EHR Implementers

EHR Implementers - EHR Triggering

Triggering of eICRs

Triggering is the set of actions in an electronic health record (EHR) that initiates the creation and transmission of an electronic initial case report (eICR) and initiates its transmission (directly or indirectly) to the Association of Public Health Laboratories (APHL) Informatics Messaging Services (AIMS) platform. When certain data in the EHR are recorded or updated, they are checked against a series of codes that have been distributed to the EHR. If a code matches, there is likely a reportable condition that needs to be processed for confirmation. If the timing parameters for reporting have been met, then the eICR should be “triggered” and transmitted to the AIMS platform. This should all be done automatically, behind the scenes, and without disrupting healthcare providers’ workflows.

Triggering is based on reporting parameters and trigger code value sets in XML or JSON format that are distributed through the Electronic Reporting and Surveillance Distribution (eRSD) system. The eRSD contains these value sets, (also sometimes referred to as the Reportable Conditions Trigger Codes (RCTC)). The trigger codes in the eRSD were collaboratively developed by the Council of State and Territorial Epidemiologists (CSTE), Centers for Disease Control and Prevention (CDC), and APHL. EHR implementers can register and subscribe at no cost to the eRSD service to receive notification and distribution of routine and emergent updates. Each update will include an effective start date, which is the date the set of codes should be implemented and in use by reporters. For routine scheduled releases, this will typically be four to six months from the release date.

eRSD - Electronic Reporting and Surveillance Distribution (external link) includes:

  • Trigger code value sets.

  • A zip file of the RCTC spreadsheet and change log (updates to the RCTC file since the previous release).

To access the eRSD, follow these steps:

  • If you have not registered, click the registration link (external link) and follow the instructions.

  • Once you have established an account, you will be able to subscribe at no cost to the eRSD service to receive notification and distribution of routine and emergent updates. In addition to subscribing, you will be able to download the entire eRSD manually on the site or the latest RCTC spreadsheet and RCTC change logs.

EHR implementers requested a more consumable version of the RCTC than the Excel spreadsheet, so the eRSD service has been developed and is built on the Health Level Seven International (HL7) Fast Healthcare Interoperability Resources (FHIR) standard. In addition to the trigger code value sets, the eRSD also includes timing parameters for reporting, and can contain rules as well. Public health seeks to have as consistent as possible reporting coming from EHRs. The eRSD’s XML or JSON distribution can be used by EHRs that have not yet implemented FHIR.

How the eRSD is used to trigger an eICR

An eICR is “triggered” or generated and sent to the AIMS platform for confirmation of reportability when a diagnosis, a laboratory order (for conditions reportable based on suspicion), a laboratory test name, a laboratory result code, or a medication is matched to one of the specific trigger code sets in the eRSD. There are five primary triggering scenarios that EHRs need to account for by matching data recorded in the EHR against the trigger codes within the eRSD.

Diagnosis (SNOMED, ICD-10 CM)

An eICR will be triggered when a diagnosis is recorded in the EHR that matches a value within the eRSD “Diagnosis_Problem” value set. These codes could be held in problem list or diagnosis fields.

Lab Results (SNOMED)

An eICR will be triggered when a laboratory result is received by the EHR where the laboratory result matches a value within the eRSD “Organism_Substance” value set.

Lab Result Test Name (LOINC)

An eICR will be triggered when a laboratory result is received by the EHR where the laboratory test name matches a value within the eRSD “Lab Observation Test Name” value set.

Lab Orders (LOINC)

An eICR will be triggered when a laboratory order is placed where the lab order matches a value within the eRSD “Lab Order Test Name” value set.

Note: Because this trigger handles reporting on suspicion of a condition to meet related laws, this triggering should occur before lab results are available.

Medication

(CVX, RXNORM, SNOMED)

An eICR can be triggered when a medication is administered or prescribed and matches a value within the eRSD “Medication” value set.

eRSD Preparation and Maintenance

It is important to implement the latest version of the eRSD within EHRs, as doing otherwise may adversely impact public health reporting, resulting in reports of public health interest going undetected and not being sent to public health. The eRSD includes value sets that will continue to evolve with additional codes and conditions reportable to public health. It may also include new codes for rapid implementation in a public health emergency setting. It is important to be able to accommodate routine and emergent eRSD updates.

In some cases, a healthcare provider may use local codes that are not specified in the eRSD. Most major labs deliver results to EHRs with the nationally accepted SNOMED and LOINC terminologies. Not all EHRs record these values on receipt. EHRs using local codes may need to map those codes into the nationally accepted SNOMED and LOINC terminologies to trigger properly. This mapping may be unique to individual healthcare providers, and it is encouraged that the healthcare provider and EHR implementer work collaboratively to determine this need.

Trigger Timing

Because of variability in accumulation of data at the start of a patient encounter, the EHR implementer should implement a time-based delay in generating and sending the eICR to allow time for required data to be captured within the patient encounter. This will ensure the eICR is more populated before sending and minimize the number of case reports that are sent for a single patient encounter. 

Full triggering timing can be described using the three suggested parameters below.

Parameter A – The time from the start of the patient encounter to when the first eICR is constructed and sent. May contain multiple trigger events before the eICR is populated.

  • Example - 1 hour after the encounter begins

Parameter B - The time period from an initial trigger code check (parameter “A” above) and the routine checking for new trigger code that matches in a long-term stay.

  • Example - 6 hours after the last eICR was sent

Parameter C - The time period from the sending of an initial eICR to the sending of an update during a long-term stay.

  • Example - 24 hours after the last eICR was sent

Parameter D – The time period after the encounter ends when a final eICR is constructed and sent.

  • Example - 24 hours after the encounter ends

eICR Triggering and Transmission Guidance

For any questions or feedback regarding the eRSD (including the RCTC), please contact the eCR Support Team eCR-Info@aimsplatform.org