Download Millennium and the Joint Commission Record of Care

Millennium and the Joint Commission Record of Care Accreditation Requirements
April 23, 2010
Introduction
The purpose of this white paper is to provide information as to the positioning of
Millennium in support of enabling the ability of clients to comply with the Record of
Care accreditation requirements of the Joint Commission. The source for the
accreditation requirements is the 2010 Comprehensive Accreditation Manual for
Hospitals (CAMH) published by the Joint Commission.
General Focus of the Requirements
The general focus of the accreditation requirements for Record of Care within the CAMH
can be summarized as follows:
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The 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 appropriate systems and mechanisms to properly capture, report, process,
store, retrieve, disseminate and display clinical and non-clinical information are
enabled
That patient medical records are complete and accurate and contain the necessary
information for the provision of care
That high risk or operative procedures are adequately documented, and use of
moderate to deep sedation or anesthesia is recorded
That the patient record contain a summary of all significant diagnosis, procedures,
drug allergies and medications to support continuing or recurring ambulatory care
That designated qualified personnel accept and transcribe verbal orders from
authorized individuals
Millennium’s Role in Enabling Compliance
Many of the requirements found within the Record of Care section of the Joint
Commission accreditation requirements 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. 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)
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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)
Supporting capture of verbal orders with appropriate review requirements by an
authorized practitioner (Order Management)
At a more granular level, Millennium can assist in enabling compliance with the
Management of Information requirements in the following ways (NOTE: Specific Joint
Commission accreditation requirements are stated followed by the abilities of Millennium
to enable compliance). The Joint Commission requirements that are highlighted for
comment are those that seem to most directly imply a system role in compliance.
RC.01.01.01 – The hospital maintains complete and accurate medical records
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The hospital defines the components of a complete medical record
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 documentation and a billing standpoint.
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The hospital provides standardized formats to document the care it provides to
patients
The medical record contains information unique to the patient which is used for
patient identification
The medical record contains the information needed to support the patient’s
diagnosis and condition
The medical record contains the information needed to justify the patient’s care
The medical record contains information about the patient’s care that promotes
continuity of care among providers
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
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clinical result or document entry are provided with the physician, nursing, clinical and
ancillary solutions as appropriate for each such Millennium solution.
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All entries in the medical record are dated
The system records a date and time stamp for each medical record entry represented
by a system event that creates, updates, completes, error corrects, addends or
authenticates a medical record entry.
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The hospital tracks the location of all components of the medical record
The hospital assembles or makes available in a summary in the medical record all
information required to provide patient care
The system helps ensure availability of the patient record not only when available on
line as an electronic record, but also for paper based records through the provision of
library functions within ProFile to manage chart requests, check out/in of records and
tracking of current chart locations for records that have been checked out of a central
source. The management of the chart can be performed on a concurrent basis to its
use.
RC.01.02.01 – Entries in the medical record are authenticated
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The hospital defines the types of entries in the medical record made by non
independent practitioners that require countersigning in accordance with law and
regulation
The system requires that a user be set up with a privilege for their signature to have a
particular effect as to document authentication or countersignature. Based on the
user’s position, the user is granted authentication privileges by document type (e.g.
for an H&P). Within the Health Information Management solution (ProFile), that
privilege is honored, and a co-signature can be required for certain documents that
may have originally created by a user in a position not authorized to authenticate a
document. The system will then additionally prompt for someone in an authorized
position to authenticate a document. The system can track unauthenticated documents
even if signed by an author who is not privileged to authenticate a document. The
patient’s chart would remain open for deficiency tracking purposes until a properly
authorized individual has satisfied all document authentication requirements.
Within Clinical Notes, the system enables differentiation of signing privileges to
know what users can authenticate a note and what users cannot (and a
countersignature is required). Within PowerNote as of 2010.01, the system will
enable the ability to display a signature line. As of 2010.02, signing privilege
capability in PowerNote will be on par with that of Clinical Notes. For 2017.19 and
prior for PowerNote, the only option is for a non-privileged provider to note in the
document that they are the originator of the note (or be shown as “performed by”),
save the note and forward it to the physician Message Center/Inbox for signature by a
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privileged physician. Cerner is working to allow a resident to sign a document, and
forward it for co-signature, and some clients are allowing residents to sign the
document and then forward the signed document to a physician who would add an
addendum to sign the resident signed note. The “sign without authenticating” project
is scheduled for availability in 2010.02.
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The author of each medical record entry is identified in the medical record
Only authorized individuals make entries in record
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 is controlled by data privileges to limit
these actions to be taken only by authorized roles (and individuals).
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.
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Entries in the record are authenticated by the author. Information introduced into
the medical record through transcription or dictation is authenticated by the
author.
The individual identified by the signature stamp or method of electronic
authentication is the only one who uses it
The system supports authentication at the time of system log in of the individual user
using both password based methods of authentication and those methods of advanced
authentication that interoperate with Imprevata. Imprevata is Cerner’s business
partner for providing support for interoperating with multiple methods of advanced
authentication including biometrics, tokens and other methods. The system also
supports time out policies to mitigate the risk of an abandoned session. As to signing
events within the system, for events that require additional event specific
authentication of the signer, Millennium supports the use of password based
authentication for signing orders and for signing documents. This can include
transcribed documents. Cerner’s transcription solution (MTM-Medical Transcription
Management) is integrated with Millennium. Documents that have been dictated and
transcribed using MTM, will display within Clinical Notes or Message Center for
final authentication. In addition, Millennium can bring in transcribed documents from
other sources for final authentication within PowerChart through Clinical Notes or
Message Center.
As of 2010.01 which is targeted for general availability in early 2010, Millennium
will support advanced authentication methods that interoperate with Imprevata for
authentication of the signer for key events related to medication management
including order verification, medication administration and pharmacist order
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verification. The system supports maintenance of an action history to show the
various actions taking for a given clinical data object such as for an order or a clinical
document, and in many cases, supports formatting a signature line showing who
signed a clinical document or transcribed document.
RC.01.03.01 – Documentation in the medical record is entered in a timely manner
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The hospital has a written policy that requires timely entry of information into the
medical record
The hospital defines the time frame for completion of the medical record which
does not exceed 30 days after discharge
The hospital implements its policy requiring timely entry of information into the
patient’s medical record
The hospital records the patient’s medical history and physical examination,
including updates, in the medical record within 24 hours after registration or
inpatient admission but prior to surgery or a procedure requiring anesthesia
services
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.
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 reauthentication in order to sign. This requirement does not apply to documents
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
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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.RC.01.04.01 – The hospital audits its medical records
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The hospital measures its medical record delinquency rate at regular intervals,
but no less than every three months
Medical record delinquency rate averaged over last four quarters is not greater
than 50% average monthly discharge rate and no quarterly measurement is
greater than 50% of AMD rate
The hospital conducts an ongoing review of medical records at the point of care
based on the following conditions: presence, timeliness, legibility, accuracy,
authentication and completeness of data and information
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. Deficiencies are aged to the
hour (for a given document) and to the day (for a complete record for a visit). 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.
RC.01.05.01 – The hospital retains its medical records
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The retention time of the medical record is determined by its use and hospital
policy in accordance with law and regulation
At present, the system enables retention of completed verified medical record entries
more or less permanently. A more flexible capability to create archived versions of
patient records so as to reduce online storage of the data is under consideration. What
may be termed as in process or transient data (e.g. workflow tasks, interim states of
activity data) may be subject to purges based on the requirements of the clinical data
type.
RC.02.01.01 – The medical record contains information that reflects the patient’s care
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Each medical record contains following demographics - name, sex, address,
DOB, authorized representative (if any), legal status (for patients receiving
behavioral health care) and the patient’s language and communications needs
The system provides for the capture of patient demographic information appropriate
to the registration or admission requirements of the services to be provided, and
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supports recording of authorized representative information through the designation
of such individuals as being in an agency relationship to the patient. The legal status
of the patient also is recorded. An emancipated minor can be indicated through a
guarantor relationship of self. The system supports the recording of the patient’s
language preference and religious affiliation, and supports the recording of patient
assessment information for patient learning requirements.
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Each record contains as applicable to case the reasons for admission, the
patient’s initial diagnosis, diagnostic impressions or conditions, emergency
care/treatment provided before arrival, documentation/findings of assessments,
conclusions/impressions from medical history/physical exam,
diagnosis/diagnostic impressions or conditions, reasons for admission, goals of
treatment/plans, diagnostic/therapeutic orders, diagnostic/therapeutic
procedures/tests/results, progress notes, reassessments and plan of care revisions,
relevant observations, response to care provided, consultation reports, allergies
to food/meds, every med ordered/prescribed, every dose of med administered
including strength, dose, rate, administration devices used, access site/route,
known drug allergies and any adverse reactions, any medications dispensed or
prescribed on discharge, discharge diagnosis, discharge plan and discharge
planning evaluation and all relevant diagnosis/conditions established during
course of care
The system supports the definition of plans of care for specific patient conditions, and
of documentation forms for the capture of specific assessments, progress notes and
clinical information particular to specific patient requirements. The system supports
the relevant capture of emergency care/treatment provided before arrival,
documentation/findings of assessments, conclusions/impressions from medical
history/physical exam, diagnosis/diagnostic impressions or conditions, reasons for
admission, goals of treatment/plans, diagnostic/therapeutic orders,
diagnostic/therapeutic procedures/tests/results, progress notes, reassessments and plan
of care revisions, relevant observations, response to care provided, consultation
reports, allergies to food/meds, every med ordered/prescribed, every dose of med
administered including strength, dose, rate, administration devices used, access
site/route, known drug allergies and any adverse reactions and all relevant
diagnosis/conditions established during course of care.
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As needed to provide care, the medical record contains evidence of informed
consent, records of communication with patient regarding care and patient
generated information if applicable
The system can support the recording and linking of patient consents (for use of
identifiable health information or for procedure based informed consent) and advance
directives to the person or the encounter as appropriate. At present time, consent
forms generally must be signed physically by the patient (and any witnesses when
appropriate) and scanned into the system for association to the right patient context.
These forms may also be signed by the patient electronically if signature pad
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technology is used. Advance directives may be recorded in a similar form if necessary
to keep a soft copy on line, or the nature of advance directives may be recorded
through the admission assessment process. The availability or indication of such
directives and consents depends on the method by which they are captured and
documented within the system.
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The medical record of a patient who receives urgent or immediate care contains
all of the following – the time and means of arrival, indication that the patient left
against medical advice when applicable, conclusions reached at the termination
of care including the patient’s final disposition, condition and instructions given
for follow up care and a copy of any information made available to the
practitioner or medical organization providing follow up care
All of the above information is able to be documented in the patient’s medical record,
and a copy of anything provided to the next provider in line providing post discharge
care can be retained whether generated using the Continuity of Care Document
(CCD) in Cerner’s Multi Media Archive or in Clinical Notes.
RC.02.01.03 - The patient’s medical record documents operative or other high risk
procedures and the use of moderate or deep sedation or anesthesia
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The hospital documents in the patient’s medical record any operative or other
high risk procedure and/or the administration of moderate or deep sedation or
anesthesia
An licensed independent practitioner involved in the patient’s care documents the
provisional diagnosis in the medical record before an operative or other high risk
procedure is performed
An operative or high risk procedure report is dictated or written upon completion
of the operative or other high risk procedure and before the patient is transferred
to the next level of care
The operative or other high risk procedure report includes the following – the
name of the licensed independent practitioner who performed the procedure and
his/her assistants, the name of the procedure performed, a description of the
procedure, findings of the procedure, any estimated blood loss, any specimen(s)
removed and the postoperative diagnosis
When a full operative or other high risk procedure report cannot be entered
immediately into the medical record after the operation or procedure, a progress
note is entered in the medical record before the patient is transferred to the next
level of care. This progress note includes the name(s) of the primary surgeon(s)
and assistant(s), procedures performed and a description of each procedure
finding, estimated blood loss, specimens removed and postoperative diagnosis
The medical record contains the following postoperative information – the
patient’s vital signs and level of consciousness, any medications including IV
fluids and any administered blood, blood product and blood components, any
unanticipated events of complications including blood transfusion reactions and
the management of those events
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The medical record contains documentation that the patient was discharged from
the post sedation or post anesthesia care area either by the licensed independent
practitioner responsible for his care or according to discharge criteria
The medical record contains documentation of the use of approved discharge
criteria that determine the patient’s readiness for discharge
The post op documentation contains the names of the licensed independent
practitioner responsible for discharge
The patient’s medical history and physical examination are recorded in the
medical record before an operative or other high risk procedure is performed
The hospital has a complete and up to date operating room register that includes
patient name, patient hospital identification number, date of operation, inclusive
or total time of operation, name of surgeon and any assistants, name of nursing
personnel, type of anesthesia used and name of person administering it, operation
performed, pre and post operative diagnosis and age of patient
The system can enable definition of what documentation is expected for the patient
encounter (e.g. through encounter forms in the ED, through surgical case
documentation in Surgery) and for specific orders, through order formats associated
to all manners of orders for required elements of documentation necessary for a given
type of order. These can embody required elements including provisional diagnosis,
site verification procedures, specimens removed, blood loss, post op diagnosis and the
particulars of sedation or anesthesia. The system can similarly support the required
elements to be completed for post operative documentation, and for documenting the
discharge criteria and activity for the patient from post op care. The system can lay
out expectations for the timeliness of the documentation to be completed in the right
sequence and tracks this expectation for deficiency management or for the
management of overdue clinical activities, but it generally requires a human to
comply with that expectation. The system supports routing of physician and surgical
documentation to the responsible physician for signature. For diagnostic image
reports, the system supports a global setting to require that a diagnostic report be
signed and documented within ”n” hours of the diagnostic exam report transcription.
Tracking is available for monitoring exams that may be come overdue for a
radiologist interpretation. Similar capabilities exist for assuring the timeliness of lab
results that require pathologist interpretation. For both surgical and diagnostic
imaging procedures, the system supports sequencing of diagnostic testing to be
completed before the procedure for scheduled procedures. Decision support rules may
be written to verify the availability of results before a diagnostic imaging exam is
started if desired. Authentication of the documentation is subject to the same kinds of
requirements as were discussed in RC.01.01.01 above. The capability of the system
to support use of the desired structure and form of the documentation similarly is
described in that response.
The system also supports a discharge criteria assessment as standard content for
surgical discharges.
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RC.02.01.05 – The medical record contains documentation of the use of restraint and/or
seclusion
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The hospital documents the use of restraint for non-behavioral health purposes in
the medical record including orders for use, results of patient monitoring,
reassessment and unanticipated changes in the patient’s condition
The hospital documents any use of restraint protocols in for non-behavioral
health purposes in the medical record
The hospital documents the use of restraint and/or seclusion for behavioral health
purposes in the medical record including each episode, the circumstances that led
to its use, consideration or failure of non-physical interventions, the rationale for
the type of intervention used, written orders for its use, each verbal order
received, each in-person evaluation and reevaluation of the patient, each 15
minute assessment of the patient’s status, continuous monitoring of the patient,
pre-existing medical conditions or any physical disabilities as risk factors, any
history of sexual or physical abuse, that the patient and/or family was informed of
hospital policy on its use, that the patient’s family was notified of its use, behavior
criteria for its discontinuance, that the patient was informed of the behavior
criteria needed for it to be discontinued, assistance provided to help the patient
meet said criteria, debriefing the patient with staff following an episode of its use,
any injuries the patient sustained and the treatment of those injuries and the
patient’s death should this occur while under the care of the hospital
See whitepaper Millennium and JC Provision of Care Accreditation Requirements for
information on system capabilities that may be relevant to the use of restraint or
seclusion for either non-behavioral or behavioral health.
RC.02.01.07 – The medical record contains a summary list for each patient who receives
continuing ambulatory care services
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A summary list is initiated for the patient by his or her third visit
The patient’s summary list is updated whenever there is a change in diagnosis,
medications or allergies to medications, and whenever a procedure is performed
The summary list is readily available to practitioners who need access to the
information of patients who receive continuing ambulatory care services
The patient’s summary list contains significant medical diagnosis and conditions,
significant operative and invasive procedures, adverse and allergic drug
reactions and current prescriptions, OTC drugs and herbal preps
The system enables the recording of all the indicated categories of information per
this requirement. The information is maintained at the person level under various
categories of clinical information accessible to clinicians with a relationship to the
patient or with access rights to the patient record as a member of the organization
providing care to the patient. This information is accessible subject to the access
rights of the role of the user. As a permanent part of the electronic record, it is
accessible by users downstream of a current given active care episode for continuity’s
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sake. The system can produce a reconciled medication profile for the patient as of any
transfer of care responsibility.
RC.02.03.07 – Qualified staff receives and record verbal orders
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Documentation of verbal orders includes the date and the names of individuals
who gave, received, recorded and implemented the orders
Verbal orders are authenticated within the time frame specified by law and
regulation
The system enables a verbal order type to be indicated when such orders are
transcribed by an authorized user who has the privileges to be able to transcribe such
orders. Verbal order types are identified as a communication type. The system will
record who took the order, who gave the order and can also create tasks from an
order. Individual responsibility for completion of the tasks required to implement the
order can be captured as tasks are completed on line. Completion requirements for
verbal orders may be tracked within ProFile for deficiency management, and overdue
verbal orders needing signature monitored. Reminders may be sent to physicians
responsible for their signature in the physician’s Message Center through messaging.
In the ED with FirstNet, the tracking board supports tracking the co-sign status
requirement for a physician – if post discharge, the system can provide reporting of
unsigned orders for monitoring orders that need a physician co-signature.
RC.02.04.01 – The hospital documents the patient’s discharge information
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In order to provide information to other caregivers and facilitate the patient’s
continuity of care, concise discharge summary providing information to other
caregivers and facilitating continuity of care includes reason for hospitalization,
significant findings, procedures performed/care provided, patient's condition at
discharge and information to patient and family as appropriate
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.
The system can provide generation of a Continuity of Care Document (CCD) to
include such information as patient demographics, a reconciled medication profile,
and diagnostic lab results for Microbiology and General Lab, allergy information,
procedures, immunization information and diagnosis. Cerner is working on
capabilities to be able to share this information electronically with another provider
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through point to point interfacing, and through health information exchanges. This
information may also be made available to removable media to be given to the next
provider in line by the patient. Cerner also will be making available electronic clinical
summaries that can be rendered into a .pdf format.
For ED visits, the system provides an auto fax capability to send the care summary of
the visit – and also can route it to the inbox of a provider who is a system user. The
discharge summary enables pulling in any of the discrete information captured
throughout the ED encounter, and generates a user friendly discharge summary that
reflects all of the required elements noted above.
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