Situational Awareness for Novel Epidemic Response - Local Development build (v0.1.0). See the Directory of published versions

Overview

The Situational Awareness for Novel Epidemic Response Implementation Guide enables transmission of high level situational awareness information from inpatient facilities to centralized data repositories to support the treatment of novel influenza-like illness.

Fighting COVID-19 with FHIR®

About This Guide

This is a draft implementation guide to promote discussion with leaders in the Health IT industry, and very much a work in progress. All content in this guide is subject to discussion and change.

The goal of publishing this guide is to encourage the creation of a community interested in extremely rapid development of an interface that can support Public Health in this time of crisis.

Situational Awareness for Novel Epidemic Response

Situational Awareness has been the focus of attention in health IT circles well before the detection of potentially pandemic flu strains during the early formation of the Office of the National Coordinator in 2005.

2006

Bird Flu (H5N1)

2009

Swine Flu (H1N1)

2012

Middle East Respiratory Syndrome (MERS)

2013

Another form of Bird Flu (H7N9)

2019

COVID-19 (SARS-Cov-2)

Situational Data Needs of Public Health Key situational data needed by public health has remained relatively consistent and well established over this time, and is to support awareness of:

1. Local, Regional and National case rates and trends
2. Bed availability for treatment
3. Other resources availability for treatment
   • Staff
   • Medications
   • Immunizations
   • Medical Equipment (e.g., Respirators, N95 Masks)
   • Supplies (e.g., Cleaning Supplies, Facemasks)

Focusing the Solution Space

In evaluating solutions for the above challenges, we have established the following principles:

1. The solution needs to be focused on providing high ROI.
2. The solution should not duplicate existing efforts.
3. The solution needs to work with existing Health IT products currently deployed.
4. The uplift needed to enable an existing product to support public health information requirements needs to be low enough to effectively deliver quickly.

Quick Assessment

1. Existing work by Johns Hopkins University in aggregating case data sets and visualizing them addresses national and even regional (at the county level) trends.
2. Bed availability is an area where there is a great deal of existing work ^1,2,3,4, but not much prior success, although there are existing Health IT solutions that have this data (not just in the EHR). If the solution can be interfaced rather than integrated, an implementation can be piloted much faster.
3. Other resource utilization is available in inventory control or central monitoring solutions, but are not necessarily readily available in the EHR. This would be a natural evolution from Bed Availability.

This rapid assessment leads this guide to a focus on bed availability.

Bed Availability

The key data for bed availability is found in Bed Management solutions integrated with current inpatient EHR Systems, and in departmental ICU and Central Monitoring systems. Such solutions support management of bed assignment for admissions and provide direction to housekeeping staff regarding bed-turnover activities (e.g., cleaning) or departmental systems which provide ICU and Nursing central monitoring capabilities. They are often separate components or modules, Standalone solutions, or third party solutions which integrate with an EHR System (e.g. Forward Advantage with MEDITECH).

Prior Solutions and Existing Standards

Prior standards developed to address these issues have been profiled through past efforts. These are briefly outlined below.

HAvBED and OASIS EDXL/HAVE Standards

Most notably, the OASIS Emergency Data Exchange Language (EDXL), and the OASIS Hospital Availability Exchange were profiled by ANSI/HITSP in response to the AHIC Emergency Responder Use Case. This work was advanced by AHRQ to develop what is now known as the HAvBED solution, which became a federally-mandated program for states to collect and report bed availability data. Health and Human Services suspended the HAvBED program in 2016. Some of the challenges with HAvBED included:

• Manually entered data in many automated bed availability systems is labor-intensive, untimely, resulting in data quality issues.
• Similar issues with to the manual data entry option.
• Technology standards have evolved, and HAvBED requirements did not keep pace.
• Facilities and states were often reluctant to share bed availability data.

HL7 Version 2

Other standards which contain information about bed availability include HL7 Version 2 (e.g., the ADT_A20 Bed Status Update message), and general observations profiled by ANSI/HITSP to support organizational reporting of bed availability using HL7 Version 2 OBX segments.

HL7 Version 3

No HL7 Version 3 standards were developed to support Bed management or availability.

HL7 FHIR

In HL7 FHIR the Location resource can describe information about any bed within a facility. The Group resource can report on specific quantities of groups of resources available that match a specific set of characteristics. The MeasureReport resource can report on measures using counts and other metrics over a variety of resources.

Device Resource

The Device Resource can report on medical devices, including ventilators, repirators, personal protective equipment such as masks, and viral test kits. Device is not widely used by systems reporting on device quantities or status.

Location Resource

While the Location resource can report on beds, it can also be used to describe buildings, wards, geographic area, or any other sort of place, including “mobile” places such as a mobile clinic or ambulance. Given its broad application, would need to be profiled to support use for bed availability.

While many existing Certified EHR Systems support the FHIR standard and the Location resource today, there’s little use of the Location resource to report data about beds. It is more commonly used to report Location data associated with the Common Clinical Data Set (now known as the US Core Data for Interoperability or USCDI) required by the ONC 2015 Certification regulations. These uses of Location are found in the Encounter, Procedure and Practitioner resources to describe the facility where an encounter occurs, the location where a procedure is performed, or the location of a practitioner.

Group Resource

While the Group resource can be used to support aggregate reporting on beds, as it allows reporting of quantities of an item without referencing an individual item, it has not been deployed in this way by any knwon system. This resource can also be used to report on other types of resources, such as ventilators, respirators, and N95 masks.

NOTE: While Group doesn’t specifically support groups of Location resources, it can be used to report on any group of things that can be defined by characteristics, it simply cannot enumerate those resources. That is not essential for the use cases in this implementation guide.

The Group resource is more lightly deployed in existing EHR products. It is not a requirement of the 2015 Certification program.

Measure Resource

The MeasureReport resource can be used to support reporting of a variety of measures, including simple counts, with measures over different strata. It is not readily searchable at the stratum level. MeasureReport is beginning to gain traction because of efforts using it in the DaVinci Project.

The table below shows the FHIR Maturity Model Level for each of the resources described above.

Resource	Maturity Level
Device	2
Group	1
Location	3
MeasureReport	2

Terminology

Terminology plays an important role in this implementation guide. It can be used to describe:

• The kind of location where the bed is located (e.g., ED, med/surgery, ICU, Pediatric, NICU, Isolation)
• The status of a bed (e.g., available, in use, isolated, contaminated, housekeeping)
• Other types of resources (e.g., ventilators, respirators, masks, et cetera)

Location Type

The HL7 Version 3 Service Delivery Location Role Type Value Set has been adopted as the Preferred classification system for Location.type in the Location resource in FHIR R4.

Bed Status

HL7 Version 2 Table 0116 Bed Status Provides Vocabulary that can describe the status of a bed, and has been adopted as the Extensible vocabulary for Location.operationalStatus in the Location resource in FHIR R4.

Footnotes