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Data Elements to be Shared

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Joshua Legler edited this page May 9, 2024 · 4 revisions

The following information is clinically or operationally important to be shared in each step of the EMS interoperability workflow.

Patient Lookup

EMS needs to have a certain amount of information already on hand in order to successfully query a health information network, including patient name, data of birth, and identifiers such as a driver license number. Once a patient lookup has been successful, the following patient demographic information is helpful to EMS:

  • Full legal name, including suffix
  • Last known address of residence
  • Preferred language
  • Current healthcare providers

Patient Medical History to EMS

Certain information needed by EMS is critical, because it immediately impacts patient care. Other information is considered important but should not be prioritized above the critical information.

Critical

  • Advance healthcare directives, portable medical orders, do-not-resuscitate orders, physician orders for life-sustaining treatment, psychiatric/mental/behavioral health directives
  • Medical history: Active health problems for which the patient is currently receiving medical care
  • Medication allergies
  • Current medications (dispensed medications, if available; otherwise, prescribed medications)

Important

  • Allergies (food, environmental)
  • Recent vitals (blood pressure, heart rate, respiratory rate, pulse oximetry, temperature)
  • Recent ECGs (if cardiac issue)
  • Recent healthcare encounters (date, location)
  • Recent diagnostic tests (labs, images)
  • Pertinent surgical history (procedures)
  • Barriers to care
  • Blood type

"Recent" may be interpreted differently depending on the situation for which the patient is being seen by EMS. For cardiac problems, recent ECGs may include the two or three most recent ECG images and interpretations along with the most recent baseline ECG for the patient.

"Pertinent" refers to information that may have relevance to emergency care by EMS. Many procedures in a patient's surgical history may be irrelevant to emergency care because they do not relate to an ongoing medical condition that would likely result in the need for emergency care, nor would they impact the course of care by EMS.

Interoperable systems should be designed to show EMS clinicians the most critical and important information that will impact immediate care without overwhelming them with irrelevant or unactionable information.

EMS Patient Care Report to Hospital

The information that a hospital needs from EMS can be categorized by when the information is needed. Certain information is critical up-front, while other information is needed later.

Prior to Patient Arrival

This information needs to be provided to the hospital prior to the patient's hospital arrival:

  • Pre-arrival notifications and specialty team activations (cardiac arrest, STEMI, stroke, trauma, etc.)
  • For cardiovascular events, ECGs, including waveform images, time of acquisition, and time of transmittal

At Transfer of Care

This information needs to be provided to the hospital when the patient arrives, usually in the emergency department. Two commonly used mnemonics are I-MIST and SBAR.

I-MIST information:

  • I: Identity - Patient Name, Age, Sex, Weight
  • M: Medical complaint / Mechanism of injury
  • I: Illness / Injuries
  • S: vital Signs, Symptoms, Significant medical history
  • T: Treatment, including medications (including time and dosage), procedures

SBAR Information:

  • S: Situation - symptoms, impressions, cause of injury
  • B: Background - medical history
  • A: Assessment - exams, vital signs
  • R: Response - medications (including time and dosage), procedures

Vital signs and assessment findings that are outside of normal ranges are especially important.

After Transfer of Care

The following information is not immediately needed in the hospital but is important later for patient registries, quality improvement, and follow-up:

  • EMS record identifiers
  • EMS times
  • Full patient demographics
  • Scene location
  • Conditions at the patient's residence or scene
  • Injury details, including vehicular indicators and patient use of safety equipment
  • Other agencies on scene
  • Method of transport
  • Barriers to care and delays in making patient contact
  • Diagnostic procedure results
  • For pediatrics, weight measurement/estimation method
  • EMS use of personal protective equipment (PPE), for exposures follow-up
  • Family member contact information

Hospital Encounter Information to EMS

This information comes from the hospital where the patient was treated after EMS care. Information may come from more than one hospital if the patient was transferred between hospitals for the same medical event.

Identifiers

EMS uses hospital-issued identifiers to link the outcome data to the right EMS patient care report.

  • Patient's Medical Record Number
  • Encounter Number
    • This information may be difficult to obtain. The hospital name/identifier and date of service may help to identify the record in lieu of Encounter Number.

Emergency Department

EMS uses information from the emergency department to understand whether EMS missed any significant symptoms and findings that were immediately identified upon arrival at the ED, and whether any procedures or medications were used in the ED that could have been performed earlier to benefit the patient.

  • ED Admission Date/Time
  • ED Discharge Date/Time
  • ED Diagnoses
  • ED Procedures:
    • Procedure Performed
    • Date/Time of Procedure
  • ED Medications Administered
  • ED Disposition

Hospital (non-ED)

EMS uses post-ED information from the hospital to understand the patient's final diagnoses and course of medical care. Procedure information (including date/time) is particularly important for time-sensitive interventions such as the placement of stents or cardiac catheterization. EMS uses this information to identify how to improve recognition of medical conditions and help patients receive time-sensitive interventions more quickly.

  • Hospital Admission Date/Time
  • Hospital Discharge Date/Time
  • Admitting Diagnoses
  • Discharge Diagnoses
  • Procedures:
    • Procedure Performed
    • Date/Time of Procedure
  • Disposition

Hospital (overall)

Information in this list may come from any location in the hospital (ED or otherwise). It helps EMS to understand the course of the patient's care within the hospital as well as planned post-hospital care, which helps EMS to adjust its care to ensure that appropriate care is given to future patients.

  • Vital Signs
    • Might be too much information. An initial set of vital signs may be useful.
  • Length of Stay
  • Treatment Plan
  • Patient Movement
  • Date/Time of Death
  • Discharge Instructions
  • Prescribed Medications
  • Referrals Made to Other Providers
  • Risk Scores; for example:
    • Cerebral Performance Category (CPC) score after cardiac arrest
    • Diabetes risk score
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