United States Health Information Knowledgebase


User Guide: Children's Electronic Health Record Format


The Children's Health Insurance Program Reauthorization Act (CHIPRA) of 2009 directed the Secretary of Health and Human Services (HHS) to develop and disseminate an electronic health record (EHR) Format for children enrolled in Medicaid or the Children's Health Insurance Program (CHIP). The Agency for Healthcare Research and Quality (AHRQ) in close partnership with the Centers for Medicare & Medicaid Services (CMS) managed this initiative. The aim of the initial project (2010-2013) was to deliver a set of functional requirements that met the needs of health care providers for children by combining best-practice clinical standards, Federal standards for information technology, and the contributions of clinical experts who treat children. Existing EHR systems often do not optimally support the provision of health care to children. The goal of the initial project was to develop an EHR Format (set of functional requirements) for children, demonstrate that it could be readily used, and package it in a way that facilitated broad incorporation into the architecture of EHR systems. The Format was intended to identify functional requirements that were important for EHR developers to meet through the design of their products.

The Format includes functional requirements that incorporate:

  • A minimum set of data elements;
  • Applicable data standards;
  • Usability; Functionality; and Interoperability.

The Format is stored as a portal of the United States Health Information Knowledgebase (USHIK).   USHIK is an on-line, publicly accessible registry and repository of health related data, metadata and standards.  USHIK is funded and directed by AHRQ with management support in partnership with CMS.

This guide provides users of the Format and interested parties an overview of how to access, navigate, and use the Format.  Included within this guide is a description of the Format structure and its meaning and a description of terminologies and labels used throughout the Format.  Click on "Glossary" from the top menu bar for a complete listing of definitions/descriptions.  To see the top menu bar, hover your cursor on the Child EHR Format tab at the top of the page.

Children's EHR Format Overview

The Format leverages existing work and specifications from a variety of sources, including but not limited to, the Health Level Seven International (HL7) EHR-S Functional Model, the HL7 Child Health Work Group's Child Health Functional Profile, and HRSA's Health IT for Children Toolbox. Building off of this work, the Format requirements are based on a gap analysis conducted by Intermountain Healthcare and the contributions of experts in health IT and child health informatics in 2010-2013 that produced 547 "normative statements" (functional requirements) and 148 headers and function statements used to hierarchically organize the normative statements. These 695 items, numbered from 89 to 1290, are considered the 2013 Format release package.

Subsequent work was performed in 2014-2015 to enhance the Format. A multi-stakeholder work group (MSWG) co-chaired by Vanderbilt University Medical Center pediatric informatics experts reviewed priority items from the 2013 Format and produced the 2015 Priority List, a set of 47 functional requirements that include implementation notes and changes intended to improve clarity and feasibility. These items, numbered 2001 to 2047, are considered the 2015 Priority List release package.

The Children's EHR Format (2013 Format) contains excerpts from the HL7 Child Health Functional Profile Specification, Release 1 developed by Health Level SevenĀ® International, the copyright owned by HL7. Portions of the Format that contain excerpts from the HL7 Child Health Functional Profile are identified in the Provenance field. Access to the full Format is available after free registration with HL7. Use of HL7 copyrighted material is governed by copyright law and HL7's policies related to the use of HL7 Intellectual Property (IP). The HL7 registration site does not currently fully support online screen readers used by visually impaired persons during the online registration process. If you encounter any difficulty, please send an email to CehrFormat@ahrq.hhs.gov for assistance. The 2015 Priority List includes eight items derived from earlier release items containing excerpts from the Hl7 Child Health Functional Profile Specification, Release 1. These eight items are also available after free registration with HL7.

The Format was developed so that it could be used by different audiences such as EHR developers seeking to augment existing systems with additional features or to build new EHR systems optimized for the care of children, and by EHR system purchasers seeking system selection criteria that can facilitate comprehensive system support for children's health care needs. Providing ready access to the Format for a variety of uses is intended to maximize the availability of systems compatible with the Format as well as the market demand for such systems.

Each requirement was assigned specific attributes that are incorporated into the Format to facilitate efficient use by the various Format users. Beyond enabling identification of the sources of requirements, the attributes enable filtering of the relevant subset of requirements by care delivery context, topic area, and other attributes of interest. The 2013 Format requirements can be viewed hierarchically (View tree) or numerically (View No Tree) to facilitate browsing. Requirements were developed for twenty-six topics in the 2013 Format, and for 20 topics in the 2015 Priority List.

The 2013 Format and the 2015 Priority List

The 2013 Format, the initial release package, includes 547 normative statements grouped in a hierarchy beneath 148 headers and function statements and publicly released in 2013. The 2013 Format was well received by software developers identifying gaps in functionality, practitioners using EHRs in the care of children, and provider organizations purchasing and configuring EHRs.

Users of the 2013 Format also identified challenges. Hundreds of the function statements were not viewed as actionable by stakeholders, despite the organization into topic areas, the hierarchical grouping, and the use of SHALL, SHOULD, and MAY in the narrative statements themselves. Early feedback on the Format suggested that its impact could be greater if software developers and other stakeholders were provided additional guidance in using it.

The 2015 Priority List is a release package of 47 normative statements designed to provide additional guidance to users of the Format. These items were drawn from preexisting 2013 Format items, and were edited or rewritten entirely for clarity, and supported by implementation notes that expand upon what is contained in the description of the requirement. A companion document, the Recommended Uses of the Format, identifies a variety of stakeholders and how they can use the 2013 Format and the 2015 Priority List to spur dialogue among software developers, practitioners, provider organizations, professional organizations, and others working to improve the care of children and the technologies supporting their care.

For more detailed information on the 2015 Priority List, please reference the full Report .

Requirements Development and Design

Functional requirements are used to describe the specific tasks that an EHR system would perform in support of recording, processing, and reporting on patient encounters. In this case, the Format describes functional requirements for an EHR system used to provide, communicate, and document medical care of children. The following principles were applied in the development of the requirements for the Format, including the 2013 Format and 2015 Priority List:

Only child-specific items (or items of particular importance for children) were included in order to manage and focus the scope of the effort. The Format presumes that other resources will be employed to identify the appropriate "general" (not child specific) EHR functionality (for example, the HL7 EHR-S Functional Model).

Requirements are focused on what child-specific EHR systems or functions should do, not what clinicians should do.

Requirements are not product-specific and were designed for a wide variety of existing and future EHRs. In some cases this leads to requirements that are not highly prescriptive, identifying an area of functionality rather than a particular approach to providing that functionality

Requirement statements in the 2013 Format release package are presented as a well-established hierarchy informed by the HL-7 EHR- S Functional Model (which is also used in the HL7 Child Health Functional Profile). Requirement statements in the 2015 Priority List are not presented as part of a hierarchy.

2013 Format requirement statements that directly inform specific functionality (called Normative Statements in the Format) consist of one of the following directions:

  • SHALL (for required functions);
  • SHOULD (for recommended actions); and
  • MAY (for optional characteristics).

2015 Priority List requirement statements were not written with the SHALL-SHOULD-MAY distinctions identified, but all were considered to be high priority and use the word "shall" in the description.

The focus of the 2013 Format is primary care for children, both well and sick, including hospitalized children. Subspecialty care is not included in the scope of this effort, though many of the requirements will be useful to subspecialists. The focus of the 2015 Priority List is primary ambulatory care for children.

The Format is not assumed to be the arbiter or enforcer of standards. When useful standards exist, the requirements point to well-maintained repositories of those standards, rather than reproducing a snapshot of them in the Format.

In addition to the requirement description, which spells out a unit of functionality for an EHR, there are a number of additional fields used to provide contextual details about a requirement. One important contextual field was added in the 2015 Priority List release package, "Implementation Notes." This field was not included in the initial 2013 Format items.

Viewing the Format in Internet Explorer

If you are using Internet Explorer as your browser for viewing the Format and your pages have out-of-place menus, images or text, you will need to click on the Compatibility View icon. The Compatibility View icon looks like a torn piece of paper and may be displayed next to the refresh icon to the right of your url. If you do not see this icon there, you will need to click on Tools from your browser menu and select Compatibility View from the list of menu items.

Format Field Descriptions

Descriptions of the Format fields, Provenances, Topic Areas and Cross-Topic Views are available in the Glossary.

Format Views

The requirements can be viewed a number of different ways depending on the user's interest. These views include 2013 Format or 2015 Priority List release packages, Cross-topic Views (independent of topic) or Topic Area Views, and the option to view a single requirement by entering a requirement number in the search box.

The 2013 Format requirements can be viewed in a "No Tree", or flat list that will not display the relationships between the selected list of requirements. A No Tree list is available for Cross-Topic Views and Topic Area Views.

Within the 2013 Format items, each requirement is related to one or more other requirements in parent/child relationships. Viewing the requirements in a "Tree" will display these relationships. To view these relationships for a specific Topic Area, select the topic area from the top menu bar of the Child EHR Format portal and click "View Tree". Tree views will display all requirements that have the selected Topic Area assigned to them and their relationship to each other.

Each item in the 2015 Priority List has one or more related requirements from the 2013 Format. The reciprocal relationships between items in the 2013 Format and in the 2015 Priority List are listed in the field {Related Requirements (for different release packages)}.

2013 Format Cross Topic Views

Cross-topic Views provide the user a numerically ordered list of requirements. Users can select the following types of Cross-Topic Views:

  • All Current Requirements: This view displays all currently released requirements.
  • Current Normative Statements: This view displays all currently released normative statements. Headers and functions are excluded.
  • SHALL Statements Only: This view displays all currently released SHALL statements which are a subset of current normative statements. "SHOULD" and "MAY" normative statements are excluded.
  • Critical/Core Requirements Only: This view displays all currently released Critical/Core requirements which are a subset of SHALL statements. Normative statements that are NOT Critical / Core requirements (as well as headers and functions) are excluded.

2015 Priority List items have the same type of normative statement "SHALL" and do not have "Cross Topic Views".

Topic Area Views

The Topic Area Views are used to focus on a subset of requirements that are included in a single topic (e.g. Medication Management) and by limiting the displayed attributes to the most useful information. Once a topic view is selected, USHIK will display the requirements for the topic as a "tree" (hierarchy, 2013 Format only) or "no tree" numerical order depending on the option selected. The list can be further refined by applying filters to the "no tree" list.

Searching the Format

To search requirements in USHIK, enter a requirement ID or a term in the "Search Child EHR Format" box in the upper right side of the portal.  Entering a term in the search box will search through all attributes of all requirements of the Format.

You can also search within the Title or Description columns of a list page of the requirements.  To perform this search, type the term in the Title or Description box. USHIK will search for the term entered in the title or description of the requirements displayed on your screen.  For example, if looking for requirements containing the term "neonatal" typing in that term into the Description box would provide a list of those requirements with "neonatal" in the description.  This same logic applies when searching in the Title column.

In addition, filters can be applied to look at various subsets of the Format.  Topic Area, Type, and Critical/Core columns of list pages all allow you to apply one or more filter to narrow the list to your specified selection(s).

To apply a filter on a column, click in the box below the column heading.  A list of the applicable filters for that column will be displayed.  You may check as many as desired, then click on the magnifying glass to apply the filtering.  If you are viewing a No Tree list, items that do not meet your filters will be removed from the list.  If you are viewing a Tree list, all items will remain on the list and items you select from the column will be highlighted.

Examples of applying filters or highlighting:

  • Sometimes the headers that form the requirements hierarchy may not be relevant to your search.  To exclude these, from the "Type" column, check "Function" and "Normative Statements" and click the magnifying glass.

Text of interest is generally best to search for in the "Description" field. Occasionally the "Title" field may be appropriate for this purpose.

Many requirements in a topic may not contain precisely the term you would expect. For example, you cannot find all of the medication-related requirements simply by searching for the term "medication." When a suitable topic exists, a topic search will provide much more complete results. When using text searches, consider any synonyms that may be needed.

To remove single filter click the "x" next to "Filtering Topic Area" on left side of screen. Use the Remove all Filters button to begin a new search/analysis.

Downloading Requirements

The Format allows users to download views of the requirements into Excel, Word, or PDF documents, enabling analysis of the requirements offline. To download pre-existing lists of requirements, select the "Downloads" tab from the Child EHR Format home page. Select a single Cross-Topic list to download, or select one or more Topic Area lists to download.

Downloads are also available from any of the lists. When viewing a list, you may use the "Select All," then click the Download button to download the entire list of selected requirements. You can also select specific requirements to be downloaded from any of the lists.

When viewing an individual requirement, you can click the Downloads tab and select Excel, Word, or PDF to download the individual requirement and all of its attributes.

Comparison of Requirements

Users can view two or more requirements side by side to see the similarities and differences between selected requirements. This may be especially helpful when comparing related requirements from different release packages, such as the 2015 Priority List vs. 2013 Format.

From a list page, select two or more requirements and click the compare button. All attributes that are the same, will be highlighted in blue and have a green circle with a check mark in it on at the left side of the comparison. Differences will be noted by a red circle with an exclamation point and highlighted in grey.

Format Feedback

Please direct any feedback to CehrFormat@ahrq.hhs.gov or use the Help/Feedback form. Clicking on the link opens an easy-to-use template for submitting your question or comments.

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