Core Data Sets for the Physician Practice Electronic Health Record

Core Data Sets for the Physician Practice Electronic Health Record

This practice brief has been retired. It is made available for historical purposes only.

Overview

The safety and quality of healthcare, homeland security, HIPAA, and escalating healthcare costs have brought the electronic health record (EHR) to the forefront of the healthcare industry. These national concerns have created several overarching initiatives that are driving the standardization and implementation of the EHR and EHR systems.

On July 1, 2003, the secretary of the Department of Health and Human Services (HHS), Tommy Thompson, announced that the department is moving the healthcare industry toward execution of the EHR. He announced that HHS had commissioned the Institute of Medicine (IOM) to design a standardized model of an EHR. The healthcare standards development organization Health Level Seven, known as HL7, has been asked to evaluate the model once it has been designed. HHS will share the standardized model record at no cost with all components of the U. S. healthcare system. The department expects to have a model record ready in 2004.¹ The model and standards will be used in demonstration projects in 2004 and will address the entire healthcare community, from large enterprises to individual physician practices.

HL7 chose to define the EHR through a functional model and published its "EHR System Functional Model and Standard" in August 2003.² This draft was preceded by the IOM definitional work document issued July 31, 2003, titled "Key Capabilities of an Electronic Health Record System." Their report states, "In the near term (2006Ð 2007), providers' EHR systems should allow for the capture of defined sets of health information. . . ."³

AHIMA has been instrumental in preparing healthcare professionals for the EHR since the early 1990s through the AHIMA board initiatives of Vision 2000, 2006, and 2010. AHIMA sponsored the 1991 IOM study on the computer-based patient record (CPR) and CPR systems. Throughout the 1990s, AHIMA worked to reduce the number one barrier to the use of EHRs through the development of legislation and regulation to address privacy and security.

AHIMA continues to support practitioners in their day-to- day privacy and security implementations. In 2002, AHIMA launched the e-HIM initiative, focused on accelerating the adoption of EHRs and reinventing how institutional and personal health records are managed. AHIMA participates in the Markle Foundation's Connecting for Health collaborative and is working with the National Alliance of Health Information Technology on a number of their workgroups. Most recently, AHIMA was instrumental in working with other organizations to create the EHR Collaborative, a group working to bring the work of HL7 to the front lines of the healthcare industry for input and feedback on the EHR model.

The purpose of this practice brief is to provide a replicable approach and model for identifying and defining the core data required to design and implement an EHR in a physician practice setting.

History

From the beginning of modern medical practice, physicians have been trying to organize patient information in a meaningful way so that it can be retrieved quickly when needed. Forward-thinking Dr. Lawrence L. Weed made a quantum leap in the organization of paper-based information with the development of his Problem Oriented Medical Record system in the 1960s. Not long after, physicians became leaders in the trend to use computers to organize information. Massachusetts General Hospital implemented the Computer Stored Ambulatory Record (COSTAR) in 1968, and Duke University developed a comprehensive medical information system known as The Medical Record to organize physician records in the 1970s.⁴

Innovative systems such as these led the IOM to study ways to improve patient records through the use of computers. Their original study findings, published in 1991, recommended that CPRs be adopted as the standard for medical documentation.⁵ Although the study was issued more than 12 years ago, the industry still has considerable work ahead to achieve the IOM's goal. Their definition of a CPR in this landmark study still sets the standard as "an electronic patient record that resides in a system specifically designed to support users by providing accessibility to complete and accurate data, alerts, reminders, clinical decision support systems, links to medical knowledge and other aids."⁶

Consumer advocacy groups, accreditation agencies, and patients themselves have embraced the idea of an EHR for the advantages it provides. The IOM issued "Crossing the Quality Chasm: The IOM Health Care Quality Initiative" in 2001, with the authors underscoring "the importance of a dramatically improved information technology infrastructure to support a 21st century health system."⁷ They cite the use of an EHR and its components of alerts, reminders, and clinical decision support systems as essential to improved quality of care and patient safety through the reduction of medical errors. Research done by the Connecting for Health Coalition tells us that almost 70 percent of consumers who use the Internet would use an online personal health record to store immunization records, track medication use, look up test results, and transfer medical histories electronically to new physicians, and 54 percent feel it would improve the quality of healthcare.⁸

Impetus for expediting EHR development has been growing since 1998, with the establishment of the Leapfrog Group, made up of Fortune 500 companies and other large private and public healthcare purchasers. Building on IOM study findings, these purchasers are tying three particular patient safety and quality of care issues to technology resolutions and advocating public reporting of healthcare organization efforts to address them, thus resulting in more informed purchasing of healthcare services.

Administratively, the EHR is seen as the vehicle to improve documentation and legibility, increase the speed of communication between providers of care, and provide multiple user accessibility, the feature physicians most often request.⁹ In addition, more structured data capture can positively affect reimbursement by collecting all necessary accurate data elements.

Legal and Regulatory

Federal

While the Centers for Medicare and Medicaid Services (CMS) currently have no regulatory requirements for the use of the EHR, HIPAA's transaction and code set requirements are mandated for any covered entity choosing to submit electronic healthcare claims on and beyond October 16, 2003. With this implementation comes the unanswered question of how to transition claim attachments from the paper world into the electronic world. The EHR would undoubtedly provide an answer to that question.

While no specific regulations exist for the physician practice setting, reimbursement guidelines for code reporting have served as drivers for documentation since 1994.

Until the EHR is the standard in the industry, a regulatory mandate for its use is not likely, but is being seen as a cost-saving element in the future of healthcare delivery. For now, CMS "is considering offering financial and other incentives to providers to encourage the deployment of EHR systems."¹⁰

State

Individual states may have laws or regulations that govern health record formats. State statutes or specific legislation may not always exist to support EHR policy development. Health plans, third-party payers, legislative bodies, and accreditation organizations may need assistance in transitioning their paper-based regulations, policies, standards, and review processes to appropriately deal with electronic information. Organizations using EHR technology should provide leadership and help develop policy to meet the needs of external organizations without compromising information security and patient confidentiality.

Accreditation Standards

The Joint Commission on Accreditation of Healthcare Organizations' Comprehensive Accreditation Manual for Ambulatory Care: Draft Standards for 2004 contains changes and additions to the management of information standards. These revisions reflect the content and management of information in both the electronic and paper environments. Prepublication language states, "The organization has a complete and accurate medical record for every individual assessed or treated" and "records contain patient specific information, as appropriate, to the care, treatment, and services provided."¹¹

The Accreditation Association for Ambulatory Health Care is silent in the Accreditation Handbook for Ambulatory Health Care regarding the content and management of electronic health information, and the American Osteopathic Association does not currently issue separate standards for physician practices.

Abbreviations

Many abbreviations and acronyms are used within healthcare. To provide a frame of reference for the abbreviations used in the core data sets, the following list is provided:

ABN	advanced beneficiary notice	MMR	measles, mumps, and rubella
BMI	body mass index	MS	musculoskeletal
B/P	blood pressure	Neuro	neurologic, neurological
CV	cardiovascular	NP	nurse practitioner
DOB	date of birth	NPP	notice of privacy practices
DPT	diphtheria, pertussis, and tetanus	opt	optional
ENMT	ears, nose, mouth, and throat	PA	physician assistant
ENT	ears, nose, and throat	PCP	primary care provider
ETOH	alcohol	PPD	purified protein derivative of tuberculin test
GI	gastrointestinal	PSA	prostate-specific antigen
GU	genitourinary	psych	psychiatric
GYN	gynecologist, gynecologic	Resp	respiratory
Hep A/B	hepatitis A and B vaccines, respectively	RN	registered nurse
HiB	hemophilus influenza type B vaccine	ROS	review of systems
HPI	history of present illness	SOAP	subjective, objective, assessment, plan
LMP	last menstrual period	SSI	Supplemental Security Income
LPN	licensed practical nurse	Temp	temperature
MA	medical assistant	VIS	vaccine information sheet
MD	medical doctor	WIC	Women, Infants and Children's program

Best Practices

The acceptance and value of the EHR within physician practice settings are directly related to the EHR's usefulness for real-life application. In addition to addressing administrative/ financial realities, the EHR must offer indispensable clinical benefits to make the effort to shift from a paper to electronic environment worthwhile. Caregivers require practical, related information during patient visit, assessment, treatment, and follow-up phases. The foundation of core data sets must be information that drives care-giving activities. The aggregation of this data, in turn, builds the EHR.

The AHIMA e-HIM Work Group on Core Data for the Physician Practice EHR, author of this practice brief, believes that in order to understand the data needs of a physician practice, one first must understand the clinical work flow of a physician practice. Thus, it is essential to provide a model that the clinician and others will understand and use to acquire, design, and implement EHRs.

Clinical work flows became the framework to develop model core data sets as the blueprints for EHR development in a physician practice. Specifically, model core data sets were created for eight sample clinical work flows. Four basic types of patient visits, for both new and established patients (and for both well and sick visits), were identified for pediatric and adult patients. The core data collected during well and sick visits for pediatric and adult patients are itemized and organized within the framework of the work flow that takes place during these visits. These data sets are not specific to any particular specialty or size of physician practice.

The eight clinical work flows and their corresponding core data sets are intended to be used by physician practices as a guideline and model for the development and implementation of an EHR in their practices. The clinical work flow begins with the patient (new or established) arriving at the reception desk and registering for the visit (well or sick), as well as completing the necessary consents and authorizations. The clinical encounter begins with vital signs being taken, followed by chief complaint/ reason for visit, then on to history of present illness, and so forth.

In each step, the core data needed to complete the documentation are identified. Each clinical work flow ends with the clinical encounter being completed and the patient being discharged, having received the necessary patient handouts, instructions, and so forth. Although these work flows focus on primary care for both adults and children, the model is adaptable to other specialties and healthcare settings.

Core Data Sets

Pediatric Well Patient Clinical Work Flow: New Patient and Established Patient

	New Patient--Pediatric Well Visit Core Data	Established Patient--Pediatric Well Visit Core Data
Administrative or Front Office Function	Demographic and Administrative Information Patient name Address Phone number DOB Age Sex Race and ethnicity Religion (opt) Parent(s) name Custodial parent Noncustodial parent Guardian Self (for emancipated minor) Phone number (per parent or guardian) Address (per parent or guardian) Emergency contact Occupation of parent or guardian Insurance information Primary insurance: name, address, and policy and group number Secondary insurance: name, address, and policy and group number Name of insured for primary and secondary policies Address of insured Consents and release forms Preferred pharmacy Notice of Privacy Practices acknowledgment	Demographic and Administrative Information Patient name Address Phone number DOB Age Parent(s) name Insurance verification
MA/LPN/RN	Vital Signs Weight Height BMI Head circumference Plot on growth chart Temp Pulse Respirations BP LMP	Vital Signs Weight Height Prior height and weight BMI Head circumference Plot on growth chart Temp Pulse Respirations BP LMP
MA/LPN/RN/ MD/NP/PA	Reason for Visit, Chief Complaint	Reason for Visit, Chief Complaint
MD/NP/PA	History of Present Illness Clinical episode Questions for parents, age appropriate for child Questions for child, age appropriate Developmental observations, age appropriate Dietary issues Sleep issues Family concerns	History of Present Illness Clinical episode Questions for parents, age appropriate for child Questions for child, age appropriate Developmental observations, age appropriate Dietary issues Sleep issues Family concerns
MD/NP/PA	Past Medical History Medications Allergies Recent injuries or illness Special healthcare needs Visits to other healthcare providers or hospitalizations (including psychological) Diagnostic test results Changes or stressors in family or home (including psychological) School issues, age appropriate Sibling names and ages Birth status Newborn history Gestational age	Interval History Medications Allergies Recent injuries or illness Special healthcare needs Visits to other healthcare providers or hospitalizations (including psychological) Diagnostic test results Changes or stressors in family or home (including psychological) School issues, age appropriate
MD/NP/PA	Physical Exam General Skin Head Eyes Ears Nose and throat Mouth: teeth, mucosa Neck Lungs Heart Abdomen Back GU Extremities Neuro Reflexes Signs of abuse	Physical Exam General Skin Head Eyes Ears Nose and throat Mouth: teeth, mucosa Neck Lungs Heart Abdomen Back GU Extremities Neuro Reflexes Signs of abuse
MD/NP/PA	Problem List and Medication List Acute and chronic problems Date provider became aware of problem or diagnosis Date resolved Name of medication Start and stop dates Who prescribed For what condition Preferred pharmacy Other items from HPI and history that provider feels are appropriate (e. g. , allergies, medications)	Problem List and Medication List Acute and chronic problems Date provider became aware of problem or diagnosis Date resolved Name of medication Start and stop dates Who prescribed For what condition Preferred pharmacy Other items from HPI and history that provider feels are appropriate (e. g. , allergies, medications)
MD/NP/PA	Anticipatory Guidance Age appropriate Healthy habits Social competence Family relationships Community interaction Safety issues (e. g. , car seats, bike helmets, home frst-aid products, smoke detectors in home, home wiring and electrical) Pets in home Guns in home	Anticipatory Guidance Age appropriate Healthy habits Social competence Family relationships Community interaction Safety issues (e. g. , car seats, bike helmets, home frst-aid products, smoke detectors in home, home wiring and electrical) Pets in home Guns in home
MD/NP/PA/ MA/LPN/RN	Screenings Age appropriate Vision Hearing Assess lead risk Assess hyperlipidemia risk PPD Fluoride in water and city water	Screenings Age appropriate Vision Hearing Assess lead risk Assess hyperlipidemia risk PPD Fluoride in water and city water
MD/NP/PA/ MA/LPN/RN	Immunizations Immunizations up to date? Self-reported immunization dates DPT (lot # and VIS date) Varicella (lot # and VIS date) MMR (lot # and VIS date) Meningococcal (lot # and VIS date) Polio (lot # and VIS date) HiB (lot # and VIS date) Hep A (lot # and VIS date) Hep B (lot # and VIS date) Pneumococcal conjugate (lot # and VIS date) Infuenza (lot # and VIS date) Other Side effects discussed? Refusal or objection to immunization Consent	Immunizations Immunizations up to date? Self-reported immunization dates DPT (lot # and VIS date) Varicella (lot # and VIS date) MMR (lot # and VIS date) Meningococcal (lot # and VIS date) Polio (lot # and VIS date) HiB (lot # and VIS date) Hep A (lot # and VIS date) Hep B (lot # and VIS date) Pneumococcal conjugate (lot # and VIS date) Infuenza (lot # and VIS date) Other Side effects discussed? Refusal or objection to immunization Consent
MD/NP/PA/ MA/LPN/RN/ Clerical Staff	Summary or Results Visit summary (include diagnosis, procedure[s], and codes) Summarize other visits (include diagnosis, procedure[s], and codes) Diagnostic tests ordered and results reported Prescription or treatment Medication reflls Arrange continuing care as needed Forms completion (e. g. , school, camp, day care) Patient instructions Handouts provided Disposition	Summary or Results Visit summary (include diagnosis, procedure[s], and codes) Summarize other visits (include diagnosis, procedure[s], and codes) Diagnostic tests ordered and results reported Prescription or treatment Medication reflls Arrange continuing care as needed Forms completion (e. g. , school, camp, day care) Patient instructions Handouts provided Disposition
MD/NP/PA/ MA/LPN/RN/ Clerical Staff	Referral Clinical referral Social referral Health insurance Social services SSI Housing WIC Food stamps Other	Referral Clinical referral Social referral Health insurance Social services SSI Housing WIC Food stamps Other
	Authentication Required signatures and title^* Clerical staff (front desk) MA, LPN, RN Medical student Resident or fellow Scribe Attending	Authentication Required signatures and title ^* Clerical staff (front desk) MA, LPN, RN Medical student Resident or fellow Scribe Attending

Consider signatures required according to individual state laws.
Note: The SOAP process for documentation is incorporated in the above.

Pediatric Sick Patient Clinical Work Flow: New Patient and Established Patient

	New Patient--Pediatric Sick Visit Core Data	Established Patient--Pediatric Sick Visit Core Data
Administrative or Front Office Function	Demographic and Administrative Information Patient name Address Phone number DOB Age Sex Race and ethnicity Religion (opt) Parent(s) name Custodial parent Noncustodial parent Guardian Self (for emancipated minor) Phone number (per parent or guardian) Address (per parent or guardian) Occupation of parent or guardian Emergency contact Insurance information Primary insurance: name, address, and policy and group number Secondary insurance: name, address, and policy and group number Name of insured for primary and secondary policies Address of insured Consents and release forms Referral if required Preferred pharmacy Notice of Privacy Practices acknowledgment	Demographic and Administrative Information Patient name Address Phone number DOB Age Parent(s) name Insurance verification Referral if required
MA/LPN/RN	Vital Signs Weight Height Head circumference Plot on growth chart Temp Pulse Respirations BP LMP	Vital Signs Weight Height Prior height and weight Plot on growth chart Temp Pulse Respirations BP LMP
MA/LPN/RN/ MD/NP/PA	Reason for Visit, Chief Complaint	Reason for Visit, Chief Complaint
MD/NP/PA	History of Present Illness Clinical episode Questions for parents, appropriate for illness Questions for child, appropriate for illness	History of Present Illness Clinical episode Questions for parents, appropriate for illness Questions for child, appropriate for illness
MD/NP/PA	Past Medical History Medications Allergies Recent injuries or illness Special healthcare needs Visits to other healthcare providers or hospitalizations (including psychological) Diagnostic test results Sibling names and ages Birth status Newborn history Gestational age	Interval History Medications Special healthcare needs Visits to other healthcare providers or hospitalizations (including psychological) Diagnostic test results
MD/NP/PA	Review of Systems As appropriate for HPI Constitutional, general ENMT Eyes Neck Resp CV GI GU MS Integumentary Neuro Endocrine Hematologic or lymphatic Allergic or immunologic Psych	Review of Systems As appropriate for HPI Constitutional, general ENMT Eyes Neck Resp CV GI GU MS Integumentary Neuro Endocrine Hematologic or lymphatic Allergic or immunologic Psych
MD/NP/PA	Physical Exam General Skin Head Eyes ENT Mouth: teeth, mucosa Neck Lungs Heart Abdomen Back GU Extremities Neuro Reflexes Signs of abuse	Physical Exam General Skin Head Eyes ENT Mouth: teeth, mucosa Neck Lungs Heart Abdomen Back GU Extremities Neuro Reflexes Signs of abuse
MD/NP/PA	Problem List and Medication List Acute and chronic problems Date provider became aware of problem or diagnosis Date resolved Name of medication Start and stop dates Who prescribed For what condition Preferred pharmacy Other items from HPI and history that provider feels appropriate (e. g., allergies, medications)	Problem List and Medication List Update as appropriate Name of medication Start and stop dates Who prescribed For what condition Other items from HPI and history that provider feels appropriate (e. g., allergies, medications)
MD/NP/PA/ MA/LPN/RN	Screenings Appropriate for HPI	Screenings Appropriate for HPI
MD/NP/PA/ MA/LPN/RN	Immunizations Immunizations up to date? Self-reported immunization dates
MD/NP/PA/ MA/LPN/RN/ Clerical Staff	Summary and Results Visit summary (include diagnosis, procedure[s], and codes) Diagnostic tests ordered and results reported Prescription or treatment Medication reflls Arrange continuing care as needed Patient instructions Handouts provided Disposition	Summary and Results Visit summary (include diagnosis, procedure[s], and codes) Diagnostic tests ordered and results reported Prescription or treatment Medication reflls Arrange continuing care as needed Patient instructions Handouts provided Disposition
MD/NP/PA/ MA/LPN/RN/ Clerical Staff	Referral Clinical referral Social referral Health insurance Social services SSI Housing WIC Food stamps Other	Referral Clinical referral
	Authentication Required signatures and title^* Clerical staff (front desk) MA, LPN, RN Medical student Resident or fellow Scribe Attending	Authentication Required signatures and title^* Clerical staff (front desk) MA, LPN, RN Medical student Resident or fellow Scribe Attending

Consider signatures required according to individual state laws.
Note: The SOAP process for documentation is incorporated in the above.

Adult Well Patient Clinical Work Flow: New Patient and Established Patient

	New Patient--Adult Well Visit Core Data	Established Patient--Adult Well Visit Core Data
Administrative or Front Office Function	Demographic and Administrative Information Patient name Address Phone number (home and cell) E-mail address DOB Sex, marital status, spouse's info Race and ethnicity Religion (opt) Guardian name (emancipated minor) Guardian's address and phone number Work number: occupation of patient or guardian Emergency contact Insurance information Primary insurance: name, address, and policy and group number Secondary insurance: name, address, and policy and group number Name of insured for primary and secondary policy Address of insured Consents and release forms ABN forms or waiver Notice of Privacy Practices acknowledgment Preferred pharmacy PCP and GYN (opt) Advanced directives Referral if required	Demographic and Administrative Information Patient name Address Phone number Insurance verification Referral if required ABN forms or waiver Any other updates
MA/LPN/RN	Vital Signs Weight Height BMI (opt) Temp Pulse Respirations BP LMP	Vital Signs Weight Height (opt) BMI (opt) Temp Pulse Respirations BP LMP
MA/LPN/RN/ MD/NP/PA	Reason for Visit, Chief Complaint Acute and or chronic problems	Reason for Visit, Chief Complaint Acute and or chronic problems
MD/NP/PA	History, Medical Concerns Diet, sleep Family life (past history: divorce, adoption, stepchildren) Medications Allergies Recent injuries or illnesses Special healthcare needs: safety measures, tobacco use, ETOH use Other providers and hospitalizations Diagnostic tests Changes or stressors Exercise GYN history Patient self-assessment data (i.e., logbook changes or stressors or electronic log)	History, Medical Concerns Diet, sleep Family life (past history: divorce, adoption, stepchildren) Medications Allergies Recent injuries or illnesses Special healthcare needs: safety measures, tobacco use, ETOH use Other providers and hospitalizations Diagnostic tests Changes or stressors Exercise GYN history Patient self-assessment data (i.e., logbook changes or stressors or electronic log)
MD/NP/PA	Physical Exam General Skin Head Eyes ENT Mouth: teeth, mucosa Neck Lungs Heart Abdomen Back GI GU Extremities Neuro Reflexes Mental Status	Physical Exam General Skin Head Eyes ENT Mouth: teeth, mucosa Neck Lungs Heart Abdomen Back GI GU Extremities Neuro Reflexes Mental Status
MD/NP/PA	Problem List and Medication List Acute and chronic problems Date provider became aware of problem or diagnosis Date resolved Name of medication Start and stop dates Who prescribed For what condition Preferred pharmacy Other items from HPI and history that provider feels are appropriate (e. g. , allergies, medications)	Problem List and Medication List Update as appropriate Name of medication Start and stop dates Who prescribed For what condition Other items from HPI and history that provider feels are appropriate (e. g. , allergies, medications)
MD/NP/PA/ MA/LPN/RN	Anticipatory Guidance Healthy habits Social and family relations Safety issues Health maintenance: mammogram, PSA, hemoccult slides, bone density test	Anticipatory Guidance Healthy habits Social and family relations Safety issues Health maintenance: mammogram, PSA, hemoccult slides, bone density test
MD/NP/PA/ MA/LPN/RN	Screenings and Immunizations Age appropriate Vision Hearing PPD Hep B (lot # and VIS date) Pneumococcal (lot # and VIS date) Infuenza (lot # and VIS date) Tetanus (lot # and VIS date) Side effects Consents	Screenings and Immunizations Age appropriate Vision Hearing PPD Hep B (lot # and VIS date) Pneumococcal (lot # and VIS date) Infuenza (lot # and VIS date) Tetanus (lot # and VIS date) Side effects Consents
MD/NP/PA/ MA/LPN/RN/ Clerical Staff	Summary or Results Visit summary (include diagnosis, procedure[s], and codes) Diagnostic tests ordered and results reported Prescription or treatment Medication reflls Follow-up appointments Patient education or instructions Handouts Forms completion Referrals Disposition	Summary or Results Visit summary (include diagnosis, procedure[s], and codes) Diagnostic tests ordered and results reported Prescription or treatment Medication reflls Follow-up appointments Patient education or instructions Handouts Forms completion Referrals Disposition
	Authentication Required signatures and title^* Clerical staff (front desk) MA, LPN, RN Medical student Resident or fellow Scribe Attending	Authentication Required signatures and title^* Clerical staff (front desk) MA, LPN, RN Medical student Resident or fellow Scribe Attending

Consider signatures required according to individual state laws.
Note: The SOAP process for documentation is incorporated in the above.

Adult Sick Patient Clinical Work Flow: New Patient and Established Patient

	New Patient--Adult Sick Visit Core Data	Established Patient--Adult Sick Visit Core Data
Administrative or Front Office Function	Demographic and Administrative Information Patient name Address Phone number (home and cell) E-mail address DOB Sex, marital status, spouse's info Race and ethnicity Religion (opt) Guardian or emancipated minor's name Guardian's address and phone number Work number: occupation of patient or guardian Emergency contact Insurance information Primary insurance: name, address, and policy and group number Secondary insurance: name, address, and policy and group number Name of insured for primary and secondary policy Address of insured Consents and release forms ABN forms or waiver Notice of Privacy Practices acknowledgment Preferred pharmacy PCP and GYN (opt) Advanced directives Referral if required	Demographic and Administrative Information Patient name Address Phone number Insurance verification Referral if required ABN forms or waiver Any other updates
MA/LPN/RN	Vital Signs Weight Height BMI (opt) Temp Pulse Respirations BP LMP	Vital Signs Weight Height (opt) BMI (opt) Temp Pulse Respirations BP LMP
MA/LPN/RN/ MD/NP/PA	Reason for Visit, Chief Complaint Acute and or chronic problems	Reason for Visit, Chief Complaint Acute and or chronic problems
MD/NP/PA	History of Present Illness Clinical episode	History of Present Illness Clinical episode
MD/NP/PA	History, Medical Concerns Diet, sleep Family life (past history: divorce, adoption, stepchildren) Medications Allergies Recent injuries or illnesses Special healthcare needs: safety measures, tobacco use, ETOH use Other providers and hospitalizations Diagnostic tests Changes or stressors Exercise GYN history Patient self-assessment data (i.e., logbook changes or stressors or electronic log)	History, Medical Concerns Diet, sleep Family life (past history: divorce, adoption, stepchildren) Medications Allergies Recent injuries or illnesses Special healthcare needs: safety measures, tobacco use, ETOH use Other providers and hospitalizations Diagnostic tests Changes or stressors Exercise GYN history Patient self-assessment data (i.e., logbook changes or stressors or electronic log)
MD/NP/PA	Review of Systems As appropriate for HPI Constitutional, general ENMT Eyes Neck Resp CV GI Genitourinary MS Integumentary Neuro Endocrine Hematologic or lymphatic Allergic or immunologic Psych	Review of Systems As appropriate for HPI Constitutional, general ENMT Eyes Neck Resp CV GI GU MS Integumentary Neuro Endocrine Hematologic or lymphatic Allergic or immunologic Psych
MD/NP/PA	Physical Exam General Skin Head Eyes ENT Mouth: teeth, mucosa Neck Lungs Heart Abdomen Back GI GU Extremities Neuro Reflexes Mental status	Physical Exam General Skin Head Eyes ENT Mouth: teeth, mucosa Neck Lungs Heart Abdomen Back GI GU Extremities Neuro Reflexes Mental status
MD/NP/PA	Problem List and Medication List Acute and chronic problems Date provider became aware of problem or diagnosis Date resolved Name of medication Start and stop dates Who prescribed For what condition Preferred pharmacy Other items from HPI and history that provider feels appropriate (e. g., allergies, medications)	Problem List and Medication List Update as appropriate
MD/NP/PA/ MA/LPN/RN	Anticipatory Guidance Healthy habits Social and family relations Safety issues Health maintenance: mammogram, PSA, hemoccult slides, bone density test	Anticipatory Guidance Healthy habits Social and family relations Safety issues Health maintenance: mammogram, PSA, hemoccult slides, bone density test
MD/NP/PA/ MA/LPN/RN	Screenings or Immunizations Hep B (lot # and VIS date) Pneumococcal (lot # and VIS date) Infuenza (lot # and VIS date) Tetanus (lot # and VIS date) Side effects Consents	Screenings or Immunizations Hep B (lot # and VIS date) Pneumococcal (lot # and VIS date) Infuenza (lot # and VIS date) Tetanus (lot # and VIS date) Side effects Consents
MD/NP/PA/ MA/LPN/RN/ Clerical Staff	Summary and Results Visit summary (include diagnosis, procedure[s], and codes) Diagnostic tests ordered and results reported Prescription or treatment Medication reflls Follow-up appointments Patient education or instructions Handouts Forms completion Referrals Disposition	Summary or Results Visit summary (include diagnosis, procedure[s], and codes) Diagnostic tests ordered and results reported Prescription or treatment Medication reflls Follow-up appointments Patient education or instructions Handouts Forms completion Referrals Disposition
	Authentication Required signatures and title^* Clerical staff (front desk) MA, LPN, RN Medical student Resident or fellow Scribe Attending	Authentication Required signatures and title^* Clerical staff (front desk) MA, LPN, RN Medical student Resident or fellow Scribe Attending

Consider signatures required according to individual state laws.
Note: The SOAP process for documentation is incorporated in the above.

See Appendix, "Electronic HIM Knowledge and Associated Tasks Inventory".

Conclusion

This brief provides an important foundation necessary to successful EHR implementationÑ a model that identifies and defines the essential core data necessary to support high-quality patient care, a model that will be understood by those who deliver patient care.

Many physician practices, large and small, are already facing the challenges of EHR implementation or are planning for implementation. The HIM professional can act as the catalyst and change agent guiding these practices through the phases of EHR implementation. It is important for all HIM professionals to take an active role in understanding the current EHR market developments and standard-setting activities, and project how these activities will affect their organizations. The HIM professional is the ideal candidate to use EHR knowledge and experience to ensure that the EHR clinical work flows and corresponding core data are captured with the highest integrity and quality possible.

Key areas of focus for HIM professionals working in physician practices include

Monitoring standards development and legal issues related to the EHR
Providing in-services and presentations on EHR
Being involved in standard-setting groups
Adapting existing models to organization operations
Assessing and growing your knowledge base
Seeking available resources to assist in implementation
Ensuring that appropriate privacy and confidentiality policies and procedures are in place

Whether your journey toward the EHR is just beginning or well along, AHIMA offers this practice brief as a tool to help you make the trek.

Notes

Institute of Medicine. "Key Capabilities of an Electronic Health Record System: Letter Report from the Committee on Data Standards for Patient Safety." Washington, DC: National Academy Press, 2003.
Health Level Seven. "EHR System Functional Model and Standard, Release 1.0." Health Level Seven, Inc., 2003.
Institute of Medicine, 2003.
Institute of Medicine, The Computer-Based Patient Record: An Essential Technology for Health Care. Washington, DC: National Academy Press, 1991: 70Ð 71.
Ibid., 133.
Ibid., 11.
Institute of Medicine. "Crossing the Quality Chasm: The IOM Health Care Quality Initiative." Available at www. iom. edu/ focuson. asp? id= 8089.
"Americans Want Benefits of Personal Health Records. Markle Foundation, Connecting for Health: A Public-private Collaborative." Available at www. connectingforhealth. org/ PHWG_ survey. pdf.
Ball, Marion J., and Morris F. Collen. Aspects of the Computer-based Patient Record. New York: Springer-Verlag, Inc., 1992: 4.
Institute of Medicine. 2003, 4.
Joint Commission on Accreditation of Healthcare Organizations. Comprehensive Accreditation Manual for Ambulatory Care: Draft Standards for 2004. Oakbrook Terrace, IL: Joint Commission, 2003.

References

Accreditation Association for Ambulatory Health Care. Accreditation Handbook for Ambulatory Health Care. Wilmette, IL: AAAHC, 2003.

Amatayakul, Margret. The Role of the Health Information Managers in CPR Projects: A Practical Guide. Chicago: AHIMA, 1999.

American Health Information Management Association. Documentation for Ambulatory Care, Revised Edition. Chicago: AHIMA, 2001.

For the Record: Protecting Electronic Health Information. Washington, DC: National Academy Press. 1997.

Health Data in the Information Age: Use, Disclosure and Privacy. Washington, DC: National Academy Press, 1994.

Health Information Management Systems Society. "Electronic Health Record Definitional Model: Version 1.0. Electronic Health Record Attributes and Essential Requirements." HIMSS, 2003.

Institute of Medicine. The Computer-Based Patient Record: An Essential Technology for Care, Revised Edition. Washington, DC: National Academy Press, 1997.

American Health Information Management Association. "Report on the Roles and Functions of e-Health Information Management." Chicago: AHIMA, 2002.

Resources

Bright Futures (Pediatric Well-care Guidelines): www. brightfutures. org

Connecting for Health Collaborative: www. connecting forhealth. org

EHR Collaborative: www. ehrcollaborative. org

Healthcare Information and Management Systems Society: www. himss. org

Health Level Seven: www.hl7.org/ehr/

Appendix: Electronic HIM Knowledge and Associated Tasks Inventory

The HIM professional employed in the physician practice environment uses a particular knowledge base to understand work flow and perform tasks unique to EHR development and management. An inventory of the EHR responsibilities, knowledge, and associated tasks is included here for use in career advancement, continuing education planning, and job description development. It is intentionally provided as an inventory list rather than a formal job description because the tasks may be completed by several individuals, depending upon the size and type of organization. Following the inventory is a list of general attributes necessary for performing these tasks.

EHR Responsibilities	Knowledge	Associated Tasks
EHR Development and Administration	Understand the basics of the EHR software and related programs, systems design, systems architecture, data structures, database management, communications infrastructure, connectivity, down-time procedures, hardware requirements, and interface theory	Ability to operate and navigate the EHR system Adjust policies and procedures to include EHR work flow processes Develop data maps for interfaces Monitor interfaces Deploy down-time procedures
System Down-Time Processes	Data work flows involving the EHR as a deliverer or receiver of information, effect of down time of various software/ interfaces supporting the EHR, database data integrity checks, and the effect of manual data-entry processes on the EHR	Develop scheduled and unscheduled down-time procedures Develop down-time data-collection tools Monitor system synchronization during system restoration process Log down-time occurrences in the event of future data integrity concerns Determine process for EHR integration of data that are unable to be restored/ recaptured/ manually loaded, etc.
Documentation Requirements	Federal and state statutes and regulations, accreditation standards and payer requirements for clinical care, research, reimbursement, and compliance	Interpret how policies, procedures, statutes, regulations, and accreditation requirements affect the physician practice EHR Ensure that all documentation requirements are met for patient care, reimbursement, and research purposes
Confidentiality and Security	Organizational policies and procedures, federal and state statutes and regulations, HIPAA, access control, and auditing	Protect the confidentiality and security of patient health information in the EHR Protect the systems and hardware that store this information Protect nonelectronic health record information
System Implementation and Training	Organizational policies and procedures, federal and state statutes and regulations, training methods and documentation, terminology of technology systems, and project management techniques	Provide the following EHR system implementation and training to clinicians and other staff as needed: Work flow analysis Documentation Release of information Confidentiality and security Error correction and prevention Down-time procedures Suggestions for improvement or enhancement to the EHR system
Deficiency Tracking and Reporting	Organizational policies and procedures, federal and state statutes, regulations, and payer mandates	Identify, track, and communicate deficiencies Produce routine deficiency reports and distribute to clinicians and management
Forms Development	Organizational policies and procedures, federal and state statutes and regulations, and awareness of scanning issues	Participate in the development of EHR forms and templates Review and approve all new forms and templates
Release of Information	Organizational policies and procedures, federal and state statutes and regulations, and HIPAA	Provide authorized persons with copies of their designated record sets per established guidelines Provide persons with copies of records for authorized studies, research, and continuity of care Patient advocacy
Suggestions for Improvements or Enhancements	Understand database applications, work flow, and procedures for submitting improvements or enhancements	Submit suggestions for improvements or enhancements
Quality Review	Organizational policies and procedures, federal and state statutes, compliance regulations, clinical quality guidelines, disease management, and health maintenance	Identify and track required quality data Validate quality of off-site data (e. g., lab tests) loaded into the EHR Produce and distribute quality review reports on an ongoing basis
Storage and Retention	Organizational policies and procedures, federal and state statutes and regulations, disaster planning, and backup systems	Ensure EHR is stored and retained according to established guidelines Ensure backup systems are in place
Statistical Reports	EHR data required by management and other stakeholders, proper use of comparative data, and data display techniques	Produce statistical reports and distribute to management and other stakeholders Present and explain findings
Error Correction	Organizational policies and procedures, federal and state statutes, database structure, and data integrity	Identify and correct EHR errors, including documentation, master patient index transcription, and applicable errors
Coding	Coding databases and underlying systems for coded data	Ability to access and monitor how codes are generated and the EHR coding functions

General attributes required:

Knowledge of medical terminology
Attention to detail
Advanced verbal and written communications skills
Leadership and group dynamics skills
Project management experience

Prepared by

This practice brief was developed by the following AHIMA e-HIM workgroup:

Valerie Austin
Kathy Cleary, RHIA
Michelle Dougherty, RHIA (staff)
Matthew Greene, RHIA, CCS
Susan Hanson, MBA, RHIA
Beth Hjort, RHIA, CHP (staff)
Jennifer Hornung Garvin, MBA, RHIA, CPHA, CCS
Sally Koch, LPN, RHIA
Lynn Kuehn, MS, RHIA, CSS-P, FAHIMA
Lynn Mendola, CCS-P, CPC
Rebecca Reynolds, MHA, RHIA
Rita Scichilone, MHSA, RHIA, CCS, CCS-P (staff)
Cynthia Shaffer, RN, MSN, NP-C
Dianne Willard, MBA, RHIA, CCS-P

Core Data Sets for the Physician Practice Electronic Health Record work group was supported by the Foundation of Research and Education

Source: AHIMA e-HIM Work Group on Core Data Sets for the Physician Practice Electronic Health Record. (October 2003).