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-se.com
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 (?)