Data standards to support health information exchange between poison control centers and emergency departments
Data standards to support health information exchange between poison control centers and emergency departments
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DOI：
10.1136/amiajnl-2014-003127
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发表时间：
2015-05-01
影响因子：
6.4
通讯作者：
Cummins, Mollie R.
中科院分区：
文献类型：
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作者：
Del Fiol, Guilherme;Crouch, Barbara Insley;Cummins, Mollie R.
目的毒物控制中心(PCCs)经常与急诊科(EDs)合作，为中毒患者提供护理。在这一过程中，EDS和PCC之间通过电话交换大量信息，导致严重的效率低下和安全漏洞。材料与方法基于PCC-ED健康信息交换的参考模型，我们(1)将PCC-ED信息交换事件映射到HL7(Health Level 7)综合临床文档架构(C-CDA)标准中指定的临床文档，(2)将PCC-ED电话对话中常规交换的信息类型映射到C-CDA部分。结果支持PCC-ED信息交换过程所必需的四种C-CDA文档类型：历史和物理笔记、咨询笔记、进展笔记、和出院摘要。这些C-CDA文档可以很好地表示PCC和ED之间通常交换的信息类型。结论考虑到美国EHR认证所需的一套临床数据标准，基于标准的PCC和ED之间的卫生信息交换过程似乎是可行的，尽管所提出的方法仍需在实际系统实施中进行验证。这样的过程有可能提高PCC-ED通信的安全性和效率，最终导致改善患者护理结果。
Objective Poison control centers (PCCs) routinely collaborate with emergency departments (EDs) to provide care for poison-exposed patients. During this process, a significant amount of information is exchanged between EDs and PCCs via telephone, leading to important inefficiencies and safety vulnerabilities. In the present work, we identified and assessed a set of data standards to enable a standards-based health information exchange process between EDs and PCCs.Materials and methods Based on a reference model for PCC-ED health information exchange, we (1) mapped PCC-ED information exchange events to clinical documents specified in the Health Level Seven (HL7) Consolidated Clinical Document Architecture (C-CDA) Standard, and (2) mapped information types routinely exchanged in PCC-ED telephone conversations to C-CDA sections.Results Four C-CDA document types were necessary to support the PCC-ED information exchange process: History & Physical Note, Consultation Note, Progress Note, and Discharge Summary. Information types that are commonly exchanged between PCCs and EDs can be reasonably well represented within these C-CDA documents.Conclusions A standards-based health information exchange process between PCCs and EDs appears to be feasible given a set of clinical data standards that are required for EHR certification in the USA, although the proposed approach still needs to be validated in actual system implementations. Such a process has the potential to improve the safety and efficiency of PCC-ED communication, ultimately resulting in improved patient care outcomes.