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Req-694Registry and Directory Services2013 Format
STATEMENT: Enable the use of registry services and directories to uniquely identify, locate and supply links for retrieval of information related to:
- patients and providers for healthcare purposes;
- payers, health plans, sponsors, and...
STATEMENT: Enable the use of registry services and directories to uniquely identify, locate and supply links for retrieval of information related to:
- patients and providers for healthcare purposes;
- payers, health plans, sponsors, and employers for administrative and financial purposes;
- public health agencies for healthcare purposes, and
- healthcare resources and devices for resource management purposes.
DESCRIPTION: Registry and directory service functions are critical to successfully managing the security, interoperability, and the consistency of the health record data across an EHR-S. These services enable the linking of relevant information across multiple information sources within, or external to, an EHR-S for use within an application.
Directories and registries support communication between EHR Systems and may be organized hierarchically or in a federated fashion. For example, a patient being treated by a primary care physician for a chronic condition may become ill while out of town. The new provider's EHR-S interrogates a local, regional, or national registry to find the patient's previous records. From the primary care record, a remote EHR-S retrieves relevant information in conformance with applicable patient privacy and confidentiality rules.
An example of local registry usage is an EHR-S application sending a query message to the Hospital Information System to retrieve a patient's demographic data.
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Child Welfare, Children with Special Healthcare Needs, Growth Data, Immunizations, Registry Linkages, Well Child/Preventive CareFunctionno
Req-696Manage Order Sets2013 Format
STATEMENT: Provide order sets based on provider input or system prompt.
DESCRIPTION: Order sets, which may include medication and non-medication orders, allow a care provider to choose common orders for a particular circumstance or disease...
STATEMENT: Provide order sets based on provider input or system prompt.
DESCRIPTION: Order sets, which may include medication and non-medication orders, allow a care provider to choose common orders for a particular circumstance or disease state according to standards or other criteria. Recommended order sets may be presented based on patient data or other contexts.
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Well Child/Preventive CareFunctionno
Req-697Manage Practitioner/Patient Relationships2013 Format
STATEMENT: Identify relationships among providers treating a single patient, and provide the ability to manage patient lists assigned to a particular provider.
DESCRIPTION: This function addresses the ability to access and update current information about...
STATEMENT: Identify relationships among providers treating a single patient, and provide the ability to manage patient lists assigned to a particular provider.
DESCRIPTION: This function addresses the ability to access and update current information about the relationships between caregivers and the patients. This information should be able to flow seamlessly between the different components of the system, and between the EHR system and other systems. Business rules may be reflected in the presentation of, and the access to this information. The relationship among providers treating a single patient will include any necessary chain of authority/responsibility.
Example: In a care setting with multiple providers, where the patient can only see certain kinds of providers (or an individual provider allow the selection of only the appropriate providers.
Example: The user is presented with a list of people assigned to a given practitioner and may alter the assignment as required - to a group, to another individual or by sharing the assignment.
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Children with Special Healthcare NeedsFunctionno
Req-698Manage Non-Medication Patient Care Orders2013 Format
STATEMENT: Capture and track patient care orders. Enable the origination, documentation, and tracking of non-medication patient care orders.
DESCRIPTION: Non-medication orders that request actions or items can be captured and tracked including new, renewal and...
STATEMENT: Capture and track patient care orders. Enable the origination, documentation, and tracking of non-medication patient care orders.
DESCRIPTION: Non-medication orders that request actions or items can be captured and tracked including new, renewal and discontinue orders. Examples include orders to transfer a patient between units, to ambulate a patient, for medical supplies, durable medical equipment, home IV, and diet or therapy orders.
Each item ordered includes the appropriate detail, such as order identification and instructions. Orders should be communicated to the correct service provider for completion.
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Medication ManagementFunctionno
Req-701Encounter Specific Functionality2013 Format
STATEMENT: Provide assistance in assembling appropriate data, supporting data collection and processing output from a specific encounter.
DESCRIPTION: Workflows, based on the encounter management settings, will assist (with triggers alerts and other means in determining...
STATEMENT: Provide assistance in assembling appropriate data, supporting data collection and processing output from a specific encounter.
DESCRIPTION: Workflows, based on the encounter management settings, will assist (with triggers alerts and other means in determining and supporting the appropriate data collection, import, export, extraction, linkages and transformation. As an example, a pediatrician is presented with diagnostic and procedure codes specific to pediatrics. Business rules enable automatic collection of necessary data from the patient's health record and patient registry. As the provider enters data, workflow processes are triggered to populate appropriate transactions and documents. For example, data entry might populate an eligibility verification transaction or query the immunization registry.
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Specialized Scales/ScoringFunctionno
Req-702Secure Data Routing2013 Format
STATEMENT: Route electronically exchanged EHR data only to/from known, registered, and authenticated destinations/sources (according to applicable healthcare-specific rules and relevant standards
DESCRIPTION: An EHR-S needs to ensure that it is exchanging EHR information with the...
STATEMENT: Route electronically exchanged EHR data only to/from known, registered, and authenticated destinations/sources (according to applicable healthcare-specific rules and relevant standards
DESCRIPTION: An EHR-S needs to ensure that it is exchanging EHR information with the entities (applications, institutions, directories it expects. This function depends on entity authorization and authentication to be available in the system. For example, a physician practice management application in an EHR-S might send claim attachment information to an external entity. To accomplish this, the application must use a secure routing method, which ensures that both the sender and receiving sides are authorized to engage in the information exchange. Known sources and destinations can be established in a static setup or they can be dynamically determined. Examples of a static setup are recordings of IP addresses or recordings of DNS names. For dynamic determination of known sources and destinations systems can use authentication mechanisms as described in Req-759 (HL7 ID: IN.1.1 For example, the sending of a lab order from the EHRS to a lab system within the same organization usually uses a simple static setup for routing. In contrast sending a lab order to a reference lab outside of the organization will involve some kind of authentication process.
In general, when the underlying network infrastructure is secure (e.g. secure LAN or VPN the simple static setup is used.
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Parents and Guardians and Family Relationship DataFunctionno
Req-703Support for Medication Recommendations2013 Format
STATEMENT: The system should provide recommendations and options in medication and monitoring on the basis of patient diagnosis, cost, local formularies or therapeutic guidelines and protocols.
DESCRIPTION: Offer alternative medications on the basis of practice...
STATEMENT: The system should provide recommendations and options in medication and monitoring on the basis of patient diagnosis, cost, local formularies or therapeutic guidelines and protocols.
DESCRIPTION: Offer alternative medications on the basis of practice standards (e.g. cost or adherence to guidelines a generic brand, a different dosage, a different drug, or no drug (watchful waiting Suggest lab order monitoring as indicated by the medication or the medical condition to be affected by the medication. Support expedited entry of series of medications that are part of a treatment regimen, i.e. renal dialysis, Oncology, transplant medications, etc.
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Medication ManagementFunctionno
Req-715Standard Terminologies and Terminology Models2013 Format
STATEMENT: Employ standard terminologies to ensure data correctness and to enable semantic interoperability (both within an enterprise and externally
Support a formal standard terminology model.

DESCRIPTION: Semantic interoperability requires standard terminologies combined with a...
STATEMENT: Employ standard terminologies to ensure data correctness and to enable semantic interoperability (both within an enterprise and externally
Support a formal standard terminology model.

DESCRIPTION: Semantic interoperability requires standard terminologies combined with a formal standard information model. An example of an information model is the HL7 Reference Information model.
Examples of terminologies that an EHR-S may support include: LOINC, SNOMED, ICD-9, ICD-10, and CPT-4.
A terminology provides semantic and computable identity to its concepts.
Terminologies are use-case dependent and may or may not be realm dependent. For example, terminologies for public health interoperability may differ from those for healthcare quality, administrative reporting, research, etc.
Formal standard terminology models enable common semantic representations by describing relationships that exist between concepts within a terminology or in different terminologies, such as exemplified in the model descriptions contained in the HL7 Common Terminology Services specification.
The clinical use of standard terminologies is greatly enhanced with the ability to perform hierarchical inference searches across coded concepts. Hierarchical Inference enables searches to be conducted across sets of coded concepts stored in an EHR-S.
Relationships between concepts in the terminology are used in the search to recognize child concepts of a common parent. For example, there may be a parent concept, "penicillin containing preparations" which has numerous child concepts, each of which represents a preparation containing a specific form of penicillin (Penicillin V, Penicillin G, etc. Therefore, a search may be conducted to find all patients taking any form of penicillin preparation.
Clinical and other terminologies may be provided through a terminology service internal or external to an EHR-S. An example of a terminology service is described in the HL7 Common Terminology Services specification.
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Medication Management, Special Terminology and InformationFunctionno
Req-718Entity Access Control2013 Format
STATEMENT: Verify and enforce access control to all EHR-S components, EHR information and functions for end-users, applications, sites, etc., to prevent unauthorized use of a resource.
DESCRIPTION: Entity Access Control is a fundamental function of...
STATEMENT: Verify and enforce access control to all EHR-S components, EHR information and functions for end-users, applications, sites, etc., to prevent unauthorized use of a resource.
DESCRIPTION: Entity Access Control is a fundamental function of an EHR-S. To ensure that access is controlled, an EHR-S must perform authentication and authorization of users or applications for any operation that requires it and enforce the system and information access rules that have been defined.
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Child Welfare, Parents and Guardians and Family Relationship Data, Patient Portals - PHR, Security and ConfidentialityFunctionno
Req-719Interchange Agreements2013 Format
STATEMENT: Support interactions with entity directories to determine the address, profile and data exchange requirements of known and/or potential partners.
Use the rules of interaction specified in the partner's interchange agreement when exchanging information.
DESCRIPTION:...
STATEMENT: Support interactions with entity directories to determine the address, profile and data exchange requirements of known and/or potential partners.
Use the rules of interaction specified in the partner's interchange agreement when exchanging information.
DESCRIPTION: Systems that wish to communicate with each other, must agree on the parameters associated with that information exchange. Interchange Agreements allow an EHR-S to describe those parameters/criteria.
An EHR-S can use the entity registries to determine the security, addressing, and reliability requirements between partners.
An EHR-S can use this information to define how data will be exchanged between the sender and the receiver.
Discovery of interchange services and capabilities can be automatic.
For example:
- A new application can automatically determine a patient demographics source using a Universal Description and Discovery Integration (UDDI for source discovery, and retrieve the Web Services Description Language (WSDL specification for binding details.
- Good Health Hospital is a member of AnyCounty LabNet, for sharing laboratory results with other partners. Good Health Hospital periodically queries LabNet's directory (UDDI to determine if additional information providers have joined LabNet. When new information providers are discovered, the Good Health IT establishes the appropriate service connections based upon the Service Description (WSDL
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ImmunizationsFunctionno
Req-720Support unit conversion during data entry and display2013 FormatThe system SHALL provide unit conversions calculation and display during data entry and data display (e.g. lbs/kgGrowth DataNormative Statementsno
Req-721Patient Reminder Information Updates2013 Format
STATEMENT: Receive and validate formatted inbound communications to facilitate updating of patient reminder information from external sources such as Cancer or Immunization Registries.

DESCRIPTION: Information from outside groups, such as immunization groups, public health...
STATEMENT: Receive and validate formatted inbound communications to facilitate updating of patient reminder information from external sources such as Cancer or Immunization Registries.

DESCRIPTION: Information from outside groups, such as immunization groups, public health organizations, etc. may periodically send updates to patient care providers. The system should be capable of generating patient reminders based on the recommendations of these organizations. Patient reminders could be provided to patients by a number of means including phone calls, or mail. A record of such reminders may become part of a patient's record. Examples of reminders could include a recommended immunization, prophylactic guidelines for MVP, patient self-testing for disease, etc.
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Well Child/Preventive CareFunctionno
Req-722Supportive Function Maintenance2013 FormatSTATEMENT: Update EHR supportive content using a manual or automated process.Well Child/Preventive CareHeaderno
Req-723Ability to incorporate risk factors and/or anticipatory guidance2013 FormatThe system MAY incorporate risk factors and/or anticipatory guidance relevant to body composition, age, and gender into display/printout of growth charts.Growth DataNormative Statementsno
Req-724Support for population, maintenance, and export of registries2013 FormatThe system SHOULD support the population, maintenance, and export of registries including patients with significant anthropometric findings and related disease risk factors.Growth DataNormative Statementsno
Req-725Support for population level reporting2013 FormatThe system SHOULD support population level reporting of collected and derived measures of growth and body composition and related clinical and demographic information.Growth DataNormative Statementsno
Req-730Flag special healthcare needs2013 FormatThe system SHALL support the flagging of individuals with special healthcare needs or complex conditions, to facilitate care management, decision support, and reporting.Children with Special Healthcare NeedsNormative Statementsno
Req-732Ability to search service registries2013 FormatService registry entries SHOULD be searchable by name, location, service categories provided, and/or parent organization.Children with Special Healthcare NeedsNormative Statementsno
Req-739Support for Monitoring Response Notifications Regarding a Specific Patient’s Health2013 Format
STATEMENT: In the event of a health risk alert and subsequent notification related to a specific patient, monitor if expected actions have been taken, and execute follow-up notification if they have not.
DESCRIPTION: Identifies that...
STATEMENT: In the event of a health risk alert and subsequent notification related to a specific patient, monitor if expected actions have been taken, and execute follow-up notification if they have not.
DESCRIPTION: Identifies that expected follow-up for a specific patient event (e.g., follow up to error alerts or absence of an expected lab result has not occurred and communicate the omission to appropriate care providers in the chain of authority. The notification process requires a security infrastructure that provides the ability to match a care provider's clinical privileges with the clinical requirements of the notification.
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Children with Special Healthcare NeedsFunctionno
Req-740Manage Medication Orders2013 Format
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You are viewing the Abridged Children's EHR Format. To view the Full Children's EHR Format, you must first agree to the HL7 License Agreement.
Medication ManagementFunctionno
Req-745Support for Accurate Specimen Collection2013 Format
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You are viewing the Abridged Children's EHR Format. To view the Full Children's EHR Format, you must first agree to the HL7 License Agreement.
Primary Care Management, Well Child/Preventive CareFunctionno
Req-749Manage Patient and Family Preferences2013 Format
STATEMENT: Capture and maintain patient and family preferences. DESCRIPTION: Patient and family preferences regarding issues such as language, religion, spiritual practices and culture may be important to the delivery of care. It is important to...
STATEMENT: Capture and maintain patient and family preferences. DESCRIPTION: Patient and family preferences regarding issues such as language, religion, spiritual practices and culture may be important to the delivery of care. It is important to capture these so that they will be available to the provider at the point of care.
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Children with Special Healthcare NeedsHeaderno
Req-765Store and Manage Health Record Information2013 Format
STATEMENT: Store and manage health record information as structured and unstructured data.

DESCRIPTION: Unstructured health record information is information that is not divided into discrete fields AND not represented as numeric, enumerated or codified...
STATEMENT: Store and manage health record information as structured and unstructured data.

DESCRIPTION: Unstructured health record information is information that is not divided into discrete fields AND not represented as numeric, enumerated or codified data.

General examples of unstructured health record information include:
- text
- word processing document
- image
- multimedia

Specific examples include:
- text message to physician
- patient photo
- letter from family
- scanned image of insurance card
- dictated report (voice recording

Structured health record information is divided into discrete fields, and may be enumerated, numeric or codified.

Examples of structured health information include:
- patient address (non-codified, but discrete field
- diastolic blood pressure (numeric
- coded result observation
- coded diagnosis
- patient risk assessment questionnaire with multiple-choice answers

Context may determine whether or not data are unstructured, e.g., a progress note might be standardized and structured in some EHR-S (e.g., Subjective/Objective/Assessment/Plan but unstructured in others.

Managing healthcare data includes capture, retrieval, deletion, correction, amendment, and augmentation. Augmentation refers to providing additional information regarding the healthcare data, which is not part of the data itself, e.g. linking patient consents or authorizations to the healthcare data of the patient.
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Well Child/Preventive CareHeaderno
Req-767Manage Structured Health Record Information2013 Format
STATEMENT: Create, capture, and maintain structured health record information.

DESCRIPTION: Structured health record information is divided into discrete fields, and may be enumerated, numeric or codified.

Examples of structured health information include:
-...
STATEMENT: Create, capture, and maintain structured health record information.

DESCRIPTION: Structured health record information is divided into discrete fields, and may be enumerated, numeric or codified.

Examples of structured health information include:
- patient address (non-codified, but discrete field
- diastolic blood pressure (numeric
- coded result observation
- coded diagnosis
- patient risk assessment questionnaire with multiple-choice answers

Context may determine whether or not data are unstructured, e.g., a progress note might be standardized and structured in some EHRS (e.g., Subjective/Objective/Assessment/Plan but unstructured in others.
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Well Child/Preventive CareFunctionno
Req-772Interchange Standards Versioning and Maintenance2013 Format
STATEMENT: Enable version control according to local policies to ensure maintenance of utilized interchange standards.
Version control of an interchange standard implementation includes the ability to accommodate changes as the source interchange standard undergoes its...
STATEMENT: Enable version control according to local policies to ensure maintenance of utilized interchange standards.
Version control of an interchange standard implementation includes the ability to accommodate changes as the source interchange standard undergoes its natural update process.

DESCRIPTION:
The life cycle of any given standard results in changes to its requirements. It is critical that an organization know the version of any given standard it uses and what its requirements and capabilities are.

For example, if the organization migrates to an HL7 v2.5 messaging standard, it may choose to take advantage of new capabilities such as specimen or blood bank information. The organization may find that certain fields have been retained for backwards compatibility only or withdrawn altogether. The EHR-S needs to be able to handle all of these possibilities.

Standards typically evolve in such a way as to protect backwards compatibility. On the other hand, sometimes there is little, or no, backwards compatibility when an organization may need to replace an entire standard with a new methodology. An example of this is migrating from HL7 v2 to HL7 v3.

Interchange standards that are backward compatible support exchange among senders and receivers who are using different versions. Version control ensures that those sending information in a later version of a standard consider the difference in information content that can be interchanged effectively with receivers, who are capable of processing only earlier versions. That is, senders need to be aware of the information that receivers are unable to capture and adjust their business processes accordingly.
Version control enables multiple versions of the same interchange standard to exist and be distinctly recognized over time.
Since interchange standards are usually periodically updated, concurrent use of different versions may be required.
Large (and/or federated organizations typically need to use different versions of an interchange standard to meet internal organizational interoperability requirements.
For example, the enterprise-wide standard might use HL7 v2.5 for Lab messages, but some regions of the enterprise might be at a lower level.
It should be possible to retire deprecated interchange standards versions when applicable business cycles are completed while maintaining obsolete versions. An example use of this is for possible claims adjustment throughout the claim's life cycle.
When interchange standards change over time, it is important that retrospective analysis and research correlate and note gaps between the different versions' information structures to support the permanence of concepts over time. An example use of this is the calculation of outcome or performance measures from persisted data stores where one version of a relevant interchange standard, e.g., CDA Release 1 captures the relevant data, e.g., discharge data, differently than CDA Release 2.
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Immunizations, Registry LinkagesFunctionno
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