Data Element
Submitted By: Smitha Vellanky, on behalf of Joel Andress and Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) / On behalf of Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ)
Data Element Information
Data Element Description Summary of a patient’s interval status during an emergency department encounter, including narrative and free text data.
Emergency department notes typically include information related to assessment and plans of care, chief complaints, physical findings, interventions, and results.
Rationale for Separate Consideration Clinical notes provide important clinical information necessary for care coordination and patient care. Specifically, Emergency Department Notes should be a distinct clinical note data element to distinguish data from other Progress Notes, for the purposes of coordination of care and care continuity. This ensures capture of a critically unique encounter type that represents a key interface between and across acute and outpatient care settings. A separate Emergency Department Notes data element will also ensure patient access to this information. As historically vulnerable and underserved populations disproportionately use Emergency Departments for primary care, these clinical notes may be particularly useful in supporting the Office of the National Coordinator for Health Information Technology (ONC) United States Core Data for Interoperability (USCDI) v4 goals of addressing needs of underserved communities and public health interoperability needs related to emergency response.
Use Case Description(s)
Use Case Description Emergency department notes are complementary to the other clinical note data elements included in USCDI and will provide a complete picture of patient emergency department encounters. They are necessary for coordination of patient care across the care continuum. Emergency department notes are exchanged and used routinely throughout the course of care. Emergency Departments can be fully integrated within a healthcare system, fully independent and administratively distinct from a nearby healthcare or hospital system, or some intermediate state between these extremes. They represent a unique and critical connection between inpatient and outpatient care settings and are therefore an important component of both acute and chronic disease management.
Estimate the breadth of applicability of the use case(s) for this data element Emergency department notes are used widely in care coordination across healthcare systems and would be used by a large proportion of USCDI stakeholders.
Use Case Description Clinical notes are a key component to communicate the status of a patient. Particularly in the context of transition of care, emergency department notes can provide additional information regarding patients’ health status at the presentation for care to inform care pathways as well as those care pathways. These notes are also important to ensure patient access to data and interoperability of data for care coordination and handoffs.
Estimate the breadth of applicability of the use case(s) for this data element This data element is captured commonly in electronic health records (EHRs) and used and exchanged broadly across health systems.
Healthcare Aims
  • Improving patient experience of care (quality and/or satisfaction)
  • Improving the health of populations
  • Reducing the cost of care
  • Improving provider experience of care
Maturity of Use and Technical Specifications for Data Element
Applicable Standard(s) LOINC
LOINC Group Code: Emergency department|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain, LOINC LG41825-7
Or at a minimum, Emergency department Discharge summary note, LOINC 59258-4
https://loinc.org/
Additional Specifications HL7 FHIR US Core Implementation Guide STU5 based on FHIR R4: US Core Document Reference Profile; US Core Diagnostic Report Profile for Report and Note Exchange
Current Use Extensively used in production environments
Supporting Artifacts EHRs routinely collect notes for patient encounters including Emergency Department visits. This data element has been used at scale between multiple different production environments to support the majority of anticipated stakeholders.
Extent of exchange 5 or more. This data element has been tested at scale between multiple different production environments to support the majority of anticipated stakeholders.
Supporting Artifacts Emergency department notes are broadly collected and used every day across healthcare systems, settings, and specialties and would be used by a large proportion of USCDI stakeholders.
Potential Challenges
Restrictions on Standardization (e.g. proprietary code) No challenges anticipated. This data is available in standard terminology that can be publicly accessed via the Value Set Authority Center (VSAC) and HL7.
Restrictions on Use (e.g. licensing, user fees) We are not aware of any restrictions.
Privacy and Security Concerns This data, like any patient data should be exchanged securely. Current processes exist, governed by CMS and ONC, to securely transfer this data.
Estimate of Overall Burden Emergency department notes are regularly captured as part of EHR systems. Most hospitals are already capturing and exchanging these notes pertaining to Emergency Departments.
Other Implementation Challenges N/A
ASTP Evaluation Details
Each submitted Data Element has been evaluated based on the following criteria. The overall Level classification is a composite of the maturity based on these individual criteria. This information can be used to identify areas that require additional work to raise the overall classification level and consideration for inclusion in future versions of USCDI
Criterion #1
Maturity - Current Standards		 Level 2 - Data element is represented by a terminology standard or SDO-balloted technical specification or implementation guide.
Criterion #2
Maturity - Current Use 		Level 2 - Data element is captured, stored, or accessed in multiple production EHRs or other HIT modules from more than one developer.
Criterion #3
Maturity - Current Exchange		 Level 2 - Data element is electronically exchanged between more than two production EHRs or other HIT modules of different developers using available interoperability standards.
Criterion #4
Use Case(s) - Breadth of Applicability		 Level 2 - Use cases apply to most care settings or specialties.
Evaluation Comment This looks to be a level 2

Comment

Submitted by nedragarrett_CDC on

CDC's Comment for draft USCDI v5

This lacks clarity regarding its contents and purpose. Is this the progress notes in the ed, transfer notes when the patient is admitted to inpatient, some other clinical notes? If the encounter type is already defined, stating "ED" may not be necessary. Clarifying whether an ED note refers to progress notes, transfer notes, or a summary of all ED-related documentation can help mitigate ambiguity and ensure accurate data capture.

Submitted by hswmin on

THIA Support for Emergency Department Note

The Texas Health Informatics Alliance (THIA) Policy and Standards Working Group are in support of an emergency department (ED) note as a separate encounter-specific clinical note. This would facilitate ambulatory practices contacting patients with a recent ED visit to report on follow-ups with their PCP. The records are already there, so additional work from clinicians would not be required.

Additionally, we would like to emphasize our support for the automation of reporting and homogenization of requests to remove some of the reporting burden on hospitals. Replication of the same data is often asked for by multiple government agencies, including the trauma registry. This is a requirement for safe reporting and certification. Information could be pulled in part from the ER record.

THIA Policy & Standards WG - USCDI v5 Recommendations - Clinical Notes - Emergency Department Note.pdf

Submitted by texasstateuni on

Emergency Department Note Data Element

I am a student who interviewed an Emergency Department nurse to gain their perspective on the emergency department note data element. It would be useful to add a section to input IV infusion start and end times to have that documented for when nurses switch their shifts. 

 

Submitted by bmyers_md on

Support addition of Emergency Department Note with clarification

Good day, and thank you for the ability to comment.  As the Chief Medical Officer for one of the largest integrators of Emergency Medical Services and Emergency Department clinical information (www.eso.com), I write in support of the inclusion of this data element.  In order to have maximum utility, I suggest clarity around the exact nature of the Emergency Department Note.  Specifically, this should be the clinical documentation (inclusive of History/Physical/Past Medical and Surgical History/Medications/Allergies/Vital Signs/Clinical Decision Making/Diagnosis/Disposition) as recorded by the Qualified Independent Healthcare Pracitioner in the Emergency Department (e.g., Physician/Physicians Assistant/Nurse Practioner).  This is important for several reasons; three deserve specific mention.  First, this provides clarity for any continuation of the episode of care in the inpatient setting.  Second, this is important for continuity of care, as many patients receive a large portion of their care in the emergency department for a host of socioeconomic and other factors.  The inclusion of a designated note will facilitate appropriate on-going care.  Finally, this provides the opportunity for Emergency Medical Services providers to understand the outcome of their care and thus facilitate quality assurance and performance improvement activities for EMS.  This will improve community health and safety for the entire population, inclusive of those at highest risk and may have historically experienced disparities in care.

Submitted by yale-coredQMRoadmap on

CMS-CCSQ Support for Emergency Department Notes for USCDI v5

CMS-CCSQ  recommends this Level 2 data element be added to USCDI v5. Emergency Department Notes should be a distinct clinical note data element to distinguish data from other Progress Notes, for the purposes of coordination of care and care continuity for routine exchange throughout the course of care. Emergency Departments can be fully integrated within a healthcare system, fully independent and administratively distinct from a nearby healthcare or hospital system, or some intermediate state between these extremes. This ensures capture of a critically unique encounter type that represents a key interface between and across acute and outpatient care settings and therefore an important component of both acute and chronic disease management. A separate Emergency Department Notes data element will also ensure patient access to this information and will support transitions of care. This data element is currently classified with LOINC Group Code LG41825-7 or at the Emergency Department Discharge Summary Note LOINC 59258-4, at a minimum. This aligns with the ISWG Recommendations on Draft USCDI v4  (April 12, 2023) to include LOINC 59258-4 Emergency Department Discharge Summary as the generic or minimum Emergency Department Note codes.

Submitted by yale-coredQMRoadmap on

CMS-CCSQ USCDIv4 Priority: Emergency Department Note

Emergency Department Notes should be a distinct clinical note data element to distinguish data from other Progress Notes, for the purposes of coordination of care and care continuity. This ensures capture of a critically unique encounter type that represents a key interface between and across acute and outpatient care settings. A separate Emergency Department Notes data element will also ensure patient access to this information. As historically vulnerable and underserved populations disproportionately use Emergency Departments for primary care, these clinical notes may be particularly useful in supporting the ONC USCDI v4 goals of addressing needs of underserved communities and public health interoperability needs related to emergency response.

Maturity:

  • Current standards:
    • LOINC codes, Emergency department|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain, LOINC Group Code LG41825-7 or at a minimum, Emergency department Discharge summary note, LOINC 59258-4.
  • Current uses, exchange, and use cases: Emergency department notes are exchanged and used routinely throughout the course of care. Emergency Departments can be fully integrated within a healthcare system, fully independent and administratively distinct from a nearby healthcare or hospital system, or some intermediate state between these extremes. They represent a unique and critical connection between inpatient and outpatient care settings and are therefore an important component of both acute and chronic disease management. The information is particularly important to reflect a patient’s health status to support transitions of care.

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