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Req-265Notifications and Reminders for Preventive Services and Wellness2013 Format
STATEMENT: Between healthcare encounters, notify the patient and/or appropriate provider of those preventive services, tests, or behavioral actions that are due or overdue.
DESCRIPTION: The provider can generate notifications to patients regarding activities that are...
STATEMENT: Between healthcare encounters, notify the patient and/or appropriate provider of those preventive services, tests, or behavioral actions that are due or overdue.
DESCRIPTION: The provider can generate notifications to patients regarding activities that are due or overdue and these communications can be captured. Examples include but are not limited to time sensitive patient and provider notification of: follow-up appointments, laboratory tests, immunizations or examinations. The notifications can be customized in terms of timing, repetitions and administration reports. E.g. a PAP test reminder might be sent to the patient two months prior to the test being due, repeated at three month intervals, and then reported to the administrator or clinician when nine months overdue.
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EPSDT, Newborn Screening, Patient Portals - PHR, Well Child/Preventive CareFunctionno
Req-266Present Ad Hoc Views of the Health Record2013 Format
STATEMENT: Subject to jurisdictional laws and organizational policies related to privacy and confidentiality, present customized views and summarized information from a patient's comprehensive EHR. The view may be arranged chronologically, by problem, or other parameters,...
STATEMENT: Subject to jurisdictional laws and organizational policies related to privacy and confidentiality, present customized views and summarized information from a patient's comprehensive EHR. The view may be arranged chronologically, by problem, or other parameters, and may be filtered or sorted.
DESCRIPTION: A key feature of an electronic health record is its ability to support the delivery of care by enabling prior information to be found and meaningfully displayed. EHR systems should facilitate search, filtering, summarization, and presentation of available data needed for patient care. Systems should enable views to be customized, for example, specific data may be organized chronologically, by clinical category, or by consultant, depending on need. Jurisdictional laws and organizational policies that prohibit certain users from accessing certain patient information must be supported.
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Immunizations, Patient Portals - PHR, Primary Care Management, Well Child/Preventive CareFunctionno
Req-267Produce a Summary Record of Care2013 Format
STATEMENT: Present a summarized review of a patient's comprehensive EHR, subject to jurisdictional laws and organizational policies related to privacy and confidentiality.
DESCRIPTION: Create summary views and reports at the conclusion of an episode of...
STATEMENT: Present a summarized review of a patient's comprehensive EHR, subject to jurisdictional laws and organizational policies related to privacy and confidentiality.
DESCRIPTION: Create summary views and reports at the conclusion of an episode of care. Create service reports at the completion of an episode of care such as, but not limited to, discharge summaries and public health reports, without additional input from clinicians.
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Primary Care Management, Well Child/Preventive CareFunctionno
Req-268Manage Patient History2013 Format
STATEMENT: Capture and maintain medical, procedural/surgical, social and family history including the capture of pertinent positive and negative histories, patient-reported or externally available patient clinical history.
DESCRIPTION: The history of the current illness and patient...
STATEMENT: Capture and maintain medical, procedural/surgical, social and family history including the capture of pertinent positive and negative histories, patient-reported or externally available patient clinical history.
DESCRIPTION: The history of the current illness and patient historical data related to previous medical diagnoses, surgeries and other procedures performed on the patient, and relevant health conditions of family members is captured through such methods as patient reporting (for example interview, medical alert band or electronic or non-electronic historical data. This data may take the form of a pertinent positive such as: "The patient/family member has had..." or a pertinent negative such as "The patient/family member has not had..." When first seen by a health care provider, patients typically bring with them clinical information from past encounters. This and similar information is captured and presented alongside locally captured documentation and notes wherever appropriate.
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Birth Information, Child Abuse Reporting, Child Welfare, Genetic information, Parents and Guardians and Family Relationship Data, Patient Identifier, Prenatal Screening,...
Birth Information, Child Abuse Reporting, Child Welfare, Genetic information, Parents and Guardians and Family Relationship Data, Patient Identifier, Prenatal Screening, Primary Care Management, Security and Confidentiality, Specialized Scales/Scoring, Well Child/Preventive Care
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Functionno
Req-269Support for Standard Care Plans, Guidelines, Protocols2013 Format
STATEMENT: Support the use of appropriate standard care plans, guidelines and/or protocols for the management of specific conditions.
DESCRIPTION: Before they can be accessed upon request (e.g., in DC 1.6.1 standard care plans, protocols, and...
STATEMENT: Support the use of appropriate standard care plans, guidelines and/or protocols for the management of specific conditions.
DESCRIPTION: Before they can be accessed upon request (e.g., in DC 1.6.1 standard care plans, protocols, and guidelines must be created. These documents may reside within the system or be provided through links to external sources, and can be modified and used on a site specific basis. To facilitate retrospective decision support, variances from standard care plans, guidelines, and protocols can be identified and reported.
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EPSDT, Growth Data, Primary Care Management, Well Child/Preventive CareFunctionno
Req-271Support for Research Protocols Relative to Individual Patient Care2013 FormatSTATEMENT: Provide support for the management of patients enrolled in research protocols.
DESCRIPTION: The clinician is presented with appropriate protocols for patients participating in research studies, and is supported in the management and tracking of study participants.
Primary Care ManagementFunctionno
Req-272Support for Patient Specific Dosing and Warnings2013 Format
STATEMENT: Identify and present appropriate dose recommendations based on known patient- conditions and characteristics at the time of medication ordering.
DESCRIPTION: The clinician is alerted to drug-condition interactions and patient specific contraindications and warnings e.g....
STATEMENT: Identify and present appropriate dose recommendations based on known patient- conditions and characteristics at the time of medication ordering.
DESCRIPTION: The clinician is alerted to drug-condition interactions and patient specific contraindications and warnings e.g. pregnancy, breast-feeding or occupational risks, hepatic or renal insufficiency. The preferences of the patient may also be presented e.g. reluctance to use an antibiotic. Additional patient parameters, such as age, gestation, height, weight, and body surface area (BSA shall also be incorporated.
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Immunizations, Medication ManagementFunctionno
Req-273Support for Medication and Immunization Administration2013 Format
STATEMENT: Alert providers to potential administration errors (such as wrong patient, wrong drug, wrong dose, wrong route and wrong time in support of safe and accurate medication administration and support medication administration workflow.
DESCRIPTION: To...
STATEMENT: Alert providers to potential administration errors (such as wrong patient, wrong drug, wrong dose, wrong route and wrong time in support of safe and accurate medication administration and support medication administration workflow.
DESCRIPTION: To reduce medication errors at the time of administration of a medication, the patient is positively identified; checks on the drug, the dose, the route and the time are facilitated. Documentation is a by-product of this checking; administration details and additional patient information, such as injection site, vital signs, and pain assessments, are captured.
Access to drug monograph information may be provided to allow providers to check details about a drug and enhance patient education. Workflow for medication administration is supported through prompts and reminders regarding the "window" for timely administration of medications.
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Immunizations, Medication Management, Registry LinkagesFunctionno
Req-274Patient Privacy and Confidentiality2013 Format
STATEMENT: Enable the enforcement of the applicable jurisdictional and organizational patient privacy rules as they apply to various parts of an EHR-S through the implementation of security mechanisms.
DESCRIPTION: Patients' privacy and the confidentiality of...
STATEMENT: Enable the enforcement of the applicable jurisdictional and organizational patient privacy rules as they apply to various parts of an EHR-S through the implementation of security mechanisms.
DESCRIPTION: Patients' privacy and the confidentiality of EHRs are violated if access to EHRs occurs without authorization. Violations or potential violations can impose tangible economic or social losses on affected patients, as well as less tangible feelings of vulnerability and pain. Fear of potential violations discourages patients from revealing sensitive personal information that may be relevant to diagnostic and treatment services. Rules for the protection of privacy and confidentiality may vary depending upon the vulnerability of patients and the sensitivity of records. Strongest protections should apply to the records of minors and the records of patients with stigmatized conditions. Authorization to access the most sensitive parts of an EHR is most definitive if made by the explicit and specific consent of the patient. Please see the definition of masking in the glossary.
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Patient Identifier, Prenatal Screening, Security and ConfidentialityFunctionno
Req-275Auditable Records2013 Format
STATEMENT: Provide audit capabilities for system access and usage indicating the author, the modification (where pertinent and the date and time at which a record was created, modified, viewed, extracted, or deleted. Date and Time...
STATEMENT: Provide audit capabilities for system access and usage indicating the author, the modification (where pertinent and the date and time at which a record was created, modified, viewed, extracted, or deleted. Date and Time stamping implies the ability to indicate the time zone where it was recorded (time zones are described in ISO 8601 Standard Time Reference Auditable records extend to information exchange, to audit of consent status management (to support Req-256 (HL7 ID: DC.1.3.3 and to entity authentication attempts. Audit functionality includes the ability to generate audit reports and to interactively view change history for individual health records or for an EHR-S.
DESCRIPTION: Audit functionality extends to security audits, data audits, audits of data exchange, and the ability to generate audit reports. Audit capability settings should be configurable to meet the needs of local policies. Examples of audited areas include:
- Security audit, which logs access attempts and resource usage including user login, file access, other various activities, and whether any actual or attempted security violations occurred
- Data audit, which records who, when, and by which system an EHR record was created, updated, translated, viewed, extracted, or (if local policy permits deleted. Audit-data may refer to system setup data or to clinical and patient management data
- Information exchange audit, which records data exchanges between EHR-S applications (for example, sending application; the nature, history, and content of the information exchanged and information about data transformations (for example, vocabulary translations, reception event details, etc.
- Audit reports should be flexible and address various users' needs. For example, a legal authority may want to know how many patients a given healthcare provider treated while the provider's license was suspended. Similarly, in some cases a report detailing all those who modified or viewed a certain patient record
- Security audit trails and data audit trails are used to verify enforcement of business, data integrity, security, and access-control rules
-There is a requirement for system audit trails for the following events:
>Loading new versions of, or changes to, the clinical system;
>Loading new versions of codes and knowledge bases;
>Taking and restoring of backup;
>Changing the date and time where the clinical system allows this to be done;
>Archiving any data;
>Re-activating of an archived patient record;
>Entry to and exiting from the clinical system;
>Remote access connections including those for system support and maintenance activities
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Growth DataFunctionno
Req-276Maintenance and Versioning of Standard Terminologies2013 Format
STATEMENT: Enable version control according to customized policies to ensure maintenance of utilized standards.
This includes the ability to accommodate changes to terminology sets as the source terminology undergoes its natural update process (new codes,...
STATEMENT: Enable version control according to customized policies to ensure maintenance of utilized standards.
This includes the ability to accommodate changes to terminology sets as the source terminology undergoes its natural update process (new codes, retired codes, redirected codes Such changes need to be cascaded to clinical content embedded in templates, custom formularies, etc., as determined by local policy.
DESCRIPTION: Version control allows for multiple sets or versions of the same terminology to exist and be distinctly recognized over time.
Terminology standards are usually periodically updated, and concurrent use of different versions may be required. Since the meaning of a concept can change over time, it is important that retrospective analysis and research maintains the ability to relate changing conceptual meanings. If the terminology encoding for a concept changes over time, it is also important that retrospective analysis and research can correlate the different encodings to ensure the permanence of the concept. This does not necessarily imply that complete older versions of the terminology be kept in the EHR-S, only access to the changes needs to be maintained.
It should be possible to retire deprecated versions when applicable business cycles are completed while maintaining obsolescent code sets. An example use of this is for possible claims adjustment throughout the claim's lifecycle.
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Special Terminology and InformationFunctionno
Req-277Registry Notification2013 Format
STATEMENT: Enable the automated transfer of formatted demographic and clinical information to and from local disease specific registries (and other notifiable registries for patient monitoring and subsequent epidemiological analysis.
DESCRIPTION: The user can export personal...
STATEMENT: Enable the automated transfer of formatted demographic and clinical information to and from local disease specific registries (and other notifiable registries for patient monitoring and subsequent epidemiological analysis.
DESCRIPTION: The user can export personal health information to disease specific registries, other notifiable registries such as immunization registries, through standard data transfer protocols or messages. The user can update and configure communication for new registries.
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Birth Information, Children with Special Healthcare Needs, Genetic information, Immunizations, Registry LinkagesFunctionno
Req-278Standard Report Generation2013 Format
STATEMENT: Provide report generation features using tools internal or external to the system, for the generation of standard reports.
DESCRIPTION: Providers and administrators need access to data in the EHR-S for clinical, administrative, financial decision-making,...
STATEMENT: Provide report generation features using tools internal or external to the system, for the generation of standard reports.
DESCRIPTION: Providers and administrators need access to data in the EHR-S for clinical, administrative, financial decision-making, audit trail and metadata reporting, as well as to create reports for patients. Many systems may use internal or external reporting tools to accomplish this (such as Crystal Report
Reports may be based on structured data and/or unstructured text from the patient's health record.
Users need to be able to sort and/or filter reports. For example, the user may wish to view only the diabetic patients on a report listing patients and diagnoses.
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Activity Clearance, Birth Information, EPSDT, Well Child/Preventive CareFunctionno
Req-279Support Clinical Communication2013 Format
DESCRIPTION: Healthcare requires secure communications among various participants: patients, doctors, nurses, chronic disease care managers, pharmacies, laboratories, payers, consultants, and etcetera. An effective EHRS supports communication across all relevant participants, reduces the overhead and costs...
DESCRIPTION: Healthcare requires secure communications among various participants: patients, doctors, nurses, chronic disease care managers, pharmacies, laboratories, payers, consultants, and etcetera. An effective EHRS supports communication across all relevant participants, reduces the overhead and costs of healthcare-related communications, and provides automatic tracking and reporting. The list of communication participants is determined by the care setting and may change over time. Because of concerns about scalability of the specification over time, communication participants for all care settings or across care settings are not enumerated here because it would limit the possibilities available to each care setting and implementation. However, communication between providers and between patients and providers will be supported in all appropriate care settings and across care settings. Implementation of the EHRS enables new and more effective channels of communication, significantly improving efficiency and patient care. The communication functions of the EHRS will eventually change the way participants collaborate and distribute the work of patient care.
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Child Welfare, Children with Special Healthcare Needs, Growth Data, Primary Care Management, Well Child/Preventive CareHeaderno
Req-280Clinical Decision Support2013 FormatSystem supports Clinical Decision Support.
Activity Clearance, Children with Special Healthcare Needs, EPSDT, Growth Data, Immunizations, Medication Management, Newborn Screening, Patient Portals - PHR, Primary...
Activity Clearance, Children with Special Healthcare Needs, EPSDT, Growth Data, Immunizations, Medication Management, Newborn Screening, Patient Portals - PHR, Primary Care Management, Registry Linkages, Well Child/Preventive Care
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Headerno
Req-281Documentation of Care, Measurements and Results2013 FormatSystem will document Care, Measurements and Results
Activity Clearance, Children with Special Healthcare Needs, EPSDT, Growth Data, Immunizations, Medication Management, Newborn Screening, Primary Care Management, Registry Linkages,...
Activity Clearance, Children with Special Healthcare Needs, EPSDT, Growth Data, Immunizations, Medication Management, Newborn Screening, Primary Care Management, Registry Linkages, Specialized Scales/Scoring, Well Child/Preventive Care
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Headerno
Req-282Operations Management and Communication2013 FormatSystem supports Operations Management and Communication.Child Welfare, Children with Special Healthcare Needs, Growth Data, Primary Care Management, Well Child/Preventive CareHeaderno
Req-283Manage Health Information to Provide Decision Support2013 FormatSystem manages health information to provide Decision SupportChildren with Special Healthcare Needs, Well Child/Preventive CareHeaderno
Req-284Measurement, Analysis, Research and Reports2013 FormatSystem supports measurement, analysis, research and reports.
Activity Clearance, Birth Information, Children with Special Healthcare Needs, EPSDT, Growth Data, Immunizations, Patient Identifier, Primary Care Management, Quality Measures,...
Activity Clearance, Birth Information, Children with Special Healthcare Needs, EPSDT, Growth Data, Immunizations, Patient Identifier, Primary Care Management, Quality Measures, Registry Linkages, Security and Confidentiality, Well Child/Preventive Care
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Headerno
Req-285Administrative and Financial2013 FormatSystem supports Administrative and Financial functions.Children with Special Healthcare Needs, Genetic information, Registry Linkages, Specialized Scales/Scoring, Well Child/Preventive CareHeaderno
Req-286Summary Lists2013 FormatSystems ability to capture summary lists.
Activity Clearance, Child Abuse Reporting, Child Welfare, Children with Special Healthcare Needs, Immunizations, Medication Management, Parents and Guardians and Family...
Activity Clearance, Child Abuse Reporting, Child Welfare, Children with Special Healthcare Needs, Immunizations, Medication Management, Parents and Guardians and Family Relationship Data, Registry Linkages, Well Child/Preventive Care
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Headerno
Req-287Preferences, Directives, Consents and Authorizations2013 FormatMaintain preferences, directives, consents and authorizations.
Children with Special Healthcare Needs, Parents and Guardians and Family Relationship Data, Primary Care Management, Security and Confidentiality, Special Terminology...
Children with Special Healthcare Needs, Parents and Guardians and Family Relationship Data, Primary Care Management, Security and Confidentiality, Special Terminology and Information
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Req-288Orders and Referrals Management2013 FormatManage Orders and Referrals.Medication Management, Primary Care Management, Well Child/Preventive CareHeaderno
Req-289Care Plans, Treatment Plans, Guidelines, and Protocols2013 FormatMaintain Care Plans, Treatment Plans, Guidelines and Protocols.Children with Special Healthcare Needs, EPSDT, Patient Portals - PHR, Primary Care Management, Quality Measures, Well Child/Preventive CareHeaderno
Req-290Support for Condition Based Care and Treatment Plans, Guidelines, Protocols2013 FormatSystem supports Condition Based Care and Treatment Plans, Guidelines and Protocols.EPSDT, Growth Data, Primary Care Management, Well Child/Preventive CareHeaderno
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