Consolidated Health Informatics Initiative
Final Recommendation Information Sheet[1]
Domain Title(s) and Team Lead
Clinical Encounters: Gregg Seppala, VHA
Scope
Clinical encounter is defined by ASTM as “(1) an instance of direct provider/practitioner to patient interaction, regardless of the setting, between a patient and a practitioner vested with primary responsibility for diagnosing, evaluating or treating the patient’s condition, or both, or providing social worker services. (2) A contact between a patient and a practitioner who has primary responsibility for assessing and treating the patient at a given contact, exercising independent judgment.” Encounter serves as a focal point linking clinical, administrative and financial information. Encounters occur in many different settings — ambulatory care, inpatient care, emergency care, home health care, field and virtual (telemedicine).
The ASTM definition excludes ancillary service visit, which is defined as “the appearance of an outpatient in a unit of a hospital or outpatient facility to receive service(s), test(s), or procedures.” The clinical encounter definition also excludes practitioner actions in the absence of a patient such as practitioner-to-practitioner interaction and practitioner-to-records interaction.
Domain/Sub-domain
In-Scope (Y/N)
Clinical Encounters Y
Admission Information Y
Transfer (Patient Movement) Information Y
Discharge Information Y
Provider Information Y
Accident Information Y
Death and Autopsy Information Y
Allergy Information N
Demographics N
Diagnosis/Problem Lists N
Financial/Payment N
Insurance Information N
Interventions/Procedures N
Alternatives Identified
| Standard | Comments |
| ASTM E1384-02a Standard Guide for Content and Structure of the Electronic Health Record (EHR) | The work group concluded that E1384 offers the best definition for clinical encounter and adopted that definition to define the scope for our effort. However, E1384 does not contain significant clinical encounter data elements or value sets beyond those in the HL7 v2.x ADT message specification. |
| ASTM E1633-02a Standard Specification for Coded Values Used in the Electronic Health Record | The work group determined that E1633 offered coded values for only five of the 38 clinical encounter coded data elements. Of the five, one is derived from the UB-92 and another is derived from DEEDS. |
| CDCP Data Elements for Emergency Department Systems, Release 1.0 (DEEDS) | The work group reviewed DEEDS for data elements and code sets and recommends that several of the HL7 value sets be harmonized with codes in DEEDS. |
| CMS Form HCFA-1450 (UB-92) | The work group recommends code sets from the UB-92 for several HL7 clinical encounter coded data fields. This is consistent with the HL7 standard which also recommends the UB-92 values for use in the United States. |
| Health Level 7, version 2.4 and above | The work group determined that the CHI-selected messaging standard — HL7 v2.4 Application, Transfer and Discharge (ADT) message — included all of the data elements and most of the value sets for exchanging information about clinical encounters. |
| SNOMED-CT | The work group matched SNOMED concepts to HL7 data fields but concluded that SNOMED does not provide better coverage overall compared with the suggested values sets in HL7 at this time. |
| X12N 837 Health Care Claim message | The work group reviewed the Event type (Loop ID 2300) for clinical encounter data elements and value sets but was not able to identify any significant data elements or values sets beyond those in the HL7 v2.x ADT message specification. |
Final Recommendation
The workgroup recommends adoption of Health Level Seven (HL7), Version 2.4 and higher, with identified gaps to be addressed in the future.
Content Coverage
The team identified 92 of the 612 data fields in the HL7 v2.4 Application, Transfer and Discharge (ADT) message as falling within the scope of clinical encounter standards recommendation. A gap that needs to be addressed in the future is support for exchanging information about clinical services that do not fall under the definition of encounter such as practitioner to practitioner and practitioner to record interactions.
The team concluded that 37 of the 92 data fields require no further standardization because they hold date and time (16 data fields), yes/no responses (10 data fields), text (6 data fields), address (1 data field), telephone (1 data field), organization name (1 data field) or number (2 data fields) data.
The team concluded that for the 17 data fields that hold identifiers, visit id (2 data fields) does not require standardizing, healthcare facility (1 data field) and practitioner (7 data fields) should use National Provider System identifiers once they are available, but location identifier (7 data fields) cannot be standardized across facilities at this time and must be addressed in the future.
The team concluded that for the remaining 38 data fields that hold coded data, 8 data fields should reference externally-defined value sets, 13 data fields should reference tables published in HL7 v2.4, 7 data fields should reference tables published in HL7 v2.5, 4 data fields should reference value sets published in HL7 v3, but 6 data fields do not have value sets published in any version of HL7 and must be addressed in the future.
| Data Element Type | Coverage |
| Clinical Encounters | 29 data elements; 1 needs future work |
| Admission Information | 15 data elements; 2 need future work |
| Transfer (Patient Movement) Information | 9 data elements |
| Discharge Information | 6 data elements; 1 needs future work |
| Provider Information | 15 data elements; 2 need future work |
| Accident Information | 9 data elements |
| Death and Autopsy Information | 9 data elements |
Acquisition
Standards are available from HL7. HL7 asserts and retains copyright in all works contributed by members and non-members relating to all versions of the Health Level Seven standards and related materials unless other arrangements are specifically agreed upon in writing. No use restrictions are applied.
Conditions
The workgroup identified issues that should be addressed in the future but the standard is usable in its current state so our recommendation is not conditional.
[1] Information Sheet designed specifically to facilitate communication between CHI and NCVHS Subcommittee on Standards and Security resulting from May 20, 2003 testimony. CHI may seek assistance to help further define scope, alternatives to be considered and/or issues to be included in evaluation process.