Overview: Beacon-EHR Vendor Technical Work Group Version 1.0 work products

Transcription

1 Overview: Beacon-EHR Vendor Technical Work Group Version 1.0 work products This document provides an overview of each of the Beacon-EHR Vendor Technical Work Group work products developed between January and April, The following vendors and Beacon Communities participated in the Technical WG: Beacons Cincinnati Tulsa San Diego Southeast Michigan Inland NW Tulsa Vendors Allscripts GE Greenway NextGen Vitera Cerner Although the work products were created and develop by the Technical WG members, all Beacons provided input and review of the workgroup deliverables. Beacon Technical Discovery Guide Version 1.0 Interviews were completed with every Beacon to assess what interoperability capabilities exist in their systems today and these capabilities are represented in this spreadsheet. There are three main areas that were focused on: Triggers, Transport/Patient Identity and Security and Privacy. This document will be helpful for vendors working with the Beacon communities to understand their current exchange infrastructure and interoperability capabilities. Beacon User Stories Version 1.0 User stories were collected from all Beacons, which represented the top priority user stories involving CCD exchange. All User stories were reviewed and consolidated into two common user stories: Update Clinical Registry or Repository and Patient Referral. These are to be the basis of further workgroup efforts to meet medium term goal as outlined in the charter. Beacon-Vendor C83 Data Element Analysis Version 1.0 This document contains feedback from vendors about which data elements, and to what extent their systems are capable of exporting a CCD from a production environment today as well as feedback from the Beacons on what their priorities and capabilities are for consumption of these data elements. ONC Beacon-EHR Vendor Affinity Group/Technical Work Group 1

2 Each vendor was asked to review the C83 spreadsheet and for each data element to identify the ability (KEY: 0 = Nothing at all, 1 = Text, 2 = Structured, but not coded, 3 = Coded, but not accepted standards, 4 = coded and standards) of their system(s) as of May 20, 2012 to a) support the data element in the EHR and 2) be included in a CCD for export. The vendor data was consolidated and deidentified. In a spreadsheet containing the de-identified vendor information, the T-WG member Beacons were asked to review both the C83 sections and the C83 data elements and to prioritize (: 0 = None/Not,,, ) their need for each data element. A combined effort between Beacons and vendors was completed to agree on priority set of data elements to be supported on May 20, 2012, and to also identify gaps where vendors may not be able to support the Beacons priorities in a production environment today. Additionally the group identified data elements that will be needed during the Beacon program timeline, but were not as urgent as the highest priority elements. Those additional data elements will be reviewed as a medium term goal to determine timeline for inclusion in the vendor EHRs. The final consensus document was review and approved by each Beacon community. The spreadsheet directions were provided as part of the spreadsheet: The C83 Data Element Analysis is intended to serve as a set of common data elements, referenced in a C83 document, that Beacon Community participants and EHR vendors have indicated as their top priority to be implemented in EHR systems EHR vendors participating in the ONC Beacon-EHR Affinity Group have agreed that these data elements will be included in their production product. How to Use this document: Beacon Instructions - Instructions to the Beacon Communities on how to complete the Sections and Entries tabs C83 Sections - Beacons - For those Beacons that choose to respond to their data needs at the C83 Sections level, this identifies Beacon's responses indicating their highest priority Data Sections, without specifying the detail data elements contained within those sections. C83 Entries - Beacons - For those Beacons that choose to respond to their data needs at the C83 Data Entries level, this identifies Beacon's responses indicating their priority for each of the individual data elements identified in the C83 document Beacon-Vendor Consolidated - This represents both the Beacons highest priority data elements compared against the EHR vendors ability to support those data elements in their May 20,2012 version of their products C83 implementation. A consensus was arrived at and is identified in column "U". The data elements with a response of "Y represents the data elements to be supported in EHR vendor systems on May 20th. Column "V" represents data elements that will be reviewed in the next 3-4 for possible inclusion. Column W represents data elements where the Beacons have identified ONC Beacon-EHR Vendor Affinity Group/Technical Work Group 2

3 that they want it included in the EHR product but more than 1 vendor has indicated that it will not be available ONC Beacon-EHR Vendor Affinity Group/Technical Work Group 3

4 Background and Purpose: A version of this spreadsheet was initially used as part of the NYeC led HIE EHR Interoperability WG initiative to capture the capability of vendors systems to produce various data elements in a C83 based document. We are reusing this in order to capture an update of these EHR vendor systems to understand what they are capable of producing on or before May 20th, 2012 as well as to capture the priority for each data elements from all the Beacons. This is not intended to meet all the needs of every Beacon user story, but is more intended provide a starting point for discussions between Beacons and EHRs to achieve C83 interoperability as soon as possible. Instructions: There are two worksheets included in this spreadsheet (see additional details below) and depending on the level of C83 implementation or the understanding of the data elements by the Beacon one or both of these worksheets should be completed. Those Beacons that have an understanding of C83 entries should fill out both the C83 Sections and C83 Entries worksheets. Those Beacons that do not have an understanding of C83 Entries should only focus on the C83 Sections worksheet. The highlighted columns should be filled out with priority based on Beacon goals and whether or not the data can be consumed by the Beacon on or before May 20th, If an answer to a C83 Section is 0 then the corresponding C83 Entries rows should not be filled out. Key Definitions: Do not ever need to capture/collect data element Beacon needs it now and is ready to consume it. A data element cannot have a priority of 1 without a Beacon being capable of consuming it now. Beacons need it but either are not quite ready to process, or is lower on priority list of goals to achieve. Beacons may need for stretch goals, lowest priorty in relation to other data elements.

5 HOW TO USE THIS SPREADSHEET The C83 Data Element Analysis is intended to serve as a set of common data elements, referenced in a C83 document, that Beacon Community participants and EHR vendors have indicated as their top priority to be implemented in EHR systems EHR vendors participating in the ONC Beacon-EHR Affinity Group have agreed that these data elements will be included in their production product. How to Use this document: Beacon Instructions - Instructions to the Beacon Communities on how to Complete the Sections and Entries tabs C83 Sections - Beacons - For those Beacons that choose to respond to their data needs at the C83 Sections level, this identifies Beacon's responses indicating their highest priority Data Sections, without specifying the detail data elements contained within those sections. C83 Entries - Beacons - For those Beacons that choose to respond to their data needs at the C83 Data Entries level, this identifies Beacon's responses indicating their priority for each of the individual data elements identified in the C83 document Beacon-Vendor Consolidated - This represents both the Beacons highest priority data elements compared against the EHR vendors ability to support those data elements in their May 20,2012 version of their products C83 implementation. A consensus was arrived at and is identified in column "U". The data elements with a response of "Y", represent the data elements to be supported in EHR vendor systems on May 20th. Column "V" represents data elements that will be reviewed in the next 3-4 for possible inclusion. Column W represents data elements where the Beacons have identified that they want it included in the EHR product but more than 1 vendor has indicated that it will not be available.

6 Number of vendors indicating this response (CCD in Production) KEY (see Instructions worksheet for definitions) 0 = Nothing at all 1 = Text 2 = Structured, but not coded 3 = Coded, but not accepted standards 4 = coded and standards Gap = Consens Future needed for us Conside May 20, but (Include ration - some Y/N) for past vendors May 20 May 20 cannot meet * O/R stands for O=Optionality (when the data element is to be sent) which has the values of Required [R], Required, if known [R2], Optional [O], or Conditional [C]; and Repeatability (when the data element is repeatable) which has values of Yes [Y] or No [N]. Details of the definitions can be found in the C83 document in tables 2-3 and 2-4. Identifier Name Description CO - Beacon Priority Cincinnati - Beacon Priority SE MN Tulsa ILNW So Piedmont WNY Count = 0 Count = 1 Count > C83 (O/R)* 1. Patient Demographics (Personal Information) 1.01 Timestamp Date and time that document was created Y N R/N 1.02 Person ID Unique Patient Identifier Y N R/N 1.03 Person Address Home street, town, county, state, zip - Multiple Addresses allowed Y N R/Y 1.04 Person Phone/ /URL A telephone number (voice or fax), address or other locator Y N R/Y 1.05 Person Name Last, First, Middle Initial Y N R/Y 1.06 Gender Administrative gender of Patient Y N R/N 1.07 Date of Birth Date of Patients Birth Y N R/N 1.08 Marital Status A value representing the domestic partnership status of a person Y N R2/Y 1.09 Religious Affiliation the religious preference of the person N Y O/N 1.1 Race Race of Patient Y N O/Y 1.11 Ethnicity Ethnicity of Patient Y N O/N 2. Language Spoken 2.01 Primary Language Spoken, written or understood primary language of Patient Y N/A R/Y 3. Support 3.01 Date The period over which the support is provided N Y R/N 3.02 Contact Type This represents the type of support provided, such as immediate N Y R/N 3.03 Contact Relationship Identifies the relationship of the contact person to the individual for which N Y R2/N 3.04 Contact Address The address of the contact individual or organization providing support N Y R2/Y 3.05 Contact Phone/ /URL A telephone number (voice or fax), address, or other locator for the N Y R2/Y 3.06 Contact Name The name of the individual or organization providing support N Y R/Y 4. Health Care Providers Date Range The period over which this provider has provided healthcare services N Y R/N 4.02 Provider Role Code PCP, Referring, Attending, Consulting, etc N Y R2/N 4.03 Provider Role Free-Text N Y R2/N 4.04 Provider Type Physician, Dentist, etc N Y R2/N 4.05 Provider Address Practice Address Y N R2/Y 4.06 Provider Phone/ /URL A telephone number (voice or fax), address or other locator Y N R2/Y 4.07 Provider Name Last, First, Middle Initial, NPI Y N R2/N 4.08 Provider's Organization Name of Practice where this patient was seen Y N R2/Y 4.09 Providers Patient ID The user visible Medical Record Number of Patient N Y R2/N 4.1 National Provider ID National Provider Identifier or NPI is a unique identification number Y N Y R2/N 5. Health Insurance Provider 5.01 Group Number The policy or group contract number N Y R/N 5.02 Insurance Type HMO, PPO, Medicare, etc N Y R2/N 5.03 Health Plan Insurance Information The coded identifier of the payer corresponding to the Health Plan N Y O/Y 5.04 Health Plan Insurance Information Postal Address of Health Plan N Y O/Y 5.05 Health Plan Insurance Information A telephone number (voice or fax), address or other locator N Y O/Y 5.06 Insurance Information Source Name Name of the entity that is the source of information N Y R2/N 5.07 Health Plan coverage dates the beginning and end dates of the health plan coverage of the individual N Y R2/N 5.08 Member/Subscriber ID Identifier assigned to Patient by the health plan N Y R2/N 5.09 Patient Relationship to Subscriber Specified only when patient is not the subscriber N Y R2/N 5.14 Financial Responsibility Party Type The type of party that has responsibility for all or a portion of the patient's N Y R2/N 5.15 Subscriber ID The identifier assigned by the health plan to the actual member or health N Y R/N 5.16 Subscriber Address The official mailing address of the actual member or health plan contract N Y R/N 5.17 Subscriber Phone/ /URL A telephone number (voice or fax), address or other locator for a N Y R2/Y 5.18 Subscriber Name The name of the actual member or health plan contract holder N Y R/N 5.19 Subscriber Date of Birth The date of birth of the actual member or health plan contract holder N Y R/N 5.24 Health Plan Name Name of the specific health insurance product N Y R2/N 5.25 Insurance Company Name The name of the insurance company N Y - 6. Allergy/Drug Sensitivity 6.01 Adverse event date Date of when allergy or intolerance became known Y N R2/N 6.02 Adverse event type Coded type of product and event Y N R/N 6.03 Product Free Text Name or description of product/agent that causes allergy Y N R/N 6.04 Product Code Code describing the product Y N R2/N 6.05 Reaction Free Text Reaction that may be caused by product SPECIFIC FOR PATIENT Y N R2/N 6.06 Reaction Coded Code describing the reaction Y N R2/N 6.07 Severity Free Text Level of severity of reaction to product Y N Y R2/N 6.08 Severity Coded Code describing the level of severity of the allergy to product Y N Y R2/N 7. Problem/Condition 7.01 Problem Date When the problem became active (or Date of Diagnosis) Y N R2/N 7.02 Problem Type Fixed value to determine the existence of a problem Y N R2/N 7.03 Problem Name Text description of the problem Y N R/N

7 Number of vendors indicating this response (CCD in Production) KEY (see Instructions worksheet for definitions) 0 = Nothing at all 1 = Text 2 = Structured, but not coded 3 = Coded, but not accepted standards 4 = coded and standards Gap = Consens Future needed for us Conside May 20, but (Include ration - some Y/N) for past vendors May 20 May 20 cannot meet * O/R stands for O=Optionality (when the data element is to be sent) which has the values of Required [R], Required, if known [R2], Optional [O], or Conditional [C]; and Repeatability (when the data element is repeatable) which has values of Yes [Y] or No [N]. Details of the definitions can be found in the C83 document in tables 2-3 and 2-4. Identifier Name Description CO - Beacon Priority Cincinnati - Beacon Priority SE MN Tulsa ILNW So Piedmont WNY Count = 0 Count = 1 Count > C83 (O/R)* 7.04 Problem Code Coded describing the problem Y N O/N 7.05 Treating Provider Name of Treating Provider N Y O/Y 7.06 Age (at Onset) The age of the patient or subject at onset of the condition N Y O/N 7.07 Cause of Death Indicates that this problem was one of the causes of death for the patient or N Y O/N 7.08 Age (at Death) The age of the patient or subject at death N Y O/N 7.09 Time of Death Date and time of death N Y O/N 7.11 Treating Provider ID NPI number for provider or providers treating the patient for condition N Y R2/N 7.12 Problem Status Status of problem (active, inactive, resolved) Y N Y O/N 8. Medication 8.01 Free Text Sig The instructions, typically from the ordering provider, to the patient Y N O/N 8.02 Medication Stopped Whether or not a medication was discontinued Y N O/N 8.03 Administration Timing A Sig Component: defines a specific administration or use time N Y O/N 8.04 Frequency How often the medication is to be administered Y N Y O/N 8.05 Interval A Sig Component: defines how the product is to be administered as an N Y O/N 8.06 Duration Length of time medication should be continued Y N Y O/N 8.07 Route A Sig Component: indicates how the medication is received by the patient Y N O/N 8.08 Dose The amount of medication to be given Y N O/N 8.09 Site A Sig Component: The anatomic site where the medication is administered N Y O/N 8.1 Dose Restriction A Sig Component: defines a maximum or dose limit N Y O/N 8.11 Product Form Physical form of medication (Tablet, liquid, etc.) N Y O/N 8.12 Delivery Method A Sig Component: A description of how the product is N Y O/N 8.13 Coded Product Name Code describing the product Y N R2/Y 8.14 Coded Brand Name Code describing the product as a branded or trademarked name N Y R2/Y 8.15 Free Text Product Name The name of the substance or product Y N R/N 8.16 Free Text Brand Name The branded or trademarked name of substance or product N Y R2/N 8.17 Drug Manufacturer The manufacturer of the substance or product as ordered or supplied N Y O/N 8.18 Product Concentration The amount of active ingredient, or substance of interest, in a specified N Y R2/N 8.19 Type of Medication Prescription, OTC N Y R2/N 8.2 Status of medication Active, Discharge, Chronic, Acute, etc Y N Y R2/N 8.21 Indication A Sig Component: The medical condition or problem intended to be N Y O/Y 8.22 Patient Instructions Instructions to the patient that are not traditionally part of the Sig N Y O/N 8.23 Reaction Any noted intended or unintended effects of the product N Y O/N 8.24 Vehicle A Sig Component: Non-active ingredient(s), or substances not of N Y O/Y 8.25 Dose Indicator A Sig Component: A criteria that specifies when an action is, or is not, to N Y O/Y 8.26 Order Number The order identifier from the perspective of the ordering clinician N Y R2/N 8.27 Fills The number of times that the ordering provider has authorized the N Y O/N 8.28 Quantity Ordered The amount of product indicated by the ordering provider to be dispensed N Y R2/N 8.29 Order Expiration Date when order is no longer valid N Y R2/N 8.3 Order Date Date when the ordering provider wrote the prescription/order Y N Y O/N 8.31 Ordering Provider NPI of provider who ordered Medication Y N Y O/N 8.32 Fulfillment Instructions Instructions to the dispensing pharmacist or nurse that are not traditionally N Y O/N 8.33 Fulfillment History History of dispenses for this order N Y O/Y 8.34 Prescription Number The prescription identifier assigned by the pharmacy N Y R2/N 8.35 Dispensing Pharmacy The pharmacy that performed this dispense N Y O/N 8.36 Dispensing Pharmacy Location The pharmacy's location N Y O/N 8.37 Dispense Date Date prescrioption was dispensed (fulfillment history) N Y O/N 8.38 Quantity Dispensed The actual quantity of product supplied in this dispense N Y R2/N 8.39 Fill number The fill number for the history entry N Y R2/N 8.4 Fill Status Completed, never dispensed, etc N Y O/N 9. Pregnancy 9.01 Pregnancy Whether the patient is currently pregnant N Y O/N 10. Information Source Author Time Time which information was created Y N R/N Author Name Name of person who created the information Y N R/N Reference A reference to the original document from which this information was N Y R2/Y Reference Document ID Identifier of the external document that was referenced N Y R/N Reference Document URL A URL from which this document may be retrieved N Y O/N Source Name Name of organization that provided information N Y R/N 12. Advance Directive Advance Directive type Code describing the type of advance directive N Y R2/N Advance directive text Free text describing advance directive N Y R/N Effective Date Effective date for advance directive N Y R/N Custodian of the Document Name, address or other contact information for the person or organization N Y R/N

8 Number of vendors indicating this response (CCD in Production) KEY (see Instructions worksheet for definitions) 0 = Nothing at all 1 = Text 2 = Structured, but not coded 3 = Coded, but not accepted standards 4 = coded and standards Gap = Consens Future needed for us Conside May 20, but (Include ration - some Y/N) for past vendors May 20 May 20 cannot meet * O/R stands for O=Optionality (when the data element is to be sent) which has the values of Required [R], Required, if known [R2], Optional [O], or Conditional [C]; and Repeatability (when the data element is repeatable) which has values of Yes [Y] or No [N]. Details of the definitions can be found in the C83 document in tables 2-3 and 2-4. Identifier Name Description CO - Beacon Priority Cincinnati - Beacon Priority SE MN Tulsa ILNW So Piedmont WNY Count = 0 Count = 1 Count > C83 (O/R)* 13. Immunizations Refusal Flag that immunization did not occur; nature of refusal N Y R/N Administered Date Date immunization was administered or refused Y N O/N Medication Series Number Indicate which in a series of administrations a particular administration N Y O/N Reaction Any noted intended or unintended effects of the product. For example: full N Y O/Y Performer NPI of provider that administered immunization N Y O/N Coded Product Name Code describing the product Y N R2/Y Product Name free text Name of substance or product Y N R/N Drug Manufacturer Manufacturer of the substance or pruduct N Y O/N Lot Number Production Lot number N Y R2/N 13.1 Refusal Reason A coded representation of the reason for refusing the immunization N Y R2/N Immunization Information Source N Y Vital Signs Vital Sign Result ID An identifier for this specific vital sign observation Y N R/Y Vital sign date Date of observation Y N R/N Vital sign type The coded representation of the vital sign observation Y N R/N Vital sign result status Status for vital sign observation (e.g. complete, preliminary, etc.) N Y R/N Vital sign value The value of the result including units of measure Y N C/N Vital Sign Result Interpretation An abbreviated interpretation of the vital sign observation, e.g., normal, N Y O/N Vital Sign Result Reference Range Reference range(s) for the vital sign observation N Y not O/Y 15. Results Result ID An identifier for this specific observation Y N R/Y Result Date/Time Date and time of observation Y N R/N Result Type Code describing the observation performed or made Y N R/N Result Status Status for observation (Complete, preliminary, addendum, etc.) Y N Y R/N Result Value The value of the result including units of measure Y N C/N Result Interpretation An abbreviated interpretation of the observation, e.g., normal, abnormal, Y N Y O/N Result Reference Range Reference range(s) for the observation Y N O/Y 16. Encounter captured Encounter ID An identifier for this Encounter Y N R/Y Encounter Type Coded value describing the type of encounter Y N R2/N Encounter type free text Free text describing the type of enounter Not sure N Y R/N Encounter Date Date of encounter Y N R/N Enounter Provider Name provider who performed encounter (or NPI) N Y R2/Y Admission Source Identifies where the patient was admitted N Y O/N Admission Type Indicates the circumstances under which the patient was or will be admitted N Y O/N Encounter location The service delivery location N Y represent O/N Arrival date/time The date and time the patient arrived at the location N Y represent O/N Reason for Visit ndicates the rationale for the encounter N Y represent O/N 17. Procedure Procedure ID An identifier for this Procedure Y N R/Y Coded Procedure Type Code describing the type of procedure Y N Y R2/N Procedure type free text Free text describing the procedure Y N R/N Procedure Date Date procedure was performed Y N R2/N Procedure Provider NPI of provider who performed procedure N Y realted to R2/N 19. Social History Social History Date Range of time of which social history event was active Y N Y R2/N Coded social history Code describing the type of social history observation Y N Y R2/N Social History free text Textual description of social history (e.g. smoking status) N Y R/N Social History Observed Value Value describing the social history (e.g. smoking history) Y N Y O/N 24. Order Order Group Number An order group is a list of orders associated with an -placer group number N Y Order Status Report the status of an order either upon request or when the status N Y Parent Order Number The Order number of the Parent Order which may have spawned Child N Y Date Time of Transaction The date and time of the order transaction N Y Order Entered By The identity of the person who actually keyed the request into the order N Y Order Verified By The identity of the person who verified the accuracy of the entered request N Y Order Setting Type Indicates the care setting in which the order is executed N Y Requested Order Start Date/Time The date/time when the ordering provider is requesting the execution of N Y Order Priority The priority of the order N Y Placer Order Number The order identifier from the perspective of the system placing the order N Y Filler Order Number The order identifier from the perspective of the system fulfilling the order N Y Order Code The order code for the requested observation, test, and/or battery. Note: N Y -

9 Number of vendors indicating this response (CCD in Production) KEY (see Instructions worksheet for definitions) 0 = Nothing at all 1 = Text 2 = Structured, but not coded 3 = Coded, but not accepted standards 4 = coded and standards Gap = Consens Future needed for us Conside May 20, but (Include ration - some Y/N) for past vendors May 20 May 20 cannot meet * O/R stands for O=Optionality (when the data element is to be sent) which has the values of Required [R], Required, if known [R2], Optional [O], or Conditional [C]; and Repeatability (when the data element is repeatable) which has values of Yes [Y] or No [N]. Details of the definitions can be found in the C83 document in tables 2-3 and 2-4. Identifier Name Description CO - Beacon Priority Cincinnati - Beacon Priority SE MN Tulsa ILNW So Piedmont WNY Count = 0 Count = 1 Count > C83 (O/R)* Specimen Action Identifies the action to be taken with respect to the specimens that N Y Ordering Provider The person that wrote this order (may include both a name and an N Y Results Distribution List Identifies the people and/or organization that are to receive copies of the N Y Specimen Collector ID The person, department, or facility that collected the specimen. (may N Y -

10 BEACON Data Element Requirements 1 Colorado Responses Colorado Comments Cincinnati Responses Cincinnati Comments SE Michigan Responses SE Michigan Comments Tulsa Responses Tulsa Comments Inland NW Responses Inland NW Comments Southern Piedmont Responses Southern Piedmont Comments WNY Beacon Responses WNY BEacon Comments able to KEY for MyHealth Usage consume by M = Beacon Measure May 20th, 2012 P = Portal Display A = Analytics 2012 able to consume by May 20th, 2012 Identifier Name Description Beacon Priority Consume Beacon Priority Consume Beacon Priority Consume Beacon Priority Consume Beacon Priority Consume Beacon Priority Consume 1. Patient Demographics (Personal Information) Note: We are currently in the process of standing up, testing and certifying our HIE, and will be concurrently piloting 1 Health System, 2 FQHCs and 2 private practices around the May 20th time frame, with plans Not a Beacon priority as we already get 1.01 Timestamp Date and time that document was created 0 Yes R Y to be fully operational by mid to late June 1 y M. P, A 1 Y 1 Y 0 Yes What about patient local ID? (For all sections, we need a primary ID or system ID.) We also want to know who the primary provider for the patient is Person ID Unique Patient Identifier R Y 1 y M. P, A 1 Y 1 Y 1 Y 1 y M. P, A 1 Y 1 Y 0 Yes 1.03 Person Address Home street, town, county, state, zip - Multiple Addresses allowed Person Phone/ /URL A telephone number (voice or fax), address or other locator 1 Y 1 y M. P, A 1 Y 1 Y 0 Yes Already broken out by first, last name 1.05 Person Name Last, First, Middle Initial Need broken out first name, last name. R Y 1 y M. P, A 1 Y 1 Y 0 Yes 1.06 Gender Administrative gender of Patient R Y 1 y M. P, A 1 Y 1 Y 1.07 Date of Birth Date of Patients Birth R Y 1 y M. P, A 1 Y 1 Y converted to age 1.08 Marital Status A value representing the domestic partnership status of a person. 2 Y 1 y M. P, A 1 Y 1 Y 0 Yes 1.09 Religious Affiliation the religious preference of the person 0 Yes 3 Y 1 y M. P, A 1 Y 1 Y 0 Yes 1.1 Race Race of Patient 1 Y 1 y M. P, A 1 Y 1 Y 1.11 Ethnicity Ethnicity of Patient 1 Y 1 y M. P, A 1 Y 1 Y 2. Language Spoken 2.01 Primary Language Spoken, written or understood primary language of Patient 2 Y 1 y P, A 1 Y 1 Y 3. Support 3.01 Date The period over which the support is provided 2 Y 1 y P, A 2 Y 2 Y This represents the type of support provided, such as immediate emergency contacts, next of kin, family relations, guardians, agents, et cetera 3.02 Contact Type 2 Y 1 y P, A 2 Y 2 Y Identifies the relationship of the contact person to the individual for which this exchange refers 2 Y 1 y P, A 2 Y 2 Y 3.03 Contact Relationship 3.04 Contact Address The address of the contact individual or organization providing support 2 Y 1 y P, A 2 Y 2 Y 3.05 Contact Phone/ /URL A telephone number (voice or fax), address, or other locator for the contact individual or organization providing support 2 Y 1 y P, A 2 Y 2 Y 3.06 Contact Name The name of the individual or organization providing support 2 Y 1 y P, A 2 Y 2 Y 4. Health Care Providers 4.01 Date Range The period over which this provider has provided healthcare services 0 Yes Need clarification. 0 No 2 Y 1 y M, P, A 1 Y 1 Y 0 Yes 4.02 Provider Role Code PCP, Referring, Attending, Consulting, etc. Area of specialty? 2 Y 1 y M, P, A 1 Y 1 Y 4.03 Provider Role Free-Text Area of specialty? 2 Y 1 y M, P, A 1 Y 1 Y 4.04 Provider Type Physician, Dentist, etc. Area of specialty? 2 Y 1 y M, P, A 1 Y 1 Y 4.05 Provider Address Practice Address Actually trying to link this to provider location. 2 Y 1 y M, P, A 1 Y 1 Y 4.06 Provider Phone/ /URL A telephone number (voice or fax), address or other locator Thought we would get this from location. 2 Y 1 y M, P, A 1 Y 1 Y 4.07 Provider Name Last, First, Middle Initial, NPI Need broken out first name, last name. 2 Y 1 y M, P, A 1 Y 1 Y get by first name, last name Provider's Organization Name of Practice where this patient was seen Thought we would get this from location. 2 Y 1 y M, P, A 1 Y 1 Y 4.09 Providers Patient ID The user visible Medical Record Number of Patient Would this be patient's primary provider in this practice? 2 Y 1 y M, P, A 1 Y 1 Y 4.1 National Provider ID National Provider Identifier or NPI is a unique identification number What about local provider ID from EMR? 2 Y 1 y M, P, A 1 Y 1 Y Can consume, but currently not using at this 5. Health Insurance Provider time What about plan, co-pay, primary physician? 5.01 Group Number The policy or group contract number 3 No 3 Y 1 y P, A 3 N 2 Y 0 Yes 3 Y 1 y M, P, 3 N 2 Y 0 Yes 5.02 Insurance Type HMO, PPO, Medicare, etc. A The coded identifier of the payer corresponding to the Health Plan Information 5.03 Health Plan Insurance Information Source ID Source Name. 0 No 3 Y 1 y P, A 3 N 2 Y 0 Yes 5.04 Health Plan Insurance Information Source Address Postal Address of Health Plan 0 No 3 Y 1 y P, A 3 N 2 Y 0 Yes Health Plan Insurance Information Source 5.05 Phone/ /URL A telephone number (voice or fax), address or other locator 0 No 3 Y 1 y P, A 3 N 2 Y 0 Yes Already have, but not a beacon priority 5.06 Insurance Information Source Name Name of the entity that is the source of information 0 No 3 Y 1 y P, A 3 N 2 Y 0 Yes 5.07 Health Plan coverage dates the beginning and end dates of the health plan coverage of the individual 3 No 3 Y 1 y P, A 3 N 2 Y 0 Yes 5.08 Member/Subscriber ID Identifier assigned to Patient by the health plan 3 No 3 Y 1 y P, A 3 N 2 Y 0 Yes 5.09 Patient Relationship to Subscriber Specified only when patient is not the subscriber 3 No 3 Y 1 y P, A 3 N 2 Y 0 Yes 5.14 Financial Responsibility Party Type The type of party that has responsibility for all or a portion of the patient's 3 No 3 Y 1 y P, A 3 N 2 Y 0 Yes 5.15 Subscriber ID The identifier assigned by the health plan to the actual member or health plan 3 No 3 Y 1 y P, A 3 N 2 Y 0 Yes 5.16 Subscriber Address The official mailing address of the actual member or health plan contract holder 3 No 3 Y 1 y P, A 3 N 2 Y 0 Yes 5.17 Subscriber Phone/ /URL A telephone number (voice or fax), address or other locator for a resource 3 No 3 Y 1 y P, A 3 N 2 Y 0 Yes 5.18 Subscriber Name The name of the actual member or health plan contract holder 3 No 3 Y 1 y P, A 3 N 2 Y 0 Yes 5.19 Subscriber Date of Birth The date of birth of the actual member or health plan contract holder 3 No 3 Y 1 y P, A 3 N 2 Y 0 Yes 5.24 Health Plan Name Name of the specific health insurance product 3 No 3 Y 1 y P, A 3 N 2 Y 0 Yes 5.25 Insurance Company Name The name of the insurance company. 3 No 3 Y 1 y M, P, A 3 N 2 Y 0 Yes 6. Allergy/Drug Sensitivity 6.01 Adverse event date Date of when allergy or intolerance became known 1 Y 1 y M, P, A 1 Y 2 Y 6.02 Adverse event type Coded type of product and event 1 Y 1 y M, P, A 1 Y 2 Y 6.03 Product Free Text Name or description of product/agent that causes allergy 3 Y 1 y M, P, A 1 Y 2 Y 6.04 Product Code Code describing the product Is this the SNOMED-CT allergen set? 1 Y 1 y M, P, A 1 Y 2 Y 6.05 Reaction Free Text Reaction that may be caused by product SPECIFIC FOR PATIENT 3 No 3 Y 1 y M, P, A 1 Y 2 Y 6.06 Reaction Coded Code describing the reaction 3 No 1 Y 1 y M, P, A 1 Y 2 Y 6.07 Severity Free Text Level of severity of reaction to product 3 Y 1 y M, P, A 1 Y 2 Y 6.08 Severity Coded Code describing the level of severity of the allergy to product 1 Y 1 y M, P, A 1 Y 2 Y 7. Problem/Condition 7.01 Problem Date When the problem became active (or Date of Diagnosis) 1 Y 1 y M, P, A 1 Y 2 Y 7.02 Problem Type Fixed value to determine the existence of a problem Code 1 Y 1 y M, P, A 1 Y 2 Y 7.03 Problem Name Text description of the problem Text 3 Y 1 y M, P, A 1 Y 2 Y 7.04 Problem Code Coded describing the problem What code system? 1 Y 1 y M, P, A 1 Y 2 Y 7.05 Treating Provider Name of Treating Provider 2 Y 1 y M, P, A 1 Y 2 Y 7.06 Age (at Onset) The age of the patient or subject at onset of the condition 3 Y 1 y M, P, A 3 N 2 N 7.07 Cause of Death Indicates that this problem was one of the causes of death for the patient or subject of the condition 3 Y 1 y M, P, A 3 N 2 N 0 Yes 7.08 Age (at Death) The age of the patient or subject at death 3 Y 1 y M, P, A 3 N 2 N 0 Yes 7.09 Time of Death Date and time of death 3 Y 1 y M, P, A 3 N 2 N 0 Yes 7.11 Treating Provider ID NPI number for provider or providers treating the patient for condition 2 Y 1 y M, P, A 1 N 2 N 0 Yes 7.12 Problem Status Status of problem (active, inactive, resolved) Text 1 Y 1 y M, P, A 1 N 2 N 8. Medication 8.01 Free Text Sig The instructions, typically from the ordering provider, to the patient We want the Med ID. 2 Y 1 y M, P, A 1 Y 2 Y 8.02 Medication Stopped Whether or not a medication was discontinued 2 Y 1 y M, P, A 3 N 3 N R = Required; R2 = Required if Known; Y = Section can repeat; O = Optional

11 BEACON Data Element Requirements 2 Colorado Responses Colorado Comments Cincinnati Responses Cincinnati Comments SE Michigan Responses SE Michigan Comments Tulsa Responses Tulsa Comments Inland NW Responses Inland NW Comments Southern Piedmont Responses Southern Piedmont Comments WNY Beacon Responses WNY BEacon Comments able to KEY for MyHealth Usage consume by M = Beacon Measure May 20th, 2012 P = Portal Display A = Analytics 2012 able to consume by May 20th, 2012 Identifier Name Description 8.03 Administration Timing A Sig Component: defines a specific administration or use time. 0 Yes 2 Y 1 y M, P, A 3 N 3 N 0 Yes 8.04 Frequency How often the medication is to be administered 1 Y 1 y M, P, A 1 Y 2 Y A Sig Component: defines how the product is to be administered as an interval 8.05 Interval of time. 2 Y 1 y M, P, A 1 Y 2 Y 8.06 Duration Length of time medication should be continued 1 Y 1 y M, P, A 1 Y 2 Y 8.07 Route A Sig Component: indicates how the medication is received by the patient (e.g., by mouth, intravenously, topically, etc.) 2 Y 1 y M, P, A 1 Y 2 Y 2 No 8.08 Dose The amount of medication to be given 1 Y 1 y M, P, A 1 Y 2 Y 8.09 Site A Sig Component: The anatomic site where the medication is administered 3 Y 1 y M, P, A 1 Y 2 Y 2 No 8.1 Dose Restriction A Sig Component: defines a maximum or dose limit. 3 Y 1 y M, P, A 3 N 2 N 2 No 8.11 Product Form Physical form of medication (Tablet, liquid, etc.) 2 Y 1 y M, P, A 3 N 2 N 2 No 8.12 Delivery Method A Sig Component: A description of how the product is administered/consumed 3 No 2 Y 1 y M, P, A 1 Y 2 Y 2 No 8.13 Coded Product Name Code describing the product 1 Y 1 y M, P, A 1 Y 2 Y 8.14 Coded Brand Name Code describing the product as a branded or trademarked name 2 Y 1 y M, P, A 1 Y 2 Y 8.15 Free Text Product Name The name of the substance or product 3 Y 1 y M, P, A 1 Y 2 Y 8.16 Free Text Brand Name The branded or trademarked name of substance or product 3 Y 1 y M, P, A 1 Y 2 Y 8.17 Drug Manufacturer The manufacturer of the substance or product as ordered or supplied. 3 Y 1 y M, P, A 3 N 0 N 8.18 Product Concentration The amount of active ingredient, or substance of interest, in a specified product dosage unit, mass or volume. 3 Y 1 y M, P, A 1 Y 0 Y 8.19 Type of Medication Prescription, OTC 2 Y 1 y M, P, A 1 Y 2 Y 8.2 Status of medication Active, Discharge, Chronic, Acute, etc. 2 Y 1 y M, P, A 1 Y 2 Y 8.21 Indication A Sig Component: The medical condition or problem intended to be addressed by the ordered product. 3 No 2 Y 1 y M, P, A 1 Y 2 Y 8.22 Patient Instructions Instructions to the patient that are not traditionally part of the Sig. 3 No 2 Y 1 y M, P, A 3 N 3 Y 8.23 Reaction Any noted intended or unintended effects of the product. 3 No 2 Y 1 y M, P, A 2 Y 2 Y 2 No 8.24 Vehicle A Sig Component: Non-active ingredient(s), or substances not of therapeutic interest, in which the active ingredients are dispersed. 3 No 2 Y 1 y M, P, A 1 Y 2 Y 8.25 Dose Indicator A Sig Component: A criteria that specifies when an action is, or is not, to be taken. 3 No 2 Y 1 y M, P, A 1 Y 2 Y 8.26 Order Number The order identifier from the perspective of the ordering clinician. 0 Yes 0 No 3 Y 1 y M, P, A 3 N 3 Y 0 Yes 8.27 Fills The number of times that the ordering provider has authorized the pharmacy to dispense this medication 0 Yes 0 No 2 Y 1 y M, P, A 3 N 3 Y 0 Yes 8.28 Quantity Ordered The amount of product indicated by the ordering provider to be dispensed. 0 Yes 0 No 2 Y 1 y M, P, A 3 N 3 Y 0 Yes 8.29 Order Expiration Date when order is no longer valid 0 Yes 0 No 3 Y 1 y M, P, A 3 N 3 Y 0 Yes 8.3 Order Date Date when the ordering provider wrote the prescription/order 0 Yes 0 No 1 Y 1 y M, P, A 3 N 3 Y 0 Yes 8.31 Ordering Provider NPI of provider who ordered Medication 0 Yes 0 No 1 Y 1 y M, P, A 1 Y 2 Y 0 Yes Instructions to the dispensing pharmacist or nurse that are not traditionally part 8.32 Fulfillment Instructions of the Sig. 0 Yes 0 No 3 Y 1 y M, P, A 3 N 3 Y 0 Yes 8.33 Fulfillment History History of dispenses for this order. 0 Yes 0 No 3 Y 1 y M, P, A 3 N 3 Y 0 Yes 8.34 Prescription Number The prescription identifier assigned by the pharmacy 0 Yes 0 No 3 Y 1 y M, P, A 3 N 3 Y 0 Yes 8.35 Dispensing Pharmacy The pharmacy that performed this dispense 0 Yes 0 No 2 Y 1 y M, P, A 3 N 3 Y 0 Yes 8.36 Dispensing Pharmacy Location The pharmacy's location 0 Yes 0 No 3 Y 1 y M, P, A 3 N 3 Y 0 Yes 8.37 Dispense Date Date prescrioption was dispensed (fulfillment history) 0 Yes 0 No 2 Y 1 y M, P, A 3 N 3 Y 0 Yes 8.38 Quantity Dispensed The actual quantity of product supplied in this dispense. 0 Yes 0 No 2 Y 1 y M, P, A 3 N 3 Y 0 Yes 8.39 Fill number The fill number for the history entry. 0 Yes 0 No 3 Y 1 y M, P, A 3 N 3 Y 0 Yes 8.4 Fill Status Completed, never dispensed, etc. 0 Yes 0 No 2 Y 1 y M, P, A 3 N 3 Y 0 Yes 9. Pregnancy 9.01 Pregnancy Whether the patient is currently pregnant 2 Y 1 y M. P, A 0 N 0 Y 0 Yes 10. Information Source Really need information about source and author on each discrete data element Author Time Time which information was created 2 Y 2 y M, P, A 3 N 0 Y 2 Y 2 y M, P, A 3 N 0 Y Author Name Name of person who created the information Reference A reference to the original document from which this information was obtained 0 Yes 0 Yes 2 Y 2 y M, P, A 3 N 0 Y 0 Yes Reference Document ID Identifier of the external document that was referenced 0 Yes 0 Yes 2 Y 2 y M, P, A 3 N 0 Y 0 Yes Reference Document URL A URL from which this document may be retrieved 0 Yes 0 Yes 2 Y 2 y M, P, A 3 N 0 Y 0 Yes Source Name Name of organization that provided information 2 Y 2 y M, P, A 3 N 0 Y Can consume, but currently not using at this 12. Advance Directive time Advance Directive type Code describing the type of advance directive 3 No 3 Y 3 y A 3 N 0 N Advance directive text Free text describing advance directive 3 No 3 Y 3 y A 3 N 0 N Effective Date Effective date for advance directive 3 No 3 Y 3 y A 3 N 0 N Custodian of the Document Name, address or other contact information for the person or organization that can provide a copy of the document 3 No 3 Y 3 y A 3 N 0 N 0 No 13. Immunizations Refusal Flag that immunization did not occur; nature of refusal 2 Y 1 y M, P, A 3 N 0 Y Administered Date Date immunization was administered or refused 1 Y 1 y M, P, A 3 N 0 Y Medication Series Number Indicate which in a series of administrations a particular administration represents 2 Y 1 y M, P, A 3 N 0 Y Reaction Any noted intended or unintended effects of the product. For example: full body rash, nausea, rash resolved 2 Y 1 y M, P, A 3 N 0 Y 0 No Performer NPI of provider that administered immunization 2 Y 1 y M, P, A 3 N 0 Y 0 No Coded Product Name Code describing the product CVX code 1 Y 1 y M, P, A 3 N 0 Y Product Name free text Name of substance or product 3 Y 1 y M, P, A 3 N 0 Y Drug Manufacturer Manufacturer of the substance or pruduct 3 Y 1 y M, P, A 3 N 0 Y Lot Number Production Lot number 2 Y 1 y M, P, A 3 N 0 Y 13.1 Refusal Reason A coded representation of the reason for refusing the immunization 2 Y 1 y M, P, A 3 N 0 Y Immunization Information Source 2 Y 1 y M, P, A 3 N 0 Y 14. Vital Signs Vital Sign Result ID An identifier for this specific vital sign observation 2 Y 1 y M, P, A 1 Y 2 Y Vital sign date Date of observation 1 Y 1 y M, P, A 1 Y 2 Y Height, weight, BP, pulse, resp, BMI are Height, weight, BP, pulse, resp, BMI are priorities Vital sign type The coded representation of the vital sign observation priorities. 1 Y 1 y M, P, A 1 Y 2 Y 2 Y 1 y M, P, A 1 Y 2 Y Vital sign result status Status for vital sign observation (e.g. complete, preliminary, etc.) Vital sign value The value of the result including units of measure 1 Y 1 y M, P, A 1 Y 2 Y Vital Sign Result Interpretation An abbreviated interpretation of the vital sign observation, e.g., normal, abnormal, high, etc 3 Yes 2 Y 1 y M, P, A 1 Y 2 Y Vital Sign Result Reference Range Reference range(s) for the vital sign observation 2 Y 1 y M, P, A 2 N 2 N R = Required; R2 = Required if Known; Y = Section can repeat; O = Optional

12 BEACON Data Element Requirements 3 Colorado Responses Colorado Comments Cincinnati Responses Cincinnati Comments SE Michigan Responses SE Michigan Comments Tulsa Responses Tulsa Comments Inland NW Responses Inland NW Comments Southern Piedmont Responses Southern Piedmont Comments WNY Beacon Responses WNY BEacon Comments able to KEY for MyHealth Usage consume by M = Beacon Measure May 20th, 2012 P = Portal Display A = Analytics 2012 able to consume by May 20th, 2012 Identifier Name Description 15. Results Result ID An identifier for this specific observation Need source and ordering physician. 2 Y 1 y M, P, A 1 Y 2 Y Result Date/Time Date and time of observation 1 Y 1 y M, P, A 1 Y 2 Y Result Type Code describing the observation performed or made 1 Y 1 y M, P, A 1 Y 2 Y Result Status Status for observation (Complete, preliminary, addendum, etc.) 1 Y 1 y M, P, A 1 Y 2 Y Result Value The value of the result including units of measure 1 Y 1 y M, P, A 1 Y 2 Y Result Interpretation An abbreviated interpretation of the observation, e.g., normal, abnormal, high, 1 Y 1 y M, P, A 1 Y 2 Y Result Reference Range Reference range(s) for the observation 1 Y 1 y M, P, A 1 Y 2 Y 16. Encounter Encounter ID An identifier for this Encounter 3 No 2 Y 1 y M, P, A 1 Y 2 Y Encounter Type Coded value describing the type of encounter CPT 1 Y 1 y M, P, A 1 Y 2 Y Encounter type free text Free text describing the type of enounter 3 No 3 Y 1 y M, P, A 1 Y 2 Y Not sure Not Sure Encounter Date Date of encounter 1 Y 1 y M, P, A 1 Y 2 Y Enounter Provider Name provider who performed encounter (or NPI) 2 Y 1 y M, P, A 1 Y 2 Y Admission Source Identifies where the patient was admitted 3 No 2 Y 1 y M, P, A 1 Y 2 Y Admission Type Indicates the circumstances under which the patient was or will be admitted 3 No 3 Y 1 y M, P, A 1 Y 2 Y Encounter location The service delivery location 2 Y 1 y M, P, A 1 Y 2 Y Arrival date/time The date and time the patient arrived at the location 2 Y 1 y M, P, A 1 Y 2 Y Reason for Visit ndicates the rationale for the encounter 1 Y 1 y M, P, A 1 Y 2 Y 17. Procedure Procedure ID An identifier for this Procedure 2 Y 1 y M, P, A 3 N 2 Y Coded Procedure Type Code describing the type of procedure E.g., colonoscopy. What if incomplete? CPT or SNOMED CT 1 Y 1 y M, P, A 3 N 2 Y Procedure type free text Free text describing the procedure 3 No 3 Y 1 y M, P, A 3 N 2 Y Procedure Date Date procedure was performed 1 Y 1 y M, P, A 3 N 2 Y Procedure Provider NPI of provider who performed procedure 2 No 2 Y 1 y M, P, A 3 N 2 Y Can consume, but currently not using at this 19. Social History time Social History Date Range of time of which social history event was active 2 Y 2 y P 3 N 0 Y Particular focus on tobacco, alcohol use Coded social history Code describing the type of social history observation coded with SNOMED CT 2 Y 2 y P 3 N 0 Y Social History free text Textual description of social history (e.g. smoking status) 3 No 3 Y 2 y P 3 N 0 Y Social History Observed Value Value describing the social history (e.g. smoking history) 2 Y 2 y P 3 N 0 Y This is where SE MI Beacon will be able to 24. Order put care gaps into a CCD Order Group Number An order group is a list of orders associated with an -placer group number. 3 No 2 Y 1 y M, P, A 3 N 2 Y Order Status Report the status of an order either upon request or when the status changes 3 No 1 Y 1 y M, P, A 3 N 2 Y Parent Order Number The Order number of the Parent Order which may have spawned Child orders. 3 No 2 Y 1 y M, P, A 3 N 2 Y Date Time of Transaction The date and time of the order transaction 3 No 1 Y 1 y M, P, A 3 N 2 Y Order Entered By The identity of the person who actually keyed the request into the order application (may include both a name and/or an identifier) 3 No 2 Y 1 y M, P, A 3 N 2 Y Order Verified By The identity of the person who verified the accuracy of the entered request (may include both a name and/or an identifier) 3 No 2 Y 1 y M, P, A 3 N 2 Y Order Setting Type Indicates the care setting in which the order is executed 3 No 2 Y 1 y M, P, A 3 N 2 Y Requested Order Start Date/Time The date/time when the ordering provider is requesting the execution of orders 3 No 2 Y 1 y M, P, A 3 N 2 Y Order Priority The priority of the order 3 No 2 Y 1 y M, P, A 3 N 2 Y 24.1 Placer Order Number The order identifier from the perspective of the system placing the order 3 No 2 Y 1 y M, P, A 3 N 2 Y Filler Order Number The order identifier from the perspective of the system fulfilling the order 3 No 2 Y 1 y M, P, A 3 N 2 Y Order Code The order code for the requested observation, test, and/or battery. Note: This can be based on local and/or standardized order codes 3 No 1 Y 1 y M, P, A 1 Y 2 Y Specimen Action Identifies the action to be taken with respect to the specimens that accompany or precede this order. 3 No 2 Y 1 y M, P, A 3 N 2 Y Ordering Provider The person that wrote this order (may include both a name and an identifier) 3 No 1 Y 1 y M, P, A 1 Y 2 Y Results Distribution List Identifies the people and/or organization that are to receive copies of the results 3 No 2 Y 1 y M, P, A 3 N 2 Y Specimen Collector ID The person, department, or facility that collected the specimen. (may include both a name and an identifier) 3 No 2 Y 1 y M, P, A 3 N 2 Y 0 Yes R = Required; R2 = Required if Known; Y = Section can repeat; O = Optional

13 BEACON Data Element Requirements 1 KEY for MyHealth Usage M = Beacon Measure #Beacons with this #Beacons with P = Portal Display as an immediate this as a future A = Analytics priority priority Notes Notes Notes Section Name Description Template Id Notes Notes Notes Notes Our Public Health EMR system PH- Doc is capable of parsing amd performing medication reconciliation from CCDs. Other systems are Contains data on the patient s payers, whether a third party insurance, self-pay, dependant on other payer or guarantor, or some combination. At a minimum, the patient's vendor timleines If section information is pertinent current payment sources should be listed. If no payment sources are and not expected coming to us as a C83 supplied, the reason shall be supplied as free text in the narrative block (e.g., Not If section information is coming to us as a If section information is coming to us as a before May 20th If section information is coming to us as a document, then we can Payers Insured, Payer Unknown, Medicare Pending, etc.) C83 document, then we can consume it. 2 N C83 document, then we can consume it. 1 C83 document, then we can consume it. 1 y P, A consume it. 3 N 4 2 Contains data on the substance intolerances and the associated adverse reactions suffered by the patient. At a minimum, currently active and any relevant Alleriges and Other Adverse Reactions historical allergies and adverse reactions shall be listed Y 1 1 y M, P, A 1 Y Problem List Contains data on the problems currently being monitored for the patient Y 1 1 y M, P, A 1 Y History of Past Illness Contains data about problems the patient suffered in the past Y 2 1 y M, P, A 1 Y Chief Complaint Contains information about the patient's chief complaint Y 2 2 y A 1 Y Reason for Referral Contains information about the reason that the patient is being referred N 2 2 y A 1 Y 1 5 Contains information about the sequence of events preceding the patient s current History of Present Illness complaints Y 2 1 y P 1 Y List of Surgeries Provides a list of surgeries the patient has received N 2 1 y M, P, A 3 N 1 3 Provides information about the capability of the patient to perform acts of daily Functional Status living N 2 2 y P, A 0 N Hospital Admission Diagnosis Contains information about the primary reason for admission to a hospital facility N 1 1 y M, P, A 1 Y 4 2 Contains information about the conditions identified during the hospital stay that either need to be monitored after discharge from the hospital and/or where Discharge Diagnosis resolved during the hospital course Y 1 1 y M, P, A 1 Y 6 1 Contains information about the relevant medications for the patient. At a Medications minimum, the currently active medications should be listed Y 1 1 y M, P, A 1 Y 6 0 Contains information about the relevant medications of a patient prior to Admission Medications History admission to a facility N 1 1 y M, P, A 1 Y 4 2 Contains information about the relevant medications of the medications ordered Hospital Discharge Medications for the patient for use after discharge from the hospital N 1 1 y M, P, A 1 Y 4 2 Contains information about the relevant medications administered to a patient Medications Administered during the course of an encounter N 1 1 y M, P, A 1 Y 4 2 Contains information that defines the patient s expectations and requests for care 3 Yes Advance Directives along with the locations of the documents N 2 2 y P 3 N Immunizations Contains information describing the immunizations administered to the patient Y 1 1 y M, P, A 3 N Physical Examination Contains information describing the physical findings Y 2 1 y P, A 1 Y Vital Signs Contains information documenting the patient vital signs Y 2 1 y P, A 1 Y 4 2 Contains information describing patient responses to questions about the function 3 Yes Review of Systems of various body systems Y 2 2 y P 3 N 1 3 Contains information about of the sequence of events from admission to Hospital Course discharge in a hospital facility N 2 2 y P 3 N 1 4 Contains information about the results from diagnostic procedures the patient Diagnostic Results received Y 1 1 y M, P, A 1 Y 5 1 Contains information about the assessment of the patient s condition and expectations for care including proposals, goals, and order requests for monitoring, tracking, or improving the condition of the patient. An assessment and plan section varies from the plan of care section defined later in that it includes a physician assessment of the patient condition. Please note that the assessments described in this section are physician assessments of the patient's current condition, and do not include assessments of functional status, or other assessments typically used in nursing. In Implementation Guides currently selected, when both the assessment and plan are documented, they are included together in a single section documenting both. When the physician assessment is not present, only the Plan of Care Section appears. There are no cases where a physician assessment is provided without a Assessment and Plan plan N 2 1 y P, A 3 N 1 4 Contains information about the expectations for care to be provided including proposed interventions and goals for improving the condition of the patient. A plan of care section varies from the assessment and plan section defined above Plan of Care in that it does not include a physician assessment of the patient condition Y 2 1 y P, A 3 N 2 3 Contains information about the genetic family members, to the extent that they are known, the diseases they suffered from, their ages at death, and other Family History relevant genetic information N 2 1 y P, A 3 N 1 4 Contains information about the person s beliefs, home life, community life, work Social History life, hobbies, and risky habits Y 2 1 y P, A 3 N 5 1 Contains information describing the patient history of encounters. At a minimum, current and pertinent historical encounters should be included; a full encounter Encounters history may be included Y 2 1 y M, P, A 1 Y 4 2 Contains information describing a patient s implanted and external medical devices and equipment that their health status depends on, as well as any 3 Yes Medical Equipment pertinent equipment or device history N 2 1 y P, A 3 N 1 3 Records the surgical diagnosis or diagnoses that are assigned to the patient before the surgical procedure, and is the reason for the surgery. The Preoperative Diagnosis is, in the opinion of the surgeon, the diagnosis that will be confirmed Preoperative Diagnosis during surgery N 2 2 y P, A 3 N 0 4 Records the diagnosis or diagnoses discovered or confirmed during the surgery Postoperative Diagnosis Often it is the same as the Preoperative Diagnosis N 2 2 y M, P, A 3 N 0 4 Records the particulars of the surgery with an extensive narrative describing the Surgery Description surgery N 2 1 y P, A 3 N 1 3 Records clinically significant observations confirmed or discovered during the Surgical Operation Note Findings surgery N 2 1 y P, A 3 N 1 4 Briefly records the type of anesthesia (e.g., general or local) and may state the Anesthesia actual agent used N 2 2 y P, A 3 N Estimated Blood Loss Records the approximate amount of blood that the patient lost during the surgery N 2 2 y 3 N Specimens Records the tissues, objects, or samples taken from the patient during surgery N 2 1 y M, P, A 3 N 1 3 Records problems that occurred during surgery. The complications may have Complications been known risks or unanticipated problems N 2 2 y P, A 3 N 0 4 Records the procedure(s) that the surgeon thought would need to be done based Planned Procedure on the preoperative assessment N 1 2 y P, A 3 N Indications Records further details about the reason for the surgery N N 0 3 Records the status and condition of the patient at the completion of the surgery. It Disposition often also states where the patient was transferred to for the next level of care N 2 1 y M, P, A 3 N Operative Note Fluids May be used to record fluids administered during the surgical procedure N 2 2 y P, A 3 N 0 4 May be used to restate the procedures performed if appropriate for an enterprise Operative Note Surgical Procedure workflow N N Surgical Drains May be used to record drains placed during the surgical procedure N 2 1 y P, A 3 N Implants May be used to record implants placed during the surgical procedure N 2 1 y P, A 3 N Assessments May be used to record assessments of the patient status N 1 2 y P, A 3 N 3 3 May be used to record the procedures and interventions that have been Procedures and Interventions performed Y 1 1 y M. P. A 3 N 4 1 May be used to record orders that are to be implemented, including any orders for treatment (e.g., medications, therapy, et cetera), monitoring (testing, monitoring, Provider Orders etc.), education and follow-up care N 2 1 y M. P. A 1 Y 3 2 Contains tools/instruments structured in a question/answer format that are used in various healthcare settings to document (or provide information to assess) the 3 Yes patient s overall clinical status, functional status, treatment given, or other patient Questionnaire Assessment status or care N 2 2 y P, A 3 N 0 3 R = Required; R2 = Required if Known; Y = Section can repeat; O = Optional Colorado Cincinnati SE Michigan SE Minnesota Tulsa Hawaii Beacon INHS