This page is part of the Situational Awareness for Novel Epidemic Response (v1.0.0: STU 1) based on FHIR R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Introduction

The Situational Awareness for Novel Epidemic Response Implementation Guide enables transmission of situational awareness information from healthcare facilities to centralized data repositories to support the focus and response to novel influenza-like illness, such as COVID-19. The COVID-19 pandemic has caused a need to have immediate awareness of available aggregate facility status, patient outcomes and resource availability for public health and emergency response agencies to support monitoring, coordination, and management. Similar outbreaks and other public health emergencies can immediately benefit from the work in this project to support public health emergency preparedness and response.

Scope

The scope of this project is to support reporting of data required by public health and emergency response agencies to address management of the COVID-19 Pandemic. The project will develop solutions that address COVID-19 and similar public health emergencies.

Principles

The following principles were established for development of this guide:

1. The solution needs to be focused on providing high return on investment (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.

Approach

This guide will focus on existing FHIR Release 4 resources with extensions where necessary. The project team assessed past efforts to support situational awareness, including:

• Existing standards,
• Existing HL7 FHIR resources, and
• Terminology

Based on these assessments, this IG prioritized its focus on supporting bed and ventilator availability, but includes support for other reporting efforts (e.g., PPE supplies, staffing).

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 data is available in inventory control or central monitoring solutions, but are not necessarily readily available in the EHR. This is a natural evolution from 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, that 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.

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 American Health Information Community (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.
• 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 that 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. The HL7 SOA Workgroup Collaborated with the OASIS EDXL Committee to develop a Cross Paradigm specification supporting the communication of bed availability information.

HL7 FHIR Resources Supporting Situational Awareness Reporting

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, respirators, 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 (a precursor to 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 or facility.

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 known 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.

Immunization

The Immunization resource can be used to determine the quantity of immunizations dispensed to vaccinate patients. The Immunization resource is included in USCDI and generally available in EHR systems in the US.

MedicationDispense, MedicationAdministration

The MedicationDispense resource can be used to determine the quantity of specific types of medications dispensed to treat patients (e.g., Remdesivir). MedicationAdministration would be used to determine the quantity of medications given. MedicationDispense and MedicationAdministration are not widely available through EHR systems generally.

SupplyRequest and SupplyDelivery

The SupplyDelivery resources can be used to determine quantities of supplies, such as PPE or disposable items used during treatment. These resources are relatively new and not widely available.

Measure and MeasureReport Resource

The Measure and MeasureReport resource can be used to support reporting of a variety of measures, including simple counts, tracking of inventory (e.g., PPE, medication supply), or used 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 and in clinical quality reporting efforts.

Questionnaire Response

The QuestionnaireResponse resource has been profiled for use in reporting to CDC’s National Healthcare Safety Network (NHSN) in two implementation guides to report the occurrence of Healthcare Acquired Infections. These guides have seen limited implementation and testing.

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.

Codes used for Stratifying Populations

Other codes are essential for stratifying populations to determine the impact of disease, by age, gender or race and ethnicity, either to determine risk factors, or identify disparities in treatment. Existing code sets are available to support these sorts of stratification efforts.

New Codes

Until COVID-19 and SARS-Cov-2 were discovered, codes to describe the disease, diagnostic tests, antibody tests, or test results did not exist because these concepts did not yet exist. Since then organizations like AMA, WHO, Regenstrief and IHTSDO, responsible for managing code systems used by EHR and other Health IT systems have produced codes where needed, and developed value sets and guidelines for coding conditions and situations related to COVID-19 including diagnosis, evaluation, treatment, procedures, and medications associated with the disease.

These new codes and guidelines for use of existing codes support:

• Laboratory Testing and Results
• Diagnosis of COVID-19
• Suspected Diagnosis of COVID-19

• Suspected or actual Exposure to COVID-19