The Emergency Medical Service System (EMSS) in the United States has largely arisen since 1945 and has drawn to a great degree from the experience gained in military conflicts during and since World War II. The documentation of care, however, has remained largely paper record–based until recently. Beginning in the 1970s both civilian and military agencies have closely examined electronic means of storing and managing patient data about emergency medical care. The report of the Institute of Medicine on the Computer-Based Patient Record has emphasized the use of information technology in patient care in general and emergency care data in particular. During this period ASTM has documented the logical structure of the electronic health record in Guide E1239 and Practice E1384, while Guides F1288 and F1629 has defined the patient care data, to be gathered in the pre-hospital record, and the outcome data, relative to the pre-hospital phase of the emergency, which are collected in the emergency department and after inpatient admission. Specifications for the logical model are also presented in Practice E1715. This practice shows how the data gathered for EMS operations and management merge smoothly into the computer-based patient record, consistent with the recognition that these data are part of the primary record of care. Several states have formalized that recognition in state law. This practice does not instruct physicians how to collect data for patient care. This practice does not indicate what information needs to be collected at the time of patient care. The task now is to document, using standard conventions, the means by which this integration occurs in order to set the stage for the capture and transfer of such emergency care data using information technology and telecommunications in a standardized way consistent with all other settings of care while protecting the privacy and confidentiality of that data. The electronic health record has the potential to reduce health care costs by optimizing case management and supporting effective post ED follow-up. Systematizing the data also enhances its ability to be used consistently, with proper protection, for research into and for management of EMSS operations within the various jurisdictional boundaries. The electronic form of the emergency episode documentation utilizes the same logical data model as the electronic health record, but it focuses on data collected during the different phases of the emergency. These data sets do not limit what may be recorded, or by whom, but they do identify those data considered essential, when they exist. These data sets include all those data recorded to document instances of emergency medical care. Data organized to enhance flexible and efficient management of information. Identifications of practitioners and facilities will be coded, when necessary, to protect confidentiality and to make provider data comparable. Names will be included when they are necessary to support patient care. Privacy and confidentiality of patient data should be handled according to Guide E1869. Provider identification numbers will be maintained on master data files which also include additional information such as specialty, license level, and the like. Provider identification numbers recorded in the electronic health record will automatically link to the master data files to eliminate the need for duplicate data entry of reference material in the patient record. Coding systems for emergency reporting (ICD-9-CM, CPT, HCPCS, SNOMED ) will be referenced in the master data files for Practice E1384 as appropriate. The efficient arrangement of the logical model of Practice E1384 permits output to be generated and identified to mirror the paper record, such as nurse-specific or physician-specific notes. The arrangement of the logical model permits multiple entries of assessment data, using a small group of variables, that can then be used to generate output. For example, sequence of diagnoses by date-time. 1.1 This practice covers the identification of the information that is necessary to document emergency medical care in an electronic, paperless patient record system that is designed to improve efficiency and cost-effectiveness. 1.2 This practice is a view of the data elements to document the types of emergency medical information that should be included in the electronic health record. 1.2.1 The patient's summary record and derived data sets will be described separately from this practice. 1.2.2 As a view of the electronic health record, the information presented will conform to the structure defined in other ASTM standards for the electronic health record. 1.3 This practice is intended to amplify Guides E1239 and F1629 and the formalisms described in Practices E1384 and E1715. 1.3.1 This practice details the use of data elements already established in these standards and other national guidelines for use during documentation of emergency care in the field or in a treatment facility and places them in the context of the object models for health care in Practice E1384 that will be the vehicle for communication standards for health care data. 1.3.1.1 The data elements and the attributes referred to in this practice are based on national guidelines whenever available. 1.3.1.2 The EMS definitions are based on those generated from the previous EMS consensus conference sponsored by NHTSA and from ASTM task group F 30.03.03 on EMS Management Information Systems. 1.3.1.3 The Emergency Department (ED) definitions are based on the Data Elements for Emergency Department Systems (DEEDS) distributed by the Centers for Disease Control in June 1997. 1.3.1.4 The hospital discharge definitions are based on recommendations from the Centers for Medicare and Medicaid Services (CMS) for Medicare and Medicaid payment and from the Department of Health and Human Services for the Uniform Hospital Discharge Data Set. 1.3.1.5 Because the current trend is to store data as text, the codes for the attribute values have been determined as unnecessary and thus are eliminated from this document. 1.3.1.6 The ASTM process allows for the data elements to be updated as the national consensus changes. When national or professional guides do not exist, or whenever there is a conflict in the existing EMS, ED, hospital or other guides, the committee will recommend a process for resolving the conflict or an explanation of the conflict within each guide. 1.3.2 This practice reinforces the concepts set forth in Guide E1239 and Practice E1384 that documentation of care in all settings shall be seamless and be conducted under a common set of precepts using a common logical record structure and common terminology. 1.4 The electronic health record focuses on the patient. 1.4.1 In particular, the computer–based patient record sets out to ensure that the data document includes: 1.4.1.1 The occurrence of the emergency, 1.4.1.2 The symptoms requiring emergency medical treatment, and potential complications resulting from preexisting conditions, 1.4.1.3 The medical/mental assessment/diagnoses established, 1.4.1.4 The treatment rendered, and 1.4.1.5 The outcome and disposition of the patient after emergency treatment. 1.4.2 The electronic health record consists of subsets of data for the emergency patient that have been captured by different care providers at the time of treatment at the scene and en route, in the emergency department, and in the hospital or other emergency health care settings. 1.4.3 The electronic record focuses on the documentation of information that is necessary to support patient care but does not define appropriate care.

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This practice is directed at defining the application of existing conventions for the structure and content of EHR systems used to support healthcare practitioners in a workplace setting. In addition to supporting the capture of data on encounters and of periodic patient health assessments conducted during the time the employee is at work, this document also recognizes the interaction of care rendered over a lifetime and when not at work with that due to the work environment that is delivered on the work site, either for care events that have occupational significance or for surveillance of potential health conditions that may result from the work or living environment. This document recognizes not only the privacy and confidentiality of records that are kept in the work setting but also the need to be able to interchange data from the workplace record with health records in other settings in order to fully support employee and environmental health.Occupational Health Programs:Most occupational health programs are oriented, first, to any regular surveillance for observations associated with potentially adverse health conditions known to attend environmental stressors that may be present in either the workplace or the living environment and, second, to care and documentation of any illness or injury incurred during the workday at the work site or in other living environments. Each of these activities requires recording data for the care record that is a subset of that regularly required for care in other more extensive ambulatory and inpatient care settings. It also requires relating the events occurring in either the work place or the living environment to those observed healthcare data.This practice is intended to identify the most frequently used of the general data elements which are more completely documented in Practice E1384 and Specification E1633. Thus, this description constitutes a “view” of the more comprehensive set of data that might be captured in a general ambulatory care encounter. If the conventions given in this document are adhered to, the data will ensure a record that is portable to any other setting and the record will be interoperable with other standards conformant systems, regardless of their implementation techniques. Fig. 1 shows the inter-relationships of the basic information domains that support Occupational/Environmental Health programs within healthcare. The Care Record subdomain embraces the conceptual content and structure that have been documented in Practice E1384 and associated standards. Resource Management and Epidemiology data analytic functions and subdomains are documented elsewhere in descriptions of the requirements of the HIPAA legislation and the CDC Public Health Information NetworkPHIN(X). The Occupational Health Programs are generally organized in employing organizations, but healthcare enterprises need to also recognize that they too are “employers” in the same sense as any other societal business organization and that their employees, including all healthcare practitioners, as well as their associate professional discipline colleagues, are entitled to management of their occupational health information by the same principles. Thus, occupational health information management is intrinsic to management of all information in the healthcare enterprise and sets the stage for the management of information of the enterprise’s “Patient” population. An occupational/environmental health “case” is defined to be that informational record that identifies a specific instance of an occupational/environmentally induced health condition and its associated attributes from the patient care and environmental assessment records that will enable resolution of both the health condition and the causal environmental factors associated with it. The handling of “cases” relating to adverse effects of stressors in with general living environment is somewhat different since the adverse effects are usually first detected by the individual’s personal practitioner and then only indirectly related to environmental events. These cases are not tracked organizationally in the same way that is used for those in the workplace. Even in workplaces for very small businesses, the environmental effects of the workplace are usually detected in this latter unstructured fashion and these “cases” are not currently formally tracked, nor is environmental monitoring performed.Reportable Data—Certain data about care events are required to be regularly reported to public authorities, state or federal. These include occupational illness or injury. These reportable data constellations are subsets of the occupational health “view” described here and do not include all of the attributes of the “view.” Such “Reportable Data” are explicitly defined. These data can be composed into electronic messages for transmission to reporting authorities. While this “view” does not deal with the format of such messages, its constituent data elements provide the fields needed to compose such messages. For discussion of reportable data, consult Refs. (1, 2).Health Surveillance Processes—Health Surveillance processes supporting Occupational/Environmental Health begin with the Basic Patient Care Scenario given in Practice E1384. In occupational/environmental healthcare, the “patient” must first be registered and have updated demographic data available to the sites who give care for the illnesses and injuries resulting from either the occupations or the general living environment. Likewise, periodic environmental assessment measurements must be posted to the susceptible individuals’ patient record. When a health event occurs, provoking the individual to visit a healthcare enterprise, the individual demographic information must be easily accessible during the event encounter’s Receipt Phase. Attributes of that phase denote potential occupational or environmental involvement in the health condition(s) assessed during the Activities Phase of the Encounter. The care data is captured during the encounter and is related to the individual’s recorded environmental exposure measurements. These observations become the source of reportable data that supports surveillance. Those encounter attributes also control the data that flows to all of the various other (for example, public health) information domains at the completion of the encounter. For best followup, the data captured in the EHR need to identify either the living or the work locations and associated activities that produce the adverse health events that may potentially be related either to the living or the work environment.1.1 This Practice is intended to assemble a logical occupational/environmental health view of the already defined general structure and vocabulary for the Electronic Health Record (EHR) and to suggest the ways in which this view can be used to support employee health assessments and other healthcare delivered at the work site. This view is consistent with the ANSI/ADA Clinical Concept Data Model 2005, which identified the major data entities that will need to be involved. This view would complement other views addressed in other settings of care for the employee and could logically either request other EHR data or deliver to other practitioner requester’s record systems portions of occupational/environmental health data that have been recorded at the work site. This practice does not deal with the specific implementation of the content and it also does not either suggest or recommend implementation techniques. Likewise, it does not suggest standards of care. These functions are dealt with in other domains.

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