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|Requirement ID:||Req-1122: Produce completed forms from EHR data||Req-2027: Produce completed forms from EHR data|
|Release Package:||2013 Format||2015 Priority List|
|Title:||Produce completed forms from EHR data||Produce completed forms from EHR data|
|Description:||The system SHOULD produce paper and electronic forms (e.g. for camp, school, or child care) and complete them with information from the patient record (both examination and immunization record).||The system shall produce reports (e.g., for camp, school, or child care) of a child's immunization history, including the following elements: child's name, date of birth and sex, date the report was produced, antigen administered, date administered, route of administration (when available), and an indication of whether a vaccine was refused or contraindicated.|
|Topic Area(s):||Immunizations, Well Child/Preventive Care||Immunizations, Well Child/Preventive Care|
|Requirement Type:||Normative Statements||Normative Statement|
|Implementation Notes:||Background: Schools and camps generally require at a minimum documentation of immunizations and a general assessment of health status and clinician determination of ability to participate in sports activities. Many also require inclusion of anthropometric measurements, medications, and problems. Although there is no standard template approved by all schools, the “School/Camp Form” is a core document for pediatric primary care. The ability to print the form during and between visits has been shown to reduce administrative burden and improve communication. A second type of form includes more detailed information about immunizations delivered. Typically called a “Vaccine Administration Record,” this report is limited to immunization data but includes all available information (e.g., site, lot number, manufacturer, etc.) for immunizations given to patients. Vaccine Administration Record Specifications: The system shall be able to produce a detailed listing of immunization data sorted either by date of administration or by vaccine series that include child's name; date of birth and sex; date the report was produced; and all available information for each immunization, including antigen administered, date administered, route of administration, site of administration, manufacturer, lot number, expiration data, Visualization (VIS) publication data, contraindications, and immunities. The system also should be capable of capturing and including in the report an indication of refusal or contraindication in order to support a physician’s choice to include this information as needed and clinically relevant. The data field for contraindication should include the ability to state why the immunization was not administered. School/Camp Form Specifications: The system shall be able to produce a report for use by Schools and Camps that includes (1) the child's name, date of birth and sex, and date the report was produced; (2) an immunization summary in tabular format that includes immunization dates of administration by series, sorted from earliest to latest; (3) anthropomorphic data (most recent Hgt, Wgt, BMI, BMI %ile, and Blood Pressure with date[s] obtained); and (4) clinician assessment of general state of health and any special considerations related to participation in sports and/or other physical activities. Additional information that may be included in the report includes (1) list of active problems, (2) list of active medications with dosing, and (3) detailed physical examination. This additional information is especially pertinent for patients that have been flagged in the system as having special or complex health care needs. This requirement was modified to limit the required forms to an immunization history that can be attached to existing forms that require immunizations. Typical use in ambulatory practice is to label the section “See attached.” The intent of this requirement is to not limit vendors to printing the immunization history in a custom format that fit on the original form, and it is acceptable to use the same printed immunization history for all forms used by a practice. In the future, EHR vendors are encouraged to pursue new technologies that allow mapping of data fields from the EHR onto to specific locations on a PDF form. There is a best practices guide called “PDF for Healthcare” that illustrates how a widely used proprietary forms generation and completion software package can map information extracted through database queries into previously developed PDF forms with custom layout and graphics developed by the creator of the form, such as a local school system or camp. The use of the HL7 Clinical Document Architecture (CDA) also holds promise for development of nationally standard school or camp forms that could exploit the technology that EHRs are already using to complete Continuity of Care Documents (CCD) for patient summaries. Automated templates for CDA documents that could be implemented automatically by EHRs are clearly desirable. This allows EHR vendors to implement the tool once and re-use it for many CDAs populated from data in the EHR. However, adoption of CDA templates and documents are limited outside of the Meaningful Use effort.|