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Millennium and JCI Access to Care and Continuity
of Care Accreditation 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 Access to Care and Continuity of Care (ACC) section
(pp. 39-51) 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.
General Focus of the Standards
The general focus of the accreditation standards in this area can be summarized as follows:
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That the healthcare provider enables access to services appropriate to the patient
population it serves both on scheduled and emergent basis
That the provider furnishes information on treatment options and possible outcomes to
the patient and the patient’s family
That such materials are provided in a form and manner appropriate to the patient’s
language, background, and level of learning
That the organization provides care according to appropriate plans of care
That a process is in place for assuring continuity of care upon transfer and discharge
including providing of appropriate information on the patient’s condition and the
treatment provided
That planning for transfer and discharge is coordinated and done with the patient’s full
knowledge
That the involvement of other facilities in receipt of the patient upon transfer or post
discharge is done in a coordinated fashion
Millennium’s Role in Enabling Compliance
The standards found within this section of the JCI accreditation standards are focused on the
access, admission, care planning, transfer, and discharge processes. Many of the requirements
are procedural in nature, but many also are directly supported by different aspects of
Millennium’s Patient Admission and Scheduling (PAS) or registration capabilities, care planning
capabilities, nursing/physician documentation, clinical event and clinical document viewing,
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pharmacy, and other applications that support direct patient care. The key Millennium solutions
involved include:
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Order Management
PowerPlans
CareNet Documentation Management
INet
eMAR
PowerPOC
Results review
Discern Expert
PAS/Registration Management and Scheduling
PharmNet
PathNet
RadNet
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 these 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.
Admission to the Organization
ACC.1 – Patients are admitted to receive inpatient care or registered for outpatient services based
on their identified health care needs and the organization’s mission and resources.
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Screening is initiated at first point of contact within or outside the organization.
Based on the results of screening, it is determined if the needs of the patient match the
organization’s mission and resources.
Patients are accepted only if the organization can provide the necessary services and the
appropriate outpatient or inpatient settings for care.
There is a process to provide the results of diagnostic tests to those responsible for
determining if the patient is to be admitted, transferred, or referred.
Policies identify which screening and diagnostic tests are standard before admission.
Patients are not admitted, transferred, or referred before the test results required for
these decisions are available.
Policies define how patients are informed when there will be a wait or delay in care and
treatment and the reasons for the delay or wait, and how the information will be
documented.
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The system enables the definition of the scope of health services provided by the
organization in terms of services that may be scheduled, ordered, and resulted or
documented. The system enables the processes for support of pre-registration, scheduling,
and eligibility verification for those health services that are appropriate to a patient’s
individual care. For patients that are to be admitted, the system enables the definition of care
plans to identify, schedule, and manage those activities that are required elements of service
such as for nursing care, for diagnostic testing, and as packaged elements of surgical services
as examples.
The system supports the definition of standardized assessment formats for performing initial
assessments. For assigning and managing assessments on a timely basis, the assessment can
be supported by an assessment order with a defined duration to match the policy of the
hospital. These forms can be elaborated to support specific patient conditions and needs.
Many types of assessment forms are available as predefined content, and as part of starter
reference data for new implementations. Such content is available through www.cerner.com
on the Cerner Knowledge Manager web page. Further, orders can facilitate documentation
based with system generated tasks reminders around the order frequency.
The system is able to route clinical orders to specific work areas based on patient location,
availability of the required instrumentation/work site, and priority of the request. The system
is able to provide for proactive monitoring for specific work requests to warn about
potentially overdue requests as a means on online monitoring. For ordering of diagnostic
imaging exams, the system makes available decision support through Discern Advisor using
content provided from a third party supplier (Medicalis) to provide guidance as to the
appropriate diagnostic exam options given the circumstances of a patient’s need.
The system provides for synonym logic to assure that regardless of how the requestor of the
diagnostic service might refer to the service, the right clinical test is ordered and performed.
For support of clinical interpretation, the system can generate interpretative text based upon
the actual clinical values recorded in the system, and based on age, species, and gender of the
patient. The system also supports use of structured vocabulary for documentation of
interpretations to assist the clinician. The system enables the marking of abnormal results
based on reference ranges (for lab values) or based on radiologist interpretation of a
diagnostic image (for diagnostic imaging). These allow for a diagnostic result to be
displayed with abnormal or critical result indicators on the Flowsheet in Powerchart. For
diagnostic imaging, Cerner is considering the use of third party content to help provide
assistance through an online reference guide for interpretation of abnormal results which
would be driven by user requests to information to help substantiate the abnormal finding.
In the ED, events can be attached to each order, and status can be attached to the events to
track how long orders have been open of a particular type across all patients to highlight to
the ED staff that there may be a workflow issue slowing down availability of diagnostic test
results.
ACC.1.1 – The organization has a process for admitting inpatients and for registering
outpatients.
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Policies and procedures are used to standardize the outpatient registration process.
Policies and procedures are used to standardize the inpatient admitting process.
Staff are familiar with the policies and procedures and follow them.
The policies and procedures address admitting emergency patients to inpatient units.
The policies and procedures address holding patients for observation.
The policies and procedures address managing patients when bed space is not available
on the desired service or unit or elsewhere in the facility.
The system enables the admission process through automation of pre-registration,
scheduling, and admission activities. The system enables different registration paths to be
supported for inpatients, outpatients, emergency room patients, and other types of patients.
The system enables definition of required registration conversation elements and rules to
assure appropriate levels of information are captured as required for the given type of
admission.
When a patient is admitted from the ED, Millennium has the capability of using the same
encounter for both portions of that visit. This means that all results and documentation that
were entered on the patient during the ED portion of the visit are available during the
inpatient portion without the clinician having to click onto a different screen or search for the
information in another place. Also, all orders that are active for the patient in the ED remain
active when the patient is moved to the floor. The inpatient physician can then decide if it is
appropriate to cancel any of those orders. This allows things such as continuous IVs to be
maintained in the system from the ED to the floor.
Through FirstNet, the system enables ED beds to be designated to include hallway beds and
to designate separate tabs within the Tracking Board to show areas that are designated for
temporary bed locations.
Through Bed Board Management, the system allows the definition of virtual beds that can be
used for such needs as swing beds, and the room charges are managed appropriately based on
the use of the bed. The system provides a bed board capability to manage current bed
availability statuses and ongoing for monitoring purposes – patient waits times can be
captured as a byproduct of scheduling activity and reporting as long as key events are known
such as patient arrival, patient check-in, patient rooming, or similar events for service in an
ambulatory environment where the system helps track the service times for particular service
resources on the patient schedule.
The system also provides a capability for performing capacity planning through registration
and scheduling to help project capacity needed for patients who may be roomed at a future
point in time. This can be used for dealing with patients returning from surgery or for
support of scheduled admissions in the near term. This can be based on estimated arrival and
departure dates from pre-registration, and has the effect of reserving bed capacity for future
scheduled admissions.
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ACC.1.1.1 – Patients with emergency or immediate needs are given priority for assessment and
treatment.
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The organization has established criteria to prioritize patients with immediate needs.
The criteria are physiologic-based, where possible and appropriate.
Staff are trained to use the criteria.
Patients are prioritized based on the urgency of their needs.
The system enables definition of assessment forms to support the triage process for
emergency care to assure that appropriate information is captured indicative of the patient’s
condition. The system also enables the labeling of diagnostic orders as “Stat” orders to give
them priority for scheduling of testing activities necessary to fulfill them. Medication orders
may also be indicated as “Stat” orders with necessary administration times scheduled based
on the indicated frequency and duration of the orders. For emergency patients that are
admitted, available rooms and beds are managed for availability through an electronic bed
board function to support efficient processing of rooming the patient. Information
documented through services provided in emergency care that are captured within the
electronic medical record are also immediately available when in a verified format to other
care providers who may benefit from access to the information.
ACC.1.1.2 – Patient needs for preventive, palliative, curative and rehabilitative services are
prioritized based on the patient’s condition at the time of admission as an inpatient to the
organization.
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The screening assessment helps staff understand and prioritize the preventive, palliative,
curative and rehabilitative services needed by the patient.
The service or unit selected to meet these needs is appropriate.
The system enables the assignment of care plans to the patient’s encounter appropriate to the
patient’s condition that lay out the schedule and sequence of events that should occur
appropriate to the patient’s condition. The system also enables scheduling activities for care
as may be required both within and beyond the current admission that consider both the
availability of necessary resources to provide care, based on other scheduled activities
already planned for the patient, and based on special considerations that may apply such as
reserved time slots for particular kinds of procedures or high priority patient requirements.
ACC.1.2 – At admission as an inpatient, patients and families receive information on the
proposed care, the expected outcomes of that care, and any expected cost to the patient for the
care.
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There is a process to provide the patient/family with information at admission. (Also see
MCI.2, ME 1)
The process includes information on the proposed care.
The process includes information on the expected outcomes of care.
The process includes information on any expected costs to the patient or family.
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Patients receive sufficient information to make knowledgeable decisions. (Also see
AOP.4.1, ME 3)
The system can assist in automating eligibility determination to verify any available
insurance coverage for the patient or for determining possible patient responsibility. The
outcomes of the eligibility verification can be documented in the system, but the system does
not utilize this information to determine an up front “demand bill” or estimated patient
responsibility until charge activity is processed through the billing system.
The system supports the definition and documentation of patient specific education activities
performed through a documentation form. 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 itself. 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.
In Millennium 2007, the system supports generation of discharge instructions both to the
provider and to the patient in a common manner across different settings of care. For the
patient version of the discharge summary, the system supports use of third party content to
provide educational or instructional information in a manner to the appropriate the reading
level of the patient, and relative to the patient condition. In the ED within FirstNet,
information as to why the patient was discharged or transferred may be documented within a
patient educational form and pulled into the discharge summary.
ACC.1.3 – The organization seeks to reduce physical, language, cultural and other barriers to
access and delivery of services.
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The leaders and staff of the organization understand the most common barriers in its
patient population.
There is a process to overcome or limit barriers during the admission process.
There is a process to limit the impact of barriers on the delivery of services.
These processes are implemented.
The system provides for localization of system messages, labels, display fields, literals, and
documentation for end use.
The system can provide 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 work list 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,
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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.
ACC.1.4 – Admission or transfer to or from units providing intensive or specialized services is
determined by established criteria.
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The organization has established entry and/or transfer criteria for its intensive and
specialized services or units, including research and other programs to meet special
patient needs.
The criteria are physiologic-based where possible and appropriate.
Appropriate individuals are involved in developing the criteria.
Staff are trained to apply the criteria.
Patients transferred or admitted to intensive and specialized units/services meet the
criteria and this is documented in the patient’s record.
Patients who no longer meet the criteria to remain in the unit are transferred or
discharged.
The system enables the management of patient rooming activities upon admission or transfer
through the electronic bed board. The system enables definition of reserved units to be used
for particular types of admissions such as intensive care, psychiatric care, and the like. The
system enables definition of goals for care plans that can provide the basis for evaluating
patient condition and progress. This information can inform a decision to transfer or
discharge the patient along with evaluation of the other clinical information available in the
patient’s record. The system does not automatically prevent or trigger transfer or discharge
as it is presumed that is done based on a physician/clinician order which itself can be
documented in the patient’s electronic record.
Continuity of Care
ACC.2 – The organization designs and carries out processes to provide continuity of patient care
services in the organization and coordination among health professionals.
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The leaders of services and settings design and implement processes that support
continuity and coordination of care, including those identified in the intent statement.
Established criteria or policies determine the appropriateness of transfers within the
organization.
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The system enables access to the patient’s electronic medical record on a real time basis for
any information that is updated to the record as verified by clinicians. Access to particular
information is dependent on the clinician/user having an appropriate authorized relationship
to the patient and access rights to clinical data based on the security policies of the
organization. (See Millennium and JCI Management of Communication and Information
Requirements white paper for more information on access controls and security.)
The system can assist in scheduling external resources to a limited extent if they have been
defined as schedulable resources to the system, but the system would not have awareness of
external conflicting demands on those resources not defined to the system as reserved time
slots. The system can help facilitate 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.
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Continuity and coordination are evident throughout all phases of patient care.
Continuity and coordination are evident to the patient.
The system enables the definition of care plans and scheduling of orders and tasks to
coordinate medical and nursing activities that are planned as scheduled tasks to be sequenced
for the patient’s care. This includes scheduling of diagnostic orders, assessments, nursing
activities, patient maintenance activities, medication administrations, and other activities.
In the case of external reference labs, the system supports definition of external testing
resources for purpose of generating outbound orders for those procedures. In the case of post
discharge referrals from the ED, the system can support documentation of to whom the
patient is referred to post discharge, and the system can support a reference list of providers
who may be used for post discharge referral that can be incorporated into the discharge
summary.
If those providers are also system users, they may be given relationships to the patient’s
record based on direct care providing involvement or based on providing diagnostic or
therapeutic services that the system may route to them for being performed – or the system
can output clinical reports to external providers identified as ordering or referring providers –
or the system 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 2007 and 2008 development for different kinds of visit, discharge and referral
summaries.
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
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simpler to use and more streamlined as to the accessibility of the information through a
consolidated system function.
ACC.2.1 – During all phases of care, there is a qualified individual identified as responsible for
the patient’s care.
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The individual responsible for the patient’s care is identified. (Also see PFR.6.1, ME 6)
The system enables the identification of individuals responsible for the patient’s care in terms
of physician roles for attending, admitting, consulting, referring, and performing physicians
involved in that care. This information is both recorded in the patient’s record so as to create
an accountability trail associated to any individual health information contributed to the
patient’s record by such individuals or as may be modified or verified by such individuals.
This information also is utilized in validating the need to know for individuals as having a
relationship to the patient that is active and valid to the system in granting access to the
patient’s record.
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The individual is qualified to assume responsibility for the patient’s care.
The individual is identified to the organization’s staff.
The system does not directly utilize the credentials or certification of a clinician or staff
member in determining whether or not that individual is “qualified” to perform a particular
clinical activity. It is assumed that the organization implementing Millennium will consider
that in how a user is assigned to a position that has a particular set of access rights to system
application tasks and functions for carrying out position or role related activities in the
system. There are also certain reserved rights such as pharmacy order verification or
electronic signature of clinical results that are only available to certain roles (registered
pharmacist in the former, and a physician user in the latter). The system does enable the
recording of the user’s identity with any action taken in the system to create, modify or verify
clinical data through the user’s ID stamp. This in turn can enable the display of the user’s
name and credentials as appropriate for such displays as signature lines, action history for
modifications to orders and documents and other places where display (or output) of such
information is significant to the clinical context.
The system enables security policies to also require that individuals are identified to
organizations as having privileges that allow those individuals to access patient data created
and maintained by organizations.
ACC.3 – There is a policy guiding the appropriate referral or discharge of patients.
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There is a policy guiding the appropriate referral and/or discharge patients.
The referral and/or discharge is based on patient’s needs for continuing care. (Also see
AOP.1.8.1, ME 1, and GLD.6.1, ME 3)
The patient’s readiness for discharge is determined.
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When indicated, planning for referral and/or discharge begins early in the care process
and, when appropriate, includes the family. (Also see AOP.1.8.1, ME 2)
Patients are appropriately referred and/or discharged.
Organization policy guides the process of patients “on pass” for a defined period of time.
The system provides support for automated discharge processing through the
PAS/registration system. The system can generate appropriate discharge documentation. The
system typically does not get involved in processing referrals unless the organization to be
referred to is also automated by the same Millennium domain in which case it may be
possible to schedule post discharge care and follow up for the recipient organization. Patient
readiness for discharge can be documented through a discharge readiness assessment.
ACC.3.1 – The organization cooperates with health care practitioners and outside agencies to
ensure timely and appropriate referrals.
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The discharge planning process considers the need for both support services and
continuing medical services.
The organization identifies the health care providers, organizations, and individuals in
its community that are most associated with the organization’s services and patient
population. (Also see PFE.3, ME 2)
Referrals outside the organization are to specific individuals and agencies in the
patient’s home community whenever possible.
Referrals are made, when possible, for support services.
See response to ACC.2 on care coordination and continuity and ACC.3 – if such
organizations are also automated by the same Millennium domain or if such practitioners
also have access to the same electronic medical record as the discharging facility, it may be
possible to schedule activities for and share patient information with the receiving
organization or practitioners. Printed material also may be made available from the patient’s
electronic record as mentioned above.
ACC.3.2 – Patient records contain a copy of the discharge summary.
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All discharge summaries contain the items a) through h) identified in the intent.
[NOTE: The following section is from the intent statement.]
a) Reason for admission;
b) Significant physical and other findings;
c) Significant diagnoses and co-morbidities;
d) Diagnostic and therapeutic procedures performed;
e) Significant medications and other treatments;
f) The patient’s condition at the time of discharge;
g) Discharge medications, all of the medications to be taken at home; and
h) Follow-up instructions
A copy of the discharge summary is placed in the patient record.
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Unless contrary to organization policy, laws, or culture, patients are given a copy of the
discharge summary.
The system can support planning for post discharge care through support of documentation,
and for reporting on active medications at time of discharge (medication reconciliation
project). The system can support communication of care summaries and activities as of the
time of discharge, and Medical Record Publishing (MRP) can be used for output if the
transferred to provider is not also a user. Support for the generation and transmission of
standards based (e.g., HL7 CDA R2) document types for communication of structured
electronic clinical documents for discharge summaries or visit summaries are in the process
of being developed in 2007 and 2008.
In Millennium 2007, the system supports generation of discharge instructions both to the
provider and to the patient in a common manner across different settings of care. For the
patient version of the discharge summary, the system supports use of third party content to
provide educational or instructional information in a manner to the appropriate the reading
level of the patient, and relative to the patient condition. In the ED within FirstNet,
information as to why the patient was discharged or transferred may be documented within a
patient educational form and pulled into the discharge summary.
ACC.3.3 – Patients and, as appropriate, their families are given understandable follow-up
instructions at referral or discharge.
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Follow up instructions are provided in an understandable form and manner.
The instructions include any return for follow-up care.
The instructions include when to obtain urgent care.
Families are also provided the instructions as appropriate to the patient’s condition.
In Millennium 2007, the system supports generation of discharge instructions both to the
provider and to the patient in a common manner across different settings of care. For the
patient version of the discharge summary, the system supports use of third party content to
provide educational or instructional information in a manner to the appropriate the reading
level of the patient, and relative to the patient condition. In the ED within FirstNet,
information as to why the patient was discharged or transferred may be documented within a
patient educational form and pulled into the discharge summary.
Transfer of Patients
ACC.4 – There is a policy guiding the appropriate transfer of patients to another organization to
meet their continuing care needs.
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There is policy guiding the appropriate transfer of patients.
The transfers are based on the patient’s needs for continuing care.
The process addresses the transfer of responsibility to another provider or setting.
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The process addresses criteria that define when transfer is appropriate. (Also see
GLD.6.1, ME 3)
The process addresses who is responsible during transfer.
The process addresses the situation in which transfer is not possible.
Patients are appropriately transferred to other organizations.
See responses in section ACC.3 – similar responses apply here. The system can support
planning for post discharge care through support of documentation, and for reporting on
active medications at time of discharge (medication reconciliation project). The system can
support communication of care summaries and activities as of the time of discharge, and
Medical Record Publishing (MRP) can be used for output if the transferred to provider is not
also a user. Support for the generation and transmission of standards based (e.g. HL7 CDA
R2) document types for communication of structured electronic clinical documents for
discharge summaries or visit summaries are in the process of being developed in 2007 and
2008.
ACC.4.1 – The referring organization determines that the receiving organization can meet the
patient’s continuing care needs.
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The referring organization determines that the receiving organization can meet the needs
of the patient to be transferred.
Formal or informal arrangements are in place with receiving organizations when
patients are frequently transferred to the receiving organization.
The system does not play a direct role in this process aside from the possibility of managing
scheduling of receiving organization resources if supported by the same Millennium domain.
In this case, the kinds of services that may be scheduled to the receiving organization and the
availability of its resources may be managed through the system in support of this kind of
transfer.
ACC.4.2 – The receiving organization is given a written summary of the patient’s clinical
condition and the interventions provided by the referring organization.
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Patient clinical information or a clinical summary is transferred with the patient.
The clinical summary includes patient status.
The clinical summary includes procedures and other interventions provided.
The clinical summary includes the patient’s continuing care needs.
See response to ACC.3.1, 3.3, and ACC.4. Continuing care needs may also be documented.
ACC.4.3 – During direct transfer, a qualified staff member monitors the patient’s condition.
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All patients are monitored during direct transfer.
The qualifications of the staff member are appropriate for the patient’s condition.
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The system does not play a direct role in this activity other than may be documented – see
next response.
ACC.4.4 – The transfer process is documented in the patient’s record.
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The records of transferred patients note the name of the health care organization and
name of the individual agreeing to receive the patient.
The records of transferred patients contain other notes as required per the policy of the
transferring organization.
The records of transferred patients note the reason(s) for transfer.
The records of transferred patients note any special conditions related to transfer.
The records of transferred patients note any change of patient condition or status during
transfer.
The system enables the documentation of the transfer of care process as may be appropriate.
Structured documentation templates may be defined appropriate to this purpose.
ACC.5 – The process for referring, transferring or discharging the patient considers
transportation needs.
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The process for referring patients considers transportation needs
The process for transferring patients considers transportation needs
The process for discharging patients considers transportation needs
Transportation is appropriate to the patient’s needs
The system typically does not play a role in facilitating this process unless transport is
considered a schedulable resource for purpose of scheduling the actual transport activity in
relation to the service or if transport may be “ordered” as a part of a clinical order.
ACC.6 – Medical transport services meet relevant laws and regulations and licensing
requirements.


The medical transport service meets relevant laws and regulations.
The medical transport service is licensed when required.
See above response.
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