By Rex Brooks
The Emergency Data Exchange Language (EDXL) from the Emergency Management Technical Committee (EM TC) of the Organization for the Advancement of Structured Information Standards (OASIS) can play a critical role in making the most of the ‘Golden Hour’ for patients injured in emergency situations.
The ‘Golden Hour’— also known as golden time — refers to the period of time following a traumatic injury during which there is the highest likelihood that prompt medical and surgical treatment will prevent death.
Setting aside for the moment, the many other issues at work in the emergency context, EDXL provides two ICT (Information and Communications Technology) specifications which directly affect healthcare in those precious moments of the “Golden Hour”. These are:
- Hospital AVailablity Exchange (EDXL-HAVE) currently in version 2.0 issued jointly with the healthcare standards body Health Level 7, and
- Tracking of Emergency Patients (EDXL-TEP) currently in version 1.1, and which is used in the bi-directional transform specification that allows emergency patient information to be translated from OASIS EDXL-TEP v1.1-based data to HL7 v2.7.1 Admit, Discharge and Transfer data used by hospital administrations.
In addition to the immediate emergency, the bi-directional transform also serves to keep a patient’s information current during routine transfers between hospital systems or in evacuations.
These specifications fall within the intersection of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), legislation which provides data privacy and security provisions for safeguarding medical information, and the rapidly developing National Public Safety Broadband Network (NPSBN), known as “FirstNet, being built out by AT&T to provide dedicated network availability for the exchange of vital data in emergency and non-emergency situations for United States’ first responders from local, state, tribal and national jurisdictions.
Both of these specifications answer or address important issues noted in the following paragraph from the Abstract of a recent report sponsored and published by the National Institute of Standards and Technology (NIST). The report is titled Interoperability of Real-Time Public Safety Data: Challenges and Possible Future States.
“The proliferation of advanced data sharing technologies and the emergence of a national public safety broadband network (NPSBN) are revolutionizing the communications capabilities of first responders in the United States. Fire departments, law enforcement agencies, emergency medical service providers, and other public safety entities are beginning to adopt messaging applications, sensors, networked cameras, and other technologies that provide a wealth of real-time information about people, infrastructure, and incident environments. However, the rapid expansion of these technologies presents important technical, economic, and governance challenges that need to be addressed for these technologies to provide interoperable communication solutions for all members of the public safety community.”
These specifications also answer the questions cited next from the Abstract for of presentation by the Chair of the EM TC for the 2019 International Association of Emergency Managers (IAEM) Conference to be held in Savannah, GA in November 15-20, 2019.
“What if we had a method for collecting data from a patient at first encounter through triage, transport and to final care? What if this data could be updated and monitored along the way and used to provide dispatch direction to ambulances so that patients would be transported to the nearest hospital with the care needed? What if the hospital emergency room doctors had access to the incoming patient data to include the vitals, actions and any medications provided along the way? What if all the data could be automatically input into the patient’s electronic health record in the hospital? What if this could be done using current hospital systems and triage products? What if this could be done securely? What if this same data format could be used for hospital evacuation and routine patient transfer? What if this patient data could be shared securely across local, state, federal and international boundaries?”
Coping with “Big Data”
A previous article published by Inside Analysis, Open Government Data Act – Emergency Data Exchange Language (OGDA – EDXL) detailed the current state of EDXL in the context of the OGDA, and the specifications we’re looking into here were shown to be part and parcel of the effort to make various kinds of vital data available freely within the agencies of the federal government. However, this development needs to reckon with the advent of “Big Data” and user-behavior analytics and predictive analytics.
“Big Data” is a field that treats ways to analyze, systematically extract information from, or otherwise deal with data sets that are too large or complex to be dealt with by traditional data-processing application software. Data with many cases (rows) offer greater statistical power, while data with higher complexity (more attributes or columns) may lead to a higher false discovery rate. Big data challenges include capturing data, data storage, data analysis, search, sharing, transfer, visualization, querying, updating, information privacy and data source. Big data was originally associated with three key concepts: volume, variety, and velocity. Other concepts later attributed to big data are veracity (i.e., how much noise is in the data) and value [what can we do with it?]
According to the Big Data Wikipedia article quoted above current usage of the term big data tends to refer to the use of predictive analytics, user behavior analytics or other advanced data analytics methods which extract value from data, and seldom to the size of a particular size data set. However, large datasets are an unavoidable characteristic of the new data ecosystem. So, it is important for the decision makers in the emergency management (EM) domain to stay abreast of the growth and spread of Big Data. It is essential that the data in the emergency management domain hew to consistent, open, voluntary, and non-proprietary consensus standards, especially the EDXL suite of standards and specifications.
The special considerations of the EM domain regarding the analytics capabilities noted above is a topic which deserves its own examination, since it includes topic areas such as logistics, decision management, budgeting accountability, governance policies for local to international scopes for mutual aid agreements. The need for accurate predictive analytics in the Emergency Management domain is clearly apparent in the meteorological context of global climate change.
How does it Work?
The following two graphics come from recent presentations which focus on how HAVE and TEP are designed to work together with EDXL-DE Distribution Element. The DE is the message header-wrapper which handles content-based routing of EDXL messages . The graphics show the movement of data in the Emergency Healthcare context, and how these standardized messages are designed to work in practice. Because these images are largely self-descriptive, details of how they work in any given scenario is not provided here. These details can be found in the specifications which can be accessed through the links in the third paragraph of this article.
In Fig. 1 above: EDXL-TEP v1.1from OASIS and the jointly released EDXL-HAVE-v2.0 from OASIS and Health Level Seven (HL7) are designed to work together in the continuum of patient movement.
In Figure 2 above you can see how the process is designed to unfold in practice. Note: the HavBED program before it was discontinued under the Agency for Healthcare Research and Quality (AHRQ) has been superseded by EDXL-HAVE-v2.0.
From Vision to Reality: We’re Closer Than we Think
Having access to all the data agencies collect could lead to a problematic situation unless the use of freely available data standards for specific topic areas like emergency management is mandated or accepted by common use to give our analytic capabilities a common reference system of controlled vocabularies, that is vocabularies with well-known and widely accepted data models.
This is not meant to imply that there are existing emergency management software applications, including mobile apps, which capture patient (or victim) data but all use their own proprietary formats. However, this data can be made interoperable if there are transform provided to the accepted EDXL standard.
Also, in-hospital systems do not need to change their messaging. They can just use the bi-directional transform to provide interoperability for patient (or victim) data collected and/or needed during transport. The comprehensive NIST paper quoted earlier spells out the technical, economic and governance challenges for the public safety community in regard to improving and promoting better and more widespread interoperability of emergency data. By interoperability we mean that data from one jurisdiction’s ICT system can be used by another jurisdiction’s ICT system. This is a key concept which needs to be implemented to improve emergency management communications.
To summarize the challenges:
- Low acceptance and adoption of the few existing public safety data exchange standards
- Lack of a widely accepted identity verification and access permissions standard for interoperable data stores
- End-to-end proprietary data sharing solutions limit interoperability
- Lack of modular data-sharing systems which provide features-based solutions for jurisdictions to choose from to fit their needs and budget
- Lack of community consensus on data sharing issues to provide guidance to developers
- Agencies need to establish data sharing practices before multi-agency incidents occur
- Agencies need to compare/contrast data-sharing practices for nearby local, state and federal jurisdictions
- Agencies need to develop pre-defined templates for policies, contracts and requests for proposals
EDXL-HAVE-v2.0 and EDXL-TEP-v1.1 and the Bi-directional Transformation of OASIS EDXL-TEP-v1.1 and HL7 v2.7.1 Specification Version 1.0 Committee Note 01comprise a modular solution set which answers many of the challenges noted above. This important set of OASIS specifications focuses on mission critical challenges relating directly to the emergency healthcare data sharing contexts.
Technically, this set of specifications provide three carefully developed public safety data exchange standards for the healthcare context, but simply fielding these specifications is insufficient. We must work now to achieve the acceptance and adoption required to make full use of these specifications.
Also, with the addition of EDXL-DE as the ‘header-wrapper” envelope routing mechanism, this set of specifications (and any EDXL message payloads as well as unstructured data like image, audio and video files) provide or allow for identity verification, access control and confidentiality.
Economically, this set of specifications eliminates the vendor lock-in factor for communities that use emergency management software which implements these specifications. Further, as controlled vocabularies that specify both required and optional data elements, this set of specifications encourages developers to take a feature-set based approach for their offerings, if they are wise enough to build modular software which allows various jurisdictions to prioritize the features that work best for them. This modular approach also encourages regional jurisdictions to establish guidance for developers to ensure that jurisdictions which require mutual-aid agreements can choose as much or little of optional features to optimize public safety data sharing for the emergency healthcare context.
Governance challenges are more difficult for ICT specifications and standards to address. However, due to the EDXL Process described in the previous Inside Analysis article on OGDA – EDXL, these specifications were created through a process which involved governmental and industry community input. This process included practitioners as well as emergency responders and managers. So this set of specifications is essentially predisposed to encourage community data-sharing.
Conclusion: The Golden Hour —
Precise Data When Needed is Paramount
In emergency situations, it is often the case that emergency medical personnel are required to administer first aid and begin the process of recording a patient’s vital signs and taking in personal information when time is always a critical factor. While anything which makes that process easier, faster and more consistent could be considered important, coordinating a patient’s personal electronic health records is not something that should create a bottleneck. However when a patient is unconscious, unresponsive, or otherwise unable to provide access to their health records, EMTs can only make fundamental triage decisions. Often they may only have a patient’s basic ID from a driver’s license or credit card. Therefore, if they have software incorporating EDXL-HAVE-v2.0 and EDXL-TEP-v1.1 built into their mobile devices, it can be a vital help. If they also share a healthcare data interoperability network capable of transforming patient information from EDXL-TEP to HL7 Hospital Administration documentation, it would be even better, faster and less prone to error due to redundant data input. It could well be that having a name makes a search of various healthcare systems feasible and quick enough to help with such decisions as to which local or regional hospital system is the best fit for a given patient. Such systems make it possible to keep a running account of a patient’s treatment and movement which is persistent, so that when more information becomes available, it can be added to the ongoing record rather than requiring a new intake process.
This route can be very complicated, but with EDXL-HAVE-v2.0, EDXL-TEP-v1.1, and the Bi-directional transform from EDXL-TEP-v1.1 to HL7-v2.7.1 and a local-regional or state level healthcare data sharing ecosystem could make all the difference. https://en.wikipedia.org/wiki/Golden_hour_(medicine)  http://docs.oasis-open.org/emergency/edxl-have/v2.0/cs02/edxl-have-v2.0-cs02.pdf  https://www.hl7.org/index.cfm  http://docs.oasis-open.org/emergency/edxl-tep/v1.1/cs02/edxl-tep-v1.1-cs02.pdf  http://docs.oasis-open.org/emergency/TEP-HL7v2-transforms/v1.0/TEP-HL7v2-transforms-v1.0.pdf  https://www.hhs.gov/hipaa/for-individuals/guidance-materials-for-consumers/index.html  https://www.firstnet.gov/network  https://www.nist.gov/publications/interoperability-real-time-public-safety-data-challenges-and-possible-future-states  https://iaemconference.info/2019/  https://insideanalysis.com/open-government-data-act-emergency-data-exchange-language-ogda-edxl/  https://en.wikipedia.org/wiki/Big_data  https://archive.ahrq.gov/prep/havbed/