ehr onc final certification - Department of Health Care Services

ehr onc final certification - Department of Health Care Services ehr onc final certification - Department of Health Care Services

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Certified EHR Technology. We do not believe that limiting this certification criterion to specify that just the information available at the end of an encounter is consistent with our policy objectives. Comments. Many commenters requested a definition of “diagnostic test results.” One commenter suggested that for Stage 1, the definition of diagnostic test result be made clear and be limited to, at a minimum, lab results. Response. This term is derived from the Medicare and Medicaid EHR Incentive Programs final rule, and its meaning is described there. We encourage commenters to review the Medicare and Medicaid EHR Incentive Programs final rule. Comments. Several commenters requested that ONC define how relevant procedures are determined for the certification criterion. The commenters suggested that a subset of procedures (e.g., surgeries, catheterizations) be defined to avoid generating huge lists of “small” procedures (e.g., venipunctures). These commenters expressed that it was critical for the rule to provide a clear, clinically-relevant definition of which types of procedures are to be included. Response. We appreciate the comment and have revised this certification criterion to remove “procedures” as well as “immunizations,” to be more consistent with the final meaningful use objective and measure and for greater clarity. Comment. A commenter requested clarification on how an electronic copy will be disseminated, and provided examples such as a web-portal, email, and compact disc. Response. We do not specify the method by which an individual must receive an electronic copy of the specified health information, only that Certified EHR Technology be capable of electronically generating an electronic copy in human readable format and Page 144 of 228

in accordance with one of the adopted summary record standards. While Certified EHR Technology must be capable of creating an electronic copy of a patient’s health information as specified in this certification criterion, we encourage Complete EHR and EHR Module developers to also include the capability to generate an electronic copy in a manner that allows eligible professionals (and eligible hospitals as this capability relates to Complete EHRs and EHR Modules designed for an inpatient setting) to comply with applicable provisions of the HIPAA Privacy and Security Rules. Comment. A commenter requested that we add a requirement for alerts to prompt users to ask patients if they want a copy of their health information and include the ability to record whether the information was actually provided and the patient’s preference on the format of the information. The commenter believed that this requirement is necessary because many patients are not aware that they can make such a request. Response. While potentially useful as a reminder, we do not believe that this capability should be a condition of certification. This capability would exceed the scope of the relevant meaningful use Stage 1 objective and measure. We also note that Complete EHR and EHR Module developers are not precluded from including this capability in their EHR technology. Comment. A commenter noted that with our emphasis on the representation of clinical information in the format of a CCD or CCR, it is unclear whether the certification criterion is enough to meet patients’ expectations. Response. We recognize that this minimum information may not satisfy every patient’s interests, however, we believe that the information specified represents a core set of information that most patients will appreciate is more readily accessible to them. Page 145 of 228

in accordance with one <strong>of</strong> the adopted summary record standards. While Certified EHR<br />

Technology must be capable <strong>of</strong> creating an electronic copy <strong>of</strong> a patient’s health<br />

information as specified in this <strong>certification</strong> criterion, we encourage Complete EHR and<br />

EHR Module developers to also include the capability to generate an electronic copy in a<br />

manner that allows eligible pr<strong>of</strong>essionals (and eligible hospitals as this capability relates<br />

to Complete EHRs and EHR Modules designed for an inpatient setting) to comply with<br />

applicable provisions <strong>of</strong> the HIPAA Privacy and Security Rules.<br />

Comment. A commenter requested that we add a requirement for alerts to prompt<br />

users to ask patients if they want a copy <strong>of</strong> their health information and include the ability<br />

to record whether the information was actually provided and the patient’s preference on<br />

the format <strong>of</strong> the information. The commenter believed that this requirement is necessary<br />

because many patients are not aware that they can make such a request.<br />

Response. While potentially useful as a reminder, we do not believe that this<br />

capability should be a condition <strong>of</strong> <strong>certification</strong>. This capability would exceed the scope<br />

<strong>of</strong> the relevant meaningful use Stage 1 objective and measure. We also note that<br />

Complete EHR and EHR Module developers are not precluded from including this<br />

capability in their EHR technology.<br />

Comment. A commenter noted that with our emphasis on the representation <strong>of</strong><br />

clinical information in the format <strong>of</strong> a CCD or CCR, it is unclear whether the <strong>certification</strong><br />

criterion is enough to meet patients’ expectations.<br />

Response. We recognize that this minimum information may not satisfy every<br />

patient’s interests, however, we believe that the information specified represents a core<br />

set <strong>of</strong> information that most patients will appreciate is more readily accessible to them.<br />

Page 145 <strong>of</strong> 228

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