| Use Computer Provider Order Entry (CPOE) |
Enable a user to electronically record, store, retrieve, and manage, at a minimum, the following order types: Medications; Laboratory; Radiology/imaging; Provider referrals; Blood bank; Physical therapy; Occupational therapy; Respiratory therapy; Rehabilitation therapy; Dialysis; Provider consults; and Discharge and transfer. |
CPOE is used for at least 80% of all orders; 10% for hospitals |
| Implement drug/allergy checks |
(1) Real-time, alerts at the point of care for drug-drug and drug-allergy contraindications; (2) Electronically check if drugs are in a formulary or preferred drug list; (3) Provide certain users rights to deactivate, modify, and add rules for drug-drug and drug-allergy checking; (4) Track number of alerts users respond to |
Function is enabled |
| Maintain an up-to-date problem list of current and active diagnoses based on ICD-9-CM or SNOMED CT® |
Electronically record, modify, and retrieve a patient’s problem list over multiple visits |
At least 80% of all unique patients have at least one entry or an indication of none recorded. |
| E-prescribing (EP only) |
Electronically transmit prescriptions |
At least 75% of all permissible prescriptions written by the EP are transmitted electronically |
| Maintain active medication/allergy list |
Electronically record, modify, and retrieve a patient’s active medication/allergy list |
At least 80% of all unique patients have at least one entry or an indication of “none” |
| Record demographics |
Electronically record, modify, and retrieve patient demographic data |
At least 80% of all unique patients have demographics recorded |
| Record and chart changes in vital signs |
(1) Enable a user to electronically record, modify, and retrieve a patient’s vital signs; (2) Automatically calculate and display body mass index (BMI); (3) Plot and electronically display, upon request, growth charts for patients 2-20 years old. |
For at least 80 percent of all unique patients age 2 and over seen by the EP or admitted to the eligible hospital, record blood pressure and BMI; additionally, plot growth chart for children age 2 to 20 |
| Record smoking status for patients 13 years old or older |
Electronically record, modify, and retrieve the smoking status of a patient |
At least 80% of all unique patients 13 years old or older have “smoking status” recorded |
| Incorporate clinical lab-test results into EHR as structured data |
(1) Electronically receive clinical laboratory test results and display such results in human readable format; (2) Electronically display in human readable format any clinical laboratory tests that have been received with LOINC® codes; (3) Electronically display all the information for a test report; (4) Electronically update a patient’s record based upon received laboratory test results |
At least 50% of all clinical lab tests results are incorporated as structured data |
| Generate lists of patients by specific conditions |
Electronically select, sort, retrieve, and output a list of patients and patients’ clinical information |
Generate at least one report listing patients with a specific condition |
| Report ambulatory quality measures to CMS or the States (EP only) |
(1) Calculate and electronically display quality measure results as specified by CMS or states; (2) Electronically submit calculated quality measures |
For 2011, an EP/hospital would attest this has been done |
| Send reminders to patients for preventive/follow-up care |
Electronically generate a patient reminder list for preventive or follow-up care |
Reminders sent to at least 50% of all unique patients that are 50 and over |
| Implement five clinical decision support rules relevant to specialty or high clinical priority |
(1) Implement automated, electronic clinical decision support rules according to specialty or clinical priorities; (2) Automatically and electronically generate real-time alerts and care suggestions based upon clinical decision support rules and evidence grade; (3) Automatically and electronically track, record, and generate reports on the number of alerts responded to by a user |
Implement five clinical decision support rules relevant to the clinical quality metrics the EP/Eligible Hospital is responsible for |
| Check insurance eligibility electronically |
Electronically record and display patients’ insurance eligibility, and submit insurance eligibility queries |
Insurance eligibility checked electronically for at least 80% of all unique patients |
| Submit claims electronically to public and private payers. |
Electronically submit claims |
At least 80 % of all claims filed electronically |
| Provide patients with an electronic copy of their health information upon request |
Enable a user to create an electronic copy of a patient’s clinical information and provide to a patient on electronic media, or through some other electronic means |
At least 80% of all patients who request an electronic copy of their health information are provided it within 48 hours |
| Provide patients with an electronic copy of their discharge instructions and procedures at time of discharge, upon request (Hospital only) |
Enable a user to create an electronic copy of the discharge instructions and procedures for a patient, in human readable format, at the time of discharge to provide to a patient on electronic media, or through some other electronic means |
At least 80% of all patients who are discharged from an eligible hospital and who request an electronic copy of their discharge instructions and procedures are provided it |
| Provide patients with electronic access to their health information within 96 hours of the information being available (EP only) |
Enable a user to provide patients with online access to their clinical information |
At least 10% of all unique patients are provided timely electronic access to their health information |
| Provide clinical summaries to patients for each office visit. (EP only) |
(1) Enable a user to provide clinical summaries to patients (in paper or electronic form) for each office visit; (2) If the clinical summary is provided electronically (i.e., not printed), it must be provided in: 1) human readable format; and 2) and on electronic media, or through some other electronic means. |
Clinical summaries provided to patients for at least 80% of all office visits |
| Exchange key clinical information among providers of care and patient authorized entities electronically and provide summary care record |
(1) Electronically receive a patient summary record, from other providers and organizations; (2) Electronically transmit a patient summary record, to other providers and organizations |
Provide summary of care record for at least 80 % of transitions of care and referrals; Perform at least one test of certified EHR technology’s capacity to electronically exchange key clinical information |
| Perform medication reconciliation at relevant encounters and each transition of care and referral |
Electronically complete medication reconciliation of two or more medication lists into a single medication list that can be electronically displayed in real-time |
Perform medication reconciliation for at least 80 % of relevant encounters and transitions of care |
| Submit electronic data to immunization registries and actual submission where required and accepted |
Electronically record, retrieve, and transmit immunization information to immunization registries |
Performed at least one test submission to immunization registries and public health agencies |
| Provide electronic submission of reportable lab results to public health agencies and actual submission where it can be received (Hospital only) |
Electronically record, retrieve, and transmit reportable clinical lab results to public health agencies |
Performed at least one test of certified EHR technology capacity to provide electronic submission of reportable lab results to public health agencies |
| Provide electronic syndromic surveillance data to public health agencies and actual transmission according to applicable law and practice |
Electronically record, retrieve, and transmit syndrome-based (e.g., influenza like illness) public health surveillance information to public health agencies |
Performed at least one test of certified EHR technology’s capacity to provide electronic syndromic surveillance data to public health agencies |
| Protect electronic health information through the implementation of appropriate technical capabilities |
(1) Assign unique user names; (2) Permit certain users to access health information in an emergency; (3) Terminate an electronic session after a predetermined time of inactivity; (4) Encrypt and decrypt electronic health information that is stored and exchangd; (5) Record actions (e.g., deletion) related to electronic health information; (6) Track alterations of electronic health information; (7) Set up user verification measures; (8) Record disclosures made for treatment, payment, and health care operations |
Conduct or review a security risk analysis and implement security updates as necessary |
