Electronic Health Record Features Diagram

Clinician Portal

Patient Results & Results Reports

Provides the ability to route, manage, and present current and historical clinical results and reports to appropriate clinical personnel for review; also includes the ability to filter and compare results.

Feature Description Links
Text Results Display text-based results including, but not limited to, lab results, pathology results, microbiology results, bloodbank, and radiology results from all patient data sources. A test link
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Imaging Results Display clinical images, documents, and notes originating from all patient data sources: PACS, CV PACS (ECG, Echo-cardiography), Perinatal PACS, etc.
Procedural Reports Display procedural reports from any department or patient data source.
Transcribed Reports Display transcribed reports from any department or patient data source.
Ad-hoc Physician Reports Display reports based on physician-specific, ad-hoc queries of patient data (e.g., patients with active prescription of Vioxx).

CPOE (Order Mgmt)

Computerized physician order entry, or CPOE, is a process of electronic entry of physician instructions for the treatment of patients under his or her care. These orders are communicated over a computer network to the medical staff (nurses, therapists or other physicians) or to the departments (pharmacy, laboratory or radiology) responsible for fulfilling the order. CPOE decreases delay in order completion, reduces errors related to handwriting or transcription, allows order entry at point-of-care or off-site, provides error-checking for duplicate or incorrect doses or tests, and simplifies inventory and posting of charges.

Feature Description Links
Computerized Provider Order Entry Enable providers to electronically enter all patient-care orders in a standard and complete format; Create prescriptions or other medication orders with detail adequate for correct filling and administration by pharmacy and clinical staff. Provide capability to create discharge orders for outpatient services including medication prescriptions to external pharmacies (e-prescribing).

Clinical Documentation

Provides the ability to create clinical documentation or notes as well as the ability to create, correct, authenticate, and close, as needed, transcribed or directly-entered clinical documentation.

Feature Description Links
Physician Documentation Electronic entry and viewing of physician documents and notes (e.g., H&P, Progress Note, Consults, Discharge Summaries) from all patient data sources.
Clinician Documentation Electronic entry and viewing of clinician documents and notes (e.g., Nursing Notes, Admission Assessment, Ancillary Notes) from all patient data sources.
Patient Documentation Electronic entry and viewing of documentation by the patient (e.g., demographics, allergies, history) from all patient data sources.

Workflow Support

Provides tools that represent and automate the flow of tasks--in particular healthcare procedures--through the assignment, delegation and/or transmission of tasks to the appropriate parties.

Feature Description Links
Workflow Rules Engine / Tools Manage tasks related to components of the electronic health record with appropriate timeliness; Link tasks to a relevant part of the electronic health record or to a specific patient; Assign, delegate, and/or transmit tasks to the appropriate parties; Track tasks to guarantee that each task is administered to and completed appropriately; Provide reporting capability throughout the task lifecycle; Provide notifications for results, orders needing renewal, Admission/Discharge/Transfer process based on the structured data and unstructured text available in the encounter documentation.
Coding Management Make available all pertinent patient information needed to support coding of diagnoses, procedures and outcomes; enable the use of cost management information to guide users and workflows.
E-Signature Enable an electronic "real," non-reproducible signature in accordance with a user password and personal identification number that will affix the signature to all orders (including verbal / telephone orders), results, and reports and not allow any further changes including attestation; Solution will allow changes via addendum only.
Clinical Trial Support Support clinical trial management including the enrollment of patients and enable blind / double-blind studies.
Referral Management Enable the origination, documentation and tracking of referrals between care provider or care settings, including clinical guidelines and administrative details of the referral.
Secure Messaging Enable communications between various participants: patients, doctors, nurses, chronic disease care managers, pharmacies, laboratories, payers, consultants, etc; Supports communication across all relevant participants including e-consults.

Clinical Decision Support

Clinical Decision Support links health observations with medical knowledge to influence choices by clinicians for improved health care.

Feature Description Links
Evidence-based Content Sourcing Source relevant information from evidence based medicine knowledge resources to support order entry and clinical documentation including patient education materials and discharge instructions; Provide access to online medical references to clinicians at the point of care.
Evidence-based Content Management Enables the management and integration of evidence based content with clinical expertise, pathophysiological knowledge, clinical guidelines, protocols, and order sets, and patient preferences into the decision-making process specific to the care of the patient.
Clinical Decision Support Rules Engine Provide real-time alerts, triggers, and reminders during non-medication and medication ordering and administration process; Provide real-time adverse event detection during non-medication and medication ordering and administration (e.g., drug-allergy, drug-drug, and drug-disease contra-indications); Provide real-time alerts, triggers, and reminders for weight / age dosing recommendations; Provide clinical, financial and administrative rules assistance based on the structured data and unstructured text available in the encounter documentation.

Structured Health Information

Provides the ability to collect structured and standardized healthcare data elements such as allergies, procedures, and diagnoses.

Feature Description Links
Allergies Electronic entry and viewing of patient-specific allergies and reactions - both medication and non-medication related - from all patient data sources.
Procedures Electronic entry and viewing of a chronological, filterable, comprehensive list of the patient's entire procedure history from all patient data sources.
Medical Diagnoses Electronic entry and viewing of a chronological, filterable, comprehensive list of the patient's entire medical diagnoses from all patient data sources.
Medication List Electronic entry and viewing of patient-specific medication lists from all patient data sources.
Problem List Electronic entry and viewing of active patient-specific problem lists from all patient data sources.
Immunizations Electronic entry and viewing of patient-specific immunization lists from all patient data sources.
Advance Directives Electronic entry and viewing of advanced directives, the date and circumstances under which the directives were received, and the location of any paper records of advanced directives as appropriate from all patient data sources.
Patient Preferences Electronic entry and viewing of patient preferences (e.g., DNR, Food, Religion) from all patient data sources.
Consents / Authorizations Electronic entry and viewing of patient-specific treatment decisions in the form of consents and authorizations from all patient data sources.

Technical Foundation

Infrastructure

Infrastructure is a set of interconnected technology elements that provide the framework supporting the Electronic Health Record.

Feature Description Links
Clinical Data Repository / Clinical Data Warehouse Enable the storage of a comprehensive patient record that can be shared across institutions and geographic regions with the intent of utilizing outcomes for concurrent patient care and performance improvement.
Data Backup & Archival Archive and retrieve information to/from diverse technology storage devices based on availability requirements for specific data (according to clinical or administrative business rules).
Authentication Authenticate EHRS users and/or entities before allowing access to an EHR; Manage the sets of access-control permissions granted to EHR users.
Single Sign-On Enable the capability for users to authenticate to multiple systems via a single log-on (single sign-on).
Activity Logging / Audit Trail Track changes to EHR data to verify enforcement of business, security, and access-control rules; Track who, when, and by which system an EHR record was created, updated, translated or (if local policy permits) deleted.
Role-based Access Authorize access to EHR functions and/or data based on an entity's role; Provide specialized views and functionality based on the encounter-specific values, clinical protocols and business rules; Facilitate access to and propagation of information between patient records where patients are related.
Context Management Manage a clinician's session and context; This will enable a clinician to interact with a number of applications efficiently without having to navigate through the patient look-up process.

Integration

Integration is movement of data between two systems through manipulating the data to ensure it can be read by both systems.

Feature Description Links
Integration Engine Enables standardized data exchange and transmission between disparate systems.
Financial Systems Interface Support integration with billing and supply chain systems to ensure charges are captured and other information (e.g., Product Inventory) based on care given to the patient.
Product / Patient ID Management Capture electronic patient care documentation by enabling positive identification of medical products and supplies to ensure accurate and safe administration and utilization (e.g. eMAR, eTAR, Phlebotomy).
Data Entry Interface / Devices Support communication and presentation of data captured from point of care systems, bio-medical devices, and home telemonitoring; Support multiple data entry technologies (e.g., voice recognition, handwriting capability, and document imaging).

Interoperability

Healthcare interoperability is defined as the ability of multiple IT systems and software applications to effectively, consistently, and accurately communicate and exchange data for use. Interoperability is the result of an agreement to share information using the same standards.

Feature Description Links
Standard Medical Vocabularies Support semantic interoperability between an EHR application by enabling lookup and translation of vocabulary mappings between local and standard vocabularies as defined by data exchange standards.
Electronic Medical Record Enables integration / interpretability within HCA setting, cross-setting, inpatient, outpatient and cross-organization.
Personal Health Record Enables integration / interoperability with Personal Health Records.
Continuity of Care Record Enable the transmission of a standard data set including, but not limited to, patient and provider information, insurance information, patient's health status (e.g., allergies, medications, vital signs, diagnoses, recent procedures), recent care provided, as well as recommendations for future care (care plan) and the reason for referral or transfer. This minimum data set sponsored by a consortium of national organizations (e.g. AMA, AAP, AAFP) will enhance the continuity of care by providing a method for communicating the most relevant information about a patient and providing both context and support for the electronic health record (EHR) through extensions.
Scheduling Integration Provide the necessary data to a scheduling system for optimal efficiency in the scheduling of patient care, for either the patient, staff, or a resource/device.
RHIO Interface Enables integration with Regional Health Information Organizations.
Public Health Interface Enable the collection of environment and surveillance data captured at the time of the patient-provider encounter for use in clinical state monitoring of health risks from the environment and/or population; Send or receive public health and bio-surveillance data to enhance decision support capabilities; Detect bio-terrorism and disease outbreaks.
Regulatory Agencies Interface Enables integration / interoperability with Regulatory Agencies (e.g., P4P).
Care Partners Interface Enables integration with external care partners, including, but not limited to: Outside Pharmacies (e-prescribing), Insurer, Laboratory, Transcription, Radiology, etc.

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