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Millennium and JCI Management of Communication and Information Standards
September 1, 2008
Introduction
The purpose of this white paper is to present Cerner’s opinions concerning how it believes
Millennium and associated solutions can potentially support the efforts of clients to comply with
many of the standards contained in the Management of Communication and Information (MCI)
section (pp. 213-228) of the 2007 Joint Commission International (JCI) Accreditation Standards
for Hospitals, 3rd Edition (effective January 2008).
The white paper and the information and opinions it contains have not been reviewed or
endorsed in any way by JCI. While every effort was made to ensure the accuracy and
completeness of information in the white paper when it was published, it should be used only for
reference purposes. Interested parties should contact Cerner directly to obtain the most up-todate information concerning solution offerings and functionality, and to discuss how they might
be used to address specific JCI standards.
The general focus of the accreditation standards for Management of Information within the JCI
standards can be summarized as follows:
General Focus of the Standards
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The healthcare provider generally needs to have information management processes in
place to assure that the information systems and content are available to meet the needs
of their programs and services
That information privacy and confidentiality of patient information is upheld
That the security and integrity of information is enabled
That availability and continuity of information is supported
That appropriate systems and mechanisms to properly capture, report, process, store,
retrieve, disseminate, and display clinical and non-clinical information are enabled
That information required for decision making is provided
That significant medical reference libraries and resources are available to staff and
practitioners
That patient medical records are complete and accurate and contain the necessary
information for the provision of care
That the patient record contain a summary of all significant diagnosis, procedures, drug
allergies, and medications to support continuing or recurring ambulatory care
Millennium’s Role in Enabling Compliance
Many of the requirements found within the Management of Communication and Information
section of the JCI accreditation standards are focused on how providers put into place policies
and procedures to establish requirements for the content of the medical record, assuring its
completeness, timeliness and integrity, supporting patient rights to privacy, and enabling
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adequate security capabilities to ensure integrity of the record. These policies and procedures are
supported by education and training. However, there are very significant system roles that
Millennium can play in support of these activities. At a summary level, these can include (key
Millennium solutions indicated parenthetically):
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Enabling the capture, storage, and maintenance of the patient’s electronic medical record
in a complete and accurate manner (All Millennium clinical and ancillary solutions)
Supporting access controls to limit access to, and use of, a patient’s electronic medical
record to authorized individuals in a manner appropriate to the roles of such individuals
in providing care or supporting care. (NOTE: This is a general statement relative to both
Millennium Authentication and Authorization Security and the access controls present in
non-Millennium solutions integrated with Millennium such as PowerInsight.)
Providing systems of audit to capture accesses to electronic medical records in order to
enforce and provide accountability to the privacy and security policies of a provider
(Millennium Audit Services and P2 Sentinel)
Providing validation capabilities of data entered into the electronic medical record based
on use of code set values, required field entry rules, reference ranges, format validity
rules, and other methods (Core capability common to all solutions)
Supporting required data entry parameters in forms design to assure completeness of
entry (Core capability common to all solutions)
Supporting deficiency tracking and monitoring to manage timeliness of completion of
required documentation (ProFile)
Making available required summaries of patient information to help assure continuity of
care (Documentation Management, Medical Record Publishing, FirstNet)
Note: The solutions, solution functionality, and services referenced in this white paper may not
be available in all markets.
At a more granular level, Millennium can assist in enabling compliance with the Management of
Communication and Information standards in the ways described below. (Specific JCI
accreditation standards are stated followed by the abilities of Millennium to enable compliance.)
The JCI standards that are highlighted for comment are those that seem to most directly imply a
system role in compliance.
Communication with Patients and Families
MCI.2 – The organization informs patients and families about its care and services and how to
access those services.
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Patients and families are provided information on the care and services provided by the
organization. (Also see ACC.1.2, ME 2)
Patients and families are provided information on how to access services in the
organization. (Also see ACC.1.2, ME 2)
Information on alternative sources of care and services is provided when the
organization cannot provide the care or services.
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The system supports the definition and documentation of patient-specific education activities
performed through a documentation format. The plan of care can include educational
activities so they occur in the proper sequence and context. The system does not particularly
support generation of the actual materials themselves.
From an ED perspective, as a part of the depart process, the system can provide suggested
content to provide to the patient based on the physician’s documentation of diagnosis
information so that the patient has information specific to their need.
MCI.3 – Patient and family communication and education are provided in an understandable
format and language.
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Patient and family communication and education are in an understandable format.
Patient and family communication and education are provided in an understandable
language.
The primary support the system can provide to enable compliance with this requirement is
through the documentation of the native language of the patient, and the possible need for
translation services. This information can be captured through the registration process. The
system can create a worklist off of the indication from registration that an interpreter is
required for provision of translation services. It also may be documented through the
assessment process. Secondarily, the system can assist in documenting the comprehension
level of the patient as a part of the assessment process as captured through the admission
assessment using the appropriate assessment documentation forms. As a byproduct of the
capture of clinical demographic information about the patient, the system provides support
for capture of the age of the patient, and through the assessment process, information as to
the comprehension level of the patient.
Through triage capabilities for the ED in FirstNet, the system can record the need for
translator services. The content provided to the patient through the depart process supports
comprehension requirements and language requirements for principal languages such as
Spanish, Portuguese, Russian, Vietnamese and others could be added if needed by the client
based their own experience and patient base – and the appropriate indication of language
drives generating the forms in the appropriate language.
Communication Between Providers Within and Outside of the Organization
MCI.4 – Communication is effective throughout the organization.
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The leaders ensure processes are in place for communicating relevant information
throughout the organization in a timely manner. (Also see ACC.2, ME 1 and MMU.5.1,
ME 1)
Effective communication occurs in the organization among the organization’s programs.
(Also see ACC.2, ME 1)
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Effective communication occurs with outside organizations. (Also see ACC.3.1, MEs 2
and 3 and MMU.5.1, ME 1)
The system supports efforts to provide accurate, timely information throughout the
organization related to patients and their care, as well as other types of tasks for scheduling,
ordering, documentation, resulting, billing, reporting, and other purposes.
The system can help facilitate the transmission or sharing of patient information to external
parties or to make patient information available on line if external parties have access to the
system. If providers are system users, they may be given relationships to the patient’s record
based on direct care providing involvement or based on providing therapeutic services that
the system may route to them for being performed. The system can output clinical reports to
external providers identified as ordering or referring providers. The system also can generate
patient documentation through a record publishing function. The system does not yet support
standardized electronic means of output such as Continuity of Care Record (CCR) formats
that might support formatted discharge outputs. These are planned for 2008 and 2009
development for different kinds of visit, discharge, and referral summaries.
In the case of external reference labs, the system supports definition of external testing
resources for purpose of generating outbound orders for those procedures.
MCI.5 – The leaders ensure that there is effective communication and coordination among those
individuals and departments responsible for providing clinical services.
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Leaders ensure effective and efficient communication among clinical and nonclinical
departments, services, and individual members. (Also see ACC.2.1, ME 1)
Leaders foster communication in the delivery of clinical services.
As mentioned in MCI.4, the system supports efforts to provide accurate, timely information
throughout the organization related to patients and their care.
The system can support professional communication related to care planning and delivery
through solutions such as PowerPlan, which provides a centralized location for each member
of the care delivery team to manage the care plan, helps coordinates their actions, and
provides them with real-time updates. In addition, the system can help coordinate
availability of electronic patient records and the information they contain to all staff involved
in a patient's care.
MCI.6 – Information about the patient’s care and response to care is communicated among
medical, nursing, and other care providers during each staffing shift, and between shifts.
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There is a process to communicate patient information between the care providers on an
ongoing basis or at key times in the care process. (Also see AOP.1.4, ME 3)
Information communicated includes the patient’s health status.
Information communicated includes a summary of the care provided.
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Information communicated includes the patient’s progress.
See response to MCI.5.
To help manage handoff communications, the system provides for care summaries that
incorporate many kinds of information of key interest, and can generate rounds reports for
patients that summarize information of interest to physicians and care teams for rounding
purposes. Recommended practices have been defined for use of system capabilities for
handoff, and this information is available in the Illuminations web page of www.cerner.com
for client reference. Cerner is actively working on enhancing these capabilities to make them
simpler to use and more streamlined as to the accessibility of the information through a
consolidated system function.
MCI.7 – The patient’s record(s) is available to the care providers to facilitate the communication
of essential information.
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Policy establishes those care providers who have access to the patient’s record(s).
The record(s) is available to those providers. (Also see AOP.1.5, ME 2)
The record(s) is up to date to ensure communication of the latest information.
The system's security access controls can be used to enable or restrict the privileges of
clinicians and staff, based on the organization's policies, in defined roles to access electronic
patient records as system users. See response to MCI.4 for information about external
provider access to patient information in the system.
The system also enables sharing of the electronic record with other providers. If those other
providers are users of the system, they will be able to access the electronic patient record
subject to the creation of an access right (as evidenced by a relationship to the patient directly
or as a member of the organization or work group providing care to the patient), and their
own authorization rights to access patient data in that form. If not users of the system, such
information may be shared through formatted discharge summaries or care summaries that
may be output via print or fax to the appropriate destination. Cerner is working on
supporting electronic transacting of structured clinical documents using HL7’s CDA
document types for various kinds of clinical documents.
Patient electronic information is maintained in a real-time manner for any updates to the
record, and this information is accessible to users on a similar basis as long as in final
verified forms as a general rule. In process information may only be accessible to those
clinicians and staff responsible for its entry and completion. When clinical information is in
such a form, it is instantly available to other care team members, staff, and clinicians in that
form on line, and can be output to clinical reports for distribution in other forms as may be
required.
MCI.8 – Information related to the patient’s care is transferred with the patient.
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The patient’s record or a summary of patient care information is transferred with the
patient to another service or unit in the organization.
The summary contains the reason for admission.
The summary contains the significant findings.
The summary contains any diagnosis made.
The summary contains any procedures performed.
The summary contains any medications and other treatments.
The summary contains the patient’s condition at transfer.
The system provides for availability of patient information in appropriate viewing contexts
for handoff from a physician, nursing, emergency department transfer of care, or surgeryrelated transfer of care on an up-to-date basis for any clinical documents, clinical results,
medication information, and other information that has been captured within the electronic
medical record. A current view of this information is available those care providers involved
in transition of responsibility. Care plans can provide an up-to-date view of recently
completed and pending activities. Cross patient task lists also can provide such information
on pending care events for the upcoming shift for acute care as may be appropriate. Cerner
has provided recommended procedures for use of system capabilities in support of patient
care team shift report/shift change activities, physician round reports, emergency room
transfers to admission or discharge to other facilities, pre- and post-surgical care transition,
and other common handoff use cases. These materials have been provided in Illuminations
sessions and in specific client forums and advisory groups as presentations as appropriate.
Within FirstNet, the depart process covers the ability to communicate clinical data through
the ED visit summary to the next provider in line if the patient is discharged from the ED to
the care of another provider. For admissions to the inpatient setting, the depart process could
provide support for the handoff process to the admitting physician in a similar way, or the
system could support specific custom views of the ED visit appropriate for the inpatient care
team to reference. For details, if the inpatient setting is also using Millennium, all of the
information from the ED visit may be available for reference.
Within SurgiNet as of Millennium 2007.18, there will be case overview capability to provide
for improved communication within the surgical setting most particularly interoperatively
and postoperatively.
Leadership and Planning
MCI.9 – The organization plans and designs information management processes to meet internal
and external information needs.
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The information needs of those who provide clinical services are considered in the
planning process.
The information needs of those who manage the organization are considered in the
planning process.
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The information needs and requirements of individuals and agencies outside the
organization are considered in the planning process.
The planning is appropriate to the organization’s size and complexity.
The system supports the "need to know" and "minimum necessary" policies of the
organization through security policy implementation that defines how clinicians and staff
have authorization to access electronic patient records and how they receive access rights to
system resources to support tasks for their assigned roles. The general assumption for
implementing the security capabilities of the system and for designing process automation
support of care delivery within the system is that the requirements of the organization have
been identified in terms of information needs so the system can appropriately support those
needs, and offer opportunity for process improvement through automation. In addition, the
system provides process automation in support of various care delivery tasks and support
roles.
The system helps provide management information to clinical services line management and
leadership on the activities involved with the delivery of care.
Through either online access or output of clinical information, the system helps support the
information needs of outside individuals and agencies.
MCI.10 – Information privacy and confidentiality are maintained.
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There is a written policy for addressing the privacy and confidentiality of information
that is based on and consistent with law and regulation.
The policy is implemented.
Compliance with the policy is monitored.
The organization has a policy that indicates if patients have access to their health
information and the process to gain access when permitted. (Also see PFR.1.6 Intent)
The system helps assure the privacy of identifiable patient information through its security
mechanisms that require a specifically identified user to successfully authenticate to the
system in order then to be an authorized user of system resources. The authentication can be
performed by a variety of mechanisms including advanced authentication techniques such as
by biometrics. Initial levels of capability to enable single sign-on between Millennium and
other solutions intended for integrated use with Millennium such as PowerInsight or P2
Sentinel (access audit solution) is in process, and capabilities to authenticate to external user
directories also are available. The authorization policies supported by the access control
module of the system provide for role-based application task access, and for both role- and
user-based data access to patient encounters and clinical data within encounters. The access
control capabilities also enable limiting user accesses to certain organizations and locations
within organizations appropriate to user need to know (e.g., by patient location) and to work
areas where the user is assigned to work (e.g., service resources as performing work sites).
User abilities to search for patients in the system can be wholly constrained through task
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security or limited to those patients who have been admitted or registered to provider
organizations where the user is on staff and authorized to access patient records.
Specific confidential conditions on particular patient data implemented in support of patient
requested restrictions for “seals” on data or for protecting classes of information required to
be so protected by statute are dependent either on limiting authorized accesses to users in
care-providing roles with access to specific data types on a need-to-know basis or based upon
the ability to identify affected “confidential” encounters within which the affected data
resides. The system does not offer the ability at present to mark specific parts of patient
records as protected from access (or that are subject to specific grants of access) by certain
named individuals or roles.
Also, as a general rule, the application tasks in the system have been designed to display
information about specific types of clinical data, and with patient demographics appropriate
to the purpose at hand. Online forms and formatted structured output of clinical data can also
generally be designed to be limited to the purpose of the form or output.
Relative to printing information for clinical use out of Medical Record Publishing (MRP), the
system supports the ability of a user to print clinical information to be consistent with the
user’s online access rights to patient information. Within Clinical Reporting, sensitive result
sections can be identified, and as applied to MRP, when a user goes to print, the user has to
have security to access the sensitive data online and then also be able to select them for
printing. For normal clinical report distributions done through operations, the system enables
printing of what is called for by the relevant clinical report format at hand.
Relative to Cerner’s remote hosting services provided through CernerWorks (Note:
Availability of CernerWorks hosting services outside the United States is currently quite
limited, although it may expand in the future.), Cerner’s Protection of Patient Information
standard operating procedure outlines proper methods for viewing, handling, printing,
transmitting, and disposing of patient information from workstations or other access devices
to ensure the privacy and confidentiality of the information. Workstation security is
accomplished using a combination of safeguards that includes both physical restriction and
control to the facility as well as technical safeguards such as intrusion detection, anti-virus
software, firewalls, and password management. In order to meet regulatory and contractual
requirements relating to privacy and security, Cerner is obligated to require that all
Associates handle patient information appropriately. It is Cerner’s mandatory policy that
Associates must ensure the proper use of patient information as we assist our clients in
implementing, supporting, and hosting their information systems. This means that Cerner
Associates and Consultants must not engage in any activity that may inappropriately use or
disclose protected health information. Failure to comply with this requirement will result in
sanction, up to and including termination of employment/service agreement.
The system enables the recording of accesses to a patient’s electronic medical record, thus
supporting holding users of a patient’s electronic information accountable for their activities.
Such accesses may include both activities to create or maintain information in the patient’s
record as well as activities to inquire into, or output information from, the patient’s record.
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The system makes available the audit trail of such accesses for transmission to externally
maintained audit log systems for retention and analysis. The audit system made available to
accompany Millennium implementations enables both predefined and ad hoc queries into
audit data of this kind as well as alerting of appropriate privacy or security officers or
auditors on a real-time basis should suspect access conditions occur.
For enabling a patient’s right of access to their record or to request amendment to their
record, the system enables the recording of patient requests relative to their rights and the
provider’s response through what is called the Privacy Workbench within the ProFile HIM
solution. The system can facilitate release of information from the electronic or paper record
to fulfill an authorization or an inspection request from the patient, and the system can
contribute to an accounting of disclosures for what is released through release of information
management activity supported by the system. The system can distinguish by type of
disclosure what are reportable disclosures to the patient, and also understand when a patient
authorization is required for a disclosure to occur.
MCI.11 – Information security, including data integrity, is maintained.
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The organization has a written policy for addressing information security, including data
integrity, that is based on or consistent with law and regulation.
The policy includes levels of security for each category of data and information
identified.
Those who have the need or job position that permits access to each category of data and
information are identified.
The policy is implemented.
Compliance with the policy is monitored.
The system also enables implementation of secure configurations that include components
designed to guard against unauthorized intrusion that may result in data corruption, damage,
or loss. The system is typically operated behind a firewall or on a closed network or virtual
private network if a local installation. When the system is hosted by Cerner, it is hosted
behind a secure firewall with secure communications supported by Transport Layer Security
(TLS) and with secure sessions served up by Citrix. Beyond this, unauthorized access is
mitigated by the authentication and authorization capabilities of the security architecture of
the system that requires users to be specifically identified and authenticated before being
allowed to access system resources, and to only be able to access system resources (and
patient records) in an authorized manner as understood by the access control capabilities of
the system. As to more technical security measures enabled around the system, the system
enables application of security components to assure a secure configuration of the desktop,
operating system and backend, and to maintain currency with new releases of such
capabilities relative to those components. Sound system management and change
management practices are recommended to ensure that only certified system components are
installed in production environments after they have been subjected to verification in test
environments.
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The system makes use of registered application service requests, and the system’s application
services only recognize requests from client applications that make use of one of the
registered service requests. When the system is sent a message from a different system, the
system makes use of device authentication to support message acknowledgment for
interfacing so as to assure exchange of information with a trusted source or destination.
The system also can leverage secure communication capabilities present in network
communication protocols to assure message integrity for information in transit (such as by
use of Secure Socket Layer/Transport Layer Security based encryption). The system can
make use of virtual private networks (VPNs) to enable closing a network from public access
to mitigate unauthorized intrusion. The system also supports use of session encryption for
Citrix-based sessions as well as for the audit system used for tracking accesses to the
electronic medical record.
Relative to Cerner’s remote hosting services provided through CernerWorks, each client is
responsible for the integrity of the content, while Cerner manages the integrity of the systems
on which data resides. Cerner has a written policy(ies) for addressing information security
that is based on, and consistent with, law or regulation. Cerner develops and implements
controls to safeguard data and information, including the clinical record, against loss,
destruction, and tampering using a combination of authentication, authorization, encryption,
and backups. System logging provides trails to ensure only authorized individuals actually
access a patient record.
Regarding levels of security for data and information, the system supports definition of data
privileges by a user’s position/role that provide for access rights to clinical information for
direct care providers – these also support defining what kinds of actions such users can take
regarding orders, clinical results/documents, and other clinical data in terms of creating,
modifying, verifying, or inquiring into data. For ancillary clinicians and support staff, access
rights to system application tasks also are defined by position, and these tasks are designed to
limit access to a single function and single data type for the most part – such as to be able to
accession microbiology specimens or to be able to perform interpretations of radiology
diagnostic images.
To support the integrity of the information entered, most capabilities to enter or modify
clinical information are at least supported by task security so that the functions are accessible
only to authorized individuals. Further, many specific actions to update, verify, and sign
clinical information are controlled by data privileges to limit these actions to be taken only
by authorized roles (and individuals).
Cerner provides recommendations as to how to appropriately staff for implementation,
support, and ongoing management of the security architecture of the system.
Recommendations are also provided as to how to securely configure, manage, and establish
change controls for the system, and how best to leverage recommended technologies to
harden, maintain security currency, and monitor the system.
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The identity of users for creating, updating, or completing clinical information is recorded
electronically on the clinical data record in question for accountability purposes. Such
entries are also always time stamped, and the previous version of the information is
maintained in audit trails within the record.
MCI.12 – The organization has a policy on the retention time of records, data and information.
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The organization has a policy on retaining patient clinical records and other data and
information.
The retention process provides expected confidentiality and security.
Records, data, and information are destroyed appropriately.
The system supports retention for as long as may be required (e.g., by regulation or statute)
of patient information considered the “permanent” record. The system supports purge and
archive functions for management of patient information. The same access controls that
apply to more contemporary patient data also apply to information that may be restored from
archive, and archived volumes are subject to an organization's storage and media security
controls. Cerner is working on more flexible archiving capabilities, but most clients elect to
retain the more permanent forms of patient data indefinitely in the online medical record with
“in process” activity data tables purged according to more short-term information retention
policies.
MCI.13 – The organization uses standardized diagnosis codes, procedure codes, symbols,
abbreviations, and definitions.
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Standardized diagnosis codes are used and use monitored.
Standardized procedure codes are used and use monitored.
Standardized definitions are used.
Standardized symbols are used, and those not to be used are identified and monitored.
Standardized abbreviations are used, and those not to be used are identified and
monitored.
The system enables definition of entry, format, and data type requirements for the capture of
patient information, whether through the definition of registration conversations, the design
of clinical documentation templates used for assessments, result entry validation rules for
entry of discrete clinical results, or other mechanisms.
The system supports use of standardized abbreviations, acronyms and medical vocabularies
where and when appropriate to the mode of documentation entry to be used in clinical
documentation entry, physician note entry, or diagnostic result entry (e.g., such as with the
use of BiRadalysis codes for Mammography). This helps facilitate standardized entry for
required elements of documentation especially where the collection, retrieval, and analysis of
such data is required to be in standardized meanings and forms to ease such analysis. The
system generally enables reporting of management information appropriate to the different
patient care units/departments, ancillary areas, and administrative functions supported by
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system applications. These include reporting of activity levels by period, by provider, by
shift, acuity levels (on a similar basis as for activity), and turn around time measures
appropriate to a given domain (e.g., order to clinical report for lab procedures, door to triage,
door to discharge, etc. for the ED). In the ED, this information can be presented through
graphical views of information in addition to as reports.
The system supports definition of “do not use” abbreviations, acronyms, and symbols for
reference in medication management, physician documentation entry, and order
management.
Cerner provides recommended starting sets of reference data content for most every major
type of reference data or code set used by the system. This content embodies required or
industry standard code sets such as common medical code sets (CPT, ICD9, HCPCS, NDC
codes and the like) as well as non-medical code sets (ANSI X-12, UB04) for administrative
reference data. The content also includes reference data starter sets for key reference data
tables such as the order catalog, the formulary, the charge master and for registration forms,
labels of all kinds, claims/billing formats, and all manners of system configuration settings to
ease the implementation process.
Cerner also provides a concept mapping capability called the Cerner Knowledge Index (CKI)
to map medical code sets to each other to provide for common points of reference.
For lab values, Cerner is also starting the process to map LOINC terms to results. By the end
of 2008, a reasonable level of support for this mapping should be in place. As results post to
the Clinical Events table, a reference service will associate the appropriate LOINC term to
the result in the Clinical Event activity data structure so that the system can enable outbound
interfacing using LOINC codes. Cerner is also working on posting SNOMED CT references
on a similar basis for Microbiology results.
For nursing documentation, the system supports use of standardized code sets with mapping
of evidence-based nursing concepts to standard code sets. Clients can also map in external
nursing documentation standards if they wish to Cerner’s starter content or build the mapping
out on their own for use in Cerner’s nursing documentation forms.
MCI.14 – The data and information needs of those in and outside the organization are met on a
timely basis in a format that meets user expectations and with the desired frequency.
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Data and information dissemination meets user needs.
Users receive data and information on a timely basis.
Users receive data and information in a format that aids its intended use.
Staff have access to the data and information needed to carry out their job
responsibilities.
The system supports appropriate processing and storage of patient information to fit the
workflow requirements of the particular care process at hand. For example, the system can
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create scheduled nursing tasks as generated from a care plan that is associated to a patient
encounter. This in turn drives the scheduling and completion of nursing activities which can
be charted against the assigned nursing tasks. The options for entry for completion of such
tasks are defined to support the requirements of the particular type of entry at hand. The
information can then be stored as discrete data available for inclusion in nursing
documentation and progress notes and used for on line reference or output to care providers
that need to be able to make reference to nursing documentation. Patient electronic
information is maintained in a real-time manner for any updates to the record, and this
information is accessible to users on a similar basis as long as in final verified forms as a
general rule. In-process information may only be accessible to those clinicians and staff
responsible for its entry and completion. When clinical information is in such a form, it is
instantly available to other care team members, staff and clinicians in that form on line, and
can be output to clinical reports for distribution in other forms than as on line as may be
required. Clinical report formats can be defined to reflect what is necessary for proper
reporting of the result, and distributions can be defined for both printing and faxing to allow
for accurate report distribution. Information that is not necessary for long-term retention
(such as in-process data) may be subject to purging, but information necessary for long-term
retention can be retained on line and/or archived as may be appropriate.
For clinical result reporting, the system enables definition of clinical report formats and
distributions appropriate to the type of clinical report at hand, and supportive to the need to
distribute reports to the appropriate audiences directly involved in the patient’s care such as
to the ordering physician, the patient location where the patient may be roomed as an
inpatient, to the ordering location associated to a given diagnostic test order, and to other
output destinations associated to end clinical report recipients such as in physician offices.
The clinical report formats use standard reference data infrastructure to provide for
appropriate formatting of demographic and clinical information about the patient significant
to the type of clinical data at hand.
Clinical reporting (particularly for diagnostic results for lab values and diagnostic radiology
reports) can be generated considering the priority of the diagnostic test order, and the
recipient can be notified of the results availability if appropriate through messaging to
specific physician “inboxes” or to tracking boards (such as in the ED). TAT reporting is
available to manage the service levels of diagnostic departments as is discussed under
QPS.3.2 and QPS.3.3 in the white paper Millennium and JCI Quality Improvement and
Patient Safety.
The Cerner Knowledge Index (CKI) provides assistance to map clinical concepts across
medical vocabularies, and to assure consistent meaning at a common level for reference data
that may be tagged with site specific labels, mnemonics, or display values. These help assure
that when data is aggregated from multiple sources into the electronic medical record that the
data can be seen as holding consistent meaning. This also is key to the system capability to
enable the capture and codification of regulatory- or quality-related data important to quality
measurement or outcomes measurement along with operational reporting.
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For management reporting, the system’s enterprise reporting solution, PowerInsight,
leverages the concept mapping defined with Millennium to assure reliable consistent
meaning for data. PowerInsight was designed to externalize decision support data from the
Millennium transactional domain into a separate domain which enabled re-formatting of the
data into a schema that more adequately supported processor-intensive queries, retrospective
analysis, and summary-level reporting. Many reports are created and provided through
PowerInsight. These reports provide the ability to study Key Performance Indicators (KPI)
and other items of interest. KPIs are high–level metrics that provide an organizational view
of the selected data. They are an intersection of a time dimension (last month) and a measure
(mortality) that provides the user with a view into the current state of a particular aspect of
the organization. The end user is provided access to predefined reports as well as the ability
to produce their own. Additionally, as data marts are added to the solution, new reports will
be added.
MCI.15 – Appropriate clinical and managerial staff participate in selecting, integrating, and
using information management technology.
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Clinical staff participate in information technology decisions.
Managerial staff participate in information technology decisions.
Cerner provides consulting services to assist clients in making decisions about the
implementation and use of the system. Cerner also offers services to assist clients in
integrating the use of the system into process improvement/redesign efforts.
MCI.16 – Records and information are protected from loss, destruction, tampering, and
unauthorized access or use.
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Records and information are protected from loss or destruction.
Records and information are protected from tampering and unauthorized access or use.
See response to MCI.10.
MCI.17 – Decision makers and other appropriate staff members are educated and trained in the
principles of information management.
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Decision makers and others are provided education on the principles of information
management.
The education is appropriate to needs and job responsibilities.
Clinical and managerial data and information are integrated as needed to support
decision making.
Through Learning Manager, the system can be used to define required training curricula such
as information management and to record attendance, competency, outcomes, etc.
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See white paper Millennium and JCI Quality Improvement and Patient Safety and
Millennium and JCI Governance, Leadership, and Direction Requirements for more
information on system capabilities to provide reporting and decision support. The system
generally enables reporting of management information appropriate to the different patient
care units/departments, ancillary areas, and administrative functions supported by system
applications. These include reporting of activity levels by period, by provider, by shift,
acuity levels (on a similar basis as for activity), and turn-around time measures appropriate to
a given domain (e.g., order to clinical report for lab procedures, door to triage, door to
discharge, etc., for the ED).
Patient Clinical Record
MCI.19 – The organization initiates and maintains a clinical record for every patient assessed or
treated.
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A clinical record is initiated for every patient assessed or treated by the organization.
Patient clinical records are maintained through the use of an identifier unique to the
patient or some other effective method.
The system provides for a complete electronic medical record for each patient including all
such clinical results, orders, documents, allergies, diagnosis, and other clinical data that is
produced from the delivery of care.
The system supports a unique person-level identifier for the patient that is internal to the
system to assure the uniqueness of the patient record. To this internal identifier, aliases can
be defined for the medical record number, financial number, health plan identifier(s), and
other personal identifiers that may need to be maintained. The system uses matching
algorithms that consider personal demographic information about the patient in addition to
identifiers to assure matches between the patient and information that may be submitted for
inclusion in the patient record through interfaces into the electronic medical record.
MCI.19.1 – The clinical record contains sufficient information to identify the patient, support the
diagnosis, justify the treatment, document the course and results of treatment, and promote
continuity of care among health care providers.
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Patient clinical records contain adequate information to identify the patient.
Patient clinical records contain adequate information to support the diagnosis. (Also see
ASC.7, ME 3)
Patient clinical records contain adequate information to justify the care and treatment.
Patient clinical records contain adequate information to document the course and results
of treatment. (Also see AOP.1.5, ME 1; AOP.2, COP.5, ME 2; ASC.5.2, ME 1; ASC.5.3,
ME 2; ASC.6, ME 2; ASC.7.3, ME 3; and MMU.4.3, ME 1)
The specific content of patient clinical records has been determined by the organization.
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The minimum requirements for a patient record are well supported by the system for capture
of sufficient information to ID the patient, support documentation of diagnosis or condition,
provide for documentation of the care/services provided, including justification of said
services and their results, and to provide for continuity of information among care providers
in both on line and off line forms. A starter set of standard online forms and/or reference
data build guidance for all manners of clinical result or document entry is provided with the
physician, nursing, clinical, and ancillary solutions as appropriate for each such Millennium
solution.
MCI.19.1.1 – The clinical record of every patient receiving emergency care includes the time of
arrival, the conclusions at termination of treatment, the patient’s condition at discharge, and
follow-up care instructions.
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The clinical records of emergency patients include arrival time.
The clinical records of emergency patients include conclusions at the termination of
treatment
The clinical records of emergency patients include the patient’s condition at discharge.
The clinical records of emergency patients include any follow-up care instructions.
The system supports documentation of the above, and also can provide reporting on the key
metrics represented by the above.
MCI.19.2 – Organization policy identifies those authorized to make entries in the patient clinical
record and determines the record’s content and format.
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Those authorized to make entries in the patient clinical record are identified in
organization policy. (Also see International Patient Safety Goal 2, ME 2)
The format and location of entries are determined by organization policy.
There is a process to ensure that only authorized individuals make entries in patient
clinical records.
To support the integrity of the information entered, most system capabilities to enter or
modify clinical information are at least supported by task security so that the functions are
accessible only to authorized individuals. Further, many specific actions to update, verify,
and sign clinical information are controlled by data privileges to limit these actions to be
taken only by authorized roles (and individuals).
The system enables definition of entry, format, and data type requirements for the capture of
patient information whether through the definition of registration conversations, the design of
clinical documentation templates used for assessments, result entry validation rules for entry
of discrete clinical results, or other mechanisms.
The identity of users for creating, updating, or completing clinical information is recorded
electronically on the clinical data record in question for accountability purposes. Such
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entries are also always time stamped, and the previous version of the information is
maintained in audit trails within the record.
MCI.19.3 – Every patient clinical record entry identifies its author and when the entry was made
in the record.
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The author can be identified for each patient clinical record entry.
The date of each patient clinical record entry can be identified.
When required by the organization, the time of an entry can be identified.
Each entry in the electronic patient record maintained by the system includes a user ID stamp
of the individual user responsible for making an entry into the record, the date/time of that
action, the system function used to perform that action, and in displays of the user identity,
the full user name and title or credential may be formatted into the display name. This is
most commonly used for electronic signature line displays or for clinical event history
displays. The previous version of the information is maintained in audit trails within the
record.
MCI.19.4 – As part of its performance improvement activities, the organization regularly
assesses patient clinical record content and the completeness of patient clinical records.
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Patient clinical records are reviewed regularly.
The review focuses on timeliness, legibility, and completeness of the clinical record.
The system may be a source for such reviews. To assure timely completion of the medical
record, the system supports routing and scheduling of work activity timely to patient needs,
and enables the creation of work tasks to be routed to specific work sites, queues, or
personnel to be performed. The scheduling of such tasks can consider the priority of the task
and the availability of necessary resources to support the request. As to the completion of
documentation, the system provides the means to complete the work task as the basis for
capture of clinical documentation or results, and provides for tracking of overdue work
activities based on the status of tasks (such as for lab procedures or for nursing tasks). The
system also enables the requirement for verification activities to be performed by authorized
individuals when such reviews are required such as for physician verification of orders and
clinical documents.
To support complete entry of information into the record, the system allows for definition of
particular clinical data entry forms, or for clinical document formats to be required for entry
for particular services or purposes. The system also allows for definition of particular
documents to be required for completion before the record can be regarded as “complete”
from a documentation and billing standpoint. Signing tasks can be routed to an electronic
inbox for physician reference and notification. These requirements are the basis for
deficiency tracking and monitoring of documents that require this type of completion. Users
must possess a security privilege to be able to sign clinical data, and are subject to password
based re-authentication in order to sign. This requirement does not apply to documents
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creating using PowerForms that are not textually rendered, but this use of the system usually
applies only to Nursing Notes which are not subject to physician electronic signature
requirements. Orders may also be tracked for deficiency purposes for unsigned orders. This
is especially useful for ensuring verbal orders and other types/circumstances of orders are
signed on a timely basis by the physician. The electronic signature is captured as a user ID
stamp on the affected clinical data. In some applications, limited use of digital signature
using smart card-based private keys has been enabled for signing clinical data. The private
key is used to create a hashed signature associated to the signed data, and the signature is
stored within a secure signing service to protect against possible tampering. In both cases
(electronic user ID stamp and hashed signature from a digital signature), the act of signing is
to a version of the signed data such that if it is modified, amended, or succeeded, a new
signature will be required. The system provides for deficiency reporting and monitoring
from a HIM standpoint as a control check against physician completion of signing
responsibilities on a timely basis, and can provide audit reports of who has completed
verification activities in a given patient record.
The system provides for reporting on deficiency status both for current open overdue
activities as well as for historic completion statistics. Deficiencies can also be monitored on
a concurrent basis for an active patient. The reporting of historic data for deficiencies can be
generated on an allocation date or a discharge data basis, and the data can be used to
contribute to quarterly reporting and graphing for trending analysis. The system does not
provide quarterly period based reporting itself.
Aggregate Data and Information
MCI.20 – Aggregate data and information support patient care, organization management, and
the quality management program.
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Aggregate data and information support patient care.
Aggregate data and information support organization management.
Aggregate data and information support the quality management program.
See response to MOI.17. The system also supports the de-identification of aggregated data
for use in aggregated data analysis. To assure privacy of information that is disclosed where
identifiable information is not required, the system supports development of extracts and
reports through its report writer capabilities to output information in the appropriate format
per the reporting requirement. The system also enables anonymization (through
PowerInsight) of patient identifiers in support of data aggregation needs for analytical
purposes. PowerInsight also supports reporting of aggregated data if that is the basis of need.
The system also can enable any identifying patient information to be effectively screened out,
and apply security to prevent access to identifiable patient data from within a reporting
context.
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MCI.20.1 – The organization has a process to aggregate data and has determined what data and
information are to be regularly aggregated to meet the needs of clinical and managerial staff in
the organization and agencies outside the organization.
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The organization has a process to aggregate data in response to identified user needs.
The organization provides needed data to agencies outside the organization.
See response to MOI.20.
MCI.20.2 – The organization supports patient care, education, research, and management with
timely information from current sources.
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Current scientific and other information supports patient care.
Current professional and other information supports management.
Information is provided in a time frame that meets user expectations.
The system enables reference to on line reference libraries and medical literature as
appropriate to certain contexts. As two examples – References to Multum information are
enabled for support of the medication management process. Access to physician reference
materials is enabled through the Powerchart Office/Ambulatory solution. References to the
underlying literature review citations are also available in the context of expert decision
support rules applied to clinical events such as orders when there are contraindications
present. Clients may also use these capabilities to maintain their own reference links to
online resources.
For those clients supported by Cerner’s remote hosting services through CernerWorks,
Cerner performs regular updates to the drug interaction database supported by Multum on a
monthly basis.
For mental health services, online links are not made available as a part of the predefined
recommended content – there is some reference text that can be made available on the
PowerForms as to the significance of the need to document particular information – but
reference text is not widely provided with Cerner’s recommended content.
For nursing, the system generally supports access to online knowledge resources through
hyperlinks or through enabling a web browser to be launched from within Powerchart.
Clients can also link in their own intranet resources as desired through links from within the
nursing application. Any Cerner provided links are maintained as a part of the START
database.
For physicians, the system enables a URL to be embedded in a physician note, and users can
access the reference data behind the URL contained within a physician note. For those
references provided by Cerner as content, the URLs are maintained on an annual basis.
MCI.20.3 – The organization has a process for using or participating in external databases.
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The organization has a process to participate in or use information from external
databases.
The organization contributes data or information to external databases in accordance
with law or regulation.
The organization compares its performance using external reference databases. (Also see
QPS.4.2, ME 2 and PCI.10.4, ME 1)
Security and confidentiality are maintained when contributing to or using external
databases.
See response to MCI.20.2. The system can be used as a source for abstracting information
for submission to external databases.
See responses to MCI.20.2. and MCI.20.3.
PowerInsight can provide the ability for a client to import in external benchmarks for
comparisons of their outcomes to industry benchmarks, and to use such analysis techniques
as stop light coding of the organization’s performance against such benchmarks.
Lighthouse can make use of comparative references for process redesign using recommended
practices based on industry peer reviewed recommended practices.
As explained in MCI.20, information may be de-identified when prepared for submission to
external databases.
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