Concise Guide to CCHIT Certification Criteria

Concise Guide to CCHIT Certification Criteria The CCHIT Certification Criteria represent a substantial body of work, developed by hundreds of volunteers through an open, multi-stakeholder, consensus-based process, and refined by testing and operational certification over the past 3 years. With the passage of the American Recovery and Reinvestment Act (ARRA), certification has attracted national interest from a broader audience. This Guide is intended to provide a clear, readable digest of the criteria, as well as to illustrate how certification of EHRs to these criteria ensures that they are a qualified electronic health record under ARRA. The ARRA definition is: * (13) QUALIFIED ELECTRONIC HEALTH RECORD.—The term ‘qualified electronic health record’ means an electronic record of health-related information on an individual that— (A) includes patient demographic and clinical health information, such as medical history and problem lists; and (B) has the capacity— (i) to provide clinical decision support; (ii) to support physician order entry; (iii) to capture and query information relevant to health care quality; and (iv) to exchange electronic health information with, and integrate such information from other sources. This guide explicitly assigns Certification Criteria to each of those qualifications. Note that many criteria support more than one of the qualifications. Furthermore, the ARRA qualifications are not an exhaustive list of required capabilities; for example, they do not mention technical security features essential to protection of health information privacy. Accordingly, we include additional supporting categories to accommodate these other essential functions of an EHR. CCHIT has certification programs fully operational for Ambulatory EHRs, Inpatient EHRs, Emergency Department EHRs, and Health Information Exchanges, as well as optional add-on certifications for Child Health, Cardiovascular Medicine, and Enterprise EHRs, with stand-alone Electronic Prescribing certification to be launched soon. Given the current emphasis on incentive payments available under ARRA, this initial release of the Guide to Certification Criteria focuses on the Ambulatory and Inpatient EHR domains. In the Guide, the left column represents capabilities in EHRs certified to the ’08 criteria. There are now approximately 60 EHR products certified to this standard, in the marketplace and ready for adoption and use. The right column shows additional requirements recommended by CCHIT for the next cycle of certification, subject to review and approval by ONC and its Advisory Committees. † * † Boldface added for clarity Vendors are advised that testing is always based on the detailed Criteria and Test Scripts, not the Guide. May 29, 2009 Page 1 of 9 Concise Guide to CCHIT Certification Criteria: Ambulatory EHRs Certification Criteria for Ambulatory EHRs Basic Demographic and Clinical Health Information Currently Certified (08) EHRs:  Display essential patient information  Name, birth date, gender  List responsible clinicians  Other data necessary to meet legislative, regulatory, research and public health requirements  Manage patient’s problem/diagnosis list  Coded diagnoses  Onset date, chronic vs acute status  Who entered or changed problems  Display patient’s medications  Date started, renewed or changed  Special medications (free text)  Display patient’s allergies  Explicitly indicate if there are no known allergies  Accommodate modifications and corrections  Display test results  Numerical and narrative results  Graphical comparisons  Record acknowledgement by physicians  Accept and display clinical data  Vital signs  Graph height/weight over time  Added for 09:  Additional details  History or comment  Date problem resolved Allow association of a medication with a diagnosis Display when the allergy list was last reviewed with the patient    Tie narrative results to an image  Calculate and display a Body Mass Index (BMI) Show all the names and credentials when a note has multiple authors    Accept clinical notes in structured or  free text format  Provide ability to correct errors without destroying original note  Allow searching for a specific note by diagnosis or author Accept scanned documents   Consent forms and advance directives from patients  Confidential documents Generate a patient record based on a range of dates or by summary of care Accept documentation of a patient’s dispute with information in their chart Provide an index of the scanned documents by date and type May 29, 2009 Page 2 of 9 Concise Guide to CCHIT Certification Criteria: Ambulatory EHRs  Allow more than one physician or nurse to work on the same patient record at the same time  Allow the merging of duplicate records into a single record Clinical Decision Support Currently Certified (08) EHRs:  Highlight abnormal test results  Alert prescriber if:  Patient is allergic to a drug being ordered  Drug interactions may occur  A follow up test is recommended Added for 09:  Generate an alert when the patient’s vital signs fall outside the normal range  Alert prescriber if:  Patient is currently on a drug for which an allergy has been newly entered  Drug side effects may occur based on diagnosis  More appropriate or cost-effective therapy could be substituted  Allow adjusting alert severity based on the clinician’s role  Give the reasoning behind an alert, and allow override if appropriate. Identify patients for disease and wellness management according to guidelines  Based on age, gender, diagnoses, medications, lab results  Allow physicians to personalize the care guidelines for individual patients Provide reminders of recommended care that is due or overdue Generate a list of patients for whom care is due or overdue Generate patient education material for medications and diagnosis  Allow tailoring for the patient      Generate letters to patients automatically for care that is due or overdue Generate patient education material for procedures and tests  Allow tailoring for the patient  Physician Order Entry and Electronic Prescribing Currently Certified (08) EHRs:  Allow physicians to enter orders with all details needed for the completion of the order. Added for 09:  Capture diagnosis codes for orders May 29, 2009 Page 3 of 9 Concise Guide to CCHIT Certification Criteria: Ambulatory EHRs  Accept prescription orders  Select medications by brand or generic name  Accept instructions for preparation, strength, dose  Document if samples are dispensed Send prescription to pharmacy electronically  New or refill prescription Obtain electronically  Prescription insurance eligibility  Covered medication list  Medication history list Print and fax prescriptions Reprint or refax prescription if necessary, without re-entry of data Manage referral orders with clinical details necessary Order and administer immunizations  Capture dose, site given and manufacturer lot number  Document clinical assessment  Document patient receipt of the Vaccine Information Statement (VIS)  Accept prescription orders  Allow physicians to create their own list of commonly prescribed medications with automatic prescribing details        Order and administer immunizations  Document any adverse reactions to immunizations Health Quality Information Currently Certified (08) EHRs:  Generate reports from structured clinical or administrative data to support quality improvement activities  Identify patients for whom a particular report does not apply  Produce population-based reports with selections based on  Demographic information  Diagnoses and medications  Vital signs, labs and other structured data Added for 09:  Produce population-based reports with selections based on  Care that is indicated but has not been delivered Exchange Electronic Health Information Currently Certified (08) EHRs:  Receive patient summary information as a Continuity of Care Document using the Federally-recognized standard  Demographic, medications, allergies Added for 09:  Generate and format patient summary information as a Continuity of Care Document using the Federallyrecognized standard May 29, 2009 Page 4 of 9 Concise Guide to CCHIT Certification Criteria: Ambulatory EHRs  Receive lab data in the Federallyrecognized standard format  Forward test results to other providers through a directory Supporting Security and Confidentiality Currently Certified (08) EHRs:  Access control  Must be able to limit access for individuals or roles to only what is needed to perform specified tasks  Identify certain information as confidential, accessible only by appropriately authorized users  Audit records  Must maintain detailed audit trail of all events  Authentication  Must follow specific industrystandard practices regarding log-in and passwords  Data protection  Must meet specific requirements regarding data backup, recovery, and documentation of system  Technical security  Must meet specific requirements regarding encryption and transmission of data Added for 09:  Access control  Allow ‘break the glass’ emergency access for specifically authorized users  Audit records  Export audit record using a standardized format Supporting Workflow Currently Certified (08) EHRs:  Task management  Create, assign or re-assign tasks  Mark as complete  Administration  Obtain eligibility information from patient’s insurance  Display the proper billing, professional services code  View physician’s schedule Added for 09:  Show orders for multiple patients in one view to facilitate workflow May 29, 2009 Page 5 of 9 Concise Guide to CCHIT Certification Criteria: Inpatient EHRs Certification Criteria for Inpatient EHRs Basic Demographic and Clinical Health Information Currently Certified (08) EHRs:  Display essential patient information: name, birth date, gender  Manage patient’s problem/diagnosis list Added for 09:  Display patient’s location in the hospital  Identify a Restricted or Private record  Display patient’s problem/diagnosis list in different view and with details  History or comment  Any corrections made Sort the medication list Require details about why the patient is taking the home medications Display when the allergy list was last reviewed with the patient   Display patient’s medications  Prescribed and over-the-counter  Medications brought from home Display patient’s allergies  Indicate if allergies unknown  Allow for modifications and corrections    Clinical Decision Support Currently Certified (08) EHRs:  Alert physicians if:  Patient is allergic to a drug being ordered  Drug or food interactions may occur  Patient is already on similar drug  Medication dose is out of recommended range  Immunizations are due or overdue Added for 09:  Alert physicians if:  Patient is currently on a drug for which an allergy has been newly entered  Drug side effects may occur based on diagnosis  Order may be a duplicate  More appropriate or cost-effective therapy could be substituted  A follow-up or related order is recommended    Provide dosing guidance based on:  Patient weight  Lab results  Scientific reference material  Allow adjusting alert severity based on the clinician’s role Report the effect of alerts on clinical decisions Warn when a medication should not be given because of:  Patient age or weight  Pregnancy or mother who is nursing Block ordering medications via the wrong route (such as oral vs I.V.)  Give the reasoning behind an alert, and allow override if appropriate.  May 29, 2009 Page 6 of 9 Concise Guide to CCHIT Certification Criteria: Inpatient EHRs  Display for the nurse at the time of administering medications:  Any previous alerts  Patient’s test results and allergies Allow the nurse to use bar-code technology to assure “5 rights” (right patient, drug, dose, time and route)  Require the nurse to complete tasks, such as allergy verifications, prior to giving medications  Physician Order Entry and Electronic Prescribing Currently Certified (08) EHRs:  Display important patient information when entering orders:  Demographic information, allergies, diagnoses, weight  Previously administered medications and patient response  Lab data  Allow physicians to enter orders with all details needed for completion  Support medication reconciliation  Medications taken at home  Identify medications to be continued on admission  Allow review during transitions of care  Support a variety of order types  Medication, nursing, ancillary and diagnostic orders  Doses based on weight  Conditional orders activated on timing or patient condition  Verbal orders, including a process for read back of the order details  Non-formulary orders  Tapering or adjusting doses  Orders requiring co-signature  Support “order sets”  Grouping of orders by order type  Preselected orders by evidencebased recommendations Added for 09:  Display patient information:  Body Surface Area (BSA) when drug dosing depends on BSA instead of weight  Allow physician to place orders from medication list  Provide full interaction checking  Support “order sets”  Search for order sets by name  Nested order sets  Guidance or comments  Support reporting on the use of order sets May 29, 2009 Page 7 of 9 Concise Guide to CCHIT Certification Criteria: Inpatient EHRs  Support nurses in safely administering medications  Display medication details, dosage form or comments  Document any interventions or assessments  Document response to medication  Capture the administering individual and any second witness Support “as needed” medications  Display differently from scheduled medications Allow nurses to use bar code technology to assure the “5 rights” Receive medication and lab results from outside system Order and administer immunizations  Capture details like dose, site given and manufacturer lot number  Document clinical assessment  Document patient receipt of the Vaccine Information Statement (VIS)  Nurse-pharmacy communications  Changes in schedule  Details about the dosage forms sent from the pharmacy Additional documentation  Reason for a medication not given  Medication given by a different nurse  Allow for nurses to correct errors in the administration record      Allow for physicians to electronically submit a discharge prescription to a pharmacy  Record the consent or refusal for the administration of each immunization  Document any adverse reactions to immunizations Health Care Quality Information Currently Certified (08) EHRs: Added for 09:  Search and identify patients based on  Specific Diagnosis  Specific Medication Exchange Electronic Health Information Currently Certified (08) EHRs: Added for 09:  Receive patient summary information as  Generate (for sending) patient summary a Continuity of Care Document using the information as a Continuity of Care Federally-recognized standard document using the Federallyrecognized standard  Demographics, medications, allergies  Receive patient information  From administrative system  From other outside sources  Send orders and updates  Departmental systems, lab radiology and dietary  Pharmacy systems  Generate a paper and electronic discharge summary  Medications, allergies, weight May 29, 2009 Page 8 of 9 Concise Guide to CCHIT Certification Criteria: Inpatient EHRs Supporting Security and Confidentiality Currently Certified (08) EHRs:  Access control  Must be able to limit access for individuals or roles to only what is needed to perform specified tasks  Identify certain information as confidential, accessible only by appropriately authorized users  Audit records  Must maintain detailed audit trail of all events  Authentication  Must follow specific industrystandard practices regarding log-in and passwords  Data protection  Must meet specific requirements regarding data backup, recovery, and documentation of system  Technical security  Must meet specific requirements regarding encryption and transmission of data Added for 09:  Audit records  Export audit record using a standardized format Supporting Workflow Currently Certified (08) EHRs:  Notify nurse if patient’s medications are overdue  Notify doctor if order requires a signature or renewal  Assign group of physicians or nurses to take care of groups of patients Added for 09:  Maintain directory of physicians and contact information May 29, 2009 Page 9 of 9