Long-Term Care-Nursing Homes EHR-Systems Functional Profile: Release 1

07/01/2008

HHS Logo: bird/facesU.S. Department of Health and Human Services

Long-Term Care-Nursing Homes EHR-Systems Functional Profile: Release 1

LTC-NH EHR-S Functional Profile Workgroup

Co-Facilitators:

Jennie Harvell, MEd U.S. Department of Health and Human Services Michelle Dougherty, MA, RHIA, CHP American Health Information Management Association Nathan Lake, RN, BSN, MSHA American HEALTHTECHSue Mitchell, RHIA Omnicare Information Solutions

July 2008

PDF Version: http://aspe.hhs.gov/daltcp/reports/2008/LNEHRSFP1.pdf (186 total PDF pages)


This report was prepared under contract #HHS-100-03-0026 between U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and Abt Associates. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm or contact the ASPE Project Officer, Jennie Harvell, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. Her e-mail address is: Jennie.Harvell@hhs.gov.

The opinions and views expressed in this report do not necessarily reflect the views of the Department of Health and Human Services, the contractor or any other funding organizations.


TABLE OF CONTENTS

PREFACE
1. Notes to Readers
2. Acknowledgements
3. Changes from Previous Release
1. BACKGROUND (REFERENCE)
2. PROCESS (REFERENCE)
3. NEXT STEPS (REFERENCE)
4. ORGANIZATION OF THIS DOCUMENT (REFERENCE)
5. CONFORMANCE CLAUSE (NORMATIVE)
5.1. Scope and Field of Application
5.2. Functional Priorities
5.3. Normative Language
5.4. Claiming Conformance to the Profile
6. APPLYING THE CONFORMANCE REQUIREMENTS (REFERENCE)
7. STANDARDIZING TERMS IN FUNCTION CRITERIA (REFERENCE)
8. COMPONENTS OF LTC-NH EHR-S FUNCTIONAL PROFILE OUTLINE (REFERENCES)
ATTACHMENTS (links direct you to separate files)
Direct Care Functions
Supportive Functions
Information Infrastructure Functions
APPENDIX: HIT Standards

PREFACE

1. Notes to Readers

Release 1 of the Long-Term Care Nursing Home (LTC-NH) Electronic Health Record System (EHR-S) Functional Profile, based on the Health Level Seven (HL7) EHR-S Functional Model Release 1, February 2007, has been balloted through the LTC-NH EHR-S Functional Profile Workgroup, and will be registered with the HL7 EHR Technical Committee and submitted for balloting at the committee level. The intention is for this functional profile to become an ANSI approved normative standard.

2. Acknowledgements

The LTC-NH EHR-S Functional Profile Workgroup was sponsored and facilitated by:

  • U.S. Department of Health and Human Services (HHS), Office of the Assistant Secretary for Planning and Evaluation (ASPE);
  • American Association of Homes and Services for the Aging/Center for Aging Services Technology (AAHSA/CAST);
  • American Health Care Association/National Centers for Assisted Living (AHCA/NCAL);
  • American Health Information Management Association (AHIMA); and
  • National Association for the Support of Long Term Care (NASL).

These organizations are indebted to the following workgroup facilitators and members for their contributions to the LTC-NH community and the materials presented in this profile.

The long-term care community is particularly indebted to Sue Mitchell for her leadership and significant contribution to the development of the LTC-NH EHR-S Functional Profile. This Functional Profile would not have been possible without her guidance and assistance.

  Member Name     Affiliation  
Co-Facilitators
Jennie Harvell, MEd HHS, ASPE
Michelle Dougherty, MA, RHIA, CHP   AHIMA
Nathan Lake, RN, BSN, MSHA American HEALTHTECH
Sue Mitchell, RHIA Omnicare Information Solutions
Profile Developers/Balloters
Adam Prybyl Momentum Healthware
Amy Killian Phoebe Services
Annessa Kirby NASL
Beth de la Hunt Achieve Healthcare Technologies
Betty Pilous Ohio KePRO
Brian Young Accu-Med Services, LLC
Carla Saxton McSpadden American Society of Consultant Pharmacists  
Dan Cobb HealthMEDX
Debra Ann Phillips Genesis Health Care Corp
Denine Hastings Genesis Health Care Corp
Doc DeVore MDI Achieve
Donna Brickey American HEALTHTECH
Doron Gutkind LINTECH
Eileen Doll EDHC, Inc.
Frank Leonard Armed Forces Retirement Home
Frank McKinney Achieve Healthcare Technologies
Ginna Sloan Accu-Med Services, LLC
James Hancock QS/1 Data Systems
Judy Baker Accu-Med Services, LLC
Karrie Ingram Citizens Memorial Healthcare
Karyn Downie AAHSA
Kristine Cerchiara Healthcare Innovation Partners
Linda Lucas Fulton Manor
Linda Spurrell Keane Care
Lorraine Toderash Momentum Healthware
Louis Hyman eHealth Solutions
Marcelle Feltman Sun Healthcare
Margie White Columbus Colony Elderly Care
Maria Moen Healthware Consulting Services
Melanie Brodnik The Ohio State University
Melissa Carter American Health Care Software Enterprises
Mike Crowder Golden Ventures
Nathan Simonis American Data
Peter Kress ACTS Retirement Life Communities
Rhonda Anderson Anderson Health Information Systems
September Stone National Health Care Learning Center
Shelly Spiro R. Spiro Consulting
Sue Lewis Accu-Med Services, LLC
Susan Greenly Keane Care
Tim Smith Golden Ventures
Todd Smith American Health Care Association
Zoe Bolton Independent Consultant
Workgroup Participants
Alan Adediger Medicalodges
Allan Neoh Achieve Healthcare Technologies
Allan Rosenbloom Alliance for Quality Nursing Home Care
Barbara Manard AAHSA
Bill Russell Erickson Retirement Communities
Brenda Parks Keane Care
Brett Klausman  
Bryce Berry Sunshine Terrace Foundation
Chris Thomas Accu-Med Services, LLC
Christa Hojlo Veterans Administration
Craig Baker Accu-Med Services, LLC
Daniel Stein Columbia University
Daniel Wilt Erickson Retirement Communities
Darin Ballweg American Data
Dave Dring Interactive Aging Network
Dave Oatway Care Track Systems, LLC
Dave Piehl  
Debra Sperry Good Samaritan Society
Denise Trcka Achieve Healthcare Technologies
Donna Maassen Extendicare
Eric Baker Innovatix, LLC
Gary Schoetmer RNA Health Information Systems
Geoffrey Bunza Vigilan Inc
Gillian Broderick Fundamental
Gloria Bean TMF Health Quality Institute
Gregory Kaupp  
Heath Boddy Nebraska Health Care Assocication
Hongsoo Kim NYU College of Nursing
Irene Wright American Health Care Software Enterprises
James Albert Masonicare
James Kwokon Eng American Physical Therapy Association
Jamie Husher The Evangelical Lutheran Good Samaritan Society
Janet Barber Veterans Administration
Jeanette Kranacs HHS, Centers for Medicare & Medicaid Services
Jeffrey Woodside INHOUSE Pharmacy Solutions
Jerry Gurwitz, MD Division of Geriatric MedicineUniversity of Massachusetts Medical School
Jesse Wrenn Columbia University
Jessica Dalton Park River Estates Care Center
Joann Ross Genesis Health Care Corp
Joe Wilson Omnicare
Johnine Brooks HCR Manor Care
Joy Thompson HHS, Centers for Medicare & Medicaid Services
Judi Hummel  
Julie Purcell SavaSeniorCare Administrative Services
Julie Thompson Beacon Partners, Inc
Karen Jennings Ohio Department of Jobs & Family Services
Karen Thiel Patton Boggs LLP
Karthik Natarajan Columbia University
Kathy Hurst SavaSeniorCare Administrative Services
Keith Speights American HEALTHTECH
Keith Weaver Ohio Department of Health
Kenneth Brouse Community Health Systems
Kevin McCormack Keane Care
Kevin Unrein Lake Point
Kevin Warren TMF Health Quality Institute
Larry Hillock Community Health Systems
Larry Wolf Kindred Healthcare
Linda Kunz DART Chart
Marcia DeRosia American Health Care Software Enterprises
Maria Arellano American Association of Nurse Assessment Coordinators
Martin Rice HHS, Centers for Medicare & Medicaid Services
Mary Anne Kurowski Genesis Health Care Corp
Mary Guthrie Veterans Administration
Mary Pratt HHS, Centers for Medicare & Medicaid Services
Matthew Mullins Momentum Healthware
Mike Easley Home Quality Management Inc
Murry Mercier HCR Manor Care
Nancy Robinson American Medical Directors Association
Nelwyn Madison American HEALTHTECH
Patty Padula Myers & Stauffer
Rhonda Hamilton National Government Services (FI)
Rich Castor Genesis Health Care Corp
Rich Giddings Achieve Healthcare Technologies
Rob Sutton Accu-Med Services, LLC
Robert Abrams My ZIVA
Roger Smith Strafford County IT Department
Roi Qualls eHDS Operations
Ron Cram  
Royall Chambers Eliza Bryant Village
Russ Depriest HCR Manor Care
Scott Krueger  
Sheila Dosher Sun Healthcare
Sheila Lambowitz HHS, Centers for Medicare & Medicaid Services
Sherrie Orvis Veterans Administration
Steven Handler University of Pittsburg School of Medicine
Sue Rucinski Sava Senior Care Administrative Services
Suzanne Weaver Neshaminy Manor
Thomas Welch Eagle Software Group
Tydette Tisdell Veterans Administration
Yael Harris Office of the National Coordination of Health Information Technology  

3. Changes from Previous Release

Not applicable.

1. BACKGROUND (REFERENCE)

In late 2006, the U.S. Department of Health and Human Services (HHS) authorized and funded the Certification Commission for Healthcare Information Technology (CCHIT) to expand its certification scope of work and begin addressing EHR products to include ambulatory medical specialties and specialized care settings. Key stakeholders in the long-term care community, led by the joint efforts of the American Association of Homes and Services for the Aging (AAHSA), the American Health Care Association (AHCA), and the National Association for the Support of Long-Term Care (NASL), petitioned CCHIT for the inclusion of nursing homes in this expanded scope of certification activity. In March 2007, CCHIT officially announced their “Roadmap” for expansion of product certification -- and nursing homes were included. Actual certification of nursing home EHR products is anticipated in 2010.

In creating the certification criteria for nursing home EHR products, CCHIT will draw heavily on the requirements published in the 2007 HL7 EHR-S FM standard, as well as the industry specific requirements identified in the LTC-NH EHR-S Functional Profile.

While the HL7 EHR-S FM provides a reference list of functions that may be present in an EHR-S, the nursing home community has developed this LTC Functional Profile that identifies the subset of functions from the model that reflects the unique aspects and needs for EHR systems in the long-term care setting. CCHIT will use the LTC EHR-S Functional Profile as a reference when they develop the functionality, interoperability, and security requirements for certified NH EHR-S products.

2. PROCESS (REFERENCE)

Funding for the development of this LTC EHR-S Functional Profile has been provided by the HHS Office of the Assistant Secretary for Planning and Evaluation (ASPE). Project leadership has been provided by ASPE, the American Health Information Management Association (AHIMA), the Health Level Seven Electronic Health Record Technical Committee (HL7 EHR TC) and the National Council for Prescription Drug Programs (NCPDP).

Extensive volunteer support has been provided by a broad array of LTC industry and stakeholder representatives who have participated in the virtual meetings that were held each week to define the content of the profile.

This document will be registered with the HL7 EHR TC as a conformant profile in July 2008. It will also be made available to appropriate CCHIT staff and committees at that time. In addition, the profile will be submitted to the HL7 EHR TC for the first cycle of balloting as a normative standard. This HL7 balloting will occur in the September 2008 ballot cycle.

4. ORGANIZATION OF THIS DOCUMENT (REFERENCE)

In addition to this Overview section, the LTC-NH EHR-S Functional Profile is organized into three sections of system requirements as follows.

Direct Care Functions employed in the provision of care to individual patients and to collect information that will comprise the patient’s EHR. Direct care functions are the subset of functions that enable delivery of health care or offer clinical decision support.
Supportive Functions   Functions that support the delivery and optimization of care, but generally do not impact the direct care of an individual patient. These functions assist with the administrative and financial requirements associated with the delivery of health care, provide support for medical research and public health, and improve the global quality of health care.
Information Infrastructure   Functions that support the reliability, integrity, security and interoperability of the EHR-S. These functions are not involved in the provision of health care, but are necessary to ensure the integrity and security of the patient’s electronic health information.

5. CONFORMANCE CLAUSE (NORMATIVE)

This profile is based on HL7 EHR-S FM, Release 1, February 2007. Key to the FM and derived profiles is the concept of conformance which may be defined as “verification that an implementation faithfully meets the requirements of a standard or specification”. A profile can be said to conform to the FM if it adheres to the defined rules identified by the FM specification. The LTC-NH EHR-S Functional Profile adheres to the defined rules of the EHR-S FM. Similarly, an EHR-S may claim conformance to the LTC-NH EHR-S Functional Profile if it meets all the requirements outlined in this profile.

5.1. Scope and Field of Application

The LTC-NH EHR-S Functional Profile applies to EHR systems developed for nursing homes. This profile makes no distinction regarding implementation -- the EHR-S described in this functional profile may be a single system or a system of systems.

5.2. Functional Priorities

The LTC-NH EHR-S Functional Profile Workgroup recognizes that clinical computing is an evolving field, and that many of the desired functions of EHR systems are not currently available. Nevertheless, it is important for functional profiles to outline major trends and articulate a vision for functionality (especially interoperability) for the future. Furthermore, the delineation of potential functions for future implementation and adoption should guide vendors in system development, and help purchasers develop and articulate to vendors a strategic vision for future functional requirements.

Each function in the profile is assigned a single priority as follows:

EN Essential Now Indicates that the implementation of the function is mandatory and SHALL be implemented in EHR systems claiming conformance to this profile.
EF xxxx   Essential Future   Indicates that the function has significant importance but is not widely available. The function will become mandatory and SHALL be implemented in EHR systems claiming conformance to this profile by the end of the year identified.
O Optional Indicates that, while the function may have value to some organizations, it is not viewed as being essential.
N/A Not Applicable Function not applicable in the nursing home setting and rejected for purposes of the LTC-NH EHR-S Functional Profile.

5.3. Normative Language

The key words SHALL, SHALL NOT, SHOULD, and MAY in this document are to be interpreted as described in HL7 EHR-S Functional Model, Release 1, February 2007 Chapter 2: Conformance Clause:

SHALL Indicates a mandatory requirement to be followed (implemented) in order to conform. Synonymous with "is required to" and "must".
SHALL NOT   Indicates a prohibited action. Synonymous with "prohibited" and "must not".
SHOULD Indicates an optional recommended action, one that is particularly suitable, without mentioning or excluding others. Synonymous with "is permitted and recommended".
MAY Indicates an optional, permissible action. Synonymous with "is permitted".

5.4. Claiming Conformance to the Profile

The following provisions apply to claims of conformance to the LTC-NH EHR-S Functional Profile:

Systems claiming conformance to this Profile SHALL Implement all functions designated Essential Now. Fulfill (i.e., meet or satisfy) all the SHALL criteria for each implemented function.
Systems claiming conformance to this Profile MAY Implement functions designated Essential Future. Fulfill any of the SHOULD or MAY criteria associated with an implemented function.
Systems claiming conformance to this Profile SHALL NOT Negate or contradict defined functionality of this profile when including additional functionality beyond what is specified in this profile.
Derived profiles claiming conformance to this Profile SHALL Inherit all functions designated Essential Now. Inherit all SHALL criteria for functions included in the derived profile. Follow the rules for profiles in Chapter 2, Section 6.1 of the HL7 EHR-S FM standard. Adhere to the rules for creating new functions in Chapter 2, Section 6.3 of the HL7 EHR-S FM standard.
Derived profiles claiming conformance to this Profile MAY Change SHOULD and MAY criteria to SHALL, SHOULD or MAY criteria.
Derived profiles claiming conformance to this Profile SHALL NOT Change the function’s name or statement.

6. APPLYING THE CONFORMANCE REQUIREMENTS (REFERENCE)

In some instances a “SHALL” criterion in a function may require conformance with another function in the profile that has a different timing priority (i.e., a criterion in an Essential Now (EN) function may require conformance with a function designated as Essential Future (EF) 2011). This situation would arise when HL7 requirements regarding profiles adopting mandatory requirements from the FM did not harmonize well with timing priorities for functions identified by profile developers. It is important to understand that the priority timing of a referencing function DOES NOT supersede the timing priority established for the referenced function. Examples include:

Example #1 (Referencing Function EN, Referenced Function EF)
Referencing Function
ID/Name: DC.3.2.3 (Support for Communications Between Provider and Patient…)
Priority: Essential Now
“SHALL” Criteria for This Function:
  • There are 5 “SHALL” criteria for function DC.3.2.3 found at criteria #1, 2, 3, 5, and 10.  
  • Of these, only criterion #10 requires conformance to another function within the profile. Specifically, criterion #10 states “The system SHALL conform to function IN.1.4 (Patient Access Management)”.
Referenced Function
ID/Name: IN.1.4 (Patient Access Management)
Priority: Essential Future 2010
Result
  • The SHALL criteria for function DC.3.2.3 found at criteria #1, 2, 3, and 5 are expected to be implemented at the time conformance is claimed with this profile.
  • Conformance with DC.3.2.3 criterion #10 will not be expected until 2010.
Example #2 (Referencing Function EF, Referenced Function EN)
Referencing Function
ID/Name: DC.2.2.2 (Support Consistent Healthcare Mgt of Patient Groups or Populations)
Priority: Essential Future 2012
“SHALL” Criteria for This Function:
  • There are 4 “SHALL” criteria for function DC.2.2.2 found at criteria #1, 2, 3 and 5.
  • The following criteria require conformance to other functions within the profile. Specifically,
    • Criterion #1 states “The system SHALL conform to DC.2.2.1.2 (Support for Context-Sensitive Care Plans, Guidelines, Protocols)”.
    • Criterion #5 states “The system SHALL conform to function S.2.2.2 (Standard Report Generation)”.
Referenced Functions
ID/Name: DC.2.2.1.2 (Support for Context-Sensitive Care Plans, Guidelines, Protocols)
Priority: Essential Now
ID/Name: S.2.2.2 (Standard Report Generation)
Priority: Essential Now
Result
  • Function DC.2.2.1.2 (Support for Context-Sensitive Care Plans, Guidelines, Protocols) is Essential Now, and the SHALL criteria found at DC.2.2.1.2 criteria #1, 6, 7 and 8 are expected to be implemented at the time conformance is claimed with this profile.
  • Function S.2.2.2 (Standard Report Generation) is Essential Now and the SHALL criteria found at S.2.2.2 criteria #1 and 4 are expected to be implemented at the time conformance is claimed with this profile.
  • Function DC.2.2.2 (Support Consistent Healthcare Management of Patient Groups or Populations) is Essential Future, and the ability to support context-sensitive care plans/guidelines/protocols, or generate standard reports, related to consistent healthcare management of patient groups or populations will not be expected until 2012.

7. STANDARDIZING TERMS IN FUNCTION CRITERIA (REFERENCE)

Additional clarification is necessary to understand the standardized nomenclature used to describe the functions of a system. The following chart, adapted from the EHR-S FM How to Guide for Creating Functional Profiles, illustrates the hierarchy of nomenclature. For example, “capture” is used to describe a function that includes both direct entry “create” and indirect entry through another device “input”. Similarly, “maintain” is used to describe a function that entails reading, updating, or removal of data.

MANAGE
Capture Maintain
  Input Device  (External) Create  (Internal)   Read  (Present)   Update   Remove Access  
    ViewReportDisplayAccess EditCorrectAmend  Augment   ObsoleteInactivateDestroyNullifyPurge

8. COMPONENTS OF LTC-NH EHR-S FUNCTIONAL PROFILE OUTLINE (REFERENCE)

Each function in the LTC-NH EHR-S Functional Profile is identified and described using a set of elements or components as detailed below.

  ID     Type     Priority     Name   Statement/  Description   See  Also     Conformance  Criteria   Row  # FM Source
  ID  #   Criteria  #   Criteria  Status
                     

Function ID

This is the unique outline identification of a function. Functions inherited from the HL7 EHR-S FM retain the ID assigned in the model. New functions added by the authors of the LTC-NH Functional Profile are underscored and shown in blue font.

  • Direct Care functions are identified by "DC" followed by a number (Example DC.1.1.3.1; DC.1.1.3.2).
  • Supportive functions are identified by an "S" followed by a number (Example S.2.1; S.2.1.1).
  • Information Infrastructure functions are identified by an "IN" followed by a number (Example IN.1.1; IN.1.2).

Function Type

Indication of the line item as being a header (H) or function (F).

Function Priority

Indication that implementation of the function is Essential Now (EN), Essential Future (EFxxxx), Optional (O), or Not Applicable (N/A). The definitions for these priorities are found above.

Function Name

The name of the Function (Example: Entity Authentication). Functions inherited from the HL7 EHR-S FM retain the Function Name as stated in the model. Names for new functions added by the authors of the LTC-NH EHR-S Functional Profile are underscored and shown in blue font.

Function Statement

Brief statement of the purpose of this function (Example: Authenticate EHR-S users and/or entities before allowing access to an EHR-S). Functions inherited from the HL7 EHR-S FM retain the Function Statement as shown in the model. Statements for new functions added by the authors of the LTC-NH EHR-S Functional Profile are underscored and shown in blue font.

Description

Detailed description of the function, including examples if needed (Example: Both users and applications are subject to authentication. The EHR-S must provide mechanisms for users and applications to be authenticated. Users will have to be authenticated when they attempt to use the application, the applications must authenticate themselves before accessing EHR information managed by other applications or remote EHR-S...) Functions inherited from the HL7 EHR-S FM retain the portions of the Description shown in the model that are relevant to the nursing home setting, with additional industry-specific explanation being underscored and shown in blue font. Descriptions for new functions added by the authors of the LTC-NH EHR-S Functional Profile are underscored and shown in blue font.

See Also

This element is intended to identify relationships between functions.

Conformance Criteria

This element displays valuable statements used to determine if a particular function is met (Example: The system SHALL authenticate principals prior to accessing an EHR-S application or EHR-S data). Modifications to conformance criteria inherited from the HL7 EHR-S FM are underscored and shown in blue font. Conformance criteria added to functions inherited from the functional model are indicated by an alpha designation (e.g., criterion #4a) and are underscored and shown in blue font. This numbering method allowed developers to display criteria in a logical sequence -- there is no relationship implied in regards to other criterion for the function. Finally, for new functions added to the LTC-NH EHR-S Functional Profile, criterion are underscored and shown in blue font.

Row #

This element is provided to help users when navigating the various sections (i.e., a user can reference row #38 of the IN section versus stating function IN.1.6, criterion #5).

FM Source -- ID #

This element is intended to assist with tracing profile content back to the HL7 EHR-S FM. The column displays the ID# for the source function from the model, or is blank if the function was added by the authors of the LTC-NH EHR-S Functional Profile.

FM Source -- Criteria #

This element is intended to assist with tracing profile content back to the HL7 EHR-S FM. The column displays the number for the source criterion from the model, or is blank if the criterion was added by the authors of the LTC-NH EHR-S Functional Profile.

FM Source -- Criteria Status

This element is intended to assist with tracing profile content back to the HL7 EHR-S FM. The following codes are used to convey the status of the profile’s criteria in relation to the FM:

  • N/C (No Change) -- the criterion is exactly the same as in the FM.

  • A (Added) -- the criterion was added by the EHR-S Functional Profile authors and is not found in the FM.

  • M (Modified) -- the criterion has been modified and is not the same as in the FM. Modifications to the FM text are underscored and shown in blue font.

  • D (Deleted) -- the criterion from the FM was determined to be inappropriate for the profile and was deleted. Only “SHOULD” and “MAY” criterion can be deleted -- “SHALL” criteria from the FM must be inherited by the profile.


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