| 1 Care Management |
| 1.1 Health
information capture and review |
| 1.1.1 Lookup patient |
| 1.1.2 Manage Patient
Demographics |
| 1.1.3 Manage Problem List |
| 1.1.4 Manage Medication
List (Current and Historical) |
| 1.1.5 Manage Allergy List |
| 1.1.6 Manage Patient
History |
| 1.1.7 Manage clinical
documents and notes |
| 1.1.8 Manage Health
maintenance items, immunizations |
| 1.1.9 Manage vital
signs/findings/inputs and outputs |
| 1.1.10 Review chart summary |
| 1.1.11 Review "large
objects" (image, video, waveform) |
| 1.1.12 Review growth charts
|
| 1.1.13 Document disposition
|
| 1.1.14 Patient entered data |
|
or... |
| 1.1.1
Capture of key data (e.g., using standardized code sets / nomenclature,
point-of-care capture, patient / family entered data -- including
multimedia) |
| 1.1.2
Capture of clinical documents / documentation through various means --
narrative, template, structured documents, data sets, and coded data |
| 1.2 Care
Planning, Critical Paths, Protocols |
| 1.2.1 Passive guidelines
for clinical support during data entry/patient care |
| 1.2.2 Support for disease
based protocols |
| 1.2.3 Interactive care
plans |
| 1.3 Medications,
medication management (includes prescriptions) |
| 1.3.1 Drug dosage defaults
or templates |
| 1.3.2 Prescription
formularies (optional) |
| 1.3.3 Prescription cost
(optional) |
| 1.4 Orders, Referrals,
and Results Management |
| 1.4.1 Order advice/rules (EF) |
| 1.4.2 Manage laboratory
results |
| 1.4.3 Manage other results |
| 1.5 Patient
Flags, Precautions, and Adverse Events |
| 1.5.1 Allergies |
| 1.6 Health
Maintenance: Preventive Care, Wellness, Disease Management |
| 1.7
Consents and Authorizations |
| 1.8 Episodes,
Problem Management - Problem Oriented Care |
|
| 2 Clinical Decision
Support |
| 2.1 Access to knowledge
sources |
| 2.2 Drug alerts |
| 2.3 Other rule-based
alerts |
| 2.4 Clinical reminders |
| 2.5 Clinical Pathways
and reminders |
| 2.6 Chronic disease
management |
| 2.7 Incorporate patient
and family preferences |
| 2.8 Diagnostic decision
support |
|
| 3 Operations Management
and Communications |
| 3.1 Operations
Work Flow (including staging, sequencing, and routing) |
| 3.2 Scheduling |
| 3.3 Work
Lists |
| 3.4 Communication |
| 3.4.1
Inter-Practitioner Communication |
| 3.4.2
Team Coordination |
| 3.4.3
Practitioner/Patient/Family Communication |
| 3.4.4
Patient, Family and Care Giver Education |
| 3.5 Enable business,
clinical, and regulatory rules and guidelines |
|
| 4 Clinical
Support |
| 4.1
Disease Registries |
| 4.2 Donor, Blood Bank |
| 4.3 Patient
Locator |
| 4.4 Practitioner
Locator |
| 4.5 Patient
Transport |
| 4.6 Bed
Management |
| 4.7 Demographics,
De-Identification, Anonomization |
|
| 5 Measurement,
Analysis, Research and Reports |
| 5.1 Outcomes
monitoring, measuring, and reporting |
| 5.2 Quality
Indicators |
| 5.3 Performance
and Accountability Measures |
| 5.4 Analysis
and Measures |
| 5.5 Create
Reports, Reporting (may include Print Chart) |
| 5.6 Export data (EF,
since need format for public health, CMS) |
| 5.7 Epidemiological
Surveillance |
| 5.8 Population
based disease management support (may include disease registries) |
|
| 6
Administrative and Financial |
| 6.1 Encounter
Management |
| 6.2 Eligibility
and Enrollment |
| 6.3 Authorizations
and Referrals. |
| 6.4 Practitioner/Patient
Relationship |
| 6.5 Multiple
Person Linkages |
| 6.6
Coding - Diagnosis, Procedures, Outcomes |
| 6.7 Charges,
Charge Management |
| 6.8 Costs,
Cost Management |
| 6.9 Local
Authority/Localization |
| 6.10 Acuity and Severity |
|
| 7 Infostructure |
| 7.1 Security |
| 7.2 Privacy |
| 7.3 Audit trail |
| 7.4 Registries |
| 7.5 Interoperability |
| 7.5.1 Vocabulary |
| 7.6 Record management |