The Makings of an EHR

Posted 6 July, 2007 in EHRs

When deciding on an EHR for your practice or hospital, a functional comparison between vendors is certainly in order. Fortunately, a company called CCHIT (Certification Commission for Healthcare Information Technology) provides an updated comprehensive list of functional EHR requirements for “certified” EHR systems. Whether or not a private, for-profit organization ought to be certifying EHR companies is debatable, but the CCHIT certification documents do provide a robust baseline upon which an EHR can be considered complete. I’ve summarized most of their 2007 EHR functional specifications for you below:

Criteria for a complete EHR (items the EHR system must have or do):

Identify and maintain a patient record
Manage patient demographics
Create and maintain patient specific problem lists
Create and maintain patient specific medication lists
Create and maintain patient specific allergy and adverse reaction lists
Capture, review and manage medical, procedural/surgical, social and family history
Summarize health record
Manage clinical documents and notes
Capture and store external clinical documents
Generate and record patient specific instructions
Create prescriptions with detail adequate for filing and administration
Order diagnostic tests
Route, manage and present current and historical rest results
Manage consents and authorizations
Identify drug interaction warnings at the point of medication ordering
Present alerts for disease management, preventive services and wellness
Clinical task assignment and routing
Scheduling
Report generation
Health record output
Manage and document the health care delivered during an encounter
Rules-driven financial and administrative coding assistance
Entity authorization
Enforcement of confidentiality
Data retention, availability and destruction
Audit trail
Concurrent Use

2 comments to “The Makings of an EHR”

healthTech.accordingtome.com » How good is your hospital? (JCAHO CMS to the rescue!), July 12th, 2007 at 4:31 pm:

[…] importance of universal metrics: IT security metrics (see: HIPAA intro and HIPAA enforcement) and EHR functionality. Well, now that you have patient encounter data safely in your hosted EHR database, you’ll […]

healthTech.accordingtome.com » Back to School (health records for kids), August 2nd, 2007 at 6:16 pm:

[…] side, USIIS does have a web interface and an HL7 interface and USIIS can be configured to work with EHR systems. As well, it has the ability to connect to other states’ immunization record systems […]