HIE Ready 2.0 SPECIFICATIONS MATRIX. Product Name: Version Number: Preferred Message and Trigger

Transcription

1 HIE Ready 2.0 SPECIFICATIONS MATRIX Entity Name: Street Address: City, State, Zip: Point of Contact Name: & Phone: Alternate Contact Name: Alternate & Phone: Product Name: Version Number: Please indicate "Yes" in the column labeled " " based on your organization's capabilities. A "Yes" signifies that your organization receives, stores, consumes, creates, sends, transmits, and/or submits a particular message (which can be inbound or outbound or both) in the respective context, and using the standard stated. 1.0 Patient Encounter, Person Maintenance, and Patient Merge ADT Messages 1.1.a HL ADT^A01 Receive Hospital Admission 1.1.b HL ADT^A01 Send Hospital Admission 1.2.a HL ADT^A03 Receive Hospital Discharge 1.2.b HL ADT^A03 Send Hospital Discharge 1.3 HL ADT^A03 Receive Emergency Discharge 1.4.a HL ADT^A04 Receive Register Patient message from Ambulatory or Emergency Department setting 1.4.b HL ADT^A04 Send Register Patient message, that is automatically generated upon completion of a registration process 1.5 HL ADT^A04 Send Register Outpatient Visit message 1.6 HL ADT^A04 Send Emergency Registration Copyright 2013 The California Health and Human Services Agency (CHHS). All rights reserved. Licensed under the Apache License, Version 2.0 (the "License"), you may not use this file except in compliance with the License. You may obtain a copy of the License at: Unless required by applicable law or agreed to in writing, content (including but not limited to software, documentation, information, and all other works distributed under the License) is distributed on an "AS IS" BASIS, WITHOUT WARRANTY OF ANY KIND, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO THE WARRANTIES OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE AND NONINFRINGEMENT. IN NO EVENT SHALL THE AUTHORS OR COPYRIGHT HOLDERS BE LIABLE FOR ANY CLAIM, DAMAGES OR OTHER LIABILITY, WHETHER IN AN ACTION OF CONTRACT, TORT OR OTHERWISE, ARISING FROM, OUT OF OR IN CONNECTION WITH THE CONTENT OR THE USE OR OTHER DEALINGS IN THE CONTENT. IN NO EVENT SHALL CHHS HAVE ANY OBLIGATION TO PROVIDE SUPPORT, UPDATES, AND/OR UPGRADES FOR CONTENT. See the License for the specific language governing permissions and limitations under the License. This publication/product was made possible by Award Number 90HT0029 from Office of the National Coordinator for Health Information Technology (ONC), U.S. Department of Health and Human Services. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of ONC or the State of California.

2 1.8.a 1.8.b 1.9.a 1.9.b 1.10.a 1.10.b HL ADT^A08 Receive Update of Patient Demographic Information HL ADT^A08 Send Update of Patient Demographic Information HL ADT^A31 Receive Person Update HL ADT^A31 Send Person Update HL ADT^A40 Receive Patient Merge HL ADT^A40 Send Patient Merge 2.0 Master File Updates for Patient Locations 2.1.a 2.1.b HL MFN^M05 Receive Update of Patient Location Master File HL MFN^M05 Send Update of Patient Location Master File 3.0 Laboratory Results as Electronic Structured Data 3.1.a 3.1.b (j) 1 Receive and incorporate clinical lab-test results as structured data. Standard: HL7 version AND Implementation Guide: S&I Framework Lab Results Interface (incorporated by reference in ), AND (c)(2) Receive and consume lab test results. LOINC Database version 2.40 (incorporated by reference in ) (j) Create and transmit clinical lab-test results as structured data. Standard: HL7 version AND Implementation Guide: S&I Framework Lab Results Interface (incorporated by reference in ), AND (c)(2) Receive and consume lab test results. LOINC Database version 2.40 (incorporated by reference in ) 3.2.a (a)(3) Receive and consume IHTSDO SNOMED CT International Release July 2012 (incorporated by reference ) and US Extension to SNOMED CT March 2012 Release 3.2.b 3.3.a 3.3.b (a)(3) Create and send IHTSDO SNOMED CT International Release July 2012 (incorporated by reference ) and US Extension to SNOMED CT March 2012 Release Receive and consume HL "no growth" and "preliminary" result messages and update the order status appropriately (OBR Result Status = I, S, A, P and, depending upon usage, R) Create and send HL "no growth" and "preliminary" result messages and update the order status appropriately (OBR Result Status = I, S, A, P and, depending upon usage, R) 1 Unless otherwise indicated, all code section numbers refer to the United States Federal Register, 45 CFR 170, et seq. January 21, 2014 HIE READY 2.0 SPECIFICATIONS Page 2 of 11

3 4.0 Radiology Reports 4.1.a.1 HL ORU^R01 Receive and store Radiology Report as HL ORU or MDM 4.1.a.2 HL ORU^R01 Receive and consume Radiology Report as HL ORU or MDM 4.1.b HL ORU^R01 Create and send Radiology Report as HL ORU or MDM 5.0 Corrected and Canceled Result Messages 5.1.a Receive and consume HL result correction messages (OBR Result Status = C) and order cancel messages received (OBR Result Status = X) AND update the order status appropriately based on the message 5.1.b Create and send HL result correction messages (OBR Result Status = C) AND create and send order cancel messages (OBR Result Status = X) a 6.1.b 6.2.a 6.2.b 6.3.a 6.3.b 6.4.a 6.4.b 6.5.a 6.5.b Text Reports (e.g., H&P, ECG, Discharge Summary, Colonoscopy Report, Progress Notes, Consult Notes, Other Hospital Discharge Summary, etc.) HL MDM^T02 Receive and store original document notification and content, OR, alternative method for receiving text reports: HL ORU^R01 Unsolicited transmission of an observation message (result status is in OBR) HL MDM^T02 Send original document notification and content, OR, alternative method for sending text reports: HL ORU^R01 Unsolicited transmission of an observation message (result status in in OBR) HL MDM^T04 Receive and store document status change notification and content HL MDM^T04 Send document status change notification and content HL MDM^T06 Receive and store document addendum notification and content HL MDM^T06 Send document addendum notification and content HL MDM^T08 Receive and store document edit notification and content HL MDM^T08 Send document edit notification and content HL MDM^T10 Receive and store document replacement notification and content HL MDM^T10 Send document replacement notification and content January 21, 2014 HIE READY 2.0 SPECIFICATIONS Page 3 of 11

4 7.0 Transcription 7.1.a 7.1.b HL MDM^T02 Receive and store original document notification and content for Transcription HL MDM^T02 Create and send original document notification and content for Transcription 8.0 Electronic Orders 8.1.a 8.1.b 8.2.a 8.2.b 8.3.a 8.3.b 8.4.a 8.4.b 8.5.a 8.5.b HL ORM^O01 Receive and store order messages HL ORM^O01 Create and send order messages HL ORM^O01 Receive and store laboratory order messages HL ORM^O01 Create and send laboratory order messages HL ORM^O01 Receive and store radiology order messages HL ORM^O01 Create and send radiology order messages HL ORM^O01 Receive and store other ancillary services order messages HL ORM^O01 Create and send other ancillary services order messages Receive and consumehl ORM messages with 3 or more "Copy to" providers Create and send HL ORM messages with 3 or more "Copy to" providers 9.0 Patient Referral Request 9.1.a 9.1.b 9.2.a 9.2.b HL REF^I12 Receive and store patient referral request, OR, alternatively, HL ORM^O01 is used for this action HL REF^I12 Automatically send patient referral request, OR, alternatively, HL ORM^O01 is used for this action HL RRI^I12 Receive and consume acknowledgement of patient referral request response HL RRI^I12 Create and send acknowledgement of patient referral request received January 21, 2014 HIE READY 2.0 SPECIFICATIONS Page 4 of 11

5 10.0 Transitions of Care Using CCD C a.1 Receive and store a CCD C32 document as specified in the CDA Release 2.1 as further refined by HITSP in its component specification 10.1.a.2 Receive and consume the discrete and textual sections of a CCD C32 document as specified in the CDA Release 2.1 as further refined by HITSP in its component specification 10.2.a.1 Receive and store a CCD according to Direct Project standards Applicability Statement for Secure Health Transport, Version 1.1, 10 July 2012 (incorporated by reference in ) 10.2.a.2 Receive and consume a CCD according to Direct Project Applicability Statement for Secure Health Transport, Version 1.1, 10 July 2012 (incorporated by reference in ) 10.2.b Send CCD according to Direct Project Applicability Statement for Secure Health Transport, Version 1.1, 10 July 2012 (incorporated by reference in ) 10.3.a.1 Receive and store CCD via IHE XDS.b standards as a Document Consumer 10.3.a.2 Receive and consume CCD via IHE XDS.b standards as a Document Consumer 10.3.b Send CCD via IHE XDS.b standards as a Document Source or Integrated Document Source Repository 10.4 Provide a configurable ability to automatically create and transmit a CCD 11.0 Transitions of Care Using Consolidated CDA Documents 11.1.a a b (a)(3) Receive and store clinical summary: HL7 Implementation Guide for CDA Release 2: IHE Health Story Consolidation, (incorporated by reference in ) (Note: The use of the unstructured document document level template is prohibited) (a)(3) Receive and consume clinical summary: HL7 Implementation Guide for CDA Release 2: IHE Health Story Consolidation, (incorporated by reference in ) (Note: The use of the unstructured document document level template is prohibited) (a)(3) Create and send clinical summary: HL7 Implementation Guide for CDA Release 2: IHE Health Story Consolidation, (incorporated by reference in ) (Note: The use of the unstructured document document level template is prohibited) January 21, 2014 HIE READY 2.0 SPECIFICATIONS Page 5 of 11

6 11.2.a (a) Receive and store Consolidated CDA documents according to Direct Project Applicability Statement for Secure Health Transport, Version 1.1, 10 July 2012 (incorporated by reference in ) 11.2.a (a) Receive and consume Consolidated CDA documents according to Direct Project Applicability Statement for Secure Health Transport, Version 1.1, 10 July 2012 (incorporated by reference in ) 11.2.b (a) Create and send Consolidated CDA documents according to Direct Project Applicability Statement for Secure Health Transport, Version 1.1, 10 July 2012 (incorporated by reference in ) (incorporated by reference in ) 11.3.a (b) Receive and store Consolidated CDA documents using transport standards: ONC XDR and XDM for Direct Messaging Specification, version 1, finalized 9 March 2011 (incorporated by reference in ) 11.3.a (b) Receive and consume Consolidated CDA documents using transport standards: ONC XDR and XDM for Direct Messaging Specification, version 1, finalized 9 March 2011 (incorporated by reference in ) 11.3.b (b) Create and send Consolidated CDA documents using transport standards: ONC XDR and XDM for Direct Messaging Specification, version 1, finalized 9 March 2011 (incorporated by reference in ) (a)(3) Within a Consolidated CDA regarding a Problem List: IHTSDO SNOMED CT International Release July 2012 (incorporated by reference in ) and US Extension to SNOMED CT March 2012 Release (incorporated by reference in ) (c)(2) Within a Consolidated CDA regarding Laboratory Tests: LOINC Database version 2.40 (incorporated by reference in ) (d)(2) Within a Consolidated CDA regarding Medications: RxNorm, a standardized nomenclature for clinical drugs produced by the United States National Library of Medicine, August 6, 2012 Release (incorporated by reference in ) (e)(2) Within a Consolidated CDA regarding Immunizations: LOINC Database version 2.40 (incorporated by reference in ) January 21, 2014 HIE READY 2.0 SPECIFICATIONS Page 6 of 11

7 (f) Within a Consolidated CDA regarding Race and Ethnicity: The Office of Management and Budget Standards for Maintaining, Collecting, and Presenting Federal Data on Race and Ethnicity, Statistical Policy Directive No. 15, as revised, October 30, 1997 (see Revisions to the Standards for the Classification of Federal Data on Race and Ethnicity, available at (g) Within a Consolidated CDA regarding Preferred Language: As specified by the Library of Congress, ISO alpha-3 codes limited to those that also have a corresponding alpha-2 code in ISO (incorporated by reference in ) (h) Within a Consolidated CDA regarding Smoking Status: Smoking status must be coded in one of the following SNOMED CT codes: (1) Current every day smoker ; (2) Current some day smoker ; (3) Former smoker ; (4) Never smoker ; (5) Smoker, current status unknown ; (6) Unknown if ever smoked ; (7) Heavy tobacco smoker ; (8) Light tobacco smoker (i) Within a Consolidated CDA regarding Encounter Diagnoses: Properly utilize and employ the code set specified at 45 CFR (c)(2) for the indicated conditions [45 CFR (c)(2) International Classification of Diseases, 10th Revision, Clinical Modification (ICD 10 CM) (including The Official ICD 10 CM Guidelines for Coding and Reporting), as maintained and distributed by HHS, for the following conditions: (i) Diseases. (ii) Injuries. (iii) Impairments. (iv) Other health problems and manifestations. (v) Causes of injury, disease, impairment, or other health problems] a.1 Document Consumer: Retrieve and store documents via IHE XDS.b standards as a Document Consumer from one or more Document Repository (IHE IT Infrastructure Technical Framework, Vol. 1 Integration Profiles, Rev. 9.0 Final Text ) a.2 Document Consumer: Retrieve and consume documents via IHE XDS.b standards as a Document Consumer from one or more Document Repository (IHE IT Infrastructure Technical Framework, Vol. 1 Integration Profiles, Rev. 9.0 Final Text ) b Document Source: Create and send documents via IHE XDS.b standards as a Document Source to a Document Repository (IHE IT Infrastructure Technical Framework, Vol. 1 Integration Profiles, Rev. 9.0 Final Text ) January 21, 2014 HIE READY 2.0 SPECIFICATIONS Page 7 of 11

8 11.14 Document Repository: Receive and store documents via IHE XDS.b standards as a Document Repository (IHE IT Infrastructure Technical Framework, Vol. 1 Integration Profiles, Rev. 9.0 Final Text ) Document Registry: Respond to queries from Document Consumers for documents via IHE XDS.b standards as a Document Registry (IHE IT Infrastructure Technical Framework, Vol. 1 Integration Profiles, Rev. 9.0 Final Text ) Provide a configurable ability to automatically create and transmit Consolidated CDAs 12.0 Transfer Context and Control 12.1 Provide capability to transfer context and control using context-aware interfaces: HL7 Context Management "CCOW" Standard Version 1.6, February Patient Engagement 13.1 Provide web-access for patients to Transmit Data (a) Web Content Accessibility Guidelines (WCAG) 2.0, Level A Conformance 13.2 Alignment with all BlueButton+ Content Standards: Immunization Registries Data Submission 14.1 Create and submit electronic immunization data to immunization registries or immunization information systems: (e)(3) HL (incorporated by reference ), and Implementation specifications in Implementation Guide for Immunization Messaging Release 1.4) 14.2 Create and submit electronic immunization data: (e)(2) HL7 Standard Code Set CVX - Vaccines Administered, updates through July 11, 2012 (incorporated by reference ) 14.3 Create and submit electronic immunization data in compliance with California Department of Public Health (CDPH) FAQs re Immunization Electronic Data Submission: January 21, 2014 HIE READY 2.0 SPECIFICATIONS Page 8 of 11

9 15.0 Lab Results to Public Health Agencies (g) Create and send lab results to public health agencies using HL and Implementation specifications: Implementation Guide: Electronic Laboratory Reporting to Public Health, Release 1 (US Realm) (incorporated by reference in ) with Errata and Clarifications, and ELR Clarification Document for EHR Technology Certification) (a)(3) Create and send lab results to public health agencies using: IHTSDO SNOMED CT International Release July 2012 (incorporated by reference ) and US Extension to SNOMED CT March 2012 Release (incorporated by reference ) AND (c)(2)LOINC Version Create and send lab results to public health agencies using California requirements: California Reportable Disease Information Exchange (CalREDIE) Electronic Laboratory Records (ELR) User Guide August 2013, AND California Reportable Disease Information Exchange (CalREDIE) HL ELR2PH Companion Guide Version 1.02, July Syndromic Surveillance Data Submission (d)(2) AND (d)(3) Create and submit syndromic surveillance data using (ambulatory setting only): HL (incorporated by reference in ) AND Implementation specifications: PHIN Messaging Guide for Syndromic Surveillance and Conformance Clarification for EHR Certification of Electronic Syndromic Surveillance, Addendum to PHIN Messaging Guide for Syndromic Surveillance) 17.0 Cancer Registries (Report Cancer Cases) 17.1 Identify and report cancer cases to State cancer registry (except where prohibited, and in accordance with applicable law and practice), see California Cancer Registry at Create and send cancer information to State cancer registry: (i) HL7 Clinical Document Architecture (CDA), Release 2.0, Normative Edition (incorporated by reference in ) AND Implementation specifications in Implementation Guide for Ambulatory Healthcare Provider Reporting to Central Cancer Registries, HL7 Clinical Document Architecture (CDA) 17.3 Create and send cancer information to State cancer registry: (a)(3) IHTSDO SNOMED CT International Release July 2012 and US Extension to SNOMED CT March 2012 Release AND (c)(2) LOINC Version 2.40 January 21, 2014 HIE READY 2.0 SPECIFICATIONS Page 9 of 11

10 18.0 Clinical Quality Measures (CQMs) (c) Create and send Clinical quality measure-by-measure data: Data Element Catalog) [ Approach to Interfaces & Hosting Interfaces and Hosting Yes / No Interface is integral to the EHR software. No additional hardware, software, or hosting components required. Interface is a separate software component. Software costs are included in the interface cost, but additional hardware may be required. Interface is a separate appliance. Hardware and software costs are included in the interface cost. Interface is a separate hosted service. Software and hosting services are included in the interface cost. Interface is a separate hosted service. Software is included in the interface cost; however, a hosting company MAY charge extra. Pricing Details: ENTITY-EHR Provider catalog HIE Ready price per instance in California for any client on maintenance with ENTITY-EHR Provider and on the currently supported product version for items listed above as EHR meeting this standard: Annual Maintenance cost to the client: $ $ Additional explanation of pricing if any: January 21, 2014 HIE READY 2.0 SPECIFICATIONS Page 10 of 11

11 For ENTITY: Signed By: Name: Title: Date: January 21, 2014 HIE READY 2.0 SPECIFICATIONS Page 11 of 11