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Incorporating Hospital Outcomes into NEMSIS Documents
The last leg of EMS interoperability is to incorporate data obtained from hospitals into EMS patient care reports submitted to state repositories and the national repository in NEMSIS XML format. The NEMSIS PCR data set includes an eOutcome section designed to contain data obtained from the hospital, including discharge disposition, diagnoses, procedures, and dates/times. In NEMSIS version 3.5, nearly all of the eOutcome data elements are tagged as "national elements," meaning they can be included in records submitted to the national EMS database.
Agency-level NEMSIS-compliant ePCR systems usually send PCRs to state repositories as soon as they have been finalized by the EMS clinicians completing the reports. This happens well before the patient has been discharged from the hospital, and thus the elements in the eOutcome section are usually empty. In order to include hospital outcome data, agency-level systems must re-send the entire record once the outcome data have been obtained and inserted into the record.
The following challenges (and recommended solutions) in this process have been identified.
If agency-level ePCR systems have been sending records once (upon completion of the report by the EMS clinician), and then they switch to re-sending records after receiving hospital outcome data, then the transaction volume may double in the agency-to-state and state-to-national NEMSIS data submission flows. Outcome data are important enough to warrant this increase in transaction volume. The national EMS database hosted by the NEMSIS Technical Assistance Center is prepared to handle this increase in submission volume. State EMS offices should work with their vendors to evaluate and test increased submission volume and should communicate their level of readiness to their stakeholders.
In previous versions of NEMSIS, the national EMS database sometimes incorrectly recognized resubmitted PCRs as new PCRs if certain data elements had changed enough between submissions. This weakness was fixed in NEMSIS version 3.5 with the introduction of the PCR universally unique identifier (UUID). The UUID is used to uniquely identify a PCR within an agency. The UUID is generated when the PCR is created, and it never changes. In NEMSIS 3.5, the national EMS database recognizes resubmissions correctly.
Hospital data feeds are "chatty"—that is, hospitals typically generate multiple messages during a patient encounter as the patient's status changes. Even after the patient is discharged, the hospital may continue to generate more messages as it finalizes its documentation of the encounter. Updates necessary for billing may occur up to three weeks after patient discharge. Data may continue to change for one to three months after discharge if the patient is entered into a specialty care system registry. To trigger a resubmission of NEMSIS data every time the hospital sends an update is inefficient. Also, if a patient's hospital stay is long, the hospital may stop sharing updates after a few days. The following guidance is recommended for handling these situations:
- The ePCR system should process data received from the hospital as it receives it. Once the ePCR system has received hospital data that includes a hospital discharge disposition, the ePCR system should resubmit the PCR with the outcome data included.
- If the ePCR system has received hospital outcome data, but one month has passed and it still hasn't received hospital data that includes a hospital discharge disposition, the ePCR system should resubmit the PCR with the outcome data that it has received. If the ePCR system later receives hospital data that includes a discharge disposition, it can resubmit the PCR again at that time.
The NEMSIS eOutcome section requires data to be in certain formats. For example, ED and hospital discharge dispositions must match one of the two-digit codes specified by the NEMSIS standard. Hospital diagnoses must be coded using the ICD-10-CM code set. Hospital procedures must be coded using the ICD-10-PCS code system. In actual hospital data, a variety of code systems are used; for example, procedures may be coded using CPT or SNOMED-CT instead of or in addition to ICD-10-PCS. The following guidance is recommended for handling different code systems:
- If the hospital provides codes that do not meet the NEMSIS requirements, and the hospital data does not include code translations, the receiving ePCR system may implement code mappings. The system may use available terminology mapping services, known as clinical terminology servers.
- If the ePCR system does not implement code mappings, it should at least process the codes that meet the NEMSIS requirements and include them in resubmissions.
The NEMSIS eOutcome section categorizes dispositions, diagnoses, and procedures by location: emergency department versus hospital. Hospitals often categorize diagnoses as admission, working, or discharge. ePCR systems should process information that clearly came from the ED as such. They should process all other information, including diagnoses or procedures, where the categorization is unknown as "hospital."
Multiple hospitals may treat a patient for the same incident. For example, the EMS clinicians may transport a patient to a local hospital for immediate care, and that hospital may have the patient transferred to another hospital for definitive care. In such cases, there are multiple hospital records that relate to a single PCR representing the EMS encounter with the patient at the scene of the incident. ePCR systems may implement data architectures that support the linking of multiple hospital encounters to a single PCR (and also multiple PCRs to a single hospital encounter). When it comes time to export an ePCR with hospital outcome data included in the eOutcome section, the NEMSIS Technical Assistance Center recommends that the outcomes from the hospital most immediately following the encounter documented in the EMS PCR should be given priority. Thus, in the example given, the outcomes from the local hospital should be given priority for inclusion in the ePCR representing the EMS encounter at the scene of the incident, and the outcomes from the definitive care hospital should be included in the ePCR representing the interfacility transfer.
Until interoperability is widespread and consistent standard approaches have been implemented for the issues highlighted above, users of outcome data from the national EMS database need to take care not to over-generalize their findings. For example, if one system is translating hospital disposition codes using its own internally-developed mapping table, and another system is discarding disposition codes that don't comply with the NEMSIS specification, then users must be careful in comparing data between the two systems.