Data Elements for Emergency Department Systems, Release 1.0 (DEEDS): A Summary Report

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SPECIAL CONTRIBUTION

Data Elements for Emergency Department Systems, Release 1.0 (DEEDS): A Summary Report From the National Center for Injury Prevention and Control (NCIPC), Centers for Disease Control and Prevention (CDC), which is solely responsible for the recommendations in DEEDS, Release 1.0. Each author represents a professional association or federal agency on the DEEDS Writing Committee, but these affiliations do not constitute organizational endorsement of DEEDS, Release 1.0. Author affiliations are listed in the Appendix. This article is being copublished by Academic Emergency Medicine, Annals of Emergency Medicine, and Journal of Emergency Nursing. Copyright © 1998 by the American College of Emergency Physicians.

DEEDS Writing Committee: Daniel A Pollock, MD, chair Diane L Adams, MD, MPH Lisa Marie Bernardo, RN, PhD Vicky Bradley, RN, MS Mary D Brandt, MBA, RRA Timothy E Davis, MD Herbert G Garrison, MD, MPH Richard M Iseke, MD Sandra Johnson, MSSA Christoph R Kaufmann, MD, MPH Pamela Kidd, PhD, ARNP Nelly Leon-Chisen, RRA Susan MacLean, RN, PhD Anne Manton, RN, PhD Philip W McClain, MS Edward A Michelson, MD Donna Pickett, RRA, MPH Robert A Rosen, MD Robert J Schwartz, MD, MPH Mark Smith, MD Joan A Snyder, RN, MS Joseph L Wright, MD, MPH

See editorial, p 274. Variations in the way that data are entered in emergency department record systems impede the use of ED records for direct patient care and deter their reuse for many other legitimate purposes. To foster more uniform ED data, the Centers for Disease Control and Prevention’s National Center for Injury Prevention and Control is coordinating a public-private partnership that has developed recommended specifications for many observations, actions, instructions, conclusions, and identifiers that are entered in ED records. The partnership’s initial product, Data Elements for Emergency Department Systems, Release 1.0 (DEEDS), is intended for use by individuals and organizations responsible for ED record systems. If the recommended specifications are widely adopted, then problems— such as data incompatibility and high costs of collecting, linking, and using data—can be substantially reduced. The collaborative effort that led to DEEDS, Release 1.0 sets a precedent for future review and revision of the initial recommendations. [DEEDS Writing Committee: Data Elements for Emergency Department Systems, Release 1.0 (DEEDS): A summary report. Ann Emerg Med February 1998;31:264-273.] The primary functions of an emergency department record system are to store clinical data and facilitate their retrieval during direct patient care. No matter how many additional features a record system provides, it must satisfy these basic clinical requirements and fit easily into the work flow of busy ED practitioners. However, with proper record system design and scrupulous protection of privacy and confidentiality, data generated and used during ED visits can be distributed for reuse at low cost and with potentially high yield. Authorized reuse of ED data can help ensure continuity and coordination of care for individual patients, facilitate clinical research and other investigations, and support populationbased efforts to improve health care quality, control expenses, and prevent disease and injury.

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Individuals and organizations seeking to develop fully functional ED record systems need to consider the basic items of information in ED patient records—data elements— and how to optimize their collection and use. Uniformity in data element definitions, coding conventions, and other specifications is a prerequisite for optimal record system performance. A lack of uniform data elements within individual record systems and across systems has impeded the use of ED records for direct patient care and has deterred their reuse for secondary applications. Unless standards are introduced and widely adopted, variations will persist in such items of information as the patient’s chief complaint, clinical laboratory results, and medications prescribed at ED discharge. Concerted action is needed, particularly if the rapidly accelerating pace of computerization is to facilitate rather than complicate exchange and aggregation of ED data. Several related initiatives are under way in the United States to foster more uniform emergency care data. The Centers for Disease Control and Prevention’s (CDC) National Center for Injury Prevention and Control (NCIPC) is coordinating one of these initiatives—a public-private partnership that has developed recommended specifications for many data elements used in ED patient record systems. Data Elements for Emergency Department Systems, Release 1.0 (DEEDS) is the initial product of this broad-based, collaborative effort.1 This article describes how DEEDS was developed, its purpose and scope, the contents of DEEDS, Release 1.0, and the work that lies ahead to evaluate and improve the recommended specifications.

National Association of Emergency Medical Services Physicians, National Highway Traffic Safety Administration, and Society for Academic Emergency Medicine. Representatives of these agencies and associations (the workshop planning group) met in 1994 and 1995 to define the goals for the workshop, set the agenda, draft the proposed data elements, invite other agencies and organizations to participate, and select workshop facilitators. The National Workshop on Emergency Department Data was held in January 1996, providing a public forum for review and discussion of an early draft of DEEDS, Release 1.0. Among the 160 participants were numerous ED practitioners, researchers, record system vendors, and practice management consultants, as well as representatives of 12 federal agencies and 35 professional associations. Participants in the meeting contributed many valuable recommendations for improving the draft document. The workshop planning group and facilitators, reconstituted as the DEEDS Writing Committee, met in April 1996 and incorporated as many workshop recommendations as possible into a revised version of the data elements. Review of this revision began in July 1996. The DEEDS Writing Committee met again in October 1996 to act on reviewers’ input and completed work on DEEDS, Release 1.0 in January 1997. DEEDS, Release 1.0 was posted at an NCIPC Web site in August 1997 and published in hard copy form in October 1997 (information about how to access the Web site or obtain a copy of DEEDS, Release 1.0 is provided at the end of this report).

DEVELOPMENT OF DEEDS, RELEASE 1.0

PURPOSE AND SCOPE

The impetus for developing DEEDS, Release 1.0 was a 1994 national conference on the status of emergency medicine sponsored by the Josiah Macy, Jr Foundation.2 Numerous Macy conference participants acknowledged that shortcomings in ED records limit our capacity to answer many fundamental clinical, epidemiologic, and health service utilization questions about ED patients. As a result, participants representing the major emergency medicine and nursing professional associations expressed a keen interest in joining CDC in sponsoring a national workshop on the development of ED record systems. CDC invited six professional associations and three federal agencies to cosponsor, plan, and convene the National Workshop on Emergency Department Data: the Agency for Health Care Policy and Research, American College of Emergency Physicians, American Health Information Management Association, American Hospital Association, Emergency Nurses Association, Health Resources and Services Administration,

DEEDS, Release 1.0 is intended for voluntary use by individuals and organizations responsible for maintaining or improving record systems in 24-hour, hospital-based EDs. DEEDS, Release 1.0 is not a set of mandates, but rather it is designed to provide uniform specifications for data elements that decisionmakers may choose to retain, revise, or add to their ED record systems. If the recommended data elements are uniformly recorded and data are made available to numerous legitimate users with appropriate safeguards, then problems, such as data incompatibility and high costs of collecting, linking, and using data, can be substantially reduced. The DEEDS, Release 1.0 scope of coverage comprises data elements that can serve multiple secondary purposes once they have been used for immediate patient care and administrative functions. Additional data elements, beyond the scope of DEEDS, Release 1.0, are needed to ensure that records of individual ED visits are complete (eg, data ele-

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ments to document a patient’s informed consent to disclose person-identifiable data to authorized users). The multidisciplinary process that produced DEEDS, Release 1.0 can be used in the future to develop specifications for additional data elements. Several data elements in DEEDS, Release 1.0 are not routinely recorded in EDs, but interest in their use is mounting. For example, more routine collection of observations about ED patient outcomes and patient satisfaction is on the horizon. The patient outcomes and patient satisfaction data elements in DEEDS, Release 1.0 provide a framework for data entry, but further work is needed to develop methods of gathering and analyzing relevant observations. The scope of DEEDS, Release 1.0 is not limited to data recorded by physicians and nurses. Patient identifiers entered by registration personnel, clinical data entered by allied health professionals, and medical codes assigned by health information specialists also are included. CONTENTS

The 156 data elements in DEEDS, Release 1.0 are organized into eight sections and numbered sequentially within each section. The definition of each data element is presented in the Table. More detailed specifications are available from CDC,1 including the data type and field length of each data element, a description of when data element repetition may occur, field values that designate valid data entries and coding specifications, and reference to any data standards or guidelines used to define the data element and its field values. Data types and field lengths used in DEEDS, Release 1.0 conform to formats for patient data established by Health Level 7 (HL7) and ASTM (formerly known as the American Society for Testing and Materials), two influential, standardsetting organizations.3,4 DEEDS, Release 1.0 also includes an appendix that maps individual data elements to HL7defined data fields and message segments for purposes of electronic data interchange. To the fullest extent possible, specifications for individual data elements in DEEDS, Release 1.0 incorporate national standards for health care data, particularly standards applicable to computer-based patient records. Adherence to these standards will enable ED record system planners and developers to take maximal advantage of new information technology and high-speed communication networks.5 However, many specifications in DEEDS, Release 1.0, such as the data element definitions and coding conventions, also are relevant to paper-based records, which to a varying extent EDs throughout the United States are likely to use for years to come.

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The number of data elements in DEEDS, Release 1.0 may concern some ED practitioners and other individuals responsible for entering or managing data in patient records. To place these concerns in perspective, consider the variety and amount of data customarily captured in the ED. ED records contain a wide range of clinical and administrative data, and the amount of data entered in an individual record varies according to the patient’s problem and the extent of care rendered. Regardless of whether DEEDS, Release 1.0 is implemented, a self-limited or minor problem requiring minimal intervention in the ED calls for fewer data entries than a severe condition requiring multiple diagnostic tests and therapeutic interventions. Also bear in mind that data entry using DEEDS, Release 1.0 can be streamlined in automated record systems through computer-generated time stamps, context-sensitive look-up tables, skip patterns, and other operational features. For example, when a medication order is entered in a computerbased patient record, the date and time of the order can be stored automatically by transferring data from the computer’s clock function to the record. Similarly, entry of a practitioner’s name or an abbreviated version of the name can prompt a table search and automatic input of other identifying data, such as the practitioner’s unique alphanumeric identifier, profession, and specialty. NEXT STEPS

The initial release of DEEDS is intended to serve as a starting point. Many data element definitions and coding specifications are new, and field testing is necessary to evaluate them. Systematic field studies are needed to gauge the usefulness of DEEDS, Release 1.0 for direct patient care and a variety of secondary purposes, to identify optimal methods of data collection, and to specify the resources required for implementation. Prospective users of DEEDS, Release 1.0 may contact Daniel A. Pollock, MD, at NCIPC to discuss their plans for evaluating or using the recommended data elements. Lessons learned through field use and evaluation will be a valuable source of input for subsequent revisions, but all comments and suggestions for improving DEEDS, Release 1.0 are welcome. For some data elements in DEEDS, Release 1.0, additional research and development are needed to design coding specifications or to select a coding system from the available candidates. Work is needed on codes for chief complaint, medication identifiers, outcome observation, patient satisfaction, and other coded data elements. Pending this additional work, users can select from available national or international coding systems, locally developed codes, or

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text entries. Users also can introduce expanded versions of codes specified in DEEDS, Release 1.0 to meet local needs for more detailed data. For example, users can expand the codes for patient ethnicity by subdividing the two specified groups (“Hispanic” and “Not of Hispanic Origin”) into more detailed subgroups. Users must make sure that subdivided codes can be combined into parent codes to avoid problems with data aggregation and comparison. Another factor that will influence the use of DEEDS, Release 1.0 is the movement of many EDs from predominantly paper-based to computer-based record systems. As advances in information technology are introduced, the burden of entering data will lessen, and the call for more timely, accurate, and useful ED data will intensify. Although the computerization of ED records offers opportunities to improve data collection, linkage, and exchange, it also presents challenges to data security. The prospect of increasing the availability of ED data raises concerns about the unauthorized acquisition of data. Protection of sensitive data requires that persons responsible for developing or maintaining a computer-based ED record system guard against unauthorized data access and disclosure.6 Further work will be needed to revise DEEDS, Release 1.0 as a result of field testing, new developments in health data standards, advances in information technology, and changes in ED data needs. To ensure that necessary changes are incorporated in a timely manner, CDC plans to coordinate a multidisciplinary review of DEEDS, Release 1.0 beginning 6 to 12 months after distribution of the initial release. Proposed changes will be posted at the NCIPC Web site (http://www.cdc.gov/ncipc/pub-res/deedspage.htm) for review and comment. The partnership and process used to develop DEEDS, Release 1.0 sets a valuable precedent for future review and revision.

8. American Medical Association: Physicians' Current Procedural Terminology. Chicago: American Medical Association, 1997.

Reprint no. 47/1/86562 Address for reprints: Daniel A Pollock, MD 4770 Buford Highway, NE Mailstop F41 National Center for Injury Prevention and Control Centers for Disease Control and Prevention Atlanta, GA 30341-3724 770-488-4031 Fax 770-488-4338 E-mail [email protected] DEEDS, Release 1.0 in its entirety is available from the CDC’s NCIPC in hard copy form or can be found at the NCIPC Web site: http://www.cdc.gov/ncipc/pub-res/deedspage.htm

REFERENCES 1. National Center for Injury Prevention and Control: Data Elements for Emergency Department Systems, Release 1.0. Atlanta, GA: Centers for Disease Control and Prevention, 1997. 2. Bowles LT: The Role of Emergency Medicine in the Future of American Medical Care. New York: Josiah Macy, Jr Foundation, 1995. 3. Health Level 7 (HL7): Health Level 7, version 2.3. Ann Arbor, MI: HL7, 1996. 4. ASTM: E1238-94: Standard Specification for Transferring Clinical Observations Between Independent Computer Systems. Philadelphia: ASTM, 1994. 5. Hammond WE: The role of standards in creating a health information infrastructure. Int J Biomed Comput 1994;34:29-44. 6. Committee on Maintaining Privacy and Security in Health Care Applications of the National Information Infrastructure, National Research Council: For the Record: Protecting Electronic Health Information. Washington DC: National Academy Press, 1997. 7. US Department of Health and Human Services (USDHHS): International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), 5th ed. Washington DC: USDHHS, 1995.

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Table.

Definitions of the 156 data elements recommended in Data Elements for Emergency Department Systems, Release 1.0 (DEEDS). The data elements are organized into eight sections and numbered sequentially within each section. The number of data elements used to complete a patient’s record will vary according to the complexity of the patient’s problem and the extent of care rendered during the ED visit. Data Element Section 1: Patient Identification Data 1.01 Internal ID 1.02 Name 1.03 Alias 1.04 Date of birth 1.05 Sex 1.06 Race 1.07 1.08 1.09 1.10 1.11 1.12 1.13

Ethnicity Address Telephone number Account number Social Security number Occupation Industry

1.14 1.15 1.16 1.17

Emergency contact name Emergency contact address Emergency contact telephone number Emergency contact relationship

Section 2: Facility and Practitioner Identification Data 2.01 ED facility ID 2.02 Primary practitioner name 2.03 Primary practitioner ID 2.04 Primary practitioner type 2.05 Primary practitioner address 2.06 Primary practitioner telephone number 2.07 Primary practitioner organization 2.08 ED practitioner ID 2.09 2.10

ED practitioner type ED practitioner current role

2.11

ED consultant practitioner ID

2.12 2.13

ED consultant practitioner type Date/time ED consult request initiated

2.14

Date/time ED consult starts

Section 3: ED payment data 3.01 Insurance coverage or other expected source of payment 3.02 3.03 3.04 3.05 3.06

Insurance company Insurance company address Insurance plan type Insurance policy ID ED payment authorization requirement

3.07

Status of ED payment authorization attempt

3.08 3.09 3.10 3.11

Date/time of ED payment authorization attempt ED payment authorization decision Date/time of ED payment authorization decision Entity contacted to authorize ED payment

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Definition Primary identifier used by facility to identify patient at admission (e.g., medical record number). Legal name of patient. Any names patient has been known by other than current legal name. Patient’s date of birth. Sex of patient, entered as M (male), F (female), or U (unknown or undetermined). Race of patient, entered as American Indian or Alaskan Native, Asian or Pacific Islander, Black, White, or unknown. Ethnicity of patient, entered as Hispanic, not of Hispanic origin, or unknown. Address of patient, entered with specification as to type of address (eg, mailing, permanent). Telephone number at which patient can be contacted. Identifier assigned by facility billing or accounting office for all charges and payments for this ED visit. Personal identification number assigned by US Social Security Administration. Patient’s current work, entered as code with associated text description or as text description alone. Industry or business in which patient currently works, entered as code with associated text description or as text description alone. Name of person whom the patient designates to be primary contact if notification is necessary. Address of emergency contact. Telephone number of emergency contact. Relationship of emergency contact to patient, entered as locally assigned code or as text descriptor. National Provider Identifier* for facility where patient seeks or receives outpatient emergency care. Name of physician or other practitioner who provides patient’s overall longitudinal care. National Provider Identifier or locally assigned identifier for primary practitioner. Primary practitioner’s profession or occupation and specialty or subspecialty. Address of primary practitioner. Telephone number of primary practitioner. Name of the health care organization that provides patient’s overall longitudinal care. National Provider Identifier or locally assigned identifier for ED practitioner responsible for patient’s care during ED visit. ED practitioner’s profession or occupation and specialty or subspecialty. ED practitioner’s role in patient’s care during ED visit (e.g., ED attending or staff physician, ED resident, registered nurse, physician assistant). National Provider Identifier or locally assigned identifier for consultant practitioner who participates in patient’s care during ED visit. Profession or occupation and specialty or subspecialty of consultant practitioner. Date and time when ED physician or other appropriate requester first attempts to contact specified ED consultant or consulting service. Date and time when ED consultant’s services begin. Entity or person expected to be responsible for patient’s bill, entered as insurance company, Medicare, Medicaid, workers’ compensation, other government payments, self-pay, no charge, other, or unknown. Identifier for patient’s insurance company or carrier. Address of patient’s insurance company. Insurance plan in which patient is enrolled. Identifier for patient’s insurance policy. Indicator of whether payment authorization for ED services is required by third-party payer, entered as required, not required, not applicable, or unknown. Indicator of whether contact with third-party payer is attempted and whether contact is established, entered as contact not attempted, contact attempted but not established, contact attempted and established, or unknown whether contact attempted or established. Date and time when payment authorization is sought from third-party payer. Decision made regarding payment authorization, entered as approval, denial, other, or unknown. Date and time when third-party payer provides decision regarding payment authorization. Name of insurance company or other entity contacted to authorize payment for ED services.

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Table, continued.

Definitions of the 156 data elements recommended in Data Elements for Emergency Department Systems, Release 1.0 (DEEDS). The data elements are organized into eight sections and numbered sequentially within each section. The number of data elements used to complete a patient’s record will vary according to the complexity of the patient’s problem and the extent of care rendered during the ED visit. Data Element

Definition

3.12 3.13

ED payment authorization code Person contacted to authorize ED payment

3.14

Telephone number of entity or person contacted to authorize ED payment Total ED facility charges Total ED professional fees

Identifier assigned by third-party payer to track payment authorization for ED services. Person employed by or associated with a specific third-party payer who is contacted for payment authorization. Telephone number of entity or person contacted to authorize payment for ED services.

3.15 3.16

Section 4: ED arrival and first assessment data 4.01 Date/time first documented in ED 4.02 Mode of transport to ED 4.03 4.04 4.05

EMS unit that transported ED patient EMS agency that transported ED patient Source of referral to ED

4.06

Chief complaint

4.07

Initial encounter for current instance of chief complaint

4.08

First ED acuity assessment

4.09 4.10

Date/time of first ED acuity assessment First ED acuity assessment practitioner ID

4.11

First ED acuity assessment practitioner type

4.12

First ED responsiveness assessment

4.13 4.14 4.15 4.16 4.17 4.18 4.19 4.20 4.21 4.22

Date/time of first ED responsiveness assessment First ED Glasgow eye-opening component assessment First ED Glasgow verbal component assessment First ED Glasgow motor component assessment Date/time of first ED Glasgow Coma Scale assessment First ED systolic blood pressure Date/time of first ED systolic blood pressure First ED diastolic blood pressure First ED heart rate First ED heart rate method

4.23 4.24 4.25 4.26 4.27

Date/time of first ED heart rate First ED respiratory rate Date/time of first ED respiratory rate First ED temperature reading First ED temperature reading route

4.28 4.29 4.30

Date/time of first ED temperature reading Measured weight in ED Pregnancy status reported in ED

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Total facility charges billed for this ED visit. Total professional fees billed for this ED visit. First date and time documented in patient’s record for this ED visit. Patient’s mode of transport to ED, entered as ground ambulance, helicopter ambulance, fixed-wing air ambulance, ambulance not otherwise specified, walk-in (following private transport, following public transport, following law enforcement transport, not otherwise specified), other, or unknown. Identifier for EMS unit that transported patient to ED. Identifier for EMS agency that transported patient to ED. Individual or group who decided that patient should seek care at this ED, entered as self-referral, EMS transport decision, practitioner or health care facility referral, internal facility referral or transfer, law enforcement referral, acute care hospital transfer, other health care facility transfer, other, or unknown. Patient’s reason for seeking care or attention, expressed in words as close as possible to those used by patient or responsible informant, entered as code with associated text description or as text description alone. Indicator that this is patient’s first encounter at any health care facility or with any practitioner for current instance of chief complaint, entered as yes, no (chief complaint attributable to illness or injury but this is not the initial visit), other (chief complaint not attributable to illness or injury), or unknown. First ED assessment of patient’s acuity by a practitioner, entered as requires immediate evaluation or treatment, requires prompt evaluation or treatment, time to evaluation or treatment not critical, or unknown. Date and time when patient’s acuity is first assessed in ED. National Provider Identifier or locally assigned identifier for practitioner who first assesses patient’s acuity in ED. Profession or occupation and specialty or subspecialty of practitioner who first assesses patient’s acuity in ED. First ED assessment of patient’s responsiveness, entered as alert, responds to verbal stimuli, responds to painful stimuli, unresponsive, or unknown. Date and time when patient’s responsiveness is first assessed in ED. First ED assessment of Glasgow Coma Scale eye-opening component for injured patient. First ED assessment of Glasgow Coma Scale verbal component for injured patient. First ED assessment of Glasgow Coma Scale motor component for injured patient. Date and time when Glasgow Coma Scale is first assessed in ED for injured patient. Patient’s first measured systolic blood pressure in ED. Date and time when systolic blood pressure is first measured in ED. Patient’s first measured diastolic blood pressure in ED. Patient’s first measured heart rate in ED. Method used to first measure patient’s heart rate in ED, entered as pulse rate measured by palpation, pulse rate measured by automated device, heart rate measured by palpation, heart rate measured by automated device, or unknown. Date and time when heart rate is first measured in ED. Patient’s first measured unassisted respiratory rate in ED. Date and time when unassisted respiratory rate is first measured in ED. Patient’s first measured temperature in ED. Route of patient’s first measured temperature in ED, entered as oral, tympanic membrane, rectal, axillary, urinary bladder, other, or unknown. Date and time when temperature is first measured in ED. Patient’s body weight measured in ED. Current pregnancy status of patient as reported by patient or responsible informant, entered as yes, no, not applicable, or unknown.

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Table, continued.

Definitions of the 156 data elements recommended in Data Elements for Emergency Department Systems, Release 1.0 (DEEDS). The data elements are organized into eight sections and numbered sequentially within each section. The number of data elements used to complete a patient’s record will vary according to the complexity of the patient’s problem and the extent of care rendered during the ED visit. Data Element

Definition

4.31 4.32

Date when patient was last immunized for tetanus, as reported by patient or responsible informant. Medication to which patient is allergic, as reported by patient or responsible informant, entered as code with associated text description or as text description alone.

Date of last tetanus immunization Medication allergy reported in ED

Section 5: ED history and physical examination data 5.01 Date/time of first ED practitioner evaluation

5.02 5.03 5.04

Date/time of illness or injury onset Injury incident description Coded cause of injury

5.05

Injury incident location type

5.06

Injury activity

5.07

Injury intent

5.08

Safety equipment use

5.09

Current therapeutic medication

5.10 5.11 5.12 5.13 5.14 5.15

Current therapeutic medication dose Current therapeutic medication dose units Current therapeutic medication schedule Current therapeutic medication route ED clinical finding type ED clinical finding

5.16 5.17 5.18 5.19

Date/time ED clinical finding obtained ED clinical finding practitioner ID ED clinical finding practitioner type ED clinical finding data source

Section 6: ED procedure and result data 6.01 ED procedure indication 6.02

ED procedure

6.03 6.04 6.05 6.06 6.07 6.08 6.09 6.10

Date/time ED procedure ordered Date/time ED procedure starts Date/time ED procedure ends ED procedure practitioner ID ED procedure practitioner type Date/time ED procedure result reported ED procedure result type ED procedure result

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Beginning date and time of first evaluation by ED practitioner responsible for performing brief screening examination, simultaneous assessment and resuscitation, or more comprehensive history and physical examination. Onset date and time of acute illness or injury most responsible for precipitating patient’s ED visit. Brief description of injury incident that precipitated patient’s ED visit. Encoded description of injury event that precipitated patient’s ED visit (eg, International Classification of Diseases, 9th Revision, Clinical Modification 7 external cause-of-injury code). Type of place where patient’s injury occurred, entered as home, residential institution, school or other institution and public administrative area, sports and athletic area, street and highway, trade and service area, industrial and construction area, farm, other, or unspecified. Type of activity patient was involved in at time of injury, entered as sports, leisure, paid work, unpaid work, educational activity, vital activity (eg, resting, eating), other, or unknown. Indicator of whether injury resulted from unintentional or intentional act or one of unknown intent, entered as unintentional, intentionally self-inflicted (confirmed), intentionally self-inflicted (suspected), assault (confirmed), assault (suspected), legal intervention (inflicted by police or other authorities during law enforcement), or undetermined. Use or nonuse of equipment designed to prevent injury during vehicle crash or other injury-producing event that precipitated patient’s ED visit, entered for shoulder belt, lap belt, seat belt not otherwise specified, driver’s front air bag, passenger’s front air bag, front air bag not otherwise specified, side air bag, air bag not otherwise specified, child safety seat, helmet, eye protection, protective clothing, protective flotation device, or other protective gear. Current therapeutic medication used by patient, entered as code with associated text description or as text description alone. Dose of current therapeutic medication at each administration. Units for dose of current therapeutic medication. Frequency and duration of administration of current therapeutic medication. Route by which current therapeutic medication is administered. Type of clinical finding reported (eg, history of present illness, physical examination). History or physical examination finding, entered in accordance with finding type (eg, text description for history of present illness, number for apical heart rate). Date and time when history or physical examination finding is obtained. National Provider Identifier or locally assigned identifier for practitioner who obtains clinical finding. Profession or occupation and specialty or subspecialty of practitioner who obtains clinical finding. Source of history or physical examination finding, entered as patient, paramedic/emergency medical technician, parent, spouse/partner, other family member, caretaker, nurse, physician, other practitioner, acquaintance, bystander, law enforcement personnel, existing medical records, other, or unknown. Explanation of why procedure was ordered, entered as code with associated text description or as text description alone. Service or intervention, not part of routine history or physical examination, that is designed for diagnosis or therapy, entered as code with associated text description or as text description alone. Date and time when procedure is ordered. Date and time when procedure begins. Date and time when procedure is completed or stopped. National Provider Identifier or locally assigned identifier for practitioner who performs procedure. Profession or occupation and specialty or subspecialty of practitioner who performs procedure. Date and time when procedure result is reported. Type of procedure result reported (eg, complete blood count, chest x-ray interpretation). Result of procedure, entered in accordance with result type (eg, number for a complete blood count, text description for chest x-ray interpretation).

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Table, continued.

Definitions of the 156 data elements recommended in Data Elements for Emergency Department Systems, Release 1.0 (DEEDS). The data elements are organized into eight sections and numbered sequentially within each section. The number of data elements used to complete a patient’s record will vary according to the complexity of the patient’s problem and the extent of care rendered during the ED visit. Data Element

Definition

Section 7: ED medication data 7.01 Date/time ED medication ordered 7.02 ED medication ordering practitioner ID 7.03 ED medication ordering practitioner type 7.04 ED medication 7.05 7.06 7.07 7.08 7.09 7.10 7.11 7.12

ED medication dose ED medication dose units ED medication schedule ED medication route Date/time ED medication starts Date/time ED medication stops ED medication administering practitioner ID ED medication administering practitioner type

Section 8: ED disposition and diagnosis data 8.01 Date/time of recorded ED disposition 8.02 ED disposition

8.03

Inpatient practitioner ID

8.04

Inpatient practitioner type

8.05

Facility receiving ED patient

8.06 8.07

Date/time patient departs ED ED follow-up care assistance

8.08

Referral at ED disposition

8.09 8.10

ED referral practitioner name ED referral practitioner ID

8.11

ED referral practitioner type

8.12 8.13 8.14

ED referral organization ED discharge medication order type ED discharge medication ordering practitioner ID

8.15

ED discharge medication ordering practitioner type

8.16

ED discharge medication

8.17 8.18 8.19 8.20 8.21 8.22 8.23

ED discharge medication dose ED discharge medication dose units ED discharge medication schedule ED discharge medication route Amount of ED discharge medication to be dispensed Number of ED discharge medication refills ED disposition diagnosis description

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Date and time when ED medication is ordered. National Provider Identifier or locally assigned identifier for practitioner who orders ED medication. Profession or occupation and specialty or subspecialty of practitioner who orders ED medication. Medication administered during ED visit, entered as code with associated text description or as text description alone. Dose of ED medication at each administration. Units for dose of ED medication. Frequency and duration of administration of ED medication. Route by which ED medication is administered. Date and time when administration of ED medication begins. Date and time when administration of ED medication concludes. National Provider Identifier or locally assigned identifier for practitioner who administers ED medication. Profession or occupation and specialty or subspecialty of practitioner who administers ED medication. Date and time when ED practitioner’s decision about patient’s disposition is first recorded. Patient’s anticipated location or status following ED visit, entered as discharged to home or self-care; transferred/discharged (to another short-term general hospital, skilled nursing facility, intermediate care facility, another type of institution, home under care of home intravenous drug therapy provider, or home under care of certified home care provider/program); left (without receiving medical advice against leaving or with receiving medical advice against leaving); placed in designated observation unit; admitted (to hospital floor bed, intermediate care/telemetry unit, ICU, or operating room); died; other; or unknown. National Provider Identifier or locally assigned identifier for practitioner whose inpatient service patient is admitted to. Profession or occupation and specialty or subspecialty of practitioner whose inpatient service patient is admitted to. National Provider Identifier for facility to which patient is transferred or discharged at conclusion of ED visit. Date and time when patient leaves ED. Follow-up care needs of ED patient at discharge, entered as no follow-up care assistance necessary, follow-up care assistance available or arranged before ED discharge, follow-up care arrangements pending, other, or unknown. Arranged or recommended service for patient to be provided by practitioner, health care organization, or agency after ED visit, entered as code with associated text description or as text description alone. Name of physician or other practitioner to whom patient is referred for follow-up or consultation. National Provider Identifier or locally assigned identifier for practitioner to whom patient is referred for follow-up or consultation. Profession or occupation and specialty or subspecialty of practitioner to whom ED patient is referred for follow-up or consultation. Health care organization to which patient is referred for follow-up or consultation. Indicator of whether medication is prescribed, renewed, changed, or discontinued at ED discharge. National Provider Identifier or locally assigned identifier for practitioner who issues order for ED discharge medication. Profession or occupation and specialty or subspecialty of practitioner who issues order for ED discharge medication. Medication that is prescribed, renewed, changed, or discontinued at ED discharge, entered as code with associated text description or as text description alone. Dose of ED discharge medication at each administration. Units for dose of ED discharge medication. Frequency and duration of administration of ED discharge medication. Route by which ED discharge medication is to be administered. Amount of ED discharge medication to be dispensed when prescription is filled. Number of times prescription for ED discharge medication can be refilled. Practitioner’s description of condition or problem for which services were provided during patient’s ED visit, recorded at time of disposition.

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DEEDS DEEDS Writing Committee

Table, continued.

Definitions of the 156 data elements recommended in Data Elements for Emergency Department Systems, Release 1.0 (DEEDS). The data elements are organized into eight sections and numbered sequentially within each section. The number of data elements used to complete a patient’s record will vary according to the complexity of the patient’s problem and the extent of care rendered during the ED visit. Data Element

Definition

8.24

ED disposition diagnosis code

8.25

ED disposition diagnosis practitioner ID

8.26

ED disposition diagnosis practitioner type

8.27

ED service level

8.28

ED service level practitioner ID

8.29

ED service level practitioner type

8.30

Patient problem assessed in ED outcome observation

8.31

ED outcome observation

8.32 8.33

Date/time of ED outcome observation ED outcome observation practitioner ID

8.34 8.35

ED outcome observation practitioner type ED patient satisfaction report type

8.36

ED patient satisfaction report

Encoded description of ED disposition diagnosis (eg, International Classification of Diseases, 9th Revision, Clinical Modification condition code). National Provider Identifier or locally-assigned identifier for practitioner who makes ED disposition diagnosis. Profession or occupation and specialty or subspecialty of practitioner who makes ED disposition diagnosis. Extent of services provided by ED physician, nurse, or other practitioner during patient’s ED visit (eg, Physicians’ Current Procedural Terminology 8 evaluation and management services code), entered as code with associated text description or as text description alone. National Provider Identifier or locally assigned identifier for ED practitioner whose service level is reported. Profession or occupation and specialty or subspecialty of ED practitioner whose service level is reported. Patient’s complaint or condition (eg, headache) for which outcome is observed, entered as code with associated text description or as text description alone. Change in patient’s specified health problem (eg, immediate relief of headache pain with ED treatment), as assessed by practitioner during ED visit or at follow-up, entered as code with associated text description or as text description alone. Date and time when practitioner’s outcome observation is made. National Provider Identifier or locally assigned identifier for practitioner who assesses patient’s outcome. Profession or occupation and specialty or subspecialty of practitioner who assesses patient’s outcome. Aspect of ED care for which patient satisfaction is reported (eg, waiting time before seen), entered as code with associated text description or as text description alone. Patient’s reported satisfaction with specified aspect of ED care (eg, long waiting time before seen by physician), entered as code with associated text description or as text description alone.

*In

1998 the Health Care Financing Administration plans to begin issuing a National Provider Identifier to all individual practitioners and organizations that provide health care.

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DEEDS DEEDS Writing Committee

APPENDIX

DEEDS Writing Committee: Daniel A Pollock, MD, chair* Diane L Adams, MD, MPH‡ Lisa Marie Bernardo, RN, PhD§,II Vicky Bradley, RN, MS§,¶ Mary D Brandt, MBA, RRA# Timothy E Davis, MD* Herbert G Garrison, MD, MPH**,‡‡ Richard M Iseke, MD§§,II II Sandra Johnson, MSSA¶¶ Christoph R Kaufmann, MD, MPH##,*** Pamela Kidd, PhD, ARNP§,‡‡‡ * ‡ § II ¶ # ** ‡‡ §§ II II ¶¶ ## *** ‡‡‡ §§§ II II II ¶¶¶ ### **** ‡‡‡‡ §§§§ II II II II

¶¶¶¶ ####

Nelly Leon-Chisen, RRA§§§ Susan MacLean, RN, PhD§ Anne Manton, RN, PhD§,II II II Philip W McClain, MS* Edward A Michelson, MD§§,¶¶¶ Donna Pickett, RRA, MPH### Robert A Rosen, MD§§,**** Robert J Schwartz, MD, MPH‡‡‡‡,§§§§ Mark Smith, MD§§,II II II II Joan A Snyder, RN, MS§ Joseph L Wright, MD, MPH¶¶¶¶,####

National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA Center for Information Technology, Agency for Health Care Policy and Research, Rockville, MD Emergency Nurses Association, Park Ridge, IL University of Pittsburgh School of Nursing, Pittsburgh, PA Nursing Informatics, University of Kentucky Hospital, Lexington, KY American Health Information Management Association, Chicago, IL National Association of Emergency Medical Services Physicians, Pittsburgh, PA Department of Emergency Medicine, East Carolina University, Greenville, NC American College of Emergency Physicians, Dallas, TX Emergency Department, Lawrence General Hospital, Lawrence, MA Consultant to National Center for Statistics and Analysis, National Highway Traffic Safety Administration, Washington DC Division of Trauma and Emergency Medical Systems, Health Resources and Services, Administration, Rockville, MD Uniformed Services University of the Health Sciences, Bethesda, MD Kentucky Injury Prevention and Research Center and the University of Kentucky, College of Nursing, Lexington, KY American Hospital Association, Chicago, IL Fairfield University School of Nursing, Fairfield, CT Division of Emergency Medicine, Northwestern University Medical School, Chicago, IL National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, MD Rosewood Medical Management, Tinton Falls, NJ Society for Academic Emergency Medicine, Lansing, MI Department of Emergency Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA Department of Emergency Medicine, Washington Hospital Center, and Department of Emergency Medicine, George Washington University School of Medicine, Washington DC National Medical Association, Washington DC Departments of Pediatrics and Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington DC

FEBRUARY 1998

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