EHR Infrastructure Functions



Submission to:

Health Level Seven (HL7)

Electronic Health Record Special Interest Group

EHR Functional Hierarchy and Decomposition

DRAFT v0.84, 1 July 2003

Gary L. Dickinson

Manager, Health Care Standards

Per-Sé Technologies, Inc.

R&D

268 W. Hospitality Lane, #300

San Bernardino, California USA 92408

Tel: (+1) 909-888-3282

email: gary.dickinson@per-

EHR Functional Model

Horizontal axis - EHR Function - Two Tier

Infrastructure Functions

Care Delivery Functions

Vertical axis - EHR Use - One per

Use Setting: EHR Setting Profile

User, Use Case: EHR Use Profile

EHR Function Specification Triplet

1. WHAT - Statement of Function(ality)

2. WHY - Rationale

3. Conformance Criteria

How: Implementation - OUT OF SCOPE

EHR Glossary

EHR - Electronic Health Record

IDN - Integrated Delivery Network

PHI - Protected Health Information

Per HIPAA, individually identifiable health information

SOA - Service Oriented Architecture

acts = actions = health service events =

work tasks (work flow)

EHR Functional Perspectives

Front-end user functions

Explicit functions

Extrinsic - externally invoked process/action

Embedded functions

Implicit functions

Intrinsic - bound to internal process

Service Oriented Architecture functions

Horizontal, invoked back-end services

(GLD Note: SOA mediators)

Interface functions

e.g., HL7 v2.x trigger events, query/response

In and outbound data streams

Reporting and notification functions

Outbound data streams

EHR Stakeholder Domain

Examples:

Personal Health Record

Care record, health status

Per patient/subject of care

PHI

Provider Operations (Business) Record

Record of care delivery

Per organization and business unit

PHI

Personal Practitioner Healthcare Delivery Record - Professional Service Record

Record of care delivery

Per practitioner

PHI

IDN Health Record

Record of care delivery

For multiple healthcare delivery settings

PHI

Population Health Record

Identifiable PHI or not

Local, Regional or National Health Record

Centralized EHR stores or logical linkages

PHI

Clinical Research Extract

Identifiable PHI or not

EHR References

ISO 18308 - Reqt's for an EHR (Record) Architecture

Final Draft ready for publication

ISO TC215 WG1 New Work Item, approved May 2003

Architectural Req'ts for EHR Systems

(starter list from Dr. Peter Schloeffel)

ISO 17799, 18307, 21089…

ASTM E1762, E1769…

IOM Reports: 1991 on…

International: CEN, GEHR, OpenEHR, NHS (UK)…

Regulatory: DHHS, HIPAA, FDA…

Accreditation: JCAHO, NCQA, URAC…

Public Health: CDC…

Research, Quality, Advisory: AHRQ, NCVHS, IOM…

…

EHR Model Basis

Data model

Business classes, relationships, attributes, states, identifiers, data types, version control, audit…

Vocabulary model

Terminology, coding/classification, version control, audit

Business operations, process model

Actors, actions, process state/state transition, work flows, assignments, allocations, deployments, staging, routing, conditionals, decision support algorithms, notifications, alerts, reminders, version control, audit…

Information flow (chain of trust) model

Flow patterns, end-to-end (point of origination to point of access, use or disclosure), stewardship, accountability, authentication, audit…

Clinical practice model

Standards of practice/care, protocols (e.g., care plans, critical paths), problem management and resolutions…

Decision support model

Standards for clinical decision making, algorithms, triggers, responses…

Quality assurance model

Quality standards, measures of quality and outcomes…

Trust model

Privacy and security protections/assurance

Authentication, audit, access control, encryption, trusted data stores, trusted communications, data/function security classifications, user/role security clearances…

Accountability model

Individuals, organizations, business units…

Performance model

Performance standards, measures of performance…

Application interoperability model

Common EHR (inside) domain

Disparate (outside) domain

Data and functional mapping, translation, versioning, audit…

Backup/recovery model

Testing, evaluation, rollover model

Version control, audit

EHR Interoperability

EHR Interchange Paradigms

Homogeneous - common, uniform

Heterogeneous - disparate

Homogeneous

Interchange, among and between systems with

Common architecture

Common EHR model basis

(see EHR Model Basis)

(Typically) single common datastore

Logically integrated

Even if physically distributed

FULL INTEROPERABILITY DUE TO COMMON ARCHITECTURE

Heterogeneous

Interchange, among and between systems with

Disparate architectures

Disparate EHR model basis

Multiple disparate and distributed datastores

(Often) interchange via interface mediator

e.g., interface engine, hub, router

De facto common denominator (CD)

Of information: content subset in common between systems

Of functions (e.g., HL7 trigger events): function subset in common between systems

(Often) enforced by interchange mediator

Interchange scenarios

Identical content/function

Within CD

1:1 mapping

Equivalent (but not identical) content/function

Within CD

Translation possible

Disparate content/function

Beyond CD

Mapping or translation not possible

INTEROPERABILITY CONSTRAINT -

INTEROPERABILITY LIMITED TO DATA/ FUNCTION OF COMMON DENOMINATOR

EHR Infrastructure Functions

Business Focus: Health Record/PHI Management

EHR Patient (Person) Registry

PHI

Content

Identifiers

Name, alias(es) and demographics

Location and contact information

Next of kin

Usual practitioners

Health plan, insurance, billing details

…

Functions

Create patient record

Assign patient ID

Amend patient record(s)

Merge duplicate patients

Unmerge patients (previously merged in error)

Transmit patient record(s) to external system or entity

Receive patient record(s) from external system or entity

Archive patient record(s)

De-identify or alias patient record(s)

Re-identify patient records (from alias)

Delete patient record(s)

EHR Practitioner (Person) Registry

Not PHI

Content

Identifiers

Name, alias(es) and demographics

Practitioner roles

Location and contact information

Assignment parameters: location, department, service or specialty, practice group and individual

Notification, reminder and alert parameters

Personal order sets: group and individual

User-based security access clearance(s) - User and Role Based, controlling access to

Access to EHR/PHI functions

Access to EHR/PHI content

Password, access details

Functions

Create practitioner record

Create practitioner ID

Amend practitioner record

Activate, inactivate practitioner

Delete practitioner record(s)

EHR Role Registry

Not PHI

Content

Role

Role-based security access clearance(s), controlling access to

EHR/PHI functions

EHR/PHI content

Function

Create role record

Amend role record

Delete role record(s)

EHR Entity Registry

Not PHI

Entities

Organizations

Business Units

Persons (as above): patients, practitioners

Devices: e.g., instruments, monitors

Software: e.g., applications, interface engines, hubs, routers

Content

Entity identifiers

Name, description

Location(s) and demographics

Functions

Create entity record

Assign entity ID

Amend entity record

Delete entity record

EHR Location Registry

Not PHI

Locations, where

Health(care) delivery takes place: healthcare services are performed

EHR records are created, accessed/used

Location examples

Facilities, areas, rooms, beds

Business units: departments, services, specialties

Content

Location Identifiers

Demographics

Business unit(s): departments, services, specialties

Function

Create location record

Update location ID

Amend location record

Delete location record

EHR - Multiple Person Linkage

Parts PHI

Linkages, e.g.,

Patient to practitioner(s)

Patient to other person/entity: e.g., family member, guarantor, insured, employer

Functions

Create linkage between persons

Activate, deactivate linkage between persons

EHR Chronology (Chronicle of)

>Health Service Acts

>Health Record Acts

PHI

Chronicles

Health status

Health service acts, actions

Health record acts, actions

Health service acts

[See Care Delivery Functions]

Health record acts

Often audit events (audit triggers)

Enable/show record authorship, origination

Enable/show record amendment

Enable/show record verification

Enable/show record access/use

Enable/show record translation

Enable/show record transmittal, including authorized PHI disclosure

Enable/show record receipt, including externally sourced PHI

Enable/show record ee-identification, aliasing, re-identification

Enable/show record archival

Enable/show record destruction or loss

Enable/show physical record check-out/check-in: paper, film, tracings

Enable/show record queries and responses

Health record acts -

Interchange events (in/out-bound interface triggers)

Enable/show record transmittal, including authorized PHI disclosure

Enable/show record receipt, including externally sourced PHI

EHR Timeline Perspectives

Prospective, future

Enable/show health services (care delivery) planned/scheduled - not yet underway

Concurrent. now

Enable/show health services (care delivery) in progress - but not yet complete

Retrospective, historical

Enable/show health services (care delivery) completed

EHR/PHI Record Management

Including PHI

Record retention, persistence

For duration of legal requirement

Retain patient records

Retain supporting records and registries (entities, locations…)

Record indelibility

Ensure and retain record instance as originated

Ensure and retain record instance for each successive amendment

Record creation, amendment

Enable record capture and input: e.g., formatted input screens

Ensure source (entity) authentication

Ensure means of content review and approval: e.g., user display and accept

Audit origination: who, what, when, where

Record verification

Enable record verification review and approval: e.g., display and accept

Ensure verification (entity) authentication

Audit verification: who, what verified, when, where

Record translation

Enable record/data translation: e.g., language, code sets

Retain original data value + translated value

Audit translation, as per Record Amendment

Record access/use

Enable record access: e.g., display

Ensure accessing (entity) authentication

Audit access/use: who, what, when, where

Record transmittal

[See EHR/PHI Outbound Record Transmittal]

Audit transmittal: who, what, when, where

Record receipt

[See EHR/PHI Inbound Record Receipt]

Audit receipt: who, what, when, where

Record archival

Retained according to Legal Requirement

Enable record archival: e.g., to external entity or offline storage medium

Provide archive log, index for retrieval

Audit archival: who, what, when, where

Record purge/deletion

Intentional, meeting legal requirements

Enable electronic record deletion

Audit purge/deletion: who, what, when, where

Provide

Record destruction or loss

Typically unintentional

Notate record destruction or loss

Audit destruction, loss or deletion: who, what, when, where

Record de-identification, aliasing

Enable record de-identification: e.g., per HIPAA

Enable record aliasing

Audit de-identification: who, what, when, where

Record re-identification

Enable record re-identification: e.g., for previously aliased records

Audit re-identification: who, what, when, where

Physical record check out/in

To track various physical media, including paper, film

Enable physical record checkout

Audit checkout: who, what, when, where

Enable physical record checkin

Audit checkin: who, what, when, where

Record query/response

Enable record query/response

Audit queries, if PHI: who, what, when, where

Record accuracy, consistency

Enable algorithmic checks to ensure record/data accuracy, consistency

Show checks performed, per record instance

Record completeness

Enable checks record completeness

Per encounter or episode of care

Per record instance

Enable checks for record completeness, as a function of the completeness of health(care) delivery

Per encounter or episode of care, per set of corresponding health service acts/actions - complete or not

Per record instance, per corresponding health service acts/action(s) - complete or not

Record audit

[See EHR/PHI Chronology - Health Record Acts]

Create/maintain record acts/action audit trails

Provide audit event review tools

Show audit event exceptions, per criteria

Record secure physical storage

Enable physical security controls of EHR/PHI systems, databases, networks and media: e.g., per HIPAA

IN/OUT of scope?

EHR/PHI - Inbound Record Capture/Receipt

Including PHI

From external entities or sources: organizations, business units, software systems, devices

Often via interface mediators (engines)

If homogeneous record source, assume

Identical record content

Identical context and data relationships

Identical function: communication triggers, HL7 trigger events

Identical data types

No special mapping or translation required

If heterogeneous record source, assume

Disparities (source to receiver) in record content, context, function and data types

Content, per record element: identical, translated, unmappable

Context, per record or acts/action: identical, translated, unmappable

Function, per trigger: identical, translated, unmappable

Data type, per record element: identical, translated, unmappable

If identical: 1:1 mapping, no translation required

If translated (source to receiver representation): single (original value) becomes duple (original + translation)

If unmappable, record element has no source=receiver equivalent, integrity question (unmapped function, context)

Interface standards

Enable industry standards for inbound messages: e.g., HL7 v2/CDA, DICOM, MIB, X12N, NCPDP

Per interface instance

Transmission source authentication

>Per connection, session, record or message

Ensure source (entity) authentication: e.g., software system, device, network, interface mediator

Transmission encryption, decryption

>If PHI or otherwise confidential

>If transmitted over untrusted or public network

>Per connection, session, record or message

Enable decryption of inbound record receipt

Transmission (message) authentication

>Per connection, session, record or message

Ensure record/message content integrity: record received equals record sent

Ensure record/message sequence integrity

Source to receiver sequence

Source to interface mediator to receiver sequence

Record origination evidence

>Evidence of record source, origin and/or authorship

>As represented by record transmitter to record receiver

>Per record instance

Show record source, origin and/or authorship: who, what, when, where

Record verification evidence

>Evidence of record verification

>As represented by record transmitter to record receiver

>Per record instance

Show record verification: who, what, when, where

Record content translation evidence

>Evidence of record content translation

>As represented by record transmitter to record receiver

>Per record instance, per record element translated

Show record translation: who, what, when, where

Show translated content: as originated, as translated

Record amendment history

>Evidence of record content, as originated and as amended

>Per record instance

Show record, as originated

Show record, per each subsequent amendment

Show record audit trail: who, what, when, where

Inbound record re-identification

>Per record, per record instance

Enable re-identification of inbound records, i.e., invert previous outbound aliasing

Audit re-identification: who, what, when, where

Inbound record audit

>Per connection, session, record or message received

Log record/message as received, unaltered

Audit inbound record receipt: from whom, what, when, where

EHR/PHI - Outbound record transmittal

Including PHI

To external entities: organizations, business units, software systems, devices

Often via interface mediators (engines)

Outbound records, including transmittal to:

Entities: organizations, business units, individuals

Software systems, devices

Hardcopy output: e.g., printers, faxes

Softcopy output: e.g., email, pager messages, PDAs

Media output: e.g., magnetic, optical, microfiche

If homogeneous record receiver, assume

Identical record content

Identical context and data relationships

Identical function: communication triggers, HL7 trigger events

Identical data types

No special mapping or translation required

If heterogeneous record receiver, assume

Disparities (source to receiver) in record content, context, function and data types

Content, per record element: identical, translated, unmappable

Context, per record or act/action: identical, translated, unmappable

Function, per trigger: identical, translated, unmappable

Data type, per record element: identical, translated, unmappable

If identical: 1:1 mapping, no translation required

If translated (source to receiver representation): single (original value) becomes duple (original + translation)

If unmappable, record element has no source=receiver equivalent, integrity question (unmapped function, context)

Interface standards

Enable industry standards for outbound messages: e.g., HL7 v2/CDA, DICOM, MIB, X12N, NCPDP

Per interface instance

Transmission receiver authentication

>Per connection, session, record or message

Ensure receiver (entity) authentication: e.g., software system, device, network, interface mediator

Transmission (message) authentication

>Per connection, session, record or message

Ensure record/message content integrity: record received equals record sent

Ensure record/message sequence integrity

Source to receiver sequence

Source to interface mediator to receiver sequence

Transmission encryption

>If PHI or otherwise confidential

>If transmitted over untrusted or public network

>Per connection, session, record or message

Enable encryption of outbound record transmittal

Record origination evidence

>Evidence of record source, origin and/or authorship

>As represented by record transmitter to record receiver

>Per record instance

Show record source, origin and/or authorship: who, what, when, where

Record verification evidence

>Evidence of record verification

>As represented by record transmitter to record receiver

>Per record instance

Show record verification: who, what, when, where

Record content translation evidence

>Evidence of record content translation

>As represented by record transmitter to record receiver

>Per record instance, per record element translated

Show record translation: who, what, when, where

Show translated content: as originated, as translated

Record amendment history

>Evidence of record content, as originated and as amended

>As represented by transmitter to receiver

>Per record instance, per record element

Show record, as originated

Show record, per each subsequent amendment

Show record audit trail: who, what, when, where

Outbound record de-identification, aliasing

>Per record, per record instance

Enable de-identification of outbound records: e.g., per HIPAA

Enable aliasing of outbound records

Audit record re-identification: who, when, where

Outbound record audit

>Last point of record audit for some outbound data streams, e.g.

>>Hardcopy: e.g., printers, facsimile

>>Softcopy: e.g., mails, pagers, PDAs

>>Other media: e.g., magnetic, optical, microfiche

>If PHI, if "disclosed PHI

>Per connection, session, record or message received

Log record/message as transmitted

Audit outbound record transmittal: to whom, when, where

EHR/PHI Lifecycle "Chain of Trust"

>Trusted End-to-End EHR Flow

[See Draft ISO 21089]

Health record lifecycle and flow

Evidence/show health record lifecycle and flow, at points of:

Authorship, origination

Amendment

Verification

Access/use

Translation

Transmittal, including PHI disclosure

Receipt

De-identification, aliasing

Re-identification

Archival

Destruction or loss

Purge/deletion

Physical record check-out/check-in

EHR Historical Snapshot

>Snapshot of "moment in time"

>Historical context, basis for clinical decision making

Show state of record for historical point in time

Based on state of health record at given point in time

Based on state of health(care) delivery and corresponding health service acts/actions at given point in time

Multi-media EHR

>Text, graphics/waveforms, images, audio…

Local storage

Capture

Retain

Render and display

Networked multi-media server

Enable live and reference-able link to multi-media server

Render and display

EHR Controlled Vocabulary

Enable uniform and common classification schemes and code sets

>For record elements

Industry standard: e.g., ICD, CPT, NDC, LOINC, SNOMED

Localized

EHR/PHI Privacy

Ensure continuous privacy protection/assurance: e.g., per HIPAA

Records "at rest" (retained in datastore)

Records "in transit" (during interchange)

EHR/PHI Privacy - HIPAA

"Need to know" and "minimum necessary"

>See EHR Security - Access Control

Limit access to "need to know" and "minimum necessary"

Per user, per role, per work assignment

Per use/purpose of access

Record de-identification

>See EHR Record Management - Record de-identification

Enable record de-identification

Notice of Privacy Practices

Capture, retain and display notice

Notate patient receipt of notice

Authorization for specific disclosure/use

>Beyond routine use - HIPAA TPO (treatment, payment and healthcare operations)

Capture, retain and display authorization, including

Purpose and scope of record access/use

By whom

For how long

Right to inspect or copy EHR content

>Exclusion for psychotherapy notes

Notate patient's request to inspect or copy EHR content

Notate request disposition

Right to request amendment

Notate amendment request

Notate request disposition

If request accepted, amend record according to request

As appropriate, retransmit amended record to previous recipients

EHR Security

Continuous security protection/assurance

Ensure continuous security protection/assurance: e.g., per HIPAA

Records "at rest" (retained in database)

Records "in transit" (during interchange)

EHR Security Administration

Enable single point security administration/control

Typical for homogeneous environments

Enable multi-point security administration/control

Typical for heterogeneous environments

Enable configuration of security controls

Enable audit review and monitoring

Routine and exceptional audit event monitoring

EHR Security Policy Domains

Enable security policy domains as discrete functional units requiring a unique security policy implementation, e.g.

Per organization

Per business unit: e.g., department, service, specialty

Per location or facility

Per record subset: e.g., psychotherapy, SDT results, drug and alcohol abuse records

EHR Security - Access Classifications (Locks)

>EHR Record Access, Amendment and Processing

>EHR Function Access

Enable EHR record access classifications

Per record domain

Per record type

Per record element

Enable EHR function access classifications

Per EHR function or sub-function

EHR Security - Access Clearances (Keys)

Authorizations, Privileges

Enable user-based access clearances

Per authorized user

Enable role-based access clearances

Per authorized role

EHR Security - Access Control

>EHR/PHI record access control

>EHR/PHI function access control

Enable access types

User-based

Role-based

Context-based

Audit access

>Per user, per session

Enable session management

>Per user, per session

Signon: e.g., ID, physical token, password

Enable user authentication

Log excess signon attempts

Enable automatic session timeout, signoff

EHR Security - ID and Password Management

Enable ID management

Enable token management: e.g., ID cards, buttons, keys

Enable password management

Encrypted passwords

EHR Security - Entity Authentication

>User, software system, device, network, address…

Enable entity authentication:

EHR Security - Audit

>Who, what, when, where

Audit health record acts

[See EHR Chronology - Health Record Acts]

Audit health record data states

As originated

Per successive amendment

Audit health service acts

[See EHR Chronology - Health Service Acts]

Audit EHR system events

Routine and exception

Hardware, software, database, network…

EHR Security - Communications

Enable sender/receiver authentication

Enable secure session management

Enable encryption/decryption of EHR/PHI and other confidential communications

Over public or untrusted networks

Audit communications events

Routine and exception

Session start/end

EHR Database Management

Enable database backup

Full backup

Incremental, since last backup

Enable hot database backup

With minimal (time duration) system freeze at final update pass

Enable database restore

Enable database integrity checks

EHR Database Transaction Management

Enable logical and physical transactions

Enable arbitrarily large transactions: e.g., order entry with multiple orders, acts/action scheduling, notifications in single transaction

Enable multi-phase commits: bid, lock, update, unlock

Enable multi-node concurrent locks

Enable transaction journaling

Robust roll-back and forward

EHR Availability

>Appropriate to stakeholder domain served

>24 x 7 x 365 for acute inpatient

Ensure 99.9% uptime

Ensure minimal down-time for periodic version rollovers

EHR Fault Tolerance, Redundancy

Enable fault tolerant architecture

Software: OS and application

Database

Processors

Networks

Enable dual fully redundant physical datastores

Networked together but physically separate

If appropriate, in physically separate facilities

Enable dynamic failure bypass to ensure continuous operation

Enable real-time monitors of component function and availability

EHR Responsiveness, User Response Time

>Appropriate to stakeholder domain served

Ensure responsiveness

To user commands and display requirements

EHR Time (Clock) Synchrony

Enable robust time synchrony services across multiple systems

Homogeneous: common architecture

Heterogeneous: disparate architecture(s)

EHR Record Synchrony

Enable robust record synchrony services across multiple systems

Homogeneous: common architecture

Heterogeneous: disparate architecture(s)

EHR Localization, Local Authority

Enable parameters for localization

Per use setting

Per use instance

EHR User/Use Environments

>Per EHR implementation

Enable EHR production environment

Live EHR, live PHI

Enable EHR test, development environment

Not PHI

For EHR configuration pre-live

Enable EHR training environment

Not PHI

For EHR training, practice sessions

EHR Version Management

Enable software version management, control

OS

Application

Interface mediator (e.g., interface engine)

Device

Network, communication

Enable version management/control for vocabulary files

Vocabulary, coding and classification schemes

Retain historical vocabulary files for ongoing reference

Enable version management/control for master configuration and definition files

Enable version management/control for messaging standards: e.g., HL7, DICOM, IEEE, X12N, NCPDP

EHR Scalability, Change Scale

Enable progressive (upward) scalability as capacity requirements expand

Database

Concurrent users, sessions

EHR OLTP

On-Line Transaction Processing

>Appropriate to stakeholder domain served

>Sufficient to support immediate, real-time care delivery in all venues

Enable high performance real-time transaction throughput

Large transaction payloads

High transaction volumes

Ensure upward scalability of transaction capacity

EHR OLAP

On-Line Analytical Processing

>Appropriate to stakeholder domain served

Enable retrospective record/data analysis without impacting real-time OLTP performance

Clinical

Administrative, operational

EHR Care Delivery Functions

Business Focus: Health(care) Delivery

Mostly PHI

[FUNCTION HIERARCHY and DE-COMPOSITION INCOMPLETE…]

Encounter Management

>Per Patient Encounter (Visit)

>Often Location/Site of Care Oriented

>PHI

Encounter types

Enable standard encounter types

Acute inpatient

Emergent

Ambulatory, including

Physician office

Public health clinic

Same day surgery

Dental office

Long-term inpatient care, including

Skilled nursing facility, nursing home

Inpatient hospice

Home care, including

Practitioner provided home services

Home based hospice

Patient self care

Care "in the community", including

Paramedic

School

Health education, including first aid and CPR

Wellness and prevention programs

Health fairs, immunization clinics

Encounter dataset

Capture and retain encounter data, including

Diagnosis, symptoms

Encounter date(s), time(s): e.g., admit/discharge dates

Encounter type

Encounter location, site of care

Practitioner(s)

Admitting, attending, consultant, referred to/from

Discharge type and disposition

Insurance coverage, subscriber and guarantor

Patient location tracking

Enable patient location tracking, e.g., assigned bed to assigned bed

Admit to

Transfer to

Discharge from

Enable concurrent patient movement tracking

Check-out/in to care locations: e.g., radiology, operating room

Episode Management

>Problem oriented

Problem list

Capture and retain problem list, per patient

Track/show problem list, active and resolved problems

Track/show problem onset, milestones and resolution(s)

Show related diagnosis(es), symptoms

Track/show problem management across

Encounters

Locations, sites of care

Departments, services, specialties

Multiple practitioners, inter-disciplinary care

Include goals, objectives

Include related care plans, critical paths, protocols

Include related orders, results

Orders, Order Management

>For the provision of health(care) services

>Care, diagnostics, therapies, medications, self care, followup…

Business and clinical practice rules

Enable orders, order management based on business and clinical practice rules

Enable orders, order management based on best practice (standard of practice) guidelines

Accreditation, regulatory guidance

Professional society guidelines

Local and regional conventions

Enable rules for

Order entry, verification, amendment, discontinuation and cancellation

Order scope of authority

Protocol orders

Order alerts and reminders

Order spawned acts/actions

Order-based practitioner assignment

Order notification and routing

Quality and performance measures

Cost measures

Order management

Capture and retain patient orders and order details

Order entry

Enable order entry at point of service/care or at other points of convenience for practitioner

Check order content for accuracy and consistency

Check order content for completeness

Authenticate/identify

Order author

Order scribe (if any)

Audit order: who, what, when, where

Authenticate order

Order scope of authority

Define scope of authority for orders, within and across:

Encounter types

Inpatient

Emergent

Ambulatory

Long-term care

Home care

Locations and Facilities

Disciplines and Business Units

Departments

Services

Specialties

Order verification

Verify order, e.g.,

>Prior to scheduling corresponding health(care) services

Practitioner review of order entered by scribe

Review of student, intern or resident by proctor or preceptor

Review of employee work by supervisor

Audit order verification: who, what, when, where

Authenticate order verification

Retain content of original order, and all subsequent amendments

Invoke decision agent

Order amendment

Amend order

Cancel and/or reschedule spawned acts/actions

Based on new order parameters

Audit order amendment: who, what, when, where

Authenticate order amendment

Retain content of original order, and all subsequent amendments

Invoke decision agent

Order renewal

Renew order

Schedule spawned acts/actions

Audit order renewal: who, what, when, where

Authenticate order renewal

Retain content of original order, and all subsequent amendments/renewals

Invoke decision agent

Order discontinuation, cancellation

Discontinue or cancel order

Cancel spawned acts/actions

Audit order discontinuation/cancellation: who, what, when, where

Authenticate order discontinuation/cancellation

Retain content of original order, and all subsequent amendments

Invoke decision agent

Single order

>Per patient, per service ordered

Enable single order to be entered and authenticated:

Block Order

>Per patient

Enable multiple orders to be entered in a single session and authenticated once

Order sets

Enable custom order sets, specific to

Individual practitioner

Group practice

Business unit: department, service, specialty

Diagnosis, symptoms

Invoke order set by practitioner selection

Invoke order set by real-time decision agent

Protocol based orders

Enable protocol orders based on diagnosis, symptoms

Enable protocol orders based on planned regime (care plan) for

Care services

Diagnostic services

Therapeutic services

Diet

…

Link protocols to pre-defined order sets

Invoke protocol by practitioner selection

Invoke protocol by real-time decision agent

Order alerts and reminders

Invoke real-time decision agents for immediate alerts and reminders to practitioner during order session, e.g.,

Possible allergic reaction

Possible interaction or incompatibility, e.g.,

Drug/drug

Drug/lab

Drug/food

Drug/disease

Procedure/procedure

Possible drug dosage incompatibility: e.g., weight based dosing formulas

Possible side effects

Possibly ineffective or unnecessary

Possible alternatives which may be

Less costly

More effective

Possible duplication of current or recent services, medications…

Invoke real-time decision agents to

Compute cost of services ordered or proposed to be ordered

Suggest alternative services, when appropriate

Order spawned acts/actions

Schedule health(care) service acts/actions, per order parameters, within and across:

Encounter types

Inpatient

Emergent

Ambulatory

Long-term care

Home care

Locations, Facilities and Sites of Care

Disciplines and Business Units

Departments

Services

Specialties

Ensure order and spawned health(care) service acts/actions retain continuous linkage, as parent to child

One order to one act/action

One order to many acts/actions

Order-based practitioner assignment

Enable practitioner assignment based on business and clinical practice rules

Enable practitioner work assignments based on order-spawned acts/actions

Per individual practitioner

Per work group or group practice

Order notification and routing

Enable order notification and routing based on business/clinical practice rules

Notify/route order(s) based on order status or change in status, e.g.,

Order creation

Order amendment

Order D/C

Notify/route order(s) via

Hardcopy: e.g., printer, fax

Softcopy: e.g., secure email

Outbound interface

Notify/route order(s) to work or review queue/list, per

Individual practitioner

Work group or group practice

Facility or location

Business unit: department, services, specialties

Receive and process order(s), e.g.,

Order lifecycle

[Placeholder]

Order status, state transitions

[Placeholder]

Results, Result Management

Result = Act/Action Result

Results, e.g.,

Clinical observations

Evaluations, exams, history and physical

Interventions and care activities

Diagnostic (test) parameters and findings

Assessments, SOAP

Consultations

Medication administrations

Input and output (fluid) measures

Quality measures

Costs: e.g., projected vs. actual

Business and clinical practice rules

Enable results, result management based on business and clinical practice rules

Enable results, result management based on best practice (standard of practice) guidelines

Accreditation, regulatory guidance

Professional society guidelines

Local and regional conventions

Enable rules for

Result entry, verification, amendment, completion, cancellation

Order fulfillment, as a function of result completion

Result alerts and reminders

Result notification and routing

Result management

Capture and retain acts/action results and result details

Result entry

Enable result entry at point of service/care or at point of convenience for practitioner

Check result content for accuracy and consistency

Check result content for completeness

Authenticate/identify

Result author

Result scribe (if any)

Audit result: who, what, when, where

Authenticate result

Invoke decision agent

Result verification

Verify result, e.g.,

Practitioner review of result(s) sourced by device: e.g., instrument or monitor

Practitioner review of result(s) entered by scribe

Review of student, intern or resident by proctor or preceptor

Review of employee work by supervisor

Authenticate/identify result verifier

Audit result verification: who, what, when, where

Authenticate result verification

Retain content of original result, and all subsequent amendments

Invoke decision agent

Result amendment

Amend result

Check amended result content for accuracy and consistency

Check amended result content for completeness

Authenticate/identify

Result amendment author

Result amendment scribe (if any)

Audit result amendment: who, what, when, where

Authenticate result amendment

Retain content of original result, and all subsequent amendments

Invoke decision agent

Result completion

Complete order

Authenticate/identify

Result completion verifier

Audit result completion: who, what, when, where

Authenticate result completion

Retain content of original result, and all subsequent amendments

Invoke decision agent

Result cancellation

Cancel result

Authenticate/identify

Result cancellation verifier

Audit result cancellation: who, what, when, where, why

Authenticate result cancellation

Invoke decision agent

Order fulfillment

Track result progression/completion against original order

Result alerts and reminders

Enable result alerts and reminders based on

Business and clinical practice rules

Best practice guidelines

Result notification and routing

Notify/route result(s) based on result status or change in status, e.g.,

Result creation

Result amendment

Notify/route result(s) via

Hardcopy: e.g., printer, fax

Softcopy: e.g., secure email

Outbound interface

Notify/route result(s) to work or review queue/list, per

Individual practitioner

Work group or group practice

Facility or location

Department, service, specialty

Receive and process result(s), e.g.,

Act

Act/action lifecycle

[Placeholder]

Act/action status, state transitions

[Placeholder]

Care Planning, Critical Paths, Protocols

Business and clinical practice rules

Enable care planning, critical paths and protocols based on

Business and clinical practice rules

Best practice guidelines

Care plans, critical paths, protocols

Enable care plans, critical paths and protocols, per patient, based on

Diagnosis, symptoms

Problem or disease state

Enable care plans, critical paths and protocols, per patient, for

Department, service, specialty

Facility, location or site of care

Group or individual practice

Link care plan/critical path/protocol to relevant order sets

Link care plan/critical path/protocol to corresponding orders and results, per patient

Enable/show care plan/critical path/protocol progression and current status

Enable/show variance from care plan/critical path or protocol

Clinical Decision Support, Knowledge Management

Business and clinical practice rules

Enable clinical decision support algorithms based on

Business and clinical practice rules

Best practice guidelines

Care plans, critical paths, protocols

Quality indicators

Performance and accountability measures

Cost parameters

Decision agents

Enable real-time concurrent decision agents

At user front-end, real-time during user sessions

At order entry, verification, amendment, renewal, discontinuation or cancellation

At result entry, verification, amendment completion or cancellation

At designated points in health(care) delivery process

Enable retrospective decision support: e.g., OLAP based

Enable prescribed actions (if decision algorithm evaluated as true)

Alerts, reminders, notifications

Start, hold, DC or cancel care plan

Start, hold, DC or cancel orders

Schedule, hold, resume or cancel acts/actions

Decision acts/actions

Capture and retain decision acts/actions and related detail

Per patient

Per decision

Include clinical context

Include rationale for decision

On-line medical literature references

Access/show medical literature references

On-line policies and procedure references

Access/show organizational policies and procedures

Access/show clinical practice guidelines, standards of care

Scheduling

Business and clinical practice rules

Enable scheduling based on business and clinical practice rules

Resource based scheduling

Appointments, exam rooms, OR suites…

Schedule act/action against available resources

Resources: practitioners/staff, facilities, equipment, supplies, time blocks

Patient schedule

Schedule acts/actions based on active orders and care plans

Schedule acts/actions ad hoc

Track/show acts/actions;

Prospective (future): acts/actions planned, not yet underway

Concurrent (now): acts/actions in progress, not yet complete

Retrospective (historical): acts/actions completed or cancelled

Enable/show integrated patient schedule, integrated across

Encounter types

Locations, sites of care

Departments, services, specialties

Act/action timing and inter-dependencies

Schedule health(care) service acts/actions with closely coordinated sequence, timing, precedents, staging and transportation requirements

Schedule acts/actions according to relative priority

Non-clinical and indirect patient activities

Schedule non-clinical acts/actions: e.g., housekeeping, infection control surveillance

Schedule indirect patient acts/actions: e.g., utilization review, quality reviews

Integral Work Flow to

Health(care) Delivery Management

Business and clinical practice rules

Enable integral work flow based on business and clinical practice rules

Immediate record of health(care) delivery

Enable/show record as immediate co-product (by-product?) of health(care) delivery and discrete acts/actions

Facts: clinical, operational, administrative, financial

Measures: quality, performance, outcomes, cost, utilization

Timeline based

Enable/show integral work flow along act/action timeline

Per patient

Work tasks [ = acts = actions]

Schedule acts/actions based on orders, care plans, operational protocols

Schedule acts/actions as needed, ad hoc

Assignment

[See Work Lists]

Invoke decision agent to assign acts/actions to

Individual practitioners

Work groups and group practices

Departments, services, specialties

Enable/show work lists

Staging, sequencing, routing

Invoke decision agent to stage, sequence and route acts/actions

Conditionals and Inter-dependencies

Invoke decision agent to schedule work tasks based on predicate acts/actions being complete or conditions true

Allocation, deployment and coordination

Invoke decision agent to allocate, deploy and coordinate needed resources to point of service/care, at appropriate time

Resources: practitioners/staff, facilities, equipment, supplies, time blocks

Completeness of work

Ensure/show accountability for work performance and completion

Invoke decision agent to measure completeness of work, against known and scheduled acts/actions

Per patient

Per patient encounter

Per practitioner

Show incomplete acts with responsible practitioners

Quality indicators

Capture and retain quality indicators as a function of integral work flow

Performance and utilization measures

Capture and retain performance and utilization measures as a function of integral work flow

Cost projections

Invoke decision agent to measure costs of health(care) delivery

Projected vs. actual

Work Lists

Business and clinical practice rules

Enable work lists based on business and clinical practice rules

Assignments and work list

Track/show current assignments and work list

Per individual practitioner

Per practitioner role

Per group coverage (multiple practitioner group)

Per patient list, per individual patient

Per individual health service (act) assigned

Incomplete work list

Track/show incomplete work

Per individual patient

Per patient encounter

Per practitioner

Per practitioner role

Per department, service, specialty

Medications, Medication Management

Business and clinical practice rules

Enable medication management based on business and clinical practice

Medication acts, medication lifecycle

Order medication

[See Orders, Order Management]

Capture and retain medication order act and order details

Invoke decision agent to check for drug allergies, interactions, duplications, appropriate dosing, less costly alternatives, more effective alternatives…

Invoke decision agent to check for order completeness

Invoke decision agent to check for order data accuracy and consistency

Verify medication order, requestor

>If transcribed order, By ordering practitioner

>By supervisor, proctor, preceptor

Capture and retain medication order verification act and details

Verify medication order, pharmacy

>By pharmacist

Capture and retain medication order verification act and details

Schedule medication administration acts

Print medication label

Product details, dosage form…

Administration instructions

Precautions, possible side effects

Dispense medication

Capture and retain medication dispensing act and details

Fill medication cart or distribution conveyance

Capture and retain medication cart fill act and details

Administer medication

Capture and retain medication administration act and related details

Audit each medication act (as above): who, what, when, where

IV lifecycle

[Variation of medication lifecycle]

Mediation Administration Record

Enable/show medication administration record, per patient

Current

Historical

Enable patient input of self administration acts

Specimen Collection, Specimen Management

Business and clinical practice rules

Enable specimen collection and management based on business and clinical practice rules

Specimen acts, specimen lifecycle

Schedule specimen collection, per order or care plan

Track/show specimens awaiting collection

Show specimen collection work lists

Per patient

Per scheduled time of collection

Per location, site of care

Per practitioner, per practitioner role

Per department, service, specialty

Print specimen labels

Collect specimen, label specimen container

Capture and retain specimen collection acts and related specimen details

Accession specimens: e.g., at receipt in laboratory

Capture and retain specimen accessioning acts and related specimen details

Track specimens through analytical work flow

Capture and retain specimen analysis acts and related specimen details

Recollect specimens, as necessary

Capture and retain specimen re-collection acts and related specimen details

Audit each specimen act (as above): who, what, when, where

Practitioner/Patient Relationship

Business and clinical practice rules

Enable practitioner assignment based on business and clinical practice rules

Practitioner assignment

Assign practitioners to patients in their care

Enable/show active patient list

Per practitioner

Per group coverage (multiple practitioner group)

Quality Indicators

Rules and Guidelines

Enable quality indicators based on

Regulatory, statutory guidelines

Accreditation requirements

Professional guidelines

Best practice guidelines

Local or regional conventions

Indicator capture

Capture and retain quality indicators as a function of

Acts and act results

Integral Work Flow

As a function of retrospective analysis

Performance and Accountability Measures

Rules and Guidelines

Enable performance and accountability measures based on

Regulatory, statutory guidelines

Accreditation requirements

Professional guidelines

Best practice guidelines

Local or regional conventions

Measure capture

Capture and retain performance and accountability measures as a function of

Acts and act results

Integral Work Flow

As a function of retrospective analysis

Epidemiological Surveillance

Rules and Guidelines

Enable epidemiological surveillance based on

Regulatory, statutory guidelines

Accreditation requirements

Professional guidelines

Best practice guidelines

Local or regional conventions

Surveillance

Invoke decision agents to scan

New and amended orders

New and amended results

New and amended care plans, critical paths

…

Log pertinent findings

Preventative Care, Wellness

Rules and guidelines

Enable preventative care and wellness checks based on

Business and clinical practice rules

Professional and best practice guidelines

Preventative, wellness acts/actions

Schedule upcoming wellness checks and preventative care acts/actions

Notifications and reminders

Notify/remind patients of:

Upcoming appointments

Check-ups and physicals

Tests and exams

Immunization

Health education opportunities

Health Record Review

(Chart Review)

Rules and guidelines

Enable health record review based on

Business and clinical practice rules

Professional and best practice guidelines

Longitudinal view

Enable/show health record as longitudinal record of health status and health(care) services (acts/actions)

VIews

Show health record within and across

Encounter types

Inpatient

Emergent

Ambulatory

Long-term care

Home care

Care "in the community"

Locations, Facilities and Sites of Care

Disciplines and Business Units

Departments

Services

Specialties

Show health record content based on "need to know" and "minimum necessary"

Customize health record display based on

Individual practitioner

Practitioner role

Department, service, specialty

Display multi-media record

Highlight abnormal and critical values

Highlight new and significant data, since last access: e.g., abnormal or critical results

Per practitioner

Per practitioner defined rules

Compare data with graphing, trending and visualization tools

Audit health record access/use: who, what, when, where

Practitioner Personal Use Profile

Set personal profile including

Personal (custom) health record displays

Personal (custom) trends and graphs

Personal order sets

Personal care plans, critical paths, protocols

Personal rules for notifications, alerts and reminders

Personal rules for alerts regarding abnormal and critical result values

Personal rules for recall of new and significant data, since last access

Bed Management

>Including Housekeeping

[TBD]

Diet, Diet Management

[TBD]

Patient Transport

[TBD]

Patient Locator

[TBD}

Practitioner Locator

[TBD]

Physical Record Tracking, Check-out/in

[TBD]

Consents and Authorizations

[TBD]

Charges, Charge Management

[TBD]

Costs, Cost Management

[TBD]

Localization, Local Authority

[TBD]

EHR Use Settings

Use Setting Target Profiles

ALL PHI

Acute inpatient

Emergent

Ambulatory, e.g.,

Physician office

Public health clinic

Dental office

Long-term inpatient care, e.g.,

Nursing home

Skilled nursing facility

Hospice

Home care, e.g.,

Practitioner provided

Home based hospice

Patient self care

Care "in the community", e.g.,

Paramedic

School

Health fairs, immunization clinics

Wellness & prevention programs

First aid, CPR education

EHR Users, Use Cases

Example Use Profiles - Government

Some PHI

CMS

HIPAA clinical claims attachment

Quality indicators and metrics extract

FDA

Regulatory reporting extracts

AHRQ

Research extracts

CDC, Public Health

Public health reporting extracts

Example Use Profiles - Accreditation

Some PHI

Accreditation survey profile

Target

As measured, per survey

Targets

Accountability

Quality indicators

Performance and outcome measures

Interdisciplinary care team approach

…

Example Use Profiles

Provider or IDN EHR

ALL PHI

Target, intended profile

As planned

RFP

Example Use Profiles

EHR Vendor

ALL PHI (?)

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