Tech News

Data-Element Standard Promotes Uniform EMS Documentation

ASTM E 1744, Standard Guide for a View of Emergency Medical Care in the Computer-Based Patient Record, offers uniform collection of emergency medical service (EMS) data from beginning to end of an emergency.

“The uniformity will help us discover what is working and what is not so we can ensure the best possible outcome for persons suffering a medical emergency,” says consultant Sandra Johnson, a data-linkage specialist for the National Center for Statistics and Analysis at the National Highway Traffic Safety Administration (NHTSA), Washington, D.C. “The guide provides a unique ‘view’ of emergency medical care information to be included in the electronic health record.”

Johnson developed Standard E 1744 with members of ASTM Subcommittee E31.19 on Content and Structure of Electronic Health Records. A national consensus conference sponsored by NHTSA resulted in the development of the emergency pre-hospital data elements used in the new guide.

“E 1744 reinforces the concepts set forth in E 1384 [Standard Guide for Content and Structure of the Electronic Health Record (EHR)] and E 1633 [Standard Specification for Coded Values Used in the Electronic Health Record] that the seamless documentation of care in all settings requires a common logical record structure and terminology,” she explains.

“Previous work by ASTM E31.19 along with national and professional guidelines already developed for emergency medical care provided the content for developing this ‘view’ of the electronic health record,” says Johnson. “Development of the data elements for emergency department systems (DEEDS) was sponsored by the Center for Disease Control, NHTSA, and other public and private organizations. The inpatient data elements were generated from the standard billing data set.”

Part of ASTM Committee E31 on Healthcare Informatics, the subcommittee will continue to update the standard with various data set developers. “This summer, DEEDS will be revisiting their data set with possible revisions expected in 2001,” Johnson concludes.

For further technical information, contact Sandra Johnson, National Center for Statistics and Analysis, NHTSA, 400 Seventh St. SW, Room 6125, Washington, D.C. (202/366-5364; e-mail: ). Committee E31 meets Nov. 3-5 in Los Angeles, Calif. For further details, contact manager Teresa Cendrowska, ASTM (610/832-9718). //