug-allergy, and drugfood interactions at levels appropriate to the health care entity. These alerts may be customized to suit the user or group. presentation of appropriate protocols for patients enrolled in research studies 2. The system SHALL support the management of research study protocols. 3. The system SHOULD support interactions with other systems, applications, and modules to enable participation in research studies (function S3.3.1) 4. The system SHOULD support the management and tracking of patients participating in research studies. 5. The system MAY support capture of appropriate details of resident condition and response to treatment as required for patients enrolled in research studies. 6. The system SHALL support standard report generation (function S.2.2.2) 1. The system SHALL check for interactions between prescribed drugs and medications on the current medication list.. 2. The system SHALL allow the user to prescribe a medication despite alerts for interactions and/or allergies being present. 3. The system MAY have the ability to set the severity level at which warnings should be displayed. 4. The system MAY check for duplicate therapies. 5. The system MAY provide a means for a provider to document why they chose to override a drug interaction warning. 6. The system SHOULD check for interactions between prescribed drugs and food detailing changes in a drug's effects caused by food (including beverages) consumed during the same time period. 7. The system SHOULD check for drug-lab interactions, to indicate to the prescriber that certain lab test EDIS - Functional Profile Emergency Care Special Interest Group – HL7 32 Patient specific dosing and warnings Identify and present appropriate dose recommendations based on patientspecific conditions and characteristics at the time of edication ordering. The clinician is alerted to drug condition interactions and patient specific contraindications and warnings e.g. elite athlete pregnancy, breastfeeding or occupational risks, hepatic or renal insufficiency. The preferences of the patient may also be presented e.g. reluctance to use an antibiotic. Additional patient parameters, such as age, gestation, Ht, Wt, BSA, Medication recommendations Recommend treatment and monitoring on the basis of cost, local formularies or therapeutic guidelines and protocols. Offer alternative treatments on the basis of best practice standards (e.g. cost or adherence to guidelines), a generic brand, a different dosage, a different drug, or no drug (watchful waiting). Suggest lab order results may be impacted by a patient’s drugs. 8. The system SHOULD allow checking of medications against a list of drugs noted to be ineffective for the patient in the past. 9. The system SHALL identify contraindications between drugs across patient conditions at the time of medication ordering 1. The system SHALL conform with function DC.2.3.1.1 2. The system SHALL identify specific and appropriate drug dosages for each patient condition at the time of medication ordering. 3. The system SHALL identify contraindications between drug dosages across patient conditions at the time of medication ordering. 4. The system SHALL identify specific and appropriate drug dosages based on each patient parameter at the time of medication ordering 5. The system SHALL alert the clinician if an inappropriate drug dosage does not match the patient’s parameters at the time of medication ordering. 6. The system SHALL prevent confirmation of a drug order until the clinician documents reasons for overriding a drug alert or warning at the time of ordering. 7. The system MAY provide override reasons to the pharmacy so that communication can occur between the clinician and the pharmacist. 1. The system SHALL conform with DC 2.3.1.2. 2. The system SHALL recommend medication regimen based on findings related to the patient diagnosis. 3. The system SHALL offer alternative treatments in medications on the basis of practice standards, cost, formularies, and protocols. 4. The system SHOULD suggest lab order monitoring as appropriate to a particular medication. EDIS - Functional Profile Emergency Care Special Interest Group – HL7 Support for medication and immunization administration Alert providers to potential administration errors (such as wrong patient, wrong drug, wrong dose, wrong route and wrong time) in support of safe and accurate medication administration and support medication administration workflow. 33 monitoring as appropriate. Support expedited entry of series of medications that are part of a treatment regimen, i.e. renal dialysis, Oncology, transplant medications, etcetera. To reduce medication errors at the time of administration of a medication, the patient is positively identified; checks on the drug, the dose, the route and the time are facilitated. Documentation is a byproduct of this checking; administration details and additional patient information, such as injection site, vital signs, and pain assessments, are captured. Access to drug monograph information may be provided to allow providers to check details about a drug and enhance patient education. Workflow for medication administration is supported through prompts and reminders regarding the “window” for timely administration of medications. The system SHALL present information necessary to correctly identify the patient and accurately administer medications and immunizations including patient name and medication name, strength, dose, route and frequency. The system SHOULD alert providers to potential administration errors such as wrong patient, wrong drug, wrong dose, wrong route and wrong time as it relates to medication and immunizations administration. The system SHOULD alert providers to potential medication administration errors at the point of medication administration. If the system supports medication administration, the system SHALL capture all pertinent details of the medication administration including medication name, strength, dose, route time of administration and administrator of the medication. If the system supports immunization administration, the system SHALL capture the administrator of the immunization and the immunization information identified in DC.1.3.3, Conformance Criteria #1. The system SHOULD support capture of other clinical data pertinent to the medication administration (e.g. vital signs, pain assessments). The system MAY generate documentation of medication or immunization administration as a byproduct of verification of patient, medication, EDIS - Functional Profile Emergency Care Special Interest Group – HL7 34 dose, route and time. The system SHOULD support medication administration workflow through prompts or reminders regarding the “window” for timely administration of medications. EDC.2.2 F Problem List Retrieval/Management EDC.2.3 H Clinical Pathways EDC.2.3.1 H EDC.2.3.1.1 F Order Set Management Customize Order Sets EDC.2.3.1.2 F Individual Order Sets Provide a tailored problem list for presenting problems. Provide a means to create and deliver clinical pathways for selected problems. Provide a means for organization to create customized order sets. Provide a means for individual practitioners to customize order sets. Individual order sets are not recommended Should probably be able to do this on the fly. Edit order set en-masse. Guide selection of orders. EDC.2.3.2 F Presentation Specific Pathways EDC.2.4 F Real-Time Risk Warnings System shall support multiple workflows. Risk management at time of data input and collection. Real-time prompts based upon chief complaints or specific granular elements of history and physical examination. Abnormal vital signs. Abnormal tests Non-documented results. Decision support Services Interoperability with single source knowledge bases, guidelines, et al. throughout the enterprise. EDIS - Functional Profile Emergency Care Special Interest Group – HL7 35 Standard format and interface definition to exchange order sets. Antibiogram Real time risk analysis for specific diagnoses. EDC.2.5 F Sentinel Event Flag Provide means to automatically capture and document errors and issues for department analysis, administrative review, and systemic error reduction EDIS - Functional Profile Emergency Care Special Interest Group – HL7 36 Supportive Functions ESP.1 H Clinical Support Many of the following functions were moved from Direct Care. Note that in the EHR – FM there are three sub-sections that have been created here. ESP.1.1 H Department Modeling and Room Management Describe ED physically and organizationally. Provide means to describe ED physically and organizationally, including departments, rooms, holding areas. The system shall allow for Room/Department Management. The system shall/should allow for the management of holding areas. The system shall/should provide for the management of rooms containing multiple patients. The system shall/should provide for the management of room availability The system shall provide for the management of patient placement. EDC.1.1.1 EDC.1.1.2 F F Manage room availability Manage patient placement Flag room status or availability Provide a means for the mechanics of patient placement, including overviews of the department, waiting room, and other areas for which status is of importance. Allow, permit, and facilitate relevant communications, notifications, Provide means for providers to flag rooms as reserved, clean, dirty, biohazard, etc. ED Flow is dependent on readying new rooms, changing linen, and making the room availability known. This is the key piece of asynchronous distributed communication that was provided for decades by the grease board. The system should provide a means to flag room status as reserved, in need of cleaning, or other status. This may be a new function. I can’t seem to find a similar function in the EHR-FM. EDIS - Functional Profile Emergency Care Special Interest Group – HL7 37 movement. EDC.1.1.5.3 F Manage holding areas Create holding areas as needed EDC.1.1.5.4 F Manage Multiple patients in a single room Allow/prohibit multiple patients in single room EDC.1.1.5.5 F Manage Hallway Patients Allow for the management of patients in hallways, as well as the creation, dissolution of bed status in hallways and other “temporary” locations Manage Admissions to Hospital from ED. ESP 2 Measurement, Analysis, Research and Reports ESP 3 Administrative and Financial Billing ESP.3.1.3 F Administratively determine a-priori if multiple patients are permitted in a particular room…. This is a room level function. That is, some rooms may and others may not allow multiple patients. Necessary, of course. The system should provide means to hold patients in EDIS for unique reasons, including out of department, other departments, etc. The system shall allow multiple patients to be in a single room. This may not be too critical. may not rise to the level of a function… The system shall allow for the management of hallway patients. Support for unique needs of bed requests, including service, type of bed, admitting attending, isolation, etc. Provide means to create a bill for patients. Without extra work by clinician… Should we include all relevant billing data into this function. EDIS - Functional Profile Emergency Care Special Interest Group – HL7 38 Information Infrastructure IN.1 EII.2 H H IN.3 H EDC.1.1.3 EDC.1.1.4.1 H F EDC.1.1.4.2 F Security Health record information and management Identity, registry, and directory services Protect Identities Protect all patient identities. (Has to be a better way to say this.) Protect individual patient identity. Keep patient identities invisible to other providers on public tracking screens. Flag patient identity as confidential to others. Create de-identified view for broadcast in common areas. Many EDs design or employ common displays or dashboards. Frequently called “JCAHCO view” (Move to II…note that tracking system needs special attention for protection of identity….Information Infrastructure...not only tracking) Create a flag to indicate to providers the need to protect the identity of patients at particular risk of harm. The system shall provide a means to protect patient identities from other patients, patient visitors, and non participating healthcare providers. The system shall provide a means to flag patients who require protection of their identity from others, including family, visitors, and non participating healthcare providers. Despite best efforts of confidentiality, display should identify patients at particular risk of harm during stay (e.g. domestic violence) IN.5 H IN.5.1 H EDC.1.5.5 H EDC.1.5.5.1 F Standards-based Interoperability Inbound Interoperations Cross Reference Documents Use incoming medical summaries This will have special bearing on CDR, CCR, Moved from DC EDIS - Functional Profile Emergency Care Special Interest Group – HL7 39 (CDA), and other medical summary standards. EDC.1.5.5.2 H Use Available patient reports/data Find and use relevant documents related to patient EDC.1.5.5.2.1 F IN.5.2 H IN.5.2.1 F Hospital Level Interoperations ADT Interface IN.5.2.2 F Laboratory Interface IN.5.2.3 F Pharmacy Interface IN.5.2.4 F Automated Dispensing Equipment IN.5.2.5 F Materials Management IN.5.2.6 F Radiology Interface Bed Request Interface Support for bar code registration IN.5.3 H Outbound Interoperations Structured Document Support RHIO Outbound Functionality Moved from DC Review previous medical records Reports that are available in the system or an interoperable system (say an HIS – CDR) should be searchable, findable, and usable Interface with ADT system Provide means to interface EDIS with hospital-wide ADT system The crème-de-la-crème??? Provide means to send message to automated dispensing equipment. (i.e. Pyxis) Provide means to alert materials management system with stock usage. Pharmacy system handhelds. F F Electronic Prescribing The system shall export the ED record in CDA format. Export EDIS Encounter to RHIO Export prescriptions to eRx system Provide means for provider with appropriate credentials to, or automatically export, data to RHIO Provide functionality to transmit prescriptions electronically. Moved from DC EDIS - Functional Profile Emergency Care Special Interest Group – HL7 F Agency Reporting F Primary Care Physician F Custom flags 40 Provide for automated electronic transfer of selected public health and surveillance reports. Provide means to electronically transfer ED care record to patient’s primary care physician. Provide means to create specifically formatted or customized flags or notes to other clinical systems. May be useful prior to RHIO development. Examples: medication changes to CDR, note to enterprise EHR. Billing Interface Facility Supplies E/M and Physician IN.6 F Business Rules Management IN.7 H IN.7.1 F Workflow Management Sub-second Response Time IN.7.2 F Asynchronous Distributed Communications Speed of interface is both an implementation element and a necessity for EHR adoption. Must: Not impair workflow Not impair patient flow Exhibit Ease Communicate state of needed attention in the ED (e.g. “to be seen”. Is backed up….or “labs are ready on a bunch of patients)..etc. Don’t see how this has to do with ADS EDIS - Functional Profile Emergency Care Special Interest Group – HL7 Appendix A: Glossary of Terms EHR-S Electronic health record system Follow-up The who, when, and where. and what happens if you don’t. Pre-arrival Data Data obtained on a patient prior to arrival in the ED. 41