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SECTION III: Electronic Health Record Requirement Issues

EHR data standards should be defined within a framework that is explicit in the following:

1. Medical, Legal Record. Services to ensure a targeted level of confidence (trust) with regard to the EHR as a full medical/legal record for an individual patient or health plan member, to:

.1 Chronicle the health delivery process;
.2 Evidence the provision and performance of health services; and correlatively
.3 Evidence the origination, stewardship and use of EHR content;
.4 Document key demographic and identification traits;
.5 Document the course of the patient’s illness or health status;
.6 Furnish documentary evidence of the course of an individual’s health evaluation, treatment and change in condition;
.7 Document an individual’s health status;
.8 Provide data for preventive care;
.9 Document communication between the practitioner responsible for the patient’s care and any other health care practitioner who contributes to the patient’s care;
.10 Assist in protecting the legal interest of the patient, the health care provider(s) and the responsible practitioner(s);
.11 Provide continuity of care;
.12 Provide data to substantiate insurance claims;
.13 Provide a basis for evaluating the adequacy and appropriateness of care;
.14 Document the operational and work performance of the health care provider and practitioner; and
.15 Provide data for use in continuing education and research.

Points of Authority and Reference

2. EHR Requirements Statements. Services to fulfill key requirements both de facto and de jure as set forth by national, regional and local authorities:

.1 Statute and regulation;
.2 Accreditation standards;
.3 Professional standards;
.4 Health informatics standards;
.5 Local policies and conventions.

Including:

.6 Privacy and confidentiality standards;
.7 Security, access control standards;
.8 Record stewardship standards;
.9 Business and clinical practice rules;
.10 Clinical and operational decision/action rules;
.11 Standards of practice;
.12 Standards for performance measures and quality indicators;
.13 Identifier standards;
.14 Vocabulary, classification and code set standards;
.15 Minimum/reference data set standards;
.16 Transaction set standards;
.17 Data interchange standards;
.18 Imaging standards;
.19 Automated device standards;
.20 Application component standards.

Trust

3. EHR Trust Constituency. Individuals, organizations and business units with an immediate stake in the veracity, stewardship and use of the EHR.

N/A = Not applicable
A/A = As applicable

4. Rights, Privileges and Responsibilities. Incumbent rights, privileges and responsibilities of each Trust Constituent with regard to the EHR, its origination, stewardship and use.

5. Privacy and Confidentiality Protections. Services to ensure targeted level of trust regarding privacy and confidentiality protections afforded EHR record subjects. [See preceding matrix.]

6. Individual Identifiers. Services to ensure targeted level of trust regarding assignment, stewardship and use of individual identifiers, for: patient/members, providers, and practitioners/caregivers.

7. Individually Identifiable Information. Services to ensure targeted level of trust regarding origination, stewardship and use of individually identifiable EHR information.

8. Organizational Identifiers. Services to ensure targeted level of trust regarding assignment, stewardship and use of identifiers for organizations and business units: providers, payers, health plans, employers.

Stewardship

9. EHR Stewards. Individuals and organizations who act as stewards for the EHR. [See preceding matrix.]

10. EHR Stewardship Chronicle. Services to chronicle EHR stewardship:

.1 Origination of record content: by author, scribe, or automated device;
.2 Verification of record content (e.g., of automated device input);
.3 Attestation, electronic signature of record content;
.4 Access or view of record content;
.5 Copying or duplication of record content;
.6 Disclosure or transmittal of record content;
.7 Receipt of record content from another party.

Wholeness and Integration – The EHR Continuum

11. EHR Health Delivery Chronicle. Services designed to chronicle the health delivery process, its correlative work flow, information flow and recording processes:

.1 As an immediate and concurrent function of health delivery;
.2 Once, at the point of service or care;
.3 Concurrent with the clinical service event.

12. EHR Care Continuum. Services to engage the EHR and chronicle care delivery in multiple venues: acute, emergent, ambulatory, long-term, home health.

13. EHR Business Continuum. Services to engage the EHR and chronicle care delivery across the health business continuum: health plans, IDNs, provider organizations, business units, small group and solo practitioners.

14. EHR Application System Continuum. Services to engage a robust EHR across the continuum of health application systems, including originators and non-originators of EHR content:

.1 Front-end: medical device applications (e.g., instruments, monitors);
.2 Front-end business unit: department, service, specialty or function-oriented application;
.3 Back-end enterprise: repository application;
.4 Integrated business unit and enterprise application;
.5 Mediators: (i.e., interface engines, hubs, store and forward, translators);
.6 Value-added network (VAN) applications;
.7 Third party applications.

15. EHR Individual Lifetime Health Record. Services to chronicle an individual’s health status and history, a “womb to tomb” health chronology. [See Appendix A for further detail.]

16. EHR Episode/Problem Record. Services to chronicle patient problem-oriented episodes of care:

.1 For a lifetime continuum;
.2 Across one or more encounters;
.3 With related diagnosis;
.4 With protocol and status: critical path, care plan;
.5 With milestones, resolutions and outcomes.

17. EHR Encounter Record. Services to chronicle patient encounters:

.1 With each health care provider;
.2 With each health practitioner, caregiver;
.3 At each of multiple points (locations) of service;
.4 For each encounter type: acute, emergent, ambulatory, long-term care, home health.
.5 For a lifetime continuum

18. EHR Timeline Record. Services to chronicle the health time continuum:

.1 Prospective (future): Upcoming health service events and wellness checks - scheduled but not yet underway.
.2 Concurrent (present): Current, immediate health status, health service events and wellness checks – active (in progress) but not yet complete.
.3 Retrospective (past): Historical health status, service and wellness events – completed, resolved or canceled.
.4 For individual patients/members;
.5 For individual practitioners, caregivers;
.6 For critical resources: facilities, locations, equipment;
.7 For organizations, business units.

19. Companion EHR Records. Services to define and manage interrelated, companion records as discrete EHR strata:

.1 Master person index;
.2 Patient/member health record: individual;
.3 Provider operations (business) record: organization, business unit;
.4 Practitioner/caregiver service record: individual;
.5 Population health records: with and without individually identifiable record content.

20. Logical Wholeness. Services to ensure a logically integrated record, even if physically distributed.

Accountability

21. EHR Accountable Parties. Individuals, organizations and business units accountable for:

.1 EHR content origination: authors, scribes, verifiers;
.2 EHR access and use;
.3 EHR stewardship;
.4 Health services as documented in the EHR.

[See preceding Trust Constituency matrix.]

22. EHR Accountable Actions. Services to record accountable actions relative to the EHR, its content, its origination, stewardship and use:

.1 Access or view record content;
.2 Create or amend record content: as author or scribe;
.3 Validate record content (e.g., automated device input);
.4 Copy or duplicate record content;
.5 Disclose or transmit record content;
.6 To be in receipt of record content from another party;
.7 Provide health services or perform other actions as documented in the EHR.

23. EHR Authentication. Services to authenticate individuals and actions:

.1 User authentication: proof of user identity;
.2 Data source authentication: proof of authorship or origin;
.3 Data verification authentication: proof of data validation;
.4 Data interchange authentication: proof of transmittal, proof of receipt.

24. Non-repudiation. Services to ensure non-repudiation of authorship or origin of EHR content.

25. EHR Attestation, Electronic Signature. Services to bind the identity of an accountable party to specific content of the health record, including to:

.1 Affix attestation/signature to record content;
.2 Validate attestation/signatures and corresponding record content, including downstream from the point of origination;
.3 Form encrypted encapsulations of content and identifier(s) of source individual(s) using public/private key schemes or other robust solutions.

26. EHR Attestation Context. Services which record the essential context of attested content and/or the provision or performance of health services or other actions, including:

.1 Who – subject: patient/member;
.2 Who – provider/performer: organization, business unit, individual;
.3 Who – source individual (if different): author, scribe;
.4 Who – verifier individual (if different);
.5 Who – attesting/signing individual (if different);
.6 Who – source application system;
.7 Who – disclosed to, if applicable;
.8 What – provided or performed: procedure, work flow event, sequence, stage;
.9 What – action: provide, perform, create/amend/verify record content;
.10 When – occurrence: event start date/time and duration;
.11 When – recorded: recording date/time;
.12 Where – physical location: e.g., physical point of service/access;
.13 Where – device ID, network address.

27. Public Key Certificate Authorities. Robust services to register and manage public and private key pairs:

.1 To support strong authentication, non-repudiation, attestation, electronic signature;
.2 Issued to individuals: as originators, stewards or users of the EHR;
.3 Issued to organizations, business units: as originators, stewards or users of the EHR;
.4 Issued to application systems: as originators or stewards of the EHR.

EHR Clinical Service Event Record

28. Event Detail.. Services to ensure the capture and documentation of clinical service events, as detailed previously under Electronic Signature and also including:

.1 Rationale, if applicable;
.2 Context and condition related parameters;
.3 Event or process specific parameters;
.4 Relevant clinical parameters;
.5 Relevant operational and performance parameters: performance measures, quality indicators, resource utilization, cost parameters.

Security, Access Control

29. Security Policy Domain(s). Services to configure and manage security policy domains each designed to administer sets of security policies and procedures relative to EHR content origination access and use. Domains are typically established for IDNs, organizations, and business units.

30. Orange Book C2 Level of Trust. Services to ensure security and access safeguards and functions conformant to the U.S. Department of Defense Trusted System Criteria (the “Orange Book”), Level C2 (or better).

31. Data Classifications. Services to configure and manage security classifications for EHR content (data), establishing controls for:

.1 Access to record content;
.2 Creation or amendment of record content;
.3 Verification of record content;
.4 Copying or duplication of record content;
.5 Disclosure or transmission of record content;
.6 Receipt of record content from another party.

32. Function Classifications. Services to configure and manage security classifications for EHR functions, establishing access controls for EHR:

.1 Networks;
.2 Application systems;
.3 Discrete application functions.

33. User Clearances. Services to configure and manage security clearances, which map to data and function classifications, for individuals with access to EHR data and functions, including:

.1 Discrete individual clearances;
.2 Role-based clearances.

34. User Access Control. Services and mechanisms to ensure EHR access only to authorized individuals using, for example:

.1 ID tokens: physical cards, buttons, keys;
.2 Password assignment and renewal rules;
.3 Limited signon retries;
.4 Secure intranets;
.5 Dial-back modems.

35. Master User Index. Services to configure and manage a registry of individuals with authorization to access EHR data and functions, including:

.1 Identifier(s), identification traits;
.2 Demographics;
.3 Roles;
.4 Clearances to EHR data and functions: individual or role-based;
.5 Access parameters: identifiers, tokens, passwords.

36. Encrypted data transmission. Services to ensure secured data transmission, including encryption.

Auditability

37. Audit trails. Services to ensure audit trails sufficient track actions of accountable parties relative to the provision and performance of health services, to the origination, stewardship and communication of EHR content.

38. Audit review. Services to manage and review audit trails.

Roles, Relationships

39. Roles. Services to establish and manage roles of individual practitioners/caregivers and authors, scribes and verifiers of EHR content.

40. Relationships. Services to establish and manage relationships of individual practitioners/caregivers:

.1 As responsible/accountable parties: to patients, members;
.2 As employees or agents: to organizations, business units.

Availability, Reliability

41. Availability. Services to ensure EHR availability, 24 hours x 7 days x 366 days/year.

42. Fault Tolerance. Fault tolerance services to ensure continuous availability of the EHR computing base: hardware, software, databases, networks.

43. Post Year 2000. Services to ensure availability and reliability beyond the dawn of the new millennium.

Scalability

44. Scalability. Services and facilities to ensure scalability and extensibility of the EHR domain, including:

.1 EHR data store;
.2 Additional business units, facilities, locations;
.3 Additional practitioners, caregivers;
.4 Additional encounter types;
.5 Additional types of service.

Performance

45. Rapid User Response Time. Services to ensure rapid response to user actions relative to the EHR.

46. Minimal Data Latency. Services to ensure timeliness of EHR information transmission from source to consumer.

47. Optimal Processing Throughput. Services to ensure the optimal processing throughput of the EHR computing base.

Paper Reduction

48. Permanent Record. Services to reduce and supplant paper usage and retention with regard to the permanent EHR.

49. Transitive Record. Services to reduce and supplant paper usage and retention with regard to transitive and temporal records.

Data Integrity

50. Data Registry, Data Definitions. Services to create and manage a data registry, including uniform specifications for:

.1 Attributes (data elements);
.2 Naming;
.3 Identifiers;
.4 Data types, formats;
.5 Definition of usage;
.6 Grouping of attributes into minimum and reference datasets.

51. Standards. Data definitions should allow designation of national, regional and local standards, where applicable.

52. Accuracy. Services designed to ensure accuracy of EHR content, including:

.1 In the data registry: input accuracy and validity checks and rules;
.2 At EHR content origination: rules for input accuracy and validity checks;
.3 With authentication, non-repudiation services;
.4 With attestation/electronic signature.

53. Context. Services to create and manage logical contextual data relationships within the EHR:

.1 In the data registry: contextual data relationships, rules for context checks;
.2 At EHR content origination: rules for context checks;
.3 In logical database structures;
.4 In logical EHR views;
.5 In relationships of information to work flow and clinical events;
.6 In relationships of information to EHR timeline;
.7 In relationships of information to accountable parties: individuals, organizations, business units.

54. Consistency, Structure and Comparability. Services designed to ensure data consistency, structure and comparability:

.1 In the data registry: consistency checks and rules;
.2 At EHR content origination: rules for consistency checks;
.3 Of information across patients, members and populations;
.4 Of information across health plans, provider organizations, practitioners/caregivers;
.5 Of information across sites (locations) of service, at different points in time;

55. Continuity, Completeness. Services designed to ensure the continuity and completeness of information content:

.1 In the data registry: continuity and completeness checks and rules;
.2 At EHR content origination: rules for continuity and completeness checks;
.3 Of information completeness as a function of the completeness of corresponding health services and work flow events.

56. Gap Analysis. Services to probe the EHR for gaps in continuity and completeness in record content and to identify corresponding assigned responsible(s).

57. Uniform Capture. Services designed to ensure systematic, uniform capture of EHR content.

58. Data Verification. Services designed to ensure routine verification of specific EHR inputs, particularly that of automated devices, prior to formal EHR inclusion.

59. Vocabulary, Classification and Coding. Services designed to ensure consistent vocabulary, classification and coding of EHR content.

Time Integrity

60. Clock Synchrony. Services to ensure clock synchrony across all application systems which act as EHR originators or stewards.

61. Year 2000 Compliance. Services to ensure correct EHR date and time keeping with regard to Y2K.

Persistence, Permanence

62. Permanence. Services to ensure the persistence and permanence of the EHR.

63. Non-Alterability. Services to ensure non-alterability of EHR content.

64. Revision by Amendment Only. In conjunction with the preceding points, services to ensure that EHR content revisions are in the form of amendments only.

65. Formal Amendment Process. Services to engage a formal amendment process for error correction and EHR content revision.

66. Data State Preservation. Services to ensure data state preservation, initially and through each amendment.

67. Historical Snapshot. Services to reconstruct EHR content for a given historical date/time.

Process Integrity

68. Work Flow, Procedure Definition. Services to create and manage work flow and health service procedure definitions and to thereby engage business and clinical practice rules:

.1 Security, access classifications;
.2 Clinical pathway and variance rules: protocols, care plans;
.3 Scheduling rules;
.4 Rules for orders and results;
.5 Sequencing, staging rules;
.6 Rules for assigned responsibility;
.7 Rules for resource allocation and deployment: practitioners/caregivers, facilities, locations, equipment, supplies, time;
.8 Rules to measure continuity, completeness of workflow (and thus the correlative EHR content);
.9 Decision support rules.

69. Integrated Scheduler. Services to manage a comprehensive and immediate schedule of upcoming clinical service events:

.1 Fully integrated between and across business units within a health delivery setting: a health plan, a provider organization, an IDN;
.2 Integrated with EHR timeline: prospective, concurrent aspects;
.3 Initiated by explicit practitioner orders for clinical services;
.4 Initiated by appointments for ambulatory services;
.5 Initiated by resource-based schedules: exam rooms, operating suites, etc.;
.6 Initiated by clinical pathways: protocols, care plans;
.7 Oriented to individual patients, members;
.8 Oriented to individual practitioners, caregivers;
.9 Oriented by resource: facility, location, equipment.

70. Assigned Responsibility. Services to assign, manage and verify assigned responsibility for clinical service events: of practitioners, caregivers.

71. Event Initiation. Services to initiate health service events based from:

.1 Spontaneous orders;
.2 Pre-defined orders, order sets: by individual practitioner, organization, business unit;
.3 Clinical pathways: protocols, care plans.

72. Clinical Pathways. Services to ensure optimal care progression along designated clinical pathways and to ensure notation of variances and related authorization, where applicable.

73. Resource Projection. Services to project resource requirements: personnel, facilities, locations, equipment, supplies, time.

74. Cost Projection. Facilities to project costs associated with planned clinical services.

75. Resource Allocation, Deployment. Services to ensure optimal allocation and deployment of critical resources.

76. Process (Work Flow) Continuity, Completeness. Services to verify the continuity and completeness of the health delivery process and clinical service events, along with correlative EHR documentation.

77. Process Gap Analysis. Services to probe the EHR for gaps in continuity and completeness in the health delivery process (work flow) and to identify assigned responsible(s).

Decision Support

78. Definition. Services to create and manage definitions for decision support logic, based on and to engage business and clinical practice rules;

.1 For relevant operational (business) conditions;
.2 For relevant clinical conditions;
.3 For clinical pathways: protocols, care plans;
.4 For clinical service event initiation;
.5 For initiation of prompts, alerts, notifications, reminders;
.6 To establish assigned responsibility.

79. Real-time Rules Engine. Services to detect and evaluate decision support rules in real-time:

.1 As a concurrent, proactive function of the health delivery process;
.2 To engage business and clinical practice rules;
.3 To trigger appropriate follow-up actions;
.4 To initiate condition-predicated notifications: prompts, alerts, notifications, reminders;
.5 To initiate condition-predicated actions, e.g., to initiate/modify/cancel:

.1 assigned responsibility;
.2 clinical pathways;
.3 orders;
.4 clinical service events.

.6 To detect duplicate/redundant services;
.7 To detect conflicts and undesirable interactions;
.8 To detect potential allergic reactions.

80. Record Linkage. Services to denote actions as the result of decision support triggers in the EHR.

Knowledge Bases

81. References. Services to ensure real-time support for clinical decision making, including references to:

.1 Current medical literature and bibliographies;
.2 Current diagnostic, treatment and medication guidelines;
.3 Applicable statutes and regulations;
.4 Applicable accreditation and professional standards of practice/care;
.5 Available facilities, resources and services;
.6 Local business and clinical practice rules.

82. Record Linkage. Services to denote actions pursuant to knowledge base references in the EHR.

Surveillance, Metrics and Analysis

83. Definition. Services to create and manage definitions for key surveillance, metrics and analysis, based on business and clinical practice rules:

.1 Performance, compliance measures;
.2 Quality assurance indicators;
.3 Allocations and deployments;
.4 Costs: projected and actual;
.5 Utilization: projected and actual;
.6 Productivity and work load;
.7 Clinical pathway variances;
.8 Outcomes.

84. Real-Time, Concurrent. Services to engage real-time measurement and assessment: performance, compliance, quality assurance, allocations and deployments, costs, utilization, work load, variances, etc.

85. Retrospective. Services to engage retrospective measurement and assessment: performance, productivity, compliance, quality assurance, costs, utilization, variances, outcomes, etc.

86. Epidemiological Surveillance. Services to engage epidemiological surveillance of:

.1 Patient diagnostics, treatment and care;
.2 Organizational and business unit practices;
.3 Environmental conditions.

87. Ad Hoc Query, Analysis and Reporting. Services to provide ad hoc query, analysis and reporting within:

.1 Real-time, OLTP operational data store;
.2 Retrospective, OLAP analytical data store.

Communications Infrastructure

88. Immediate Conveyance. Services to ensure immediate information conveyance from source to consumer, within an provider organization or business unit.

89. Messaging. Services to initiate and manage electronic message communication, including:

.1 Interpersonal messages;
.2 Rules-based prompts, alerts, notifications, reminders.

90. Receipt. Services to ensure affirmative acknowledgment of message receipt.

Real-Time, Immediate

91. Concurrent with Service Performance. Services to record clinical service events, once, at the point of service/care, concurrent with the event.

92. Current status. Services to review current, immediate status of health service events, work flow:

.1 For patients, members;
.2 For practitioners, caregivers;
.3 For critical resources: facilities, locations, equipment;
.4 For organizations, business units.

93. Integrated Schedule. Services to manage and review the current integrated schedule and EHR timeline: prospective, concurrent, retrospective.

94. Problem-Oriented Episodes. Services to manage and review current patient problem-oriented episodes.

95. Clinical Pathways, Variances. Services to manage and review current clinical pathways and variances.

Personalized Practitioner, Caregiver Functions

96. Personal Data Views. Services to define, maintain and access personalized views of EHR content.

97. Personal Order Sets, Clinical Pathways. Services to define, maintain and access personal order sets and clinical pathways (e.g., protocols, care plans).

98. Assigned Responsibility. Services to assign and verify personal and group assignments for clinical service events.

99. Personal Work Assignments. Services to create and manage personal work lists and action items.

100.Notifications, Alerts, Reminders. Services to create, manage and access notifications, alerts and reminders, based on personal criteria.

101.Unreviewed Information. Services to provide notification of current, yet unreviewed, EHR information, based on personal criteria. (e.g., What has changed since I last accessed the EHR?)

User Interface

102.Consistency. Services to ensure consistency of user interface experience across applications.

On-Line Transaction Processing (OLTP)

103.Real-time, Immediate. Database services to support the real-time, immediate health delivery process and the EHR.

104.Transactions. Services to support two phase database commits (including bidding and locking), tightly coupled across multiple applications to implement shared, multi-application ownership of EHR and related records, including merged lists:

.1 Patients/members (e.g., the Master Patient Index);
.2 Practitioners/caregivers;
.3 Schedules for patients, practitioners and resources;
.4 Lists of patient encounters;
.5 Lists of patient problem-oriented episodes;
.6 Lists of current medications for a patient (i.e., the medication profile);
.7 etc.

On-Line Analytical Processing (OLAP)

105.Retrospective. Database services to support retrospective analytical functions relative to the EHR and its derivative subsets.

Data Store Management

106. Database Synchrony, Replication. Services to ensure database synchrony and replication management across multiple applications:

.1 At initial application binding;
.2 Continuously during routine operation;
.3 After application downtime.

107. Retention. Services to ensure proper database retention characteristics, including services for creating and retrieving archival records.

108. Not Size Restricted. Facilities to ensure that the EHR content is not constrained by database maximum size restrictions.

Consents, Authorizations

109. Health Services. Services to track patient consents for procedures, diagnostics, therapeutics and other care.

110. Disclosure. Services to track patient consents for disclosure of their personal EHR and its subsets, including specific scope of disclosure.

Data Export, Disclosure.

111. EHR Derivatives. Services to export EHR derivatives and subsets to third parties and secondary users:

.1 while ensuring privacy and confidentiality protections for record subjects;
.2 within the scope of applicable consents/authorizations for disclosure, as applicable.

112. Disidentification. Services to ensure EHR derivatives and subsets have identifying individual and organizational traits excised prior to disclosure, as applicable.

113. Audit trails. Services to maintain audit trails of controlled disclosures of EHR derivatives and subsets.

114. Protection Labeling. Services to label disclosed EHR derivatives and subsets as protected, as applicable.

115. Requests for Amendment. Services to track patient requests for amendment of EHR content, including actions taken:

.1 Amendment made per request;
.2 Amendment refused.

Data Display

116. Equivalent Presentation. Services to ensure equivalent data presentation and display, across all applications within an organization or business unit.

117. Simultaneous Access. Services to ensure multiple simultaneous access to view EHR content.

118. Record Index, Table of Contents. Services to provide an index or table of contents to EHR content.

119. Drill Down. Services to provide discrete levels of EHR display detail, with drill down capability.

120. Customized Displays. Services to provide customized displays and views of EHR content: by organization, business unit, individual practitioner.

Master Definitions

121. Master Definition Tables. Services to create and manage master definition tables, based on business and clinical practice rules. For example:

.1 Data registry, data definition;
.2 Master user index;
.3 Security classifications for functions and data;
.4 Security clearances for users, roles;
.5 Facilities, locations;
.6 Resources;
.7 Procedures;
.8 Work flow;
.9 Clinical pathways: protocols, care plans;
.10 Decision support: initiators, rules, triggered actions;
.11 Medication formulary;
.12 etc.

Multi-Media

122. Multi-Media Record. Services and facilities to support multi-media EHR content, including: text, audio, video, images, graphics, waveforms, etc.

Personal Linkages

123. Persons. Services to support the linkage of individual EHR subjects, including:

.1 Mother/child, multiple birth, birth order;
.2 Next of kin, family groups;
.3 Guarantor;
.4 Insured, subscriber, health plan member;
.5 Emergency contact.

124. Populations. Services to support grouping of individual EHR subjects into designated groups, e.g., for clinical studies.

Localization, Local Authority

125. Localization. Services to support the parameters of local organizations and business units, including:

.1 Business and clinical practice rules;
.2 Security, access control, administration of security policy domains;
.3 Decision support rules;
.4 Practice guidelines, standards of care
.5 Surveillance, measurement and analysis rules;
.6 Procedures, work flow;
.7 Master table definitions;
.8 Data registry, definitions;
.9 Vocabulary;
.10 Classifications, code sets;
.11 Naming and identifiers;
.12 Data export, disclosure.

User Environments

126. User Environments. Services and facilities to support separate EHR user environments, including:

.1 Production, operational EHR;
.2 Test, development;
.3 Education, training.

Version Control

127. Versioning. Services and facilities to support and manage multiple versions, including:

.1 Hardware, firmware;
.2 Networks, communications;
.3 Application software;
.4 Master table definitions;
.5 Vocabulary;
.6 Classification, code sets;
.7 SDO data interchange standards;
.8 Mediator software.

128. Controlled Roll Forward. Services and facilities to support controlled version roll forward (e.g., from test/development to production environment).

Mediators (Interface Engines)

129. Synchrony. With mediator in place, services to ensure synchrony of application data stores: at initial application binding, during continuous operation, after application downtime.

130. End to End Acknowledgment. With mediator in place, services to ensure end to end (source transmitter to ultimate recipient) message acknowledgment, from source application to ultimate recipient.

131. End to End Sequencing. With mediator in place, services to ensure end to end sequencing of messages, from source application to ultimate recipient.

Application Inter-dependencies

132. Applications. Identification of application inter-dependencies (where an application cannot fully perform its function without essential precedent data from, or function by, another application).

EHR Core Architecture

133. Information Model. Services and facilities to support the core EHR information architecture, including:

.1 Data Registry: attributes (data elements), data groups and datasets;
.2 Data Model: object classes, relationships, attributes, and identifiers;
.3 Process Model: object states, state transitions, use cases and scenarios, workflow, data flow;
.4 Vocabulary, classifications, code sets;

134. Accountability Model. Services and facilities to support the accountability of individuals, organizations and business units. [See preceding sections on accountability.]

135. Data Integrity Model. Services and facilities to support the integrity of data origination, stewardship and communication. [See preceding section on data integrity.]

136. Process Integrity Model. Services and facilities to support the integrity of the health delivery process. [See preceding section on process integrity.]

137. Application Interoperability and Component Model. Services and facilities to support the full interoperability of application components, including roles, relationships, boundaries and functions.

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