According to the HITECH Act, a complete Electronic Health Record (EHR) should include several core data elements to ensure that it supports meaningful use and enhances patient care. These elements are outlined in the context of meaningful use criteria, which specify the functionalities and data that EHRs must have to qualify for incentives. Here’s a summary of the key data elements that constitute a complete EHR:

Patient Demographics

• Basic information such as name, date of birth, gender, address, and contact details.

Clinical Information

• Problem List: A comprehensive list of the patient’s diagnosed conditions and health problems.
• Medication List: Current and past medications, including dosages, administration routes, and duration.
• Allergies and Adverse Reactions: Documented allergies and any adverse reactions to medications or other substances.
• Immunization Records: Details of vaccinations received, including dates and types of vaccines.

Orders and Results

• Laboratory and Test Results: Results from lab tests and diagnostic imaging, including dates and interpretations.
• Order Management: Records of orders for tests, treatments, and procedures, including statuses and results.

Clinical Notes

• Progress Notes: Documentation of the patient’s ongoing care, including clinical observations and treatment updates.
• History and Physical Exam: Records of the patient’s medical history and results from physical examinations.

Care Plans and Treatment History

• Care Plans: Detailed plans outlining the patient’s treatment goals, interventions, and follow-up care.
• Treatment History: Records of previous treatments, surgeries, and interventions.

Patient Encounter Information

• Visit Details: Information about patient encounters, including visit dates, reasons for visits, and healthcare provider notes.

Health Information Exchange Capabilities

• Data Sharing: Capabilities for exchanging health information with other healthcare providers and systems through Health Information Exchanges (HIEs).

Clinical Decision Support

• Drug Interaction Alerts: Alerts for potential drug interactions, allergies, or contraindications based on the patient’s medical history and current medications.
• Dosage Recommendations: Automated recommendations for appropriate dosages based on patient characteristics and clinical guidelines.

Electronic Prescribing (E-prescribing)

• E-Prescribing: Functionality for electronically prescribing medications and managing prescription information.

Patient Access and Engagement

• Patient Portal: Access for patients to view their health information, test results, and communicate with their healthcare providers.

Additional Information

The “Additional Information” section of an Electronic Health Record (EHR) can include various types of supplementary data that support patient care and enhance the comprehensiveness of the medical record.

Electronic Health Record Indications

The Electronic Health Record (EHR) enhances patient care by providing a comprehensive, real-time view of a patient’s health data, improving coordination among healthcare providers. It should facilitate access to medical history, streamline communication, and support decision-making through clinical decision support tools. Intended uses include accurate documentation, efficient management of health information, and improved care continuity. However, the EHR should not replace personal interactions between patients and providers or serve as a barrier to understanding complex medical information. It should prioritize patient confidentiality and avoid overloading patients with excessive or non-relevant data.

EHR Requirements Resources and References

Here are some key resources and references for more information on EHR requirements:

Regulatory and Standards Organizations

• Office of the National Coordinator for Health Information Technology (ONC): ONC EHR Certification – Information on EHR certification requirements and standards.
• HealthIT.gov: Health IT Playbook – Comprehensive resource for EHR implementation and best practices.

Government Publications

• HITECH Act: HITECH Act Text – Full text of the HITECH Act, including provisions related to EHRs.
• HIPAA Guidelines: HIPAA for Professionals – Information on HIPAA compliance as it relates to EHRs.

Professional Organizations

• American Medical Informatics Association (AMIA): AMIA EHR Resources – Resources and research on informatics and EHR systems.
• Healthcare Information and Management Systems Society (HIMSS): HIMSS EHR Resources – Guides and reports on EHR systems and healthcare IT.

Standards and Guidelines

• HL7 International: HL7 Standards – Standards for health information exchange, including EHR interoperability.
• Fast Healthcare Interoperability Resources (FHIR): FHIR Overview – Standards for exchanging health information electronically.

Academic and Research Institutions

• National Institutes of Health (NIH): NIH Health IT Research – Research and studies related to health information technology and EHR systems.
• PubMed: PubMed EHR Studies – Search for academic articles and research studies on EHR requirements and implementation.

Consulting and Advisory Services

• The Office of the National Coordinator for Health Information Technology (ONC): ONC EHR Certification – Guidance on EHR quality improvement and certification.
• EHR Certification Commission (EHRCC): EHRCC Resources – Information on EHR certification and requirements.

These resources provide comprehensive information on EHR requirements, standards, implementation best practices, and regulatory compliance.