(2) Clinical Information Reconciliation and Incorporation

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(2) Clinical Information Reconciliation and Incorporation
Please consult the Notice of Proposed Rulemaking (NPRM) entitled: 2015 Edition Health Information Technology (Health
IT) Certification Criteria, 2015 Edition Base Electronic Health Record (EHR) Definition, and ONC Health IT Certification
Program Modifications for a detailed description of the proposed certification criterion with which these testing steps
are associated.
1. Required Tests
Note: The order in which the test steps are listed reflects the sequence of the certification criterion and does not necessarily
prescribe the order in which the test should take place.
Note that the Health IT Module must demonstrate their capabilities as it relates to transition of care/referral summaries
formatted in accordance with standards adopted at §170.205(a)(3) and §170.205(a)(4).
1.1 Correct Patient
Evaluate the Health IT Module’s ability to properly match C-CDA documents (specifically the Continuity of Care (CCD),
Discharge Summary, and Referral Summary document templates) received from third parties to correct patients with
existing records in the Health IT Module.
Item #
1
Technical Outcome
Test Lab Verification
Test Approach
A transition of care summary/referral
summary C-CDA document, formatted
according to the standard adopted at
§170.205(a)(3) or §170.205(a)(4), is
correctly matched to a patient in the
Health IT Module.
The tester verifies that the received
C-CDA documents (including a CCD,
Discharge Summary, and Referral
summary) are matched to the correct
patient record.
Visual inspection of
test data (C-CDA
documents formatted
in both the
§170.205(a)(3) and
§170.205(a)(4)
standards).
1.2 Reconciliation
Evaluate the Health IT Module’s ability to enable a user to electronically reconcile the data that represents a patient’s
active medication list, medications allergy list or problem list through the simultaneous display of the multiple
sources, creation of a single reconciled list, the review and validation of the reconciled list, and update of the patient
record in the Health IT Module.
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Item #
1
Technical Outcome
Test Lab Verification
Test Approach
A user simultaneously views data
(including active medications,
medication allergies, and
problems) that includes the
source and last modification data
from at least two sources:
• The current patient
record AND
• Transition of care
summary/referral
summary C-CDA
document, formatted
according to the standard
adopted at
§170.205(a)(3) OR
§170.205(a)(4).
The tester verifies that data from multiple sources
can be displayed for medications, medication
allergies, and problems, including both the source
and last modification date. The last modification
date is defined for each list as:
• Last date medication was documented,
ordered, prescribed, refilled, dispensed or
edited;
• Last date the problem was documented
or edited; and
• Last date the medication allergy was
documented, edited, or updated.
Visual inspection of
test data.
Note that Health IT Modules will
need to separately demonstrate
the ability to reconcile summary
of care documents formatted
according to §170.205(a)(3) and
§170.205(a)(4).
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A user creates a single, reconciled
medications, problems, or
medication allergies list using the
viewed data from the multiple
medications, problems or
medication allergies list sources.
Further, the tester must verify that the Health IT
Module can display the current patient record and
a transition of care summary/referral summary CCDA document, formatted according to the
standard adopted at §170.205(a)(3) and
separately the current patient record and a
transition of care summary/referral summary CCDA document, formatted according to the
standard adopted at §170.205(a)(4).
The tester must also verify that this can be
completed for the Continuity of Care (CCD),
Discharge Summary, and Referral Summary
document templates.
The tester verifies that for each list type, the lists
can be merged, duplicates can be consolidated
into a single representation, that list items can be
removed, and any other means the Health IT
Module may use to reconcile the list.
Visual inspection of
test data.
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Item #
3
Technical Outcome
Test Lab Verification
Test Approach
A user reviews the details of the
reconciled list and validates its
accuracy.
The tester verifies that for each list type, a
reconciled list is accurate and without omission
including:
Visual inspection.
•
•
•
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A user accepts the reconciled list
and the patient record in the
Health IT Module is updated.
the inclusion of the minimum CCDS data
elements for each list type, according to
the definition adopted at §170.102;
where applicable the use of medication
vocabularies according to the standard
adopted at §170.207(d)(3); and
where applicable the use of problem
vocabularies according to the standard
adopted at §170.207(a)(4).
The tester verifies that reconciled medications,
medication allergies, and problems data are
accurately incorporated into the patient record
without omission, and that at a minimum
•
•
•
Visual inspection.
medications are expressed according to
the standard specified in §170.207(d)(3);
medication allergies are expressed
according to the standard specified in
§170.207(d)(3); and
problems are expressed according to the
standard specified in §170.207(a)(4).
1.3 System Verification
Evaluate the capability for a Health IT Module to create a valid transition of care summary/referral summary C-CDA
document for a patient after patient data reconciliation of medication, medication allergies, and problems has
occurred.
Item #
1
Technical Outcome
Test Lab Verification
Test Approach
A user creates a CCD that includes the
reconciled and incorporated data, in
accordance with the standard adopted at
§170.205(a)(4).
The tester verifies that the C-CDA
documents (CCD only) created after a
reconciliation of medications,
medication allergies and/or problems
reconciliation has been performed,
meet the standard specified in §
170.207(a)(4).
C-CDA Validator
Tool and visual
inspection.
2. Document History
Version Number
Description of Change
Date
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1.0
Released for Public Comment
March 31, 2015
3. Dependencies
For the related and required criteria, please refer to the Master Table of Related and Required Criteria.
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