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Observations

Data Element

Information from the submission form

Apgar Score
APGAR score post-birth including scores at 1, 5 and 10 minutes.

Comment

Support for this element is…

Support for this element is submitted on behalf of MedMorph project which includes relevant specifications and supporting artifacts. We propose a new Delivery and Pregnancy Information class where data elements like Apgar score may be captured. Annually there are approximately 3.7 million births in the United States. It is important to note that 57 jurisdictions are required to report data elements like Apgar score local and nationally.  Consumption of these types of data are widespread and every jurisdiction in the country captures birth certification information. The Apgar score helps assess a newborn’s overall physical condition and can quickly determine whether a newborn needed immediate medical care.  Among other things this type of delivery and pregnancy Information provide key birth statistics that identify public health trends on fertility rates, when prenatal care was initiated, and percent of newborns born preterm. Additionally, given the current pandemic real time birth reporting for public health is paramount in assessing the medical care for both expectant mothers and newborns. While the proposed data class ‘Observation’ can capture data elements such as Apgar score it is important to recognize that birth and delivery events is information that may be captured within specific areas of a healthcare system such as labor and delivery summaries and prenatal care records. To help lessen the burden of implementations and queries of these events we propose a new Delivery and Pregnancy Information class where data elements like Apgar score may be captured. Additional relevant specification for this data element includes HL7 and IHE standards listed below. HL7 Version 2.6 Implementation Guide: Vital Records Birth and Fetal Death Reporting, Release 1 STU Release 2 - US Realm: https://www.hl7.org/implement/standards/product_brief.cfm?product_id=320 IHE Quality, Research and Public Health Technical Framework Supplement – Birth and Fetal Death Reporting-Enhanced (BFDR-E) Revision 3.1: https://www.ihe.net/uploadedFiles/Documents/QRPH/IHE_QRPH_Suppl_BFDR-E.pdf The use of the Apgar score data element includes widespread use, required to be reported nationally and is routinely collected on EHR/HIT systems. Below lists examples of artifacts of where this data element is collected. Facility worksheet information: https://www.cdc.gov/nchs/data/dvs/facility-worksheet-2016-508.pdf https://www.cdc.gov/nchs/data/dvs/fetal-death-mother-worksheet-english-2019-508.pdf EPIC stork module (obstetrics) for birth reporting: https://www.epic.com/software#PatientEngagement EPIC FHIR APIs for patient, vitals, obstetric details: https://fhir.epic.com/Specifications?api=932 https://fhir.epic.com/Specifications?api=968 https://fhir.epic.com/Specifications?api=966 BFDR-E in ISA: https://www.healthit.gov/isa/reporting-birth-and-fetal-death-public-health-agencies There has been demonstrations and exchange of this data element with outside entities and stakeholders, below are examples of such exchanges: IHE Connectathon integration profiles for BFDR-E (2013 - 2020) HL7 FHIR Connectathon results (Sept 2020): birth and fetal death reporting results testing between electronic birth registration system vendors (FHIR) NACCHO 360X Interoperability Demonstrations for Birth and Fetal Death reporting 2020 between NextGen and two state electronic birth registrations system vendors using FHIR. HIMSS Interoperability showcase (2018 – 2019)

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