Electronic Medical Summary

From TAPASWiki

There are many sections to the Electronic Medical Summary CDA specification.

This section of the wiki is here to talk about design of TAPAS as it relates to each section of the e-MS specification.

This document provides a high level summary of the various medical summary sections, as defined by the e-MS. The TAPAS medical summary is built from the HL7 RIM and is designed to record and maintain evolving patient medical summaries that are based on the e-ms standard in BC ( http://e-ms.ca ).

There are several components to the data structures that will be in the application, including: a patient model, user model, document model (e-MS). All elements will have an audit history that will record all changes made to an element.

This page breaks down the document sections of the e-MS implementation guide and describes where they fit into our current design and specifies what optional elements are out of scope in our design for this project a this time. NOTE: The order of the sections in the following tables is taken directly from the e-MS implementation guide, which is freely available as a PDF from their web site. It would be helpful to have the implementation guide in front of you for more detail while reading this document.

Contents 1 The eMS and the TAPAS Patient Model 1.1 In Scope for the Patient Model 1.2 In Scope Sections - Not Part of Patient Core Data Set 1.3 Currently Out Of Scope Sections 2 Details about e-MS Sections 2.1 Prescription Management 2.2 Patient Alerts

The eMS and the TAPAS Patient Model

In Scope for the Patient Model

For the current version of TAPAS, the core elements of the medical summary will make up the patient model. This include the following from the e-MS header and body:

e-MS Section	Location	Description
Record Target	Header	This section is the patient demographics in our model. Contains the patient name, gender, date of birth, health number, address, etc.
Alerts	Body	We will be using alerts for the alerts and flags portion of TAPAS. We will have to work out an “Alert_Type” vocabulary as this is not specified in the e-MS. There are no universally accepted alert types and we will likely have to develop our own set of categories for TAPAS.
Social History / Risks	Body	Physicians will be documenting social history risk factors in this section, such as smoking, etc. “Risk_Type” will need to be defined for TAPAS as it is not defined by the e-MS group. Likely we will look to a small subset of ICD-9 CM codes for this section.
Active Problems	Body	The Active Problem list is key for us. It will be coded using the ICD-9 CM diagnostic codes so that it is consistent with EGADSS and the e-MS.
Current Medications	Body	We’ll be using current medications. We have also discussed with the users to keep the audit trail available as this is very important information clinically. Specifically, it is important for clinicians to know if a medication was tried and discontinued. This is something that we’ll be suggesting to the e-MS group as important clinical pieces of data. Currently we are looking at the health Canada drug database as our reference database, but may move to another, better suited database if necessary. This is in review currently.
Medical History	Body	This section includes past medical history (including pregnancies) elements that may effect the patient’s care. (e.g. Heart Attacks). It will map to the same list of ICD-9 diagnostic codes in the active problems section.
Surgical History	Body	Historical data on major procedures performed on the patient. These would include elements like appendectomy, c-section, etc. The codes will come from the procedure codes in ICD-9 CM. Likely we will reduce the list to be more managable. Many procedures are in the ICD-9 CM list for documentation purposes and would not be important in a surgical history.
Allergies	Body	Allergies include both true allergies and adverse reactions to medications. Also in this section will include food allergies that are important to know. They will be coded using the HL7 Allergy Type.
Immunization	Body	Based on the BC-CDC immunization codes, this section / module will include all immunizations that the patient has received.
Past Referrals / Hospitalizations	Body	The Past referrals would be generated from the TAPAS model for referral management. This will be a later development in our cycle, but is in scope for this project.
Family History	Body	We will code this section using ICD-9 CM diagnostic codes, however, the e-MS standard only supports text entry (Title and text). We will be extending the elements in this section by including who (which family member, age of onset, what, a comment field, etc).

In order for us to have increased functions that we want, there will be some data that we will be capturing on a per element basis that won’t be stored in the e-MS. See our project documentation for clarity around this. Essentially, we'll be capturing:

• authoring information (who made a change when, when the problem was first created)
• audit trail information
• onset of problem
• Free text comments about a specific problem
• Other elements that are specific to each section (see our documentation)

In Scope Sections - Not Part of Patient Core Data Set

There are some sections of the e-MS that will only be relevant for the import and export of e-MS documents and should not, obviously, be part of the core patient model of TAPAS. This include:

e-MS Section	Location	Description
Clinical Document	Header	This provides audit information about the document. We will supercede this by providing audit information on a per element basis above as part of our core requirements.
Information Recipient	Header	This section provides information about the person who the particular e-MS is sent to. Not relevant for the patient information, would be important for exporting / importing e-MS.
Author	Header	The author, again is important for the person who has generated the e-MS. NOTE: it will be important that we capture this information in our user, in order to populate the e-MS document properly.
Custodian	Header	The custodian will be the family doctor. We do not have a custodian ID at this time. As VCH’s EHR strategy advances, this will become clear, as will the broker strategy for e-MS sharing in the health authority.
Purpose	Body	While this will not be part of the core patient data set we will use purpose for any electronic e-MS documents that will be exported in the future.

Currently Out Of Scope Sections

There are a few sections of the e-MS that will be excluded from this version of TAPAS as they do not fit the current design or are deemed not essential for this iteration. These include:

e-MS Section	Location	Description
Participant	Header	This section contains contact information for patient emergency and non-emergency contact information. This would be important to include in TAPAS in later iterative cycles.
Related Document	Header	This section allows an e-MS to associate itself with other e-MS documents. This will not be important for this version of TAPAS as the export features will only be one document per patient at this time.
Examination Measurements	Body	Currently out of scope for TAPAS. These may be added in the future as additional modules get created / funded.
Medical Imaging History	Body	Right now imaging history is not available electronically. In discussions with the clinical user group it is not expected that they will be inputting this data into TAPAS for completeness sake. Rather they will simply keep the paper records in their chart. Over time, as a electronic feed is available for the imaging reports, we will consider adding this to TAPAS.
Other Treatments	Body	Other treatments would include any alternative treatments that the patient may be on. For this first iteration, this section is deemed out of scope. It is on the high priority for inclusion once we get the first iteration out.
Labs	Body	Labs will be important in the system in the future. Out of scope currently, this is something we would like to add into scope. As labs are available electronically (unlike DI Reports) and they are well coded using LOINC codes, this is a high priority to put back in scope.
Observation Media	Body	We will have no observation media in this version of TAPAS. Currently there are no files or images in TAPAS that need to be shared through the e-MS CDA.

NOTE: Some of these will come back into scope over time, provided we complete the core functions. For example, the “Participant” section will be important information for physicians while on call and will be likely be prioritized back into our feature enhancements once our first versions are out and being used. It will be easy to add. Labs, as well, will be an important clinical win for TAPAS. However, the establishment of a lab system, with the electronic connections and changes to office workflow is considerably more complex to implement.

Details about e-MS Sections

Prescription Management

The prescription manager allows users to input, manage, and print prescriptions for patients as part of the medical summary. A streamlined prescription management system is seen by the users as a key feature of a summary tool.

Patient Alerts

Patient Alerts allow users to tag actions for sharing with others. These vary from patient to patient and have several characteristics that will support the alerts acting as shared reminders between providers and as future reminders.

NOTE: Patient Allergies are excluded from the alert section - they are in their own section of the summary.