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HL7 Child Health Profile Desired Conformance Criteria Immunization Management # Desired Conformance Criteria 1 The system SHALL provide the ability to recommend required immunizations, and when they are due, based on widely accepted immunization schedules; Provide immunization decision support. The system SHOULD provide the ability to recommend required immunizations based on patient risk factors; Provide immunization decision support. 2 3 6 The system SHALL provide the ability to update the immunization schedule on demand for reasons including but not limited to updates to external guidelines; Allow immediate updating of immunization guidelines. The system SHALL provide the ability to capture and display the date on which the allergy information was entered. The system SHOULD provide the ability to capture and display the approximate date of allergy occurrence if exact date is not known. Ability to record multiple immunizations 8 Automated electronic reporting capability for immunizations received. 9 Record adverse events associated with vaccines. 10 Automate electronic reporting capability for adverse events (for example to registries and VAERS) Allow recording of discrete vaccine refusal reasons. 4 5 11 13 14 Record signed immunization consent. Need to review with AAP Legal Affairs Need to clarify need to cull out immunizations for special handling Allow ability to download, upload and synchronize immunization history with state and/or local immunization information systems or registries. Status in Draft Child Health-FP Shall DC.1.8.2 DC.2.3.2 Shall Modified: DC.1.8.2 DC.2.3.2 Shall Modified: DC.1.8.2 Shall DC.1.4.1 Shall DC.1.4.1 Shall DC.1.4.4 Shall DC.1.4.4 Shall DC.1.4.1 Should New: DC.1.4.1 Shall DC.2.3.2 Shall DC.1.3.3 Shall New: DC.1.8.2 Growth Tracking (Manage Patient Clinical Measurement) # Desired Conformance Criteria 1 Provide ability to reuse routinely gathered growth measurements (so that users don’t have to reenter it in a growth chart application) Automatically generate growth charts (automatically plot growth data on the chart so the user doesn’t need to plot the points) Provide ability to reuse growth data and calculations for other tasks (e.g. decision support, documentation) 2 3 4 Capture weight, height or length, head circumference 5 Calculate body mass index and growth velocity 6 Calculate percentiles and standard deviations based on population norms Pediatric Data Standards Special Interest Group Status in Draft Child Health-FP Shall DC.1.8.4.6 Shall DC.1.8.4.6 Shall Not needed as criteria…general principle of design Shall DC.1.8.4.1 Shall DC.1.8.4.7 Shall DC.1.8.4.4 1 HL7 Child Health Profile Desired Conformance Criteria 7 Capture data using different units of measurement (e.g. grams, kilograms, pounds) Display growth data on standardized charts as the default view Shall DC.1.8.4.8 Shall DC.1.8.4.6 10 Display against standard population-based normal curves (e.g. cdc.gov/growthcharts) Display normal curves based on age ranges and gender Shall DC.1.8.4.6 Shall DC.1.8.4.9 11 Display time and date of birth for infants Shall DC.1.1.2.10 12 Plot the body mass index against age-based normative curves 13 Allow adding, deleting and editing of growth points Shall DC.1.8.4.6 Shall DC.1.8.4.10 14 Support printing and faxing Shall S.2.2.1 15 Make growth charts accessible from standard EHR system components 16 Capture context of measurement (e.g. laying or standing, ventilated, receiving growth hormone) Display normal curves based on other demographic characteristics Should – OK; Part of EHR description Should DC.1.8.4.11 Should DC.1.8.4.9 Should Display topic Should DC.1.8.4.4 May DC.3.2.5 May Not needed May DC.1.8.4.13 May DC.1.8.4.12 May DC.1.8.4.14 May DC.1.8.4.11 May Tool for discussion but not data standard May DC.1.8.4.15 May DC.2.1.3.4 8 9 17 18 20 Support user preferences (i.e., connected points, superimposed values, table or graphical chart) Allow capability for age-related percentiles provided for all vital signs, including blood pressure, heart rate and respiratory rate Support automated data capture from measurement devices (e.g. digital scales) Display using graphical and tabular formats 21 Display predictive growth curves or growth targets 22 Calculate mid parental height by gender-specific parent height percentiles 23 Display bone age measurements with actual age measurements 24 Display developmental stages (e.g. Tanner stages) with actual age measurements Derive and display the median age at which a given growth point is achieved 19 19 25 26 Enable varying the scale’s level of detail (i.e. zoom in or out) 27 Provide alerts about variances in the growth chart Pediatric Data Standards Special Interest Group 2 HL7 Child Health Profile Desired Conformance Criteria Medication Administration and Dosing # Desired Conformance Criteria 1 9 The system SHALL provide the ability to capture all pertinent details of the medication administration including medication name, strength, dose, route time of administration, administrator of the medication and exceptions to administration. The system’s drug dosage functions SHOULD work using any component of a combination drug (e.g. acetaminophen-hydrocodone). The system SHOULD compute drug doses, based on appropriate dosage ranges, using the patient’s body weight/BSA/IBW; Compute doses based on body weight. The system SHOULD allow the user to specify an alternative “dosing weight” for the purposes of dose calculation.(combine with #3) IF the maximum daily doses are known, THEN they system SHALL apply the maximum dose per day in dosing decision support. The system SHOULD allow the recording of the dosage (as outlined in #3 above) used to calculate the dose for a given medication order /prescription) The system SHOULD provide the ability to re-prescribe a medication from a prior prescription using the same dosage but updating the body weight. Suggest doses based on current body weight/bsa/IBW. 10 Request body weight (actual or estimated) input when not available. 11 Request height input when not available. May DC.2.3.1.2.12 12 Allow for decision support to determine whether a body weight or height obtained in the past is outdated for medication ordering. Check drug doses post hoc using accepted pediatric references and advise the user when no pediatric references exist. Support prescriptions expressed in the volume of drug to be administered and avoid expressing the prescription solely in terms of the mass of the drug. In the case where dosing guidelines or formulary benefits vary with age or gestational age, the system should incorporate those data into its decision support. Provide the capability to generate instructions to the pharmacy to dispense medication in two labeled packages – one for home administration and one for administration during the day at school, child care or other care setting. Include body weight and height (or any other data used to decide dose, like gestational age or diagnosis) in the data sent with a prescription. . Allow drug dosing based on custom compounded medications; for example, in the case where no oral solution is available in standard formularies. Support calculations of complex intravenous infusions (e.g. total parenteral nutrition, specific IV preparations or drips). Shall DC.2.3.1.2.12 May DC.2.3.1.2.13 May DC.2.3.1.2.14 2 3 4 5 6 7 13 14 15 16 17 18 19 20 Support BSA calculations, CR CLR, multiple math models and make it obvious to user which calculation method was used. Pediatric Data Standards Special Interest Group Status in Draft Child Health-FP Shall DC.2.3.2.4 Shall DC.2.3.1.2.10 Shall DC.2.3.1.2.8 Shall DC.2.3.1.2.9 Shall DC.2.3.1.2.7 Shall DC.2.3.1.2.11 Shall DC.1.7.1.15 Shall DC.2.3.1.2.7 Shall DC.2.3.1.2.12 Should DC.2.3.1.2.1 May DC.1.7.1.8 May DC.1.7.1.8 May DC.2.3.1.2.15 Not included because of scope…Neonatal or pediatric ICU… Should DC2.3.1.2.16 3 HL7 Child Health Profile Desired Conformance Criteria 21 Allow ordering of blood products in units appropriate to pediatric care (such as mL/kg, “pedipacks” and other aliquots). May DC.1.7.2.3.1 22 Allow age-based documentation templates. 23 Allow age-based guideline selection. Shall DC.1.5.3 Shall 24 Facilitate the scheduling of siblings to be seen as a group or in contiguous time slots. May S.1.6.4 Patient Identification # Desired Conformance Criteria 1 If related patients register with identical data, THEN the system SHOULD provide the ability to propogate the administrative data to all their records. 2 Allow registration of patients without government-issued identification. 3 Allow retrieval of information based on temporary identifiers. 4 Allow the assignment of an unknown gender. 5 Enable the transfer of clinical record to new patient identification record such as at the time of family changes due to adoption. 6 7 A system that stores prenatal data (e.g. from a fetal imaging procedure) should allow the logical connection of these data to the postnatal record once the child’s record is established in the system. Support retrieval of data via search on previous names. 8 Capture source of information besides patient. 9 Allow creation of a record of a patient before the patient’s birth. 10 Allow the retention of data related to prenatal procedures within the record of the patient postnatally. Status in Draft Child Health-FP Should DC.1.1.1.11 Shall DC.1.1.1.2 Shall DC.1.1.1.3 Shall DC.1.1.2.11 Shall DC.1.1.1.13 May Save for another profile Shall DC.1.1.1.14 Should DC.1.1.3.2.3 Save for another profile Save for another profile Norms # Desired Conformance Criteria 1 3 The system MAY compute normal ranges for data based on age and other parameters such as height, weight, ethnic background, gestational age. IF required by scope practice THEN the system SHALL capture patient vital signs such as blood pressure, temperature, heart rate, respiratory rate and severity of pain as discrete elements of structured or unstructured data. Include “time of birth” in description of electronic health record. 4 Include “date of birth” in description of electronic health record. 5 Age-based norms for numeric data where available. 2 Pediatric Data Standards Special Interest Group Status in Draft Child Health-FP Shall DC.1.8.4.5 Shall DC.1.8.4.1 Shall DC.1.1.2 Shall DC.1.1.2 Shall 4 HL7 Child Health Profile Desired Conformance Criteria 6 Age-based norms for non-numeric data (Eg. developmental data). 7 Distinguish post-conception (corrected age) from post-natal age. AAP: Distinguish gestational age, chronologic age and corrected age.; Gestational age as modifier in decision support. Allow decision support for Percentile values and z-scores for those few data for which the distributions are known, such as height, weight, head circumference and body mass index. Indicate normal range for items (lab values and physical exam data) based on stage of sexual maturity. 8 9 DC.1.8.4.5 Shall DC.1.8.4.5 May DC.1.1.2.12 Shall DC.1.8.4.4 May DC.1.8.4.17 Privacy # Desired Conformance Criteria 1 The system SHALL provide the ability to document, for each patient, patient’s personal representative (e.g. guardian or surrogate) varying levels of consent or authorization. 2 Adolescent flagging for sensitive content; Support privacy policies that vary by age, presenting problem and diagnosis. Assent for treatment; Provide for recording of assent for treatment combined with parental informed permission. . Provide for recording of consent for treatment combined with a record of parental involvement. Provide for recording of consents authority related to foster and custodial care circumstances. Consent by proxy; Provide for recording of custodial parents’ wishes as to which adult can consent to which child’s care and under what limitations. Adoption privacy; Allow flagging of data for special adoption-related privacy protection. Adoption record separation; In some states, the preadoption record may need to be separated entirely from any postadoption record, using two distinct patient identities. . Allow for distinction between patient’s guardian and the financial guarantor. Provide flexibility in allowing for emergency treatment of minors in which the parent or legal guardian may be absent. Protect the genetic identity of the child, when desired, when assisted reproductive technology is used. 3 4 5 6 7 8 9 10 11 Status in Draft Child Health-FP Shall DC.1.3.3.9 DC.1.3.3.10 Shall IN.1.9.9 Shall DC.1.3.3.8 May DC.1.3.3 Shall DC.1.3.3.10 Shall DC.1.3.3.8 Shall IN.1.9.9 Shall DC.1.1.1.13 Shall DC.1.3.3.9 Shall DC.1.3.3.11 Save for another profile Other # Desired Conformance Criteria 1 Support reading level appropriate educational materials at varying levels. 2 Allow recording of the exact time of birth down to the minute. 3 Include donor management support: Functions in an EMR related to organ and tissue donation may need to accommodate information about the gamete or zygote donated that resulted in pregnancy that gave rise to the patient, within applicable privacy laws. Pediatric Data Standards Special Interest Group Status in Draft Child Health-FP Should DC.3.2.4.9 Shall DC.1.1.2 Save for another profile 5