Overarching criteria are those that apply to all EHR Systems.

Manage the patient’s clinical history lists used to present summary or detailed information on patient health history.

Manage medical, procedural/surgical, mental health, substance use, social and family history. This includes pertinent positive and negative histories, patient-reported or externally available patient clinical history.

Manage patient-specific allergy, intolerance and adverse reaction lists.

Create and maintain patient-specific medication lists.

Create and maintain patient-specific problem lists.

Manage patient-specific health-related factors.

Create and maintain patient-specific immunization lists.

Create and maintain a patient-specific list of medical equipment, medical prosthetic, orthotic, and/or implantable devices.

Capture and maintain patient and family preferences.

Capture and maintain adverse events.

Render documentation and data that has been captured from multiple external sources.

Render clinical documentation that has been captured from multiple external sources.

Render data that has been captured from multiple external sources.

Render emergency medical data that has been captured from multiple external sources.

Render clinical images that has been captured from multiple external sources.

Capture and explicitly label patient-originated data, link the data source with the data, and support provider authentication for inclusion in patient health record as well as subsequent rendering of the information as part of the health record.

Clinical Documentation must be managed including the capture of the documentation during an encounter, maintenance and appropriate rendering.

Create and maintain assessment information.

Capture and manage patient clinical measures, such as vital signs, as discrete patient data.

Create, addend, amend, correct, authenticate, maintain, present and close, as needed, transcribed or directly-entered clinical documentation and notes.

Provide templates and forms for clinicians to use for care plans, guidelines and protocols during provision of care and care planning.

Review and indicate or amend other caregiver notes as permitted.

Provide the ability to manage clinical orders and results including medication, non-medication, diagnostic tests, blood products, other biologics and referrals, using order sets as appropriate.

Use Order Set templates to facilitate order entry by rendering the appropriate orders based on provider request, input or system configuration.

Create prescriptions or other medication orders with detail adequate for correct filling and administration. Provide information regarding compliance of medication orders with formularies. Provide drug utilization review functionality including alerts regarding drug interactions and allergies.

Provide alerts for potential medication interactions and medication allergy reactions.

Render medication dosing and warnings related to a medication order based on patient-specific parameters.

Provide the tooling necessary to increase the efficiency of medication ordering.

Capture the alerts and warnings for medications being overridden and reasons for the override.

Enable the origination, documentation, capture, transmission, tracking and maintenance of non-medication patient care orders.

Enable the origination, documentation, transmission, tracking and maintenance of orders for diagnostic tests.

Communicate with appropriate sources or registries to manage orders for blood products or other biologics.

Enable the origination, documentation and tracking of referrals between care providers or healthcare organizations, including clinical and administrative details of the referral, and consents and authorizations for disclosures as required.

Present, annotate, and route current and historical test results to appropriate providers for review. Provide the ability to filter and compare results.

Enable the receipt and display of results for diagnostics tests.

Provide the functionality required to support the management of medication and immunization administration.

Present providers with the list of medications that are to be administered to a patient, necessary administration information, and capture administration details.

Capture and maintain discrete data concerning immunizations given to a patient including date administered, type, manufacturer, lot number, and any allergic or adverse reactions. Facilitate the interaction with an immunization registry to allow maintenance of a patient’s immunization history.

Provide the functionality required to support the management of treatment administration and documentation. (Treatment defined as the administration or application of remedies to a patient for a disease or injury; medicinal or surgical management; therapy.)

Provide the functionality to manage treatment and care planning through presentation of guidelines and protocols as well as managing recommendations for future care.

Present organizational guidelines for patient care as appropriate to support planning of care, including order entry and clinical documentation.

Document and support the management of the disposition process for a patient by managing recommendations for future care.

Provide the functionality to effectively communicate with the patient regarding their care and document the communication as part of the patient’s medical record.

Generate and record patient-specific instructions related to pre- and post-procedural and post-treatment/discharge requirements.

Provide the functionality required to coordinate care with other providers and report care provided.

Render a summarized review of a patient’s episodic, and/or comprehensive EHR, subject to jurisdictional laws and organizational policies related to privacy and confidentiality.

Support the creation of health service reports to authorized health entities that a provider may be required to generate (e.g., the creation of an oncologist’s report that must be submitted to a national cancer registry).

Manage the patient record including all patient demographics, identifiers and other information to support the provision of care.

Manage a single logical record for each patient.

Manage patient demographic information.

Capture a registration, either directly entered or received from an external system, without complete supporting demographics, in order to facilitate patient care before the full registration is complete.

Enable the receipt and processing of referrals from care providers or healthcare organizations, including clinical and administrative details of the referral, and consents and authorizations for disclosures as required.

Manage patient encounter information, including tele-health encounters, and support follow-up encounters.

Information about the relationships between patients and others facilitate healthcare delivery and appropriate access to health information.

Provide information on relationships by genealogy.

Support interactions with other systems, applications, and modules to provide information on an insured person’s relationships. Examples of relationships include domestic partner, spouse, and guarantor of payment.

Provide information on relationships by living situation. Examples of living situations include college dormitory, military deployment, in same household.

Provide information on patient relationships that are represented other than by genealogy, insurance or living situation.

Capture and manage patient preferences, advance directives, consents and authorizations.

Support the integration of patient and family preferences into clinical decision support.

Capture and maintain patient advance directives.

Create, maintain, and verify patient decisions (such as informed consent for treatment or disclosure).

Capture and maintain a variety of information from multiple external sources.

Incorporate clinical documentation (computable and scanned) from external (to the system) sources.

Incorporate discrete clinical data from external sources and support communication/presentation of data captured from medical and non-medical devices and entities.

Provide the ability to capture and maintain patient information from an external Emergency Medical System (EMS).

Incorporate clinical images from external sources and support communication/presentation of images from medical and non-medical devices and entities.

Capture and explicitly label patient-originated data, link the data source with the data, and support provider authentication for inclusion in patient health record.

Capture and explicitly label patient health data derived from administrative or financial data; and link the data source with that data.

Capture and explicitly label patient data derived from eligibility, formulary and benefit information; and link the data source with that data.

Support collection and presentation of data captured from medical and medication monitoring devices.

Standard assessments, guidelines and prompts are provided to facilitate decision support for the optimization of patient care based on specific medical conditions.

Support the establishment, updates and use of assessment forms that will assist in the development of and adherence to care plans, guidelines, and protocols at the point of information capture.

Offer prompts based on patient-specific data at the point of information capture for assessment purposes.

Support the use of appropriate standard care plans, guidelines, protocols, and/or clinical pathways for the management of specific conditions.

Identify and present the appropriate care plans, guidelines, protocols, and/or clinical pathways for the management of patient-specific conditions that are identified in a patient clinical encounter.

Provide support for the management of patients enrolled in research protocols.

Provide the patient with decision support for self-management of a condition between patient/provider encounters.

Capture practice guidance from a variety of “trusted” external sources.

Capture the decision support prompts and manage provider actions to accept or override decision support prompts.

Capture and maintain updates of clinical decision support system guidelines and associated reference material.

Identify conditions of clinical interest, identify trends that may lead to significant problems, and provide prompts for clinical decision support.

Where not covered above, provide the means to manage and organize the documentation of the health care needed and delivered during an encounter/episode of care.

Support grammatical and lexical integrity of the health record by providing medical spelling, thesaurus and grammar ready assistance during clinical documentation as well as enabling shortcuts for pre-defined text.

Support for Orders is required to ensure that appropriate decision support and safety checks are conducted by the system at the time of ordering as well as at the time of dispensing medications or immunizations.

Maintain order set templates based on preferred standards, provider preferences, organizational policy or other criteria.

Provide functionality to alert providers to potential medication and immunization ordering errors (such as wrong patient, wrong drug, wrong dose, wrong route and wrong time).

Identify medication interaction warnings at the time of medication or immunization ordering, or prescribing, as well as at the time of dispensing.

Identify and present appropriate dose recommendations based on known patient conditions and characteristics at the time of medication ordering and dispensing.

Provide the tooling necessary to support efficient medication ordering.

Offer recommendations and options in medication treatment protocols as well as supporting medication monitoring on the basis of patient diagnosis, patient characteristics, or therapeutic guidelines and protocols.

Review a patient’s medication information (from more than one source) and reconcile conflicts.

Facilitate provider review and validation of order information to make it pertinent, effective and resource-conservative at the point of order entry.

This function has not been defined and is captured here as a place-holder for potential further development of the Functional Model and to maintain alignment with the corresponding CP section.

This function has not been defined and is captured here as a place-holder for potential further development of the Functional Model and to maintain alignment with the corresponding CP section.

Evaluate patient information for referral indicators.

Evaluate referrals within the context of a patient’s healthcare data.

Evaluate patient data and recommend patient referral based on specific criteria.

Enable the transmission of electronic referral orders from the EHR-S.

Evaluate results and notify provider and patient of results within the context of the patient’s healthcare data.

Alert providers to potential administration errors (such as wrong patient, wrong drug, wrong dose, wrong route and wrong time) in support of safe and accurate medication and immunization administration and support administration workflow.

Alert providers to potential administration errors (such as wrong patient, wrong drug, wrong dose, wrong route and wrong time) in support of safe and accurate medication administration and support medication administration workflow.

Alert providers to potential administration errors (such as wrong patient, wrong drug, wrong dose, wrong route and wrong schedule) in support of safe and accurate immunization administration and support immunization administration workflow.

Facilitate real-time checks for potential blood administration errors.

Facilitate real-time checks to ensure accurate specimen collection.

Support for Future Care is necessary to enable the planning of future care according to appropriate healthcare guidelines.

Provide pertinent information from available evidence-based knowledge, at the point of care, for use in healthcare decisions and care planning.

Support for appropriate communication with the patient or the patient representatives.

Provide the ability to access reliable information about wellness, disease management, treatments, peer support groups, public health education materials, and related information that is relevant for a specific patient.

Receive and validate formatted inbound communications to facilitate, and/or perform updating of patient education material.

Receive and validate formatted inbound communications to facilitate updating of patient reminder information from external sources such as Cancer or Immunization Registries.

Facilitate communications between providers and patients, and/or the patient representatives.

Facilitate access to educational or support resources pertinent to, and usable by, the patient or patient representative.

Statement: Enable and manage communication between EHR Systems and PHR Systems.

Support exchange and reporting of information between participants in patient-centered care.

Support exchange of information between participants in patient-centered care as needed, and the appropriate documentation of such exchanges. Support secure communication to protect the privacy of information as required by jurisdictional law.

Support exchange of information between providers as part of the patient care process, and the appropriate documentation of such exchanges. Support secure communication to protect the privacy of information as required by jurisdictional law.

Provide a means to capture and manage requests for consultation and responses.

Manage communications to professionals (e.g., coroners, medical examiners, law enforcement) for health care events.

Provide features to enable secure bi-directional communication of information electronically between practitioners and pharmacies or between practitioner and intended recipient of pharmacy orders.

Support the definition of the formal health record, a partial record for referral purposes, or sets of records for other necessary disclosure purposes.

Provide report generation features using tools internal or external to the system, for the generation of standard reports.

Provide support for ad hoc query and report generation using tools internal or external to the system. Present customized views and summarized information from a patient’s comprehensive EHR subject to jurisdictional laws and organizational policies related to privacy and confidentiality. The view may be arranged chronologically, by problem, or other parameters, and may be filtered or sorted.

Support user-defined information views.

Support the ability to manage the configuration, and/or customization of appropriate user help that is context sensitive and may include the exchange of live online chat.

Maintain, or provide access to, current provider information.

Provide a current registry or directory of practitioners that contains data needed to determine levels of access required by the system.

Provide provider location or contact information on a facility’s premises.

Provide provider location or contact information when on call.

Provide locations or facility contact information for the provider in order to direct patients or queries.

Provide access to a current directory, registry or repository of information on teams or groups of providers according to scope of practice, organizational policy, and/or jurisdictional law.

Provide access to a provider’s caseload or panel information.

Identify relationships among providers treating a single patient, and provide the ability to manage patient lists assigned to a particular provider.

Manage Provider Credentialing Information

Capture and management of patient administrative information across locations in order to support care, including directories, and/or registries.

Support interactions with other systems, applications, and modules to enable the maintenance of updated demographic information in accordance with realm-specific recordkeeping requirements.

Provide the patient’s location information within a facility’s premises.

Provide the patient’s residence information for the provision and administration of services to the patient, patient transport, and as required for public health reporting.

Support interactions with other systems, applications, and modules to ensure that the patient’s bed assignments within the facility optimize care and minimize risks e.g., of exposure to contagious patients.

Capture and manage patient participation in healthcare programs.

Provide the ability to record and manage patient-specific privacy consent directive consistent with privacy policies.

Provide the system support in managing the interaction with a patient’s PHR.

Support the ability to capture, and/or have interactions with patient PHR systems to enable the creation and maintenance of demographic, clinical and administrative information.

Manage legal and other related electronic documents that allow or restrict the use or disclosure of the Personal Health Record Account Holder’s information.

Maintain the Consents and Authorization directives/statements from the patient’s PHR.

Manage Personal Health Record electronic documents that provide the patients direction for end-of-life care and manage other types of Advance Directives.

Support communication to enable the exchange of information internally and between healthcare and non-healthcare organizations.

Enable the exchange of structured demographic and clinical information with registries (e.g., local disease-specific, notifiable, patient, provider, organization, and health services registries) for patient monitoring and subsequent epidemiological analysis.

Facilitate communications regarding patient data and status within a health care organization.

Facilitate communications regarding patient orders, data and status between organizations.

Provide support for capturing employment information, and/or special work related requirements (e.g., flyers, divers, firemen, transportation workers) to assist in medical disposition choices and notifications, and support communication to employers.

Create, schedule, update and manage tasks with appropriate timeliness.

Creation, assignment, delegation, and/or transmission of tasks to the appropriate parties.

Assignment, delegation, and/or transmission of tasks for Medication Orders and Prescription Management.

Linkage of tasks to EHR components, patients, and/or a relevant part of the electronic health record.

Track tasks to facilitate monitoring for timely and appropriate completion of each task.

Manage the availability of healthcare resources to support the provision of care.

Maintain facility demographic information.

Support the collection and distribution of local healthcare resource information, through interactions with other systems, applications, and modules, to enable planning and response to extraordinary events such as local or national emergencies.

Support interactions with other systems, applications, and modules to provide the necessary data to a scheduling system for optimal efficiency in the scheduling of patient care, for either the patient or a resource/device.

Provide support for prioritizing patients based upon acuity, wait time, and practitioner load.

Provide support to waiting room management

Provide the data necessary to support and manage patient acuity and severity determination for illness/risk-based adjustment of resources.

Manage and document the health care needed and delivered during an encounter/episode of care.

Present specialized views based on the encounter-specific values, clinical protocols and business rules.

Provide assistance in assembling data, supporting data collection and processing output from a specific encounter.

Provide clinical data to support administrative and financial reporting.

Support remote health care services such as tele-health and remote device monitoring by integrating records and data collected by these means into the patient’s record for care management, billing and public health reporting purposes.

Provide a means to manage outstanding patient issues after the encounter, for transits of care and discharge.

Support extraction, transformation and linkage of information from structured data and unstructured text in the patient’s health record for care management, financial, administrative, and public health purposes.

Make available all pertinent patient information needed to support coding of diagnoses, procedures and outcomes.

Provide financial and administrative coding assistance based on the structured data and unstructured text available in the encounter documentation.

Support interactions with other systems, applications, and modules to enable the use of cost management information required to guide users and workflows.

Support the import or retrieval of data necessary to review available quality, performance, and cost measurements regarding healthcare facilities.

Provide the ability to clinician and staff training requirements and document proficiency.

Support the creation (including using external data sources, if necessary), electronic interchange, and processing of transactions listed below that may be necessary foradministrative management during an episode of care.

Support interactions with other systems, applications, and modules to facilitate enrollment of uninsured patients into subsidized and unsubsidized health plans, and enrollment of patients who are eligible on the basis of health, and/or financial status in social service and other programs, including clinical trials.

Support interactions with other systems, applications, and modules to enable eligibility verification for health insurance and special programs, including verification of benefits and pre-determination of coverage.

Support interactions with other systems, applications, and modules to enable the creation of requests, responses and appeals related to service authorization, including prior authorizations, referrals, and pre-certification.

Support interactions with other systems, applications, and modules to support the creation of health care attachments for submitting additional clinical information in support of service requests and claims.

Support interactions with other systems, applications, and modules to enable the creation of claims and encounter reports for reimbursement.

Evaluate patient information to provide alerts, notifications and reminders regarding health, preventative care and wellness.

Identify patient-specific suggestions/reminders, screening tests/exams, and other preventative services in support of routine preventative and wellness care.

Evaluate and notify patient, and/or provider of those preventative services, tests, or behavioral actions that are due or overdue.

Support for population-based internal and external epidemiological investigations of clinical health of aggregate patient data for use in identifying health risks from the environment, and/or population in accordance with jurisdictional law.

Support for Person-Level and Aggregate-Level Queries to Generate Population Cohorts, and/or Aggregates to be used in epidemiologic investigations and reports.

Support for Cohort Person-Level and Aggregate-Level Data Content and Analysis

Support cohort and aggregate-level population data sharing within an organization, and/or with other organizations.

Upon notification by an external, authoritative source of a health risk within the cared-for population, alert relevant providers regarding specific potentially at-risk patients with the appropriate level of notification.

In the event of a health risk alert, evaluate whether expected actions have been taken, and execute follow-up notification otherwise.

Manage population-based information regarding potential human-product donors, and/or recipients.

Support the capture and subsequent export or retrieval of data necessary for the measurement, analysis, research and reporting.

Support the capture and subsequent export or retrieval of data necessary for the reporting on patient outcome of care by population, facility, provider or community.

Support the capture and subsequent export or retrieval of patient, and/or population data necessary to provide quality, performance, and accountability measurements for which providers, facilities, delivery systems, and communities are held accountable.

Support the capture and subsequent export or retrieval of data necessary to support process improvement measures and related initiatives.

Capture, determine and render data necessary to support health care organizational performance monitoring and improvement.

Receive and validate formatted inbound communications to facilitate updates to the system’s public health reporting guidelines.

Provide patient data in a manner that meets applicable requirements for de-identification.

Provide the ability to identify and consistently manage healthcare over time and across populations or groups of patients that share diagnoses, problems, functional limitations, treatment, medications, and demographic characteristics that may impact care ( e.g., population management, disease management, wellness management or care management).

Manage information that identifies key elements of a research or population study.

Manage Record Lifecycle and Lifespan

Manage Record Lifecycle

Originate and Retain Record Entry (1 instance)

Maintain Evidence of Record Entry Originate/Retain Event

Amend (Update) Record Entry (1 instance)

Maintain Evidence of Record Entry Amendment Event

Transform/Translate Record Entries (1 or more instances)

Maintain Evidence of Record Entry Translate Event

Attest Record Entries (1 or more instances)

Maintain Evidence of Record Entry Attestation Event

Access/View Record Entries (1 or more instances)

Maintain Evidence of Record Entry View/Access Event

Report (Output) Record Entries (1 or more instances)

Maintain Evidence of Record Entry Output/Report Event

Disclose Record Entry Content (1 or more instances)

Maintain Evidence of Record Entry Disclosure Event

Transmit Record Entries (1 or more instances)

Maintain Evidence of Record Entry Transmit Event

Receive/Retain Record Entries (1 or more instances)

Maintain Evidence of Record Entry Receive/Retain Event

De-Identify (Anononymize) Record Entries (1 or more instances)

Maintain Evidence of Record Entry De-Identification Event

Pseudonymize Record Entries (1 or more instances)

Maintain Evidence of Record Entry Pseudomynization Event

Re-Identify Record Entries that were previously de-identified or pseudonymized (1 or more instances)

Maintain Evidence of Record Entry Re-Identification Event

Extract Record Entry content to produce subsets, derivations or aggregations (1 or more instances)

Maintain Evidence of Record Entry Extraction Event

Archive Record Entries (1 or more instances)

Maintain Evidence of Record Entry Archive Event

Restore Record Entries from archive (1 or more instances)

Maintain Evidence of Record Entry Restore Event

Destroy/Delete Record Entries (1 or more instances)

Maintain Evidence of Record Entry Destruction Event

Deprecate Record Entries (1 or more instances)

Maintain Evidence of Record Entry Deprecation/Retraction Event

Re-activate Record Entries (1 or more instances)

Maintain Evidence of Record Entry Re-Activation Event

Merge Record Entries (2 or more instances)

Maintain Evidence of Record Entry Merge Event

Unmerge Record Entries previously merged (2 or more instances)

Maintain Evidence of Record Entry Unmerge Event

Link Record Entries (2 or more instances)

Maintain Evidence of Record Entry Link Event

Unlink Record Entries (2 or more instances)

Maintain Evidence of Record Entry Unlink Event

Add Legal Hold to Record Entries (1 or more instances)

Maintain Evidence of Record Entry Legal Hold Event

Remove Legal Hold from Record Entries (1 or more instances)

Maintain Evidence of Record Entry Legal Hold Removal Event

Verify Record Entries (1 or more instances)

Maintain Evidence of Record Entry Verification Event

Encrypt Record Entries (1 or more instances)

Maintain Evidence of Record Entry Encryption Event

Decrypt Records Entries (1 or more instances)

Maintain Evidence of Record Entry Decryption Event

Manage Record Lifespan

Manage/Persist Record Entries (Multiple instances)

Manage/Preserve Record Entries for Legal Hold (Multiple instances)

Manage Record States

Manage Record Entries during the various states of completion.

Manage Record Entries amended, corrected or augmented after finalization (or signature/attestation).

Manage successive Record Entry versions over time.

Remove a record entry from view if it is deemed erroneous and cite the reason.

Manage Record Completeness

Manage Record Synchronization

Manage Record Archive and Restore

Manage EHR-S security.

Authenticate EHR-S users, and/or entities before allowing access.

Manage set(s) of EHR-S access control permissions.

Manage access to EHR-S resources.

Manage emergency access to EHR-S resources.

Manage a patient’s access to personal health information.

Limit an EHR-S user’s ability to deny (repudiate) data origination, transmission or receipt by that user.

Secure all modes of EHR data exchange.

Route electronically exchanged EHR data only to/from known and authenticated destinations/sources (according to applicable healthcare-specific rules and relevant standards).

Enable the enforcement of the applicable jurisdictional and organizational patient privacy rules as they apply to various parts of an EHR-S through the implementation of security mechanisms.

Maintain patient identities and conditions invisible to the public and other providers who do not have “need to know” on public tracking screens.

Flag patient identity as confidential to others.

Manage the change of status of an external facility.

Manage the ability to access, render and determine information related to Service Level Agreement.

Maintain a Trusted Information Exchange environment to enable common security measures among participants in the health information exchange.

Audit Key Record, Security, System and Clinical Events

Manage Audit Triggers

Manage Record Entry Audit Triggers

Manage Security Audit Triggers

Manage Audit Trigger initiated to track Security event.

Manage Audit Trigger initiated to track user authentication to the system (start user session).

Manage Audit Trigger initiated to track user authentication (system prompt for password change).

Manage Audit Trigger initiated to track user request to change password.

Manage Audit Trigger initiated to track user log out (end user session).

Manage Audit Trigger initiated to track user access (successful).

Manage Audit Trigger initiated to track user attempts to access data (unsuccessful – access denied).

Manage Audit Trigger initiated to track extraordinary user access (break the glass).

Manage Audit Trigger initiated to track user permissions (authorization).

Manage System Audit Triggers

Manage Audit Trigger initiated to track system events.

Manage Audit Trigger initiated to track system started event.

Manage Audit Trigger initiated to track back-up started event.

Manage Audit Trigger initiated to track back-up completed event.

Manage Audit Trigger initiated to track back-up recovery started event.

Manage Audit Trigger initiated to track back-up recovery completed event.

Manage Audit Trigger initiated to track batch job started event.

Manage Audit Trigger initiated to track batch job completed event.

Manage Audit Trigger initiated to track maintenance started event.

Manage Audit Trigger initiated to track maintenance completed event.

Manage Audit Trigger initiated to track resource usage event.

Manage Audit Trigger initiated to track system maintenance events -local access.

Manage Audit Trigger initiated to track system maintenance events -remote access.

Manage Audit Trigger initiated to track system maintenance - EHR or clinical software.

Manage Audit Trigger initiated to track system maintenance of codes, vocabulary, knowledge and rules.

Manage Audit Trigger initiated to track data corruption events.

Manage Clinical Audit Triggers

Manage Audit Trigger initiated to track clinical alerts.

Manage Audit Trigger initiated to track acknowledgement of clinically significant report changes.

Manage Audit Trigger initiated to track disabling of decision support alerts.

Manage Audit Log

Manage Audit Log Indelibility

Notify of Audit Events, Review Audit Log

Enable the use of registry services and directories to uniquely identify, locate and supply links for retrieval of information related to:

• patients and providers for healthcare purposes;
• payers, health plans, sponsors, and employers for administrative and financial purposes;
• public health agencies for healthcare purposes, and- healthcare resources and devices for resource management purposes.

Support semantic interoperability through the use of standard terminologies, standard terminology models and standard terminology services.

Employ approved standard terminologies to ensure data correctness and to enable semantic interoperability (both within an enterprise and externally).Support a formal standard terminology model.

Enable version control according to scope of practice, organizational policy, and/or jurisdictional law to ensure maintenance of utilized standard terminologies.

This includes the ability to accommodate changes to terminology sets as the source terminology undergoes its natural update process (new codes, retired codes, redirected codes). Such changes need to be cascaded to clinical content embedded in templates, custom formularies, etc., as determined by existing policy.

Map or translate one terminology to another as needed by local, regional, national, or international interoperability requirements.

Provide automated health care delivery processes and seamless exchange of clinical, administrative, and financial information through standards-based solutions.

Support an EHR system’s ability to operate seamlessly with systems that adhere to recognized application interchange standards. These systems include other EHR systems, subcomponents of an EHR system, or other (authorized, non-EHR) systems.

Support the ability to operate seamlessly with other systems by using applications, and/or structured messages and documents that adhere to interchange standards.

Support the management of structured documents.

Support the management of structured messages.

Support various versions of an interchange standard.

Integrate applications in a standards-based manner.

Support the use of Interchange Agreements to specify the rules, responsibilities, expectations, and methods by which Interchange Agreement partners may exchange information.

Support the integration of the EHR system with related systems.

Manage the ability to create, update, delete, view, and version business rules including institutional preferences. Apply business rules from necessary points within an EHR-S to control system behavior. An EHR-S audits changes made to business rules, as well as compliance to and overrides of applied business rules.

Support workflow management functions including both the management and set up of work queues, personnel lists, and system interfaces as well as the implementation functions that use workflow-related business rules to direct the flow of work assignments.

Provide for the ability to backup and recover the EHR system.

Manage the change of status of an external facility and the ability to access, render and determine information related to Service Level Agreement.

Employ approved standard clinical models and clinical model service to ensure data correctness and to enable semantic interoperability (both within an enterprise and externally). Support sets of formal standard clinical models and/or clinical model services.

Employ approved standard or Preferred Clinical Models to ensure structured data correctness and to enable semantic interoperability (both within an enterprise and externally). Support a standard or Preferred Clinical Models model.

Enable version control according to scope of practice, organizational policy, and/or jurisdictional law to ensure maintenance of utilized standard or preferred clinical models.

This includes the ability to accommodate changes to clinical models as the source clinical model undergoes its update process. Such changes need to be cascaded to clinical content embedded in templates, custom formularies, etc., as determined by existing policy.

Map or translate one clinical model to another as needed by local, regional, national, or international interoperability requirements.

The Overarching Section contains Conformance Criteria that apply to all EHR Systems and consequently must be included in all EHR-S FM compliant profiles. These criteria are grouped under a single Function.

All functions within the Overarching Section have an identifier starting with “OV”.

The Care Provision Section contains those functions and supporting Conformance Criteria that are required to provide direct care to a specific patient and enable hands-on delivery of healthcare. The functions are general and are not limited to a specific care setting and may be applied as part of an Electronic Health Record supporting healthcare offices, clinics, hospitals and specialty care centers. The functions in this section are organized in general flow of an encounter; however, it is recognized that encounter flow varies considerably in different care settings and scopes of practice. All functions within the Care Provision Section have an identifier starting with “CP”. Example: For example, when a child presents with symptoms of common cold, a Direct Care EHR-S Function will enable the doctor to record that event. Additionally, Clinical decision-support functions within the Direct Care EHR-S section will alert the provider that a vaccination is due and will offer contraindication alerts for the medication given to the child who has symptoms of a cold.

The Care Provision Support Section focusses on functions required to support the provision of care to a specific patient to enable hands-on delivery of healthcare. This section is organized generally in alignment with Care Provision Section. For example, CP.4 (Manage Orders) is supported directly by CPS.4 (Support Orders). This alignment is designed to assist in finding related support functions related to care provision functions but is not expected to be 100% matched as some Care Provision Functions do not require matching Support functions or vice-versa.

All functions within the Care Provision Support Section have an identifier starting with “CPS”.

The Administrative Support Section focusses on functions required in the EHR-S to support the management of the clinical practice and to assist with the administrative and financial operations. This includes management of resources, workflow and communication with patients and providers as well as the management of non-clinical administrative information on patients and providers. All functions within the Administrative Support Section have an identifier starting with “AS”.

The Population Health Support Section focuses on those functions required of the EHR to support the prevention and control of disease among a group of people (as opposed to the direct care of a single patient), usually with something(s) in common, e.g., reside in the U.S., have diabetes, are under the age of 5, are treated by the same care provider, have pneumonia and are in a long-term care facility, etc. This section includes functions to support input to systems that perform medical research, promote public health, & improve the quality of care at a multi-patient level. Population health data must be managed carefully to avoid inadvertently breaching patient privacy and confidentiality. Individual patients may be identifiable within a population or aggregate based on information other than patient identifiers, e.g., age plus location, and/or based on a combination of public and population-based information. This section specifically addresses requirements related to patient privacy and consent for use of patient information for secondary uses, and/or reporting. All functions within the Population Health Support Section have an identifier starting with “POP”.

The Record Infrastructure Section consists of functions common to EHR System record management, particularly those functions foundational to managing record lifecycle (origination, attestation, amendment, access/use, translation, transmittal/disclosure, receipt, de-identification, archive…) and record lifespan (persistence, indelibility, continuity, audit, encryption). RI functions are core and foundational to all other functions of the Model (CP, CPS, POP, AS). Note extensive reference to RI functions in Overarching Criteria. RI functions may be implemented within the architecture of a single system or across a tightly coupled suite of systems (applications).All functions within the Record Infrastructure Section have an identifier starting with “RI”. Example: Care Provision (CP) and Care Provision Support (CPS) functions are invoked by Actors taking Actions (i.e., caregivers documenting care provision). Most all Actions taken to support individual health or to provide healthcare are captured by the EHRS and persistently evidenced in the EHR record. For example, CP immunization administration functions create EHR record entries which must be persisted over time. These same entries form the basis for transmittal to central immunization registries.

The Trust Infrastructure (TI) Section consists of functions common to an EHR System infrastructure, particularly those functions foundational to system operations, security, efficiency and data integrity assurance, safeguards for privacy and confidentiality, and interoperability with other systems. TI functions are core and foundational to all other functions of the Model (Care Provision, Care Provision Support, Population Health, Administrative Support and Record Infrastructure). Note extensive reference to TI functions in Overarching Criteria. TI functions may be implemented within the architecture of a single system or across a tightly coupled suite of systems (applications).All functions within the Trust Infrastructure Section have an identifier starting with “TI”. Example: Care Provision (CP) and Care Provision Support (CPS) functions must operate in a secure electronic environment. For example, Trust Infrastructure functions provide a secure environment for the CP immunization registration query function. Subsequently a CP function reports (transmits) the child’s immunization event in a secure manner via another TI exchange function. TI functions also transparently provide other essential services, such as periodic backups of a child’s health record and an audit trail of all accesses to that record.

This StructureDefinition represents the base EHR-S FM Function type

This StructureDefinition represents the base EHR-S FM Header type

This StructureDefinition represents the base EHR-S FM Section type

This StructureDefinition represents the base EHR-S FunctionalModel type

Requirements Statement Actors

Requirements or Statement Criteria Change Indicator

Requirements Statement Criteria is dependent

Requirements Statement Example

Requirement Change Indicators

Requirement Change Indicator