SUMMARY * Maintain updated list of problems using ICD9 or Snomed MEDS * Generate and transmit permissible prescriptions electronically * Maintain active medication list * Maintain active medication allergy list * Implement drug-drug, allergy formulary checks (ie free Allscripts Tool) * perform medication reconciliation at relevant encounters DATA * Record demographics (preferrred language and racial group, insurance type, gender and ethnicity) * Records vitals including wt ht bp and BMI * Record smoking status * LABS: Incorporate lab test results as structured data (HL7) * Record Advance Directives * collect syndromic surveillance data (for reporting to public health agencies) * immunizations PROGRESS NOTE (VISIT documentation) * Document a progress note for each encounter * Provide clinical summaries for each encounter * Implement one clinical decision rule relevant to specialty or high clincal priority ELECTRONIC ORDERING - "CPOE" * meds * labs * immunizations * procedures * diagnostic imaging * referrals ~ Receiving interfaces not needed for 2011 REPORTING * Generate lists of patients by conditions * Report ambulatory quality measures to CMS * FOLLOW UP: Send reminders to patients for preventitive and follow up care - Ticklers HMGS COMMUNICATION * capability to provide electronic syndromic surveillance data to public health agencies * capability to submit immunization data etc where required * capability to exchange key clinical information ( to be decided hy HIE work group of the HIT policy committee ) electronically * Provide patients with electronic copies of their health information upon request ( real time not required until 2013 ) o Portal can do this now and no need to wait till 2013 o Devil is in the details - "What" info SECURITY * compliance with HIPAA privacy and security rules * compliance with nationwide privacy and security framework OTHER * Provide access to patient specific education resources PMS function * Check insurance eligibility electronically from private and public payers where possible * Submit claims electronically
SUMMARY * Maintain updated list of CORE, MAJOR problems using ICD9 or Snomed MEDS * Generate and transmit permissible prescriptions electronically * Maintain active medication list * Maintain active medication allergy list * Implement drug-drug, allergy formulary checks (ie free Allscripts Tool) * perform medication reconciliation at relevant encounters DATA * Record demographics (preferrred language and racial group, insurance type, gender and ethnicity) * Record vitals including wt ht bp and BMI * Record smoking status * Record Advance Directives * collect syndromic surveillance data (for reporting to public health agencies) * immunizations * LABS: Incorporate lab test results as structured data (HL7) PROGRESS NOTE (VISIT documentation) * Document a progress note for each encounter - must it be electronic ? inking on .pdf ? * Provide clinical summaries for each encounter * Implement one clinical decision rule relevant to specialty or high clincal priority ELECTRONIC ORDERING - "CPOE" * meds * labs * immunizations * procedures * diagnostic imaging * referrals ~ Receiving interfaces not needed for 2011 REPORTING * Generate lists of patients by conditions * Report ambulatory quality measures to CMS * FOLLOW UP: Send reminders to patients for preventitive and follow up care - Ticklers HMGS COMMUNICATION * capability to provide electronic syndromic surveillance data to public health agencies * capability to submit immunization data etc where required * capability to exchange key clinical information ( to be decided hy HIE work group of the HIT policy committee ) electronically * Provide patients with electronic copies of their health information upon request ( real time not required until 2013 ) o Portal can do this now and no need to wait till 2013 o Devil is in the details - "What" info SECURITY * compliance with HIPAA privacy and security rules * compliance with nationwide privacy and security framework OTHER * Provide access to patient specific education resources PMS function * Check insurance eligibility electronically from private and public payers where possible * Submit claims electronically ================= In a stripped down HITECH EMR, only the red would be entered by the MD. orange, would probably be done by the MD, or the Billing Clerk. <font
