Transition of Care Lens
Changes coming soon!
This page includes some new functionality that will be in production on Friday July 11.
Data from Admissions, Discharges, and Transfers (ADT) is transformed into Encounter resources. In addition, Zus gets ADT data from Continuity of Care Documents (CCDs) that can provide contextual information such as notes, administered medications, and completed procedures, among others. Zus creates a single unique EpisodeOfCare for each unique hospitalization based on these data.
The Transitions of Care Lens aggregates and summarizes Encounter Lens resources for each patient into EpisodeOfCare
FHIR resources.
Inpatient, emergency, observation, and preadmit encounters that have matching visit IDs and/or any encounters that occur near each other temporally (within 36 hours) for a given patient will be grouped together and summarized into a Zus created and managed EpisodeOfCare resource.
Grouping Logic
First, Zus groups all encounters with the same visit ID together. Then we create temporal windows of these groups, collecting all encounters that occur within 36 hours of the previous encounter. These windows are then summarized into an EpisodeOfCare lens output resource.
Data Model
The output of the Transitions of Care Lens are EpisodeOfCare FHIR resources which Zus creates and manages.
| Field | Note |
|---|---|
| resource.meta.tag | All transitions of care lens output resources will include this tag:{ "system": "https://zusapi.com/summary", "code": "TransitionsOfCare" } |
| resource.diagnosis | The diagnosis field includes all diagnoses from all encounters that are part of this episode. Diagnoses may have use and rank attributes with them if they were available. |
| resource.period | The period will begin at the start of the first occurring encounter that is part of this episode. The period will end at the end of the last occurring encounter that is part of this episode. Null values are possible if the supporting encounters do not have a start or end period. |
| resource.patient | The patient will be the Zus Universal Patient. |
| resource.status | The status is inherited from the most recent Encounter that is part of the EpisodeOfCare. |
resource.extension with "url": "https://zusapi.com/lens/extension/aggregatedFrom" | The Zus aggregated from extension lists the Encounter Lens resources that were used to generate this output resource. These are nested resources with url "url": "<https://zusapi.com/lens/extension/aggregatedFromLenses"> |
resource.extension with "url": "https://zusapi.com/lens/extension/dischargeDisposition" | The Zus discharge disposition extension denotes the most recent discharge disposition collected for the episode. |
resource.extension with "url": "https://zusapi.com/lens/extension/dischargeLocation" | The Zus discharge location extension denotes the location of the most recent inpatient encounter in the episode. |
resource.extension with "url": "https://zusapi.com/lens/extension/admittingLocation" | The Zus admitting location extension denotes the location of the first encounter in the episode. (Will be deprecated in the future) |
resource.extension with "url": "https://zusapi.com/lens/extension/emergencyLocation" | The Zus emergency location extension denotes the location of the first emergency encounter in the episode. (Will be deprecated in the future) |
resource.extension with "url": "https://zusapi.com/lens/extension/admittingLocationDetails" | <https://zusapi.com/lens/extension/admittingLocationDetails> (base extension URL)<https://zusapi.com/lens/extension/location> Contains first IMP encounter location (nested)<https://zusapi.com/lens/extension/startDateTime> Contains the period.start of the first IMP encounter (nested) |
resource.extension with "url": "https://zusapi.com/lens/extension/emergencyLocationDetails" | <https://zusapi.com/lens/extension/emergencyLocationDetails> (base extension URL<https://zusapi.com/lens/extension/location> Contains first EMER encounter location (nested)<https://zusapi.com/lens/extension/endDateTime> Contains the period.end of the first EMER encounter (nested) |
resource.extension with "url": "https://zusapi.com/lens/extension/encounterClass" | The Zus encounter class extension denotes the most recent “encounter class” in the episode. Expected codes are:EMER (emergency), IMP(inpatient), OBSENC (observation), and PRENC (preadmit). |
resource.extension with "url": "https://zusapi.com/lens/extension/dischargeNarrative" | The Zus discharge narrative extension is a list of references to Binaries that have a documentation relating to the episode. The preferredDischargeNarrative nested extension noted by "url": "https://zusapi.com/lens/extension/preferredDischargeNarrative" indicates which document will potentially provide the most valuable content relating to that episode of care. Zus is matching codes based on the Commonwell/Carequality document standardization project. |
resource.extension with "url": "<https://zusapi.com/lens/extension/adtMessage"> | The ADT Message extension provides information about the triggering events received in the HL7 message for the ADT event. This includes the Message Type, Effective Time, and and the associated DocumentReference. |
resource.extension with "url":"<https://zusapi.com/lens/extension/adtMessageType"> | The ADT Message Type extension includes the ADT trigger event code. |
resource.extension with "url":"<https://zusapi.com/lens/extension/adtMessageEffectiveTime"> | The date and time of the received ADT Message Type. |
🚧 resource.extension with "url": "<https://zusapi.com/lens/extension/behavioralHealth"> | The value of the Behavioral Health extension is true when any condition from the aggregated encounters has a "CCSR" code starting with MBD(Mental, behavioral, neurodevelopmental disorders). |
🚧 resource.extension with "url": "<https://zusapi.com/lens/extension/nonelectiveAdmission"> | The nonelective admission extension indicates if it could be determined that the admission was nonelective/unplanned. If so, the valueStringwill be populated with one of the following values: emergency, direct, or holding. This will only appear on ToCs with an IMP encounter in them.If the hospitalization is also a readmission (having a hospitalization within 30 days prior to the current one), the valueString values will then be: readmission emergency, readmission direct, readmission holding. |
🚧 resource.extension with "url": "<https://zusapi.com/lens/extension/currentParticipants"> | The Current Participant extension includes the entire participant structure from the most recent Lens Encounter. |
🚧 resource.extension with "url": "<https://zusapi.com/lens/extension/reason"> | The Reason extension includes all unique Encounter.reasonCode values from the aggregated encounters. |
Beta
Fields marked with this icon are in a beta state and may be updated
Patient Journey JSON Sample
Patient shows up at the Emergency Department
Patient is admitted into the hospital
Patient is discharged from the hospital
Data Mart Access
Data from the Transition of Care Lenses can be found in the following tables in the Zus Relational Data Mart:
lens_transition_of_carelens_transition_of_care_adt_messagelens_transition_of_care_aggregated_fromlens_transition_of_care_diagnosislens_transition_of_care_discharge_dispositionlens_transition_of_care_discharge_disposition_codinglens_transition_of_care_identifier
Read more about these tables in the Data Mart documentation.
Updated 1 day ago