Table 2.
Sources and definitions of the auto-populated e-lndex and the physician-edited p-lndex.
| Variable | Auto-populated e-lndex | Physician-edited p-lndex | |
|---|---|---|---|
| Source | Definition | Source | |
| Demographics (age and sex) | Electronic health record (EHR) | Age in years; sex: male or female | Emergency physician note during emergency department (ED) visit |
| Comorbidities | ICD-9 codes | ||
| Cancer (active or history of) | Problem list in the EHR at the time of the index ED visit | 140–172; 174–175; 179–209; V10.0–V10.82, V10.84–V10.91 | Emergency physician and hospitalist notes during ED visit |
| Heart Failure (systolic or diastolic) | Problem list in the EHR at the time of the index ED visit | 402.01, 402.11, 402.91; 404.01, 404.03, 404.11, 404.13, 404.91, 404.93; 425.1, 425.11, 425.18; 425.4, 425.5, 425.7–425.9; 428 | Emergency physician and hospitalist notes during ED visit |
| Chronic Lung Disease (includes asthma) | Problem list in the EHR at the time of the index ED visit | 491.0, 491.1, 491.20–491.22, 491.8, 491.9; 492.0, 492.8; 493.00–493.02, 493.10–493.12, 493.20–493.22, 493.81, 493.82, 493.90–493.92; 494.0, 494.1; 495–496; 500–505; 506.4; 515; 516.0– 516.2, 516.30–516.32, 516.34–516.37, 516.4, 516.5, 516.8, 516; 517.2; 518.1–518.3; 518.6; 518.83; 518.84 | Emergency physician and hospitalist notes during ED visit |
| Vital Signs | EHR | The highest pulse and respiratory rate and the lowest systolic blood pressure, temperature, and oxygen saturation during the ED stay | Expanded to include unstructured vital signs documented in emergency physician or hospitalist notes during ED visita |
| Mental status | Nursing EHR flowsheet documentation | (1) Level of consciousness; (2) Orientation; (3) Mentation element of the Schmid fall-risk assessment; (4) Altered mental status | Emergency physician, nursing, and hospitalist notes during ED visit |
a. Abstractors did not reference the original pre-hospital emergency medical care documentation or the pre-ED clinic notes.