CCHIT Certified 2011 Ambulatory EHR Test Script 20100326

CCHIT Certified 2011 Ambulatory EHR Test Script April 7, 2010
Certification Commission
for Health Information
Technology
© 2010 Certification Commission for Health Information Technology
CCHIT Test Scripts

For Certification of Ambulatory EHRs
Includes steps and appendix information required for Child Health Certification
Includes steps and appendix information for Cardiovascular Medicine Certification including
CV Advanced Reporting Capability Certification
April 7th, 2010
Product (NUMBER CODE ONLY):_________________________ Date: __________________________
Evaluator: _________________________________________ Signature: _______________________
CCHIT Certified 2011 Test Script – Ambulatory + Child Health + Cardiovascular Page 1 of 121
Technology
Legend
Test steps that require the Proctor to update the Audit Trail Worksheet are highlighted in cyan.
Test steps that apply to Child Health Certification or Cardiovascular Certification are highlighted in purple.
In the Cardiovascular Scenario, items that are required ONLY for CV Advanced Reporting Capability Certification are highlighted in green.
Test Environment Setup Parameters for Script Execution
For ePrescribing steps:

 Applicants using a 3rd Party ePrescribing product must be active with the „Test PBMD‟ on the SureScripts/RxHub platform to properly perform Step 4.58.
The ePrescribing network requires that the provider is setup in their network for each Applicant, so that the ePrescribing steps can be executed. Please arrange
for the provider (Dr. Butler) to be set up in the ePrescribing network at least one week prior to your inspection date.
Users
 There must be five Physician type users with valid login. These users must have at least the following permissions: full access to all clinical functions.
o Dr. Robert Alexander – Primary Care Physician in scenario 1
o Dr. McCoy - OB/GYN in scenario 2
o Dr. Internist E. Butler – Internist in scenario 3
o Dr. Jones – Internist
o Dr. Green – Cardiologist in CV scenario
 There must be one Nurse Practitioner type user with valid login. This user must have at least the following permissions: access to all clinical functions.
o Ellen Thompson, CFNP – for use in Scenario 1
 There must be one Nurse user with valid login. This user must have at least the following permissions: access to all clinical functions.
 There must be one Reception user with valid login. This user must have access to only the following functions: registration and demographic functions.
 There must be one Medical Assistant user with valid login. This user must have at least the following permissions: access to all clinical functions.
 There must be one Office Manager user with valid login. This user must have at least the following permissions: access to all clinical functions and access
to all information necessary to carry out test procedures 4.72 to 4.86.
Technology
 There must be one Security Administrator type user with valid login. This user must have at least the following permissions: access to all information
necessary to carry out security administrative tasks; no rights to access clinical data or Protected Health Information (PHI) as defined by the Centers for
Medicare and Medicaid Services (CMS).
o See page 19, section 160.103 Definitions in CMS site: http://www.hhs.gov/ocr/privacy/hipaa/administrative/privacyrule/adminsimpregtext.pdf
External Providers: For use at step ADM.12, content of the directory is as follows:
Name Address Telephone Specialty
Dr. Dem Bones 456 Anytime Lane, Annapolis MD 21405 410-555-0151 Orthopedics
Dr. Ava Heart 344 Artery Drive, Piney Point MD 301-555-0133 Cardiology
Dr. Ivana Facey 912 Skincare Way, Hollywood MD 20636 301-555-0178 Plastic Surgery
Ms. Mary Smith, RN, CDNE 1234 Elm Street, Anytown USA 555-555-1212 Nutritionist
NOTE: The information in the table above is provided as an example only; if the applicant wishes to demonstrate this function using different content that is
acceptable.
Patients
Patient ID numbers are provided for each patient required in the inspection. If the system assigns sequential numbers or other patient ID numbers, please provide a
complete list of Patient ID numbers for all patients listed in setup, to the CCHIT Proctor prior to the inspection.
There must be a patient record for Ellen Thompson. Patient ID for Ellen Thompson is PID#41205321. As Ellen Thompson is Dr. Alexander‟s sister-in-law, Dr.
Alexander should not have access to Ellen Thompson‟s chart.
There must be a patient record for Joe Smith

Birthdate: 3/23/1967
Telephone: 312-555-1234
Patient ID: PID#41205322
There must be a patient record for Joe Smith

Mother: Jessica N. Smith
Father: J.N. Smith
Address: 1600 Rockville Pike, Rockville, Maryland
Technology
Telephone: 301-555-1212 (home)

Mom‟s cell: 202-555-1212
Patient record includes historical data. Information in Appendix A is to be entered as previous visits for this patient at this practice.
There must be a patient record for Emily Jones

Mother: Stacy Jones
Father: Michael Jones
Address: 2501 Merrvale Road, Rockville, Maryland
Mom‟s cell: 202-555-0199
Dad‟s cell: 202-555-0111
Preference for Reminders: Elected to Receive Reminders via Mail
There must be a patient record for Will Haynes

Mother: Marilyn Haynes
Father: Joseph Haynes
Address: 16167 King Street, Alexandria, Virginia
Preference for Reminders: Elected to Receive Reminders via Mail
There must be a patient record for Jennifer A. Thompson

Address: 2300 Commonwealth Avenue, Anytown, MA 02111
Jennifer‟s cell: 617-555-1234
Husband‟s cell: 617-555-2121
Technology

Patient record includes historical data. Information in Appendix B is to be entered as previous visits for this patient at this practice.
There must be a patient record for Theodore S. Smith

Birthdate: 11/08/1931.
Address: 2300 Commonwealth Avenue, Anytown, MD 22222
Telephone: 240-555-1212
Mobile email: anyone@aol.com
Patient record includes historical data. Information in Appendix C is to be entered as previous visits for this patient at this practice.
There must be a patient record for David Carter

Address: 1234 Willow Way, Silver Spring, MD 20902
Telephone: 301-555-0144
There must be a patient record for Jim Grayson

Birthdate: 09 March 1943
Address: 834 Ocean Vista Avenue, Apt. 202, Santa Monica CA 90401
Telephone: 310-555-2233
Email: jgrayson@grayson.com
There must be a patient record for Chester Pain

Birthdate: 29 January 1945
Address: 1060 W. Addison Avenue, Chicago IL 60613
Telephone: 773-555-1908
Email: c.pain@aol.com
There must be a patient record for Agatha Bloom

Birthdate: 26 February 1982
Technology
Address: 742 Evergreen Terrace, Springfield IL 62701

Telephone: 217-555-4242
Cell Phone: 217-555-9643
Email: agatha.bloom@yahoo.com
Agatha‟s most recent blood pressure reading is from 10 January 2006.
System
Enable audit logs to log, at a minimum, the events required in Appendix D (found in Security Test Script).
Environment
There must be a printer connected to the system.
There must be a scanning device connected to the system.
There must be an electronic faxing capability connected to the system.
Alert functionality must be set to show all alerts (i.e. not just display “severe” interactions, but also display “mild” interactions).
The system must be configured so that the base guideline for a reminder for a mammogram is 50 years of age.
Note to Applicants:
These scenarios are meant to test specific functional requirements; they are not meant to reflect the complete care that might be provided to a patient. In some
cases, the procedure may ask for an action that the Applicant does not feel to be clinically correct; please proceed with the procedure.
Scenarios are intended to be run consecutively, 1 through 4. If the Applicant wishes to run scenarios in a different order, or if the Applicant chooses to execute
test steps contained within the scenarios in a different order to accommodate workflow of the application, the Applicant must advise CCHIT Proctor in advance.
For clinical scenarios, Applicants should note that some elements of the test script are time compressed from what would normally occur in clinical practice setting.
This is to accommodate testing of the criteria in a timely manner. Similarly, some test steps may be accomplished by a user other than would normally do a
function in a clinical practice setting. Again, this is to accommodate testing of the criteria in a timely manner.
Following this test, the Applicant is expected to conduct the Security Test Script.
Technology
Prior to beginning clinical scenarios, these administrative steps will be carried out.
Procedure Expected Result Actual Result Pass/Fail Criteria and Reference Comments
ADM Login as required. Login successful.
.01
ADM In the Diabetes One The additional orders are  Pass  Fail FN 10.02 The system shall provide the ability to modify
.02 order set, modify the added to the order set order sets.
order set to include the “Diabetes One.” FN 10.03 The system shall provide the ability to include
following items: Order set now includes: in an order set order types including but not
limited to medications, laboratory tests,
 Basic metabolic  RhoGAM; imaging studies, procedures and referrals.
panel; and  HgbA1c;
 Non stress test.  Nutritional referral;
 Basic metabolic panel;
and
 Non stress test.
ADM Logout. Logout successful.
.03
Test Script Scenario #1 – Summary:

This Clinical Test Scenario involves a routine well-child visit to his Primary Care Physician for immunization, examination and prescription creation.
1.01 Login as Reception Login successful; patient
user and create a record for Joe Gardner is
patient record for Joe created.
Gardner (Joe Gardner‟s
Patient ID is
41205332).
1.02 Look up patient 3 patient records found.  Pass  Fail AM 01.01 The system shall create a single patient record Proctor to update
for each patient
demographic record by  Joe Smith Audit Trail
last name SMITH  Joe Smith AM 01.02 The system shall associate (store and link) key Worksheet
identifier information with each patient record
 Theodore S. Smith (Appendix D).
FN 01.02 The system shall capture and maintain
demographic information as discrete data
elements as part of the patient record.
Technology
1.03 Re-do the search; look Patient record for correct  Pass  Fail AM 01.03 The system shall provide the ability to store
up patient by another Joe Smith (second record, more than one identifier for each patient record.
method (using a mother is Jessica, from FN 01.01 The system shall provide the ability to access
different identifier) and Maryland) is found and demographic information such as name, date of
birth and gender, needed for patient care
select appropriate can be selected. Any functions.
patient record. other identifier can be
used to locate patient FN 02.01 The system shall provide the ability to query for
a patient by more than form of identification.
record.
1.04 This Joe Smith and Joe A single record is created  Pass  Fail AM 01.05 The system shall provide the ability to merge The intent is to
Gardner (patient chart for patient Joe Gardner. patient information from two patient records into merge information
a single patient record.
created at login) are the for a single patient;
same person. Merge this would include
the patient information discrete data
from the two records elements from both
into a single patient patient records.
record.
Note that the correct

record to keep is the
record for Joe Gardner.
1.05 Show age for Joe Joe Gardner‟s age is  Pass  Fail CH 01.01 The system shall allow the recording of date This step applies
Gardner. expressed in years and and time of birth (hour and minutes if known) only to CHILD
and subsequently be able to express age in
months. hours for the first 4 days of life, then in days HEALTH
from the 5th day of life through the first 28 days, certification.
Years and months will then in weeks beginning on the 29th day of life
vary depending on through the first three completed months of life,
and then in months beginning with the 4th
inspection date based on month of life through age 2 years. Subsequent
birth date of 7/1/1998. expressions of age may be expressed by year
and month (2 years 6 months) or with a decimal
place for expressing part of years (i.e. 2.5 years
old) through age 18.
Technology
1.06 Mother has remarried; Updated demographics  Pass  Fail FN 01.02 The system shall capture and maintain NOTE – if system is
and address has are displayed and include: demographic information as discrete data tied to an address
elements as part of the patient record.
changed.  Updated mother‟s last database that
 Update Mother‟s name; AM 02.04 The system shall provide the ability to modify verifies street
demographic information about the patient.
last name to  Updated address. addresses and zip
Gardner AM 02.05 The system shall store demographic codes, Applicant is
information in the patient medical record in
 Update address to Demographic information separate discrete data fields, such that data
not required to
1234 Maplewood is stored in separate extraction tools can retrieve these data. override preloaded
Drive, Bethesda, discrete data fields. address information
MD, 20810. to match the test
Demographic script; show that
information is to be address can be
stored in separate updated, and use a
discrete data fields. “real” address and
zip code if
necessary.
Proctor to update
Audit Trail
Worksheet
(Appendix D).
1.07 Show how system Applicant shows historical  Pass  Fail AM 02.02 The system shall provide the ability to maintain
maintains historical demographic information. and make available historic information for
demographic data including prior names,
information for prior Original field values are addresses, phone numbers and email
names and addresses. displayed including patient addresses.
prior last name (Smith)
and previous address
(1600 Rockville Pike,
Rockville, Maryland).
Technology
1.08 Enter information for Name and address of Joe  Pass  Fail CH 09.03 The system shall provide the ability to This step applies
Joe‟s grandmother: Gardner‟s grandmother is document the names and addresses for only to CHILD
patient‟s personal representatives (for example:
 Joanne C. Smith documented. parent, guardian, surrogate, financial guarantor) HEALTH
 Address 152 and personal relationships (foster parents, certification.
Taylor Street, biological parents) with contact information for
Chevy Chase, MD, each to include one or more telephone numbers
and address.
20815
 Telephone 301-
555-4321
1.09 Logout as Reception. Logout successful.
1.10 Login as Nurse and Login successful. Proctor to update
select patient record for Audit Trail
Joe Gardner. Worksheet
(Appendix D).
1.11 Record no family Information added to  Pass  Fail AM 06.02 The system shall provide the ability to capture
history of smoking, and patient history. structured data in the patient history.
positive family history AM 06.04 The system shall provide the ability to capture
of heart disease (father patient history as both a presence and absence
of conditions, i.e. the specification of the
died of heart attack at absence of a personal or family history of a
age 34). specific diagnosis, procedure or health risk
behavior.
Technology
1.12 Review required System displays  Pass  Fail AM 22.01 The system shall provide the ability to establish Link to the CDC
immunization boosters. immunizations due at this criteria for disease management, wellness, and schedule shows that
preventive services based on patient
visit: demographic data (minimally age and gender). an 11 year old would
This display is based  Tdap be eligible for a
AM 22.02 The system shall provide the ability to display
on setup data provided  Varicella alerts based on established guidelines.
Tdap and a varicella
for previous
immunizations and AM 23.01 The system shall provide the ability to identify http://www.cdc.gov/v
preventive services, tests or counseling that are
demographic due on an individual patient.
accines/recs/schedul
information of the es/child-
patient and should AM 23.02 The system shall provide the ability to display schedule.htm
reminders for disease management, preventive,
display automatically. and wellness services in the patient record.
AM 23.03 The system shall provide the ability to identify
If system has already criteria for disease management, preventive,
displayed notification of and wellness services based on patient
immunizations due, this demographic data (age, gender).
step may have already AM 23.06 The system shall provide the ability to notify the
been observed. provider that patients are due or are overdue for
disease management, preventive, and wellness
services.
1.13 Review allergies in Allergy to penicillin  Pass  Fail FN 05.13 The system shall provide the ability to capture,
chart. indicated. maintain and display, as discrete data, lists of
medications and other agents to which the
patient has had an allergic or other adverse
reaction.
1.14 Mother indicates Joe Penicillin is inactivated  Pass  Fail FN 05.01 The system shall provide the ability to modify or "Remove" in this
has never taken from the list of allergies inactivate an item on the allergy and adverse context implies
reaction list.
penicillin; she listed it displayed or noted as specifying that an
as an allergy because erroneous. allergy or allergen
she is allergic to specification is no
penicillin. Inactivate longer valid or active
penicillin from the list of as opposed to
allergies, or mark deleting the
erroneous. information from the
database entirely.
Technology
1.15 Mother indicates Joe is Allergy to peanuts  Pass  Fail FN 05.13 The system shall provide the ability to capture,
allergic to peanuts but indicated. maintain and display, as discrete data, lists of
medications and other agents to which the
not to any medications. patient has had an allergic or other adverse
 Add “peanuts” to reaction.
the list of allergies.
1.16 Specify type of allergic System allows  Pass  Fail FN 05.04 The system shall provide the ability to specify
or adverse reaction to specification of “hives” as the type of allergic or adverse reaction in a
discrete data field.
peanuts to be “hives,” type of reaction; must be
in a discrete data field. captured in a discrete data
Note that other terms field.
would be acceptable;
the system does not
have to use the term
“hives.”
1.17 Show identity of user Nurse displays as the user  Pass  Fail FN 05.05 The system shall provide the ability to capture Attributes include
[nurse] who inactivated who made the change and and maintain, as discrete data, the identity of the name of the
the user who added, modified, inactivated or
penicillin from the penicillin is marked removed items from the allergy list, including allergen and the
allergies list (in step identified as removed or attributes of the changed items. The user ID action (added,
1.14; the drug penicillin inactivated. and date/time stamp shall be recorded. modified, inactivated
should be listed as Note: It is acceptable to or removed).
removed or show the identity of the
inactivated). user that made the change
in the audit log.
Technology
1.18 Using a template, Items are captured and  Pass  Fail AM 08.13 The system shall provide the ability to capture For Child Health
record vital signs at displayed as discrete data patient vital signs, including blood pressure, Certifications, CH
heart rate, respiratory rate, height, and weight, 02.01 and CH 04.01
 BP 130/90 elements. as discrete data. apply at this step in
 Height 58”
AM 08.14 The system shall provide the ability to capture addition to the
 Weight 80 lbs Temperature, weight and and display temperature, weight and height in Ambulatory criteria.
 Temperature 98.6 height should display in both metric and English units.
(F) both English and metric With respect to AM
AM 08.15 The system shall be capable of indicating to the
 Pulse 124 units. user when a vital sign measurement falls 08.14, the criterion
 Respiratory rate 30 outside a preset normal range as set by requires that the
Discrete data means that authorized users. system be able to
each separate element of display both metric
If applicant does not AM 08.19 The system shall provide templates for inputting
the data needs to be data in a structured format as part of clinical and English units; it
use template to input does not require that
vital signs data in a stored in its own field. documentation.
Jurors will look for a both are able to
structured format, CH 02.01 The system shall capture patient growth display on the same
please execute the test separate data field for parameters: including weight, height or length,
head circumference; and vital signs including
screen at the same
procedure by inputting each element. time.
(but not limited to): blood pressure,
vital signs, and then temperature, heart rate, respiratory rate,
demonstrating use of a Notification will be oxygen saturation and severity of pain as Templates may
template to input other provided that the values discrete elements of structured data. include any patient
data in a structured for pulse, blood pressure, CH 04.01 The system shall include the ability to use
encounter note
and respiration are pediatric-specific reference ranges for vital documentation tools
format.
abnormal. signs (examples: pulse, blood pressure, that provide a pre-set
respiration, temperature) based on age, gender, collection of clinical
NOTE that CCHIT and length/height/weight as appropriate. findings or fields,
including macros
recognizes that this Blood
driven by speech
Pressure value is not recognition
normal, and in clinical technology, branching
situation would require logic.
attention; this value is for
testing purposes only. This list is not
necessarily all
inclusive of all the
technology that may
arrive in future.
Technology
1.19 Calculate and display Body mass index of 16.7  Pass  Fail AM 08.25 The system shall provide the ability to calculate
body mass index. displays. and display body mass index (BMI).
1.20 Document that there is Pain level is captured in  Pass  Fail CH 02.01 The system shall capture patient growth This step applies
no pain (i.e. pain level discrete data as a numeric parameters: including weight, height or length, only to CHILD
head circumference; and vital signs including
= 0 or any scale that pain scale. (but not limited to): blood pressure, HEALTH
the system provides). temperature, heart rate, respiratory rate, certification.
Illustrate pain level. oxygen saturation, and severity of pain as
discrete elements of structured data.
Pain level is to be
captured as discrete
data.
1.21. Conduct this step if Graph displays; shows  Pass  Fail AM 08.24 The system shall provide the ability to graph This may be
AM you are seeking height and weight over height and weight over time. demonstrated in
AMBULATORY time. Two graphs are either a single graph
Certification without acceptable. that displays both
Cardiovascular height and weight
certification. over time since birth
or in separate
Review graphical graphs.
display of height and
weight since birth.
Technology
1.21. Conduct this step if Graph displays; shows  Pass  Fail AM 08.24 The system shall provide the ability to graph This may be
CV you are doing height and weight over height and weight over time. demonstrated in
Ambulatory time. Two graphs are CV 11.02 The system shall provide the ability to either a single graph
Certification AND acceptable. document and display vital sign measurements that displays both
collected outside of the current patient
CARDIOVASCULAR height and weight
encounter.
Certification. Includes weights recorded over time since birth
from outside patient CV 11.03 The system shall provide the ability to include or in separate
vital sign measurements collected outside a
Review graphical encounter (data from two patient encounter in trend worksheets
graphs.
display of height and visits outside this practice
weight since birth. are included in the For Cardiovascular
Appendix). Certifications, CV
These include 11.02 and CV 11.03
measurements that apply at this step in
were not made at the addition to the
physician‟s office. Ambulatory criteria.
This step applies

only to
CARDIOVASCULAR
certification
1.22 Plot Joe‟s height and Growth chart displays with  Pass  Fail CH 02.02 The system shall display growth charts. Growth This step applies
weight on a growth data values entered today data (weight, length or height, head only to CHILD
circumference and body mass index) should be
chart and display. and from appendix A. Two graphed against normal data. HEALTH
graphs are acceptable. certification.
Growth data (weight, length or height, head
circumference and body mass index) should be
on a graph that includes normative data plotted
against population-based normative curves
(e.g. cdc.gov/growth charts) by the age ranges
and gender of the respective normative data
(e.g. females 0-36 months).
1.23 Logout as Nurse. Logout successful.
1.24 Login as Nurse Login successful
Practitioner Ellen
Thompson.
Technology
1.25 Access chart for patient Allergies display; allergic  Pass  Fail FN 05.12 The system shall provide the ability to display It must be possible
Joe Gardner and to peanuts with a reaction the allergy list, including date of entry. for a user to view the
display the allergy list, of “hives.” Date of entry is date of entry for any
including date of entry. today. allergy on the allergy
list, but it is
acceptable if that is
viewed on another
screen, e.g. a
'details' screen.
1.26 Display the information Information displays  Pass  Fail AM 05.03 The system shall provide the ability to display
that was inactivated or indicating that Penicillin is information which has been inactivated or
removed from the allergy and adverse reaction
removed from the inactivated or removed. list.
allergy list.
1.27 Review allergies for this System provides the ability  Pass  Fail FN 05.07 The system shall provide the ability for a user to This requires the
patient, and document to document that allergies explicitly capture and maintain, as discrete user to explicitly
data, that the allergy list was reviewed. The
that allergy list was were reviewed. user ID and date/time stamp shall be recorded select this option
reviewed. with the allergies reviewed option is selected. documenting that
they have reviewed
the allergies with the
patient.
1.28 Show how the system System shows date and  Pass  Fail FN 05.07 The system shall provide the ability for a user to It is acceptable to
captures the date and time (today) that the explicitly capture and maintain, as discrete show the identity of
data, that the allergy list was reviewed. The
time the review of review was performed and user ID and date/time stamp shall be recorded the user and the
allergies was the ID of the user (Ellen with the allergies reviewed option is selected. date/time in the audit
performed and the ID of Thompson, CFNP) log.
the user performing performing the review.
that review.
If a different user is
required to execute this
step, login as that user.
1.29 Logout as Nurse Logout successful.
Practitioner Ellen
Thompson.
Technology
1.30 Login as Nurse. Login successful.
1.31 Print a consent form Consent form is printed.  Pass  Fail AM 15.02 The system shall provide the ability to store, Note that consent
(for parent to provide display and print patient consent forms. forms stored in the
consent to immunize system that are
the patient). capable of being
signed by the patient
with an electronic
pen or digital
signature once
widely available will
meet the criterion.
1.32 Mother completes Completed consent  Pass  Fail AM 09.03 The system shall provide the ability to save
consent form. document is scanned and scanned documents as images.
Scan the completed displays. AM 15.01 The system shall provide the ability to capture
consent document The document that was scanned paper consent documents (covered in
DC 1.1.3.1).
(provides consent to printed in the previous
immunize). step is now completed by AM 15.04 The system shall provide the ability to store and
hand and scanned into the display administrative documents (e.g. privacy
notices).
system.
1.33 Index the scanned Scanned documents can  Pass  Fail AM 09.05.01 The system shall provide the ability to index Indexing implies
document; associated be indexed; date and scanned documents and associate a date and associating a
document type to the document.
date is today and document type are scanned document
document type is associated with the with an individual
“consent.” scanned document. patient record.
1.34 Retrieve the indexed Indexed documents of  Pass  Fail AM 09.05.02 The system shall provide the ability to retrieve
“consent” documents. document type “consent” indexed scanned documents based on
document type and date.
can be retrieved.
Technology
1.35 Display consents for Completed consent  Pass  Fail AM 15.05 The system shall provide the ability to
this patient documents display chronologically display consents and
authorizations.
chronologically. chronologically. There
should be at least three
documents, one from
today and two previously
entered as in Appendix A
(consents should be
present for immunizations
administered at the
following visits):
 06/15/2000;
 07/12/2003
 Today
Reverse chronological
order is acceptable.
1.36 Document Documentation accepted.  Pass  Fail FN 16.03 The system shall provide the ability to capture
administration of the The following elements immunization administration details as discrete
data, including:
immunizations: must be captured as (1) the immunization type and dose;
 Tdap (0.5mL IM discrete data: (2) date and time of administration;
left deltoid, lot 1) the immunization type (3) route and site;
number F2345, and dose; (4) lot number and expiration date;
(5) manufacturer; and
expiration date 2) date and time of (6) user ID.
January 2012, administration;
manufacturer 3) route and site;
sanofi pasteur) 4) lot number and
 Varicella (0.5mL, expiration date;
subcutaneous right 5) manufacturer; and
arm, lot number 6) user ID.
L6870, expiration
date September It is acceptable to review
2012, these details in the audit
manufacturer log.
Merck).
Technology
1.37 Review required System displays no  Pass  Fail AM 22.09 The system shall provide the ability to
immunization boosters immunizations due at this document that a preventive or disease
management service has been performed
visit as they have already based on activities documented in the record
been administered at this (e.g., vital signs taken).
visit.
1.38 Retrieve the current Report is created that  Pass  Fail AM 02.01 The system shall provide the ability to include This report should
immunization record shows summary of demographic information in reports. include
from the EHR view and immunizations. AM 29.02 The system shall provide the ability to generate immunizations
print report. Report includes complete reports consisting of all or part of an individual administered in step
patient‟s medical record (e.g. patient summary).
history of all 1.36).
immunizations given AM 29.05 The system shall provide the ability to access
including: immunization; reports outside the EHR application. Proctor to update
date given; patient name; AM 30.02 The system shall provide the ability to generate Audit Trail
patient identifier; and hardcopy or electronic output of part or all of the Worksheet
patient demographic individual patient‟s record. (Appendix D).
information. AM 30.05 The system shall provide the ability to create
Report prints. hardcopy and electronic report summary
information (procedures, medications, labs,
immunizations, allergies and vital signs).
1.39 The patient has had a Allergy/adverse reaction to  Pass  Fail FN 16.02 The system shall provide the ability to capture, This may be
reaction to the Tdap. a specific immunization in a discrete field, an allergy/adverse reaction to recorded in the
a specific immunization.
Capture the reaction in can be captured in a allergy/adverse
a discrete field: discrete field. reaction section of
“redness, swelling.” the patient record if
Note that this can be the applicant
captured in more than chooses to do that,
one field if necessary. but is not required.
1.40 Record the date and Date and time are  Pass  Fail CH 14.02 The system shall provide the ability to record This step applies
time of this reaction recorded. the date and time (if known) of vaccine reaction only to CHILD
or allergic occurrence.
HEALTH
certification.
Technology
1.42 Login as Nurse Login successful; patient
Practitioner Ellen record selected.
Thompson and select
patient record for Joe
Gardner.
1.43 Enter prescription: Medication list is available  Pass  Fail AM 04.03 The system shall provide the ability to maintain
medication ordering dates.
 Search for for search and selection.
Proventil from list Search is conducted for AM 04.04 The system shall provide the ability to maintain
of medications. each of the brand name other dates associated with medications
including start, modify, renewal and end dates
 Search for and generic drugs; only as applicable.
Albuterol from list one is selected.
FN 07.04 The system shall provide end users the ability
of medications and to search for medications by generic or brand
select. Medication information is name.
 Prescribe updated in the EHR,
Albuterol, 2 puffs including prescribing date.
every four hours as
needed for
wheezing.
1.44 Access general Link to general prescribing  Pass  Fail FN 07.05 The system shall provide the ability to access Acceptable sources
prescribing information information is available at reference information for prescribing/ordering. of general
for Albuterol. the point of prescribing. prescribing
This step may be information could be
combined with the 3rd-party drug
previous step. databases, links to
external websites,
etc.
Technology
1.45 Complete prescription Prescription is  Pass  Fail AM 11.08 The system shall provide the ability to print and Applicants may meet
and electronically fax to electronically faxed to the electronically fax prescriptions. the requirement by
the pharmacy (CCHIT number provided by the AM 26.01 The system shall have the ability to provide faxing directly from
Test Proctor will CCHIT Test Proctor. electronic communication between prescribers their application to
and pharmacies or other intended recipients of
provide „pharmacy fax the medication order.
the CCHIT Test
number‟). If the applicant is complying Pharmacy Fax
with e-prescribing number. It is not
Note that execution of requirements by submitting a required to utilize a
this step may differ for SureScripts/RxHub third party
certificate, has implemented
SureScripts/RxHub ePrescribing
“one-button” e-prescribing
certified Applicants. and network or partner.
 IS using the
SureScripts/RxHub Fax
Gateway,
SureScripts/RxHub will
have set up the CCHIT
pharmacy as a fax-only
pharmacy so that any
prescriptions sent will
automatically be faxed to
CCHIT
 IS NOT using the
SureScripts/RxHub Fax
Gateway, the applicant is
responsible for updating
their own pharmacy
directory with the CCHIT
fax information ahead of
time so that the
pharmacy can be
selected and the
prescription will be
automatically faxed once
the provider clicks
“submit.”
Technology
1.46 Electronically fax the Prescription resent to  Pass  Fail AM 11.09 The system shall provide the ability to re-print Applicants may meet
prescription for pharmacy fax (number and re-fax prescriptions. the requirement by
Albuterol to the provided by CCHIT Test faxing directly from
pharmacy again. Proctor) without re-entry of their application to
prescription details. the CCHIT Test
Note that execution of Pharmacy Fax
this step may differ for number. It is not
SureScripts certified required to utilize a
Applicants, as in the third party
previous step. ePrescribing
network or partner.
1.47 Access medication Medication information is  Pass  Fail FN 17.01 The system shall provide the ability to access
information for accessible, either within and review medication information (such as
patient education material or drug monograph).
Albuterol to provide to the system or through This may reside within the system or be
the patient. links to external sources. provided through links to external sources.
1.48 Configure subsequent The fixed text “printed  Pass  Fail AM 11.15 The system shall provide the ability to allow the
prescriptions to include from an EHR” prints on all user to configure prescriptions to incorporate
fixed text according to the user's specifications.
the text “printed from subsequent prescriptions.
an EHR.”
step, login as that user.
Technology
1.49 Enter prescription Medication information is  Pass  Fail AM 04.04 The system shall provide the ability to maintain
Vitamin B6 at ½ of one updated in EHR. End date other dates associated with medications
50 mg tablet daily for or duration is properly as applicable.
six months (enter stop reflected.
AM 11.13 The system shall provide the ability to prescribe
date or duration). fractional amounts of medication (e.g. 1/2 tsp,
System allows entry of a 1/2 tablet).
Other indicator of fractional amount of
AM 11.15 The system shall provide the ability to allow the
“fractional amount,” for medication. user to configure prescriptions to incorporate
example “0.5” is fixed text according to the user's specifications.
acceptable. The print preview shows
that the fixed text “printed
Show a print preview of from an EHR” will appear
this prescription. on the printed prescription.
1.50 Review current Current medications  Pass  Fail FN 06.01 The system shall provide the ability to update
medications list. display: and display a patient-specific medication list
based on current medication orders or
 Albuterol, 2 puffs prescriptions.
every four hours as
needed for wheezing
 Vitamin B6 at 25 mg
daily (½ of one 50 mg
tablet) for six months
1.51 Create site-specific Note added to chart  Pass  Fail AM 17.02 The system shall provide the ability to create
care plan: Enter note indicating need for future site-specific care plan, protocol, and guideline
documents.
“recommend an EKG tests.
and ECHO prior to
sports because of
family history of sudden
death of father at a
young age.” A text
note will be acceptable.
Technology
1.52 Sign off on clinical note. Ellen Thompson  Pass  Fail AM 08.05 The system shall provide the ability to record Date and time must
completes her portion of the identity of the user finalizing each note and be system
the date and time of finalization.
the note. generated and
Identity of user signing off recorded
on the note is captured, automatically.
along with date and time.
Proctor to update
Audit Trail
Worksheet
(Appendix D.)
1.53 Logout as Nurse Logout successful.
Practitioner Ellen
Thompson.
1.54 Login as Dr. Alexander Login successful; Joe
and select the record Gardner‟s patient record
for Joe Gardner. selected.
1.55 Place an order for Order is placed. No criterion is listed
HgbA1c for Joe here, as this order is
Gardner. Note that this order will not entered in
be fulfilled in this scenario; preparation for a
it will be used later in the subsequent step.
test script.
Technology
1.56 Dr. Alexander cosigns Cosignature is added to  Pass  Fail AM 08.04 The system shall provide the ability to finalize a
the note. the record, including date note, i.e. change the status of the note from in
progress to complete so that any subsequent
and time of the signing. changes are recorded as such.
The note is now finalized
AM 08.05 The system shall provide the ability to record
(i.e. the status of the note the identity of the user finalizing each note and
is changed to “complete” the date and time of finalization.
so that any subsequent
AM 08.06 The system shall provide the ability to cosign a
changes to the note are note and record the date and time of signature.
recorded as changes to a
completed note).
Signature may either be

visible in the record or in
an audit log. In either
case, the signature must
be date/time stamped by
the system. User may not
enter the date and time in
text form to meet AM 8.06.
1.57 Display the identities Dr. Alexander and Ellen  Pass  Fail PC 08.01 The system shall have the ability to record and This criterion does
and credentials of all Thompson, along with display the identity and credentials of all users not require that the
who entered part of a note, even if they did not
users who entered part their credentials, display finalize the notes. system identify or
of the note (the note as users who were display which portion
that is signed by Dr. involved in the creation of or portions of a final
Alexander in the this note. note were entered
previous step). by each user but
rather that the
system records and
displays which users
were involved in any
part of the creation
of the note.
Technology
1.58 Exit Joe Gardner‟s Access for Dr. Alexander  Pass  Fail AM 36.05 The system shall provide the ability to prevent
chart and attempt to is denied to Ellen specified user(s) from accessing a designated
patient's chart.
access chart for Ellen Thompson‟s chart.
Thompson.
1.59 “Break the glass” and Access for Dr. Alexander  Pass  Fail AM 36.06 When access to a chart is restricted, the system Proctor to update
access the chart for is allowed to Ellen shall provide a means for appropriately Audit Trail
authorized users to “break the glass” for
Ellen Thompson. Thompson‟s chart. emergency situations. Worksheet
(Appendix D).
1.60 Exit chart for Ellen Will Haynes‟ age is  Pass  Fail CH 01.01 The system shall allow the recording of date This step applies
Thompson, and select expressed in months. and time of birth (hour and minutes if known) only to CHILD
patient Will Haynes. hours for the first 4 days of life, then in days HEALTH
Review Will Haynes‟ Number of months will from the 5th day of life through the first 28 days, certification.
age. vary depending on then in weeks beginning on the 29th day of life
inspection date. through the first three completed months of life,
month of life through age 2 years. Subsequent
expressions of age may be expressed by year
1.61 Enter today‟s weight for Patient weight and  Pass  Fail AM 08.14 The system shall provide the ability to capture With respect to AM
Will Haynes (9.5 temperature entered. and display temperature, weight and height in 08.14, the criterion
both metric and English units.
kilograms) and requires that the
temperature of 104 CH 02.01 The system shall capture patient growth system be able to
parameters: including weight, height or length,
degrees. head circumference; and vital signs including
display both metric
(but not limited to): blood pressure, and English units; it
temperature, heart rate, respiratory rate, does not require that
oxygen saturation, and severity of pain as both are able to
discrete elements of structured data. display on the same
screen at the same
time.
Technology
1.62 Will has an ear System alerts that dosage  Pass  Fail CH 17.04 The system shall, when a maximum individual This step applies
infection; enter is incorrect based on the or daily dose exist, alert the provider when only to CHILD
weight-based or BSA-based dosing would
prescription for patient weight. cause these to be exceeded. HEALTH
Amoxicillin 250 mg/5ml, certification.
15ml, 4 times a day. Do not complete the
prescription.
1.63 Display dose calculator Dose calculator displays.  Pass  Fail AM 11.11 The system shall provide the ability to display a The intent is to allow
for patient specific Patient weight (9.5 dose calculator for patient-specific dosing input of dose-per-
based on weight. weight and patient
dosing based on kilograms) entered at step
weight. 1.61 is used in calculation, CH 17.02 The system shall provide weight-based dosing weight and calculate
when doses based on weight (e.g. mg/kg) are the corresponding
 For Amoxicillin either automatically or available for a medication. dose. The dose-per-
prescription the through repeated input by weight might be
dose-per-weight is the user. directly inputted by a
80 mg/kg and the user at the time the
patient weight is Dosage is calculated using dose calculation is to
9.5 kg (entered the calculator. The occur, or might have
previously. criterion does not require been inputted
that the dose is calculated previously as the
automatically, and it does default for a particular
not require that the results medication. The output
may be in terms that
auto-populate the sig.
take into account a
particular strength and
The corresponding dose dosage form of a
could be represented as medication (e.g. "5ml"
total dosage e.g. or "2 tablets") OR may
760mg/day. be simply in terms of
the amount of the
active drug
component, (e.g.
"250"). It is not
required that the dose
calculator
automatically populate
fields in the
prescription itself.
Technology
1.64 Prescription for Prescription is created.  Pass  Fail AM 03.07 The system shall provide the ability to associate Common drug
Amoxicillin is created to orders, medications, and notes with one or databases supply
make up the dose at Identity of prescriber (Dr. more problems / diagnoses. medication
250 mg/5 mL Alexander) is available to FN 09.04 The system shall provide the ability to capture information with
 Sig will be one review. and maintain, as discrete data, a name, form and
diagnosis/problem code or description strength combined
teaspoon three
associated with an order of any (type including
times per day for Medication information prescriptions and medications ordered for as a single unit,
10 days. must be stored as discrete administration). therefore, name,
data; at a minimum, there form and strength
AM 04.02 The system shall provide the ability to record
Associate prescription must be one field for each the prescribing of medications including the can be included
with problem “right otitis of the following: identity of the prescriber. together in a single
media.” 1. Medication name, form AM 04.07 The system shall store medication information
discrete data field.
and strength; in discrete data fields. At a minimum, there
Medication information 2. Dispense quantity; must be one field for each of the following:
must be stored as 3. Refills; and - medication name, form and strength;
- dispense quantity;
discrete data; at a 4. Sig.
- refills; and
minimum, there must - sig.
be one field for each of
AM 11.01 The system shall provide the ability to create
the following: prescription or other medication orders with
1. Medication name, sufficient information for correct filling and
form and strength; dispensing by a pharmacy.
2. Dispense quantity; AM 11.02 The system shall provide the ability to record
3. Refills; and user and date stamp for prescription related
4. Sig. events, such as initial creation, renewal, refills,
discontinuation, and cancellation of a
prescription.
AM 11.03 The system shall provide the ability to capture
the identity of the prescribing provider for all
medication orders.
AM 11.04 The system shall provide the ability to capture
common content for prescription details
including strength, sig, quantity, and refills to be
selected by the ordering clinician.
Technology
1.65 Print prescription for Prescription prints and  Pass  Fail AM 11.08 The system shall provide the ability to print and
Amoxicillin. includes associated electronically fax prescriptions.
problem or diagnosis. AM 11.17 The system shall provide the ability to display
the associated problem or diagnosis (indication)
on the printed prescription.
1.66 Reprint the prescription Prescription reprints  Pass  Fail AM 11.09 The system shall provide the ability to re-print
for Amoxicillin. without re-entry of and re-fax prescriptions.
prescription details.
1.67 Exit chart for Will Alice Brown‟s age is  Pass  Fail CH 01.01 The system shall allow the recording of date This step applies
Haynes and select expressed in days. and time of birth (hour and minutes if known) only to CHILD
patient Alice Brown. hours for the first 4 days of life, then in days HEALTH
Review Alice Brown‟s 10 days. from the 5th day of life through the first 28 days, certification.
age. then in weeks beginning on the 29th day of life
through the first three completed months of life,
1.68 Exit chart for Alice Charlie Green‟s age is  Pass  Fail CH 01.01 The system shall allow the recording of date This step applies
Brown and select expressed in hours. and time of birth (hour and minutes if known) only to CHILD
patient Charlie Green. hours for the first 4 days of life, then in days HEALTH
Review Charlie Green‟s Will vary based on from the 5th day of life through the first 28 days, certification.
age. inspection date; should be then in weeks beginning on the 29th day of life
two days ago. through the first three completed months of life,
1.69 Exit Charlie Green‟s Logout successful.

chart and logout as Dr.
Alexander.
Technology

A woman who is 29 weeks pregnant presents for a routine maternity visit to her Obstetrician. She was diagnosed in week 21 with Gestational Diabetes.
2.01 Login as Dr. McCoy Login successful; patient
and select patient record selected.
record for Jennifer
Thompson.
2.02 Review allergies. Allergies display:  Pass  Fail FN 05.09 The system shall provide the ability to explicitly
NKDA or NKA. indicate in a discrete field that a patient has no
known drug allergies or adverse reactions.
The indication that the

patient has no known drug
allergies must be in
discrete data.
2.03 Record that patient is Data from Appendix B  Pass  Fail AM 06.05 The system shall provide the ability to capture
checking her blood entered (not scanned in). history collected from outside sources.
sugars 4 times a day:
fasting and 1 hour after If record of blood sugars is
breakfast, lunch and entered using an interface,
dinner. She has a values may differ from
record of her blood those appearing in
sugars. Appendix B; this would
Enter (not scan) data meet the criterion.
into EHR. (Data in
Appendix B.)
2.04 Update patient history: Patient history displays  Pass  Fail AM 06.01 The system shall provide the ability to capture,
store, display, and manage patient history.
 Patient reports that with update.
her maternal aunt AM 06.03 The system shall provide the ability to update a
just diagnosed with patient history by modifying, adding or removing
items from the patient history as appropriate.
breast cancer.
Display patient history.
Technology
2.05 Record history of Patient history updated.  Pass  Fail AM 06.02 The system shall provide the ability to capture Not all data
pneumonia including a The patient history must structured data in the patient history. elements may
standard code for be captured in structured AM 06.06 The system shall provide the ability to capture currently be
pneumonia. data. patient history in a standard coded form. represented in
existing standard
coding schemes.
An example would
be diagnostic and
procedural history
using ICD-9, CPT, or
SNOMED codes.
As an example, ICD-
9 code 486.
2.06 Enter diagnosis: High System accepts data as  Pass  Fail AM 03.09 The system shall provide the ability to maintain Examples of ICD-9
Risk Pregnancy. Use entered. a coded list of problems / diagnoses. codes provided:
whatever coding High Risk Pregnancy is 648.8 (gestational
scheme is appropriate added to the problem list. diabetes); V23.9
for the system. (high risk
pregnancy).
2.07 Display Problem List. Problem List displays  Pass  Fail FN 04.02 The system shall provide the ability to capture, Pregnant state could
(onset date of each maintain and display, as discrete data be captured
elements, all problems / diagnoses associated
problem indicated): with a patient. someplace other
 Pregnancy than in the Problem
AM 03.03 The system shall provide the ability to maintain
 Gestational Diabetes the onset date of the problem / diagnosis.
List.
 High Risk Pregnancy Examples of ICD-9
include 648.8
Problem list entries must (gestational
be in discrete data. diabetes).
Technology
2.08 Access patient Patient educational  Pass  Fail FN 14.01 The system shall provide the ability to produce
educational materials materials accessed and patient instructions and patient educational
materials which may reside within the system or
for Gestational printed. be provided through links to an external source.
Diabetes and print to
provide for patient.
2.09 Physician determines System provides the ability  Pass  Fail AM 22.11 The system shall provide the ability to
that patient is at high to individualize the alert at individualize alerts to address a patient‟s
specific clinical situation.
risk for breast cancer; the patient level. Alert is
change mammography set to indicate that this
screening alert to begin patient requires
at age 30. mammography screening
to begin at age 30.
2.10 Access test and Test and procedure  Pass  Fail AM 10.03 The system shall have the ability to provide There is no need to
procedure instructions instructions can be access to patient-specific test and procedure order a
instructions that can be modified by the
for mammogram, and accessed, modified, and physician or health organization; these mammogram for this
modify to include “do given to the patient. instructions are to be given to the patient. step.
not use lotion or These instructions may reside within the system
deodorant prior to or be provided through links to external
sources.
mammogram.” Print
these instructions and
provide to the patient.
Technology
2.11 Jennifer disagrees with System captures the  Pass  Fail AM 08.21 The system shall be capable of recording This does not imply
the assessment that information “Jennifer comments by the patient or the patient‟s that the patient can
representative regarding the accuracy or
she is at high risk for disagrees that she is at veracity of information in the patient record document directly in
breast cancer and high risk for breast (henceforth „patient annotations‟). their chart. Some
would like her cancer.” AM 36.02 The system shall provide a means to document
methods include but
disagreement recorded a patient's dispute with information currently in are not limited to
in the chart. Record their chart. allowing the patient
comment “Jennifer a view only access
disagrees that she is at to their record,
high risk for breast printing a copy of the
cancer.” record for a patient
to review. Methods
to include the
information in the
chart could be as a
note, a scanned
copy of patient
comments, an
addendum to the
note or other method
not described.
Technology
2.12 Show how the patient Applicant shows how the  Pass  Fail AM 08.22 The system shall display patient annotations in A patient annotation
annotation is information is a manner which distinguishes them from other in free-text or
content in the system.
distinguished from distinguished from other scanned-document
other content in the content. form, when
system. displayed, should
indicate that it
comes from a
patient. This could
be a text label on the
screen or part of the
free-text note itself.
It is not necessary to
make patient
annotations visible
from any and all
sections of the
patient record.
2.13 Select the order set Order set “Diabetes One”  Pass  Fail FN 10.01 The system shall provide the ability to define a
“Diabetes One.” is selected, and includes: set of items to be ordered as a group.
 RhoGAM;
 HgbA1c;
 Nutritional referral;
and
2.14 The physician intends RhoGAM is deselected.  Pass  Fail FN 11.01 The system shall provide the ability for
to order the modified Selected items in the order individual orders in an order set to be selected
or deselected by the user.
order set Diabetes One set now include:
for Jennifer Thompson.  HgbA1c;
For Jennifer Thompson,  Nutritional referral;
deselect the order for  Basic metabolic panel;
RhoGam. and
Technology
2.15 For Jennifer Thompson, Order for HgbA1c is  Pass  Fail AM 10.04 the system shall have the ability to provide These instructions
select order for HgbA1c amended to show access to patient-specific test and procedure may reside within
instructions that can be modified by the
and modify order to physician entered physician or health organization; these the system or be
include an instruction changes. instructions are to be given to the filler of the provided through
that says “collect in a 4 order. These instructions may reside within the external links.
mL EDTA (purple top) system or be provided through links to external
sources.
tube.”
2.16 Place all orders in the The orders in order set  Pass  Fail AM 12.05 The system shall provide the ability to relay Proctor to update
order set for Jennifer Diabetes one are ordered orders for a diagnostic test to the correct Audit Trail
destination for completion.
Thompson. and relayed to their Worksheet
respective destinations (Appendix D.)
either via an appropriate
printer, work queue or
interface:
 HgbA1c – modified
with instruction to
“collect in a 4ml EDTA
(purple top) tube;
and
2.17 Show the orders in The orders in “Diabetes  Pass  Fail FN 11.04 The system shall provide the ability to display
order set Diabetes One One” display individually. orders placed through an order set either
individually or as a group.
individually.
Technology
2.18 Create a referral to a Referral order can be  Pass  Fail AM 21.01 The system shall provide the ability to create Adequate detail
dietitian as part of the reviewed to ensure referral orders with detail adequate for correct includes but is not
routing.
encounter. Referral adequate detail is present, limited to:
date is today, as well as the date/time AM 21.02 The system shall provide the ability to record  Referral date
user ID and date/time stamp for all referral
Nutritionist is Mary stamp for the entry by the related events.  Patient name
Smith, RN, CDNE, physician. and identifier
address 1234 Elm  “Refer to”
Street, Anytown USA, For example, the referral specialist name,
telephone 555-555- may be displayed using a address and
1212. print preview function or telephone
template. If the referral number
The creation of this user ID and date/time do  “Refer to”
referral order may have not show in the GUI, the specialty
already occurred in applicant shall  Reason for
conjunction with the demonstrate where in the referral
order set above. system these items have  Referring
been recorded, for physician name
example, in an audit trail.
It must be clear that this
information is associated
with the referral.
Technology
2.19 Create three tasks for Notification sent to  Pass  Fail AM 24.01 The system shall provide the ability to create
Reception: Reception with the and assign tasks by user or user role.
 To schedule follow following tasks:
up appointment for  To schedule follow up
Jennifer Thompson appointment in one
in one week. week.
 To send a letter to  To send a letter to
patient when all test patient when all test
results are received. results are received.
 To schedule visit  To schedule visit with
with the dietitian. the dietitian.
The notification to
schedule the visit with
the dietitian may have
already occurred in
conjunction with the
order set above.
2.20 Enter some information Confidential information  Pass  Fail AM 36.04 The system shall provide the ability to identify This may be
to be identified as entered into chart. certain information as confidential and only implemented by
make that accessible by appropriately
“confidential,” for Details of what the authorized users. having a
example, that the confidential information is "confidential" section
patient had once been are left to the Applicant; of the chart.
a victim of domestic the example provided may
violence, into the chart be used.
and designate as
accessible only to
Physician Users.
Technology
2.21 Show how the system The system provides  Pass  Fail AM 32.01 The system shall have the ability to provide a For AM 32.03,
provides assistance in assistance in selecting list of financial and administrative codes. criterion satisfaction
selecting the appropriate CPT E&M AM 32.02 The system shall provide the ability to select an will require that the
appropriate CPT E&M codes based on codified appropriate CPT Evaluation and Management system can
code based on data found in a clinical
billing code. clinical information in the encounter.
automatically count
encounter. elements in the
For example, select AM 32.03 The system shall have the ability to provide history and
assistance with selecting an appropriate CPT
procedure (CPT): Evaluation and Management billing code based
examination
99213 (E and M code on codified clinical information in the encounter. documentation to
for managing diabetes accomplish this
care and counseling). calculation. MDM
complexity may still
require specification
by the
provider/coder.
2.22 Show active orders for Active orders for Jennifer  Pass  Fail AM 12.06 The system shall have the ability to provide a
Jennifer Thompson. Thompson display: view of active orders for an individual patient.
 HgbA1c – modified
with instruction to
“collect in a 4ml EDTA
(purple top) tube;
and
Technology
2.23 Display all orders for Outstanding orders  Pass  Fail AM 12.08 The system shall provide the ability to display
HgbA1c. display, and include orders outstanding orders for multiple patients (as
opposed to outstanding orders for a single
for HgbA1c for both patient).
Display outstanding Jennifer Thompson and
orders for all patients. Joe Gardner. (Other
patients may appear on
this list if the Applicant has
entered other information;
that is acceptable.)
A report may satisfy this

criterion.
2.24 Logout as Dr. McCoy. Logout successful.
2.25 Login as Reception. Login successful.
2.26 Review tasks. Three tasks are received:  Pass  Fail AM 24.02 The system shall provide the ability to present a
list of tasks by user or role.
 To schedule follow up
appointment in one
week.
 To send a letter to
patient when all test
results are received.
 To schedule visit with
the dietitian.
2.27 Re-assign the following Scheduling task is routed  Pass  Fail AM 24.03 The system shall provide the ability to re-assign
task to Nurse: to Nurse. and route tasks from one user to another user.
 To schedule visit
with the dietitian.
2.28 Logout as Reception. Logout successful
2.29 Login as Nurse. Login successful.
Technology
2.30 Access tasks; receive Task is displayed as  Pass  Fail AM 24.03 The system shall provide the ability to re-assign
notification to schedule completed. and route tasks from one user to another user.
visit with dietician. AM 24.04 The system shall provide the ability to
Complete task and designate a task as completed.
designate task as
completed.
2.31 Attempt to access the The confidential  Pass  Fail AM 36.04 The system shall provide the ability to identify
confidential information information is inaccessible certain information as confidential and only
make that accessible by appropriately
entered at step 2.20. to this user. Note that authorized users.
depending on system
setup this user may not be
aware or may not be
advised that confidential
information exists.
Technology
Test Script Scenario 3A – Interoperability Testing – Laboratory Results
3.01 Login as Dr. Butler. Login successful.
3.02 Receive lab results for Lab results in data files  Pass  Fail IO-AM 07.01 The system shall provide the ability to receive Applicants must
Jennifer Thompson provided by CCHIT are and store general laboratory results using the refer to the
HL7 v.2.5.1 ORU message standard
electronically. received into the EHR and document CCHIT
the lab test name, result AM 14.01 The system shall provide the ability to indicate Certified 2011
normal and abnormal results based on data
(value), and unit are provided from the original data source.
Interoperability
correctly displayed as Testing Guide for
discrete data (vs. report detailed information
format). Based on the on the execution of
data files provided by this scenario.
CCHIT, the system should Jurors will be
differentiate normal from provided with the
abnormal results. Discrete expected results for
data means that each each Applicant‟s test
separate element of the file that will be used
data needs to be stored in for the inspection.
its own field. Jurors will
look for a separate data
field for each element.
Technology
3.03 Receive lab results for Lab results in data files  Pass  Fail IO-AM 07.01 The system shall provide the ability to receive Applicants must
Theodore Smith. provided by CCHIT are and store general laboratory results using the refer to the
Note that the received into the EHR and document CCHIT
cholesterol results the lab test name, result AM 14.01 The system shall provide the ability to indicate Certified 2011
(total cholesterol, LDL (value), and unit are provided from the original data source.
Interoperability
and HDL) will be correctly displayed as Testing Guide for
expected to appear in discrete data (vs. report detailed information
graphing functions in format). Based on the on the execution of
step 4.15. data files provided by this scenario.
CCHIT, the system should Jurors will be
differentiate normal from provided with the
abnormal results. Discrete expected results for
data means that each each Applicant‟s test
separate element of the file that will be used
look for a separate data
field for each element.
Technology
3.04 For Applicants that are Lab results in data files  Pass  Fail IO-AM 07.01 The system shall provide the ability to receive Applicants must
also conducting the provided by CCHIT are and store general laboratory results using the refer to the
Cardiovascular received into the EHR and document CCHIT
inspection: the lab test name, result AM 14.01 The system shall provide the ability to indicate Certified 2011
(value), and unit are provided from the original data source.
Interoperability
Receive lab results for correctly displayed as Testing Guide for
Jim Grayson discrete data (vs. report detailed information
electronically. format). Based on the on the execution of
Note that the data files provided by this scenario.
cholesterol results CCHIT, the system should Jurors will be
(total cholesterol, LDL differentiate normal from provided with the
and HDL) will be abnormal results. Discrete expected results for
expected to appear in a data means that each each Applicant‟s test
subsequent step. . separate element of the file that will be used
look for a separate data This step applies
field for each element. only to
Cardiovascular
certification.
3.05 Logout as Dr. Butler. Logout successful.
Technology

This scenario involves a preventive care visit for a male Veteran with multiple chronic problems including poorly controlled diabetes, hypertension, hyperlipidemia,
Gastroesophageal Reflux Disease, Degenerative Joint Disease and drug allergies. Data from this case is used for a quality improvement initiative.
4.01 Login as Dr. Butler and Login successful; patient
select patient record for record selected.
Theodore Smith.
4.02 Check patient‟s medical System displays medical  Pass  Fail AM 33.01 The system shall provide the ability to display
eligibility; this should eligibility obtained from medical eligibility obtained from patient‟s
insurance carrier, populated either through data
indicate that “patient is patient‟s insurance carrier. entry in the system itself or through an external
eligible for coverage This can be accomplished application interoperating with the system.
through the upcoming by a text note following
year.” telephone verification.
4.03 Note that patient has an EHR reflects the presence  Pass  Fail AM 16.01 The system shall provide the ability to indicate
advance directive; the of an advance directive, that a patient has completed advance
directive(s).
type of advanced and indicates that the type
directive is a living will. of advance directive is a AM 16.02 The system shall provide the ability to indicate
the type of advance directive, such as living will,
living will. durable power of attorney, or a “Do Not
Resuscitate” order.
4.04 Show how system Information is presented  Pass  Fail AM 16.03 The system shall provide the ability to indicate This may be
indicates when advance that indicates advance when advance directives were last reviewed. recorded in non-
directives were last directives were last structured data or as
reviewed. reviewed on today‟s date. discrete data.
4.05 Indicate that the Dr. Patient record identifies  Pass  Fail FN 03.02 The system shall provide the ability to capture
Butler is the principal Dr. Butler as the principal and maintain, as discrete data elements, the
principal provider responsible for the care of an
care provider for this care provider. individual patient
patient (physician of
record).
Technology
4.06 Review health System indicates that PSA  Pass  Fail AM 22.01 The system shall provide the ability to establish
maintenance services is due. criteria for disease management, wellness, and
preventive services based on patient
for this patient. System indicates that demographic data (minimally age and gender).
patient should have a
pneumovax as he is over
65.
4.07 Demonstrate how Applicant demonstrates  Pass  Fail AM 22.05 The system shall provide the ability to update Associated
preventive process for updating preventive services/wellness guidelines and reference material
any associated reference material.
services/wellness preventive can be within the
guidelines and service/wellness AM 35.02 The system shall provide the ability to update system or accessed
clinical decision support guidelines and
associated reference guidelines and associated associated reference material.
through links to
material are updated. reference material. external sources.
For example, change Example provided may be
the guidelines to show used.
PSA due at age 40 and
create a new reference
called “AUA updated
recommendations.”
step, please login as
that user.
4.08 PSA: System provides the ability  Pass  Fail AM 22.06 The system shall provide the ability to override
guidelines.
 Patient does not to document the reason;
want the PSA test. reason is captured as AM 22.07 The system shall provide the ability to
Override the prompt discrete data. document reasons disease management or
preventive services/wellness prompts were
and enter reason overridden.
“patient preference.”
Reason to be FN 18.02 The system shall provide the ability to capture
and maintain, as discrete data, the reason for
captured as discrete variation from rule-based clinical messages (for
data. example alerts and reminders).
Technology
4.09 Pneumovax: Documentation accepted;  Pass  Fail AM 22.10 The system provides the ability to document This service was
that a disease management or preventive
 Patient indicates he the vaccine was given at
service has been performed with associated
provided external to
had this vaccine at an outside clinic the dates or other relevant details recorded. the practice.
a local clinic. previous Tuesday.
Document the date
of the vaccine (the
previous Tuesday).
4.10  Modify parameters Parameters for  Pass  Fail AM 22.08 The system shall provide the ability to modify
pneumovax alert for this the rules or parameters upon which guideline-
for pneumovax alert related alerts are based.
for this patient; patient can be modified to
change it to require “once every 10 years.”
the vaccine once
every 10 years.
Technology
4.11 Add history of tobacco Problem list displays:  Pass  Fail AM 03.04 The system shall provide the ability to maintain For example, ICD-9
the resolution date of a problem / diagnosis.
abuse to problem list  Positive for type 2 CM code V15.82
Review problem list diabetes, elevated AM 03.06 The system shall provide the ability to record
including current and cholesterol, the user ID and date of all updates to the
problem / diagnosis list.
inactive/resolved hypertension, GERD,
problems. BPH, Hypothyroidism, AM 03.09 The system shall provide the ability to maintain
and arthritis a coded list of problems / diagnoses.
If a different user is  Tobacco abuse is FN 04.02 The system shall provide the ability to capture,
required to identify the added to problem list maintain and display, as discrete data
user ID and date of elements, all problems / diagnoses associated
along with appropriate with a patient.
updates to the problem coding.
list, please login as that  System records user
user to show that ID and date of this
portion of the expected update to the problem
result. list.
Resolved problems
include:
 Appendicitis,
cholecystitis and a
cataract.
 Resolution date for
Appendicitis is
September 12, 2004
Problem list must be

captured as discrete data.
Technology
4.12 Document tobacco Quantitative tobacco  Pass  Fail AM 08.16 The system shall provide the ability to capture Any quantitative
consumption as consumption is captured other clinical data elements as discrete data. measure of amount
discrete data. For as discrete data. CV 06.06 The system shall be capable of documenting of consumption, date
example, 20 year current and past tobacco use in a quantitative of start, date of stop,
fashion.
history of two packs per or total duration is
day. Any quantitative acceptable.
measure of amount of
consumption is For Cardiovascular
acceptable. Certification, CV
06.06 applies at this
step in addition to
the Ambulatory
criterion.
4.13 Document tobacco Tobacco cessation  Pass  Fail AM 08.16 The system shall provide the ability to capture
cessation counseling counseling is documented. other clinical data elements as discrete data.
provided. CV 06.06.01 The system shall be capable of documenting
that tobacco cessation counseling was
provided, including a date stamp.
4.14 Show active problems. Problem list displays:  Pass  Fail FN 04.06 The system shall provide the ability to display For example, active,
different views of the problem / diagnosis list
 Positive for type 2 based upon the status of the problem.
all, resolved or
Display a view of the diabetes, elevated charted in error.
problem list based on cholesterol,
status of the problem hypertension, GERD,
(active). BPH, Hypothyroidism,
and arthritis, tobacco
abuse
Technology
4.15 Display cholesterol lab Graph displays with  Pass  Fail AM 09.07 The system shall provide the ability to accept,
results (total distinct data points by date store in the patient's record, and display clinical
results received through an interface with an
cholesterol, LDL and and event. Graph should external source.
HDL) graphically. include four data points as
entered from appendix numerical results in flow sheets and graphical
These can be separate and one from lab result form in order to compare results, and shall
graphs. received today. provide the ability to display values graphed
over time.
These can be separate
graphs.
4.16 Display lab results for LDL results display as per  Pass  Fail AM 09.07 The system shall provide the ability to accept,
LDL for this patient Appendix C, sorted by test store in the patient's record, and display clinical
sorted by test date. date. external source.
AM 14.05 The system shall provide the ability to filter or
sort results by type of test and test date.
4.17 Display all lab results Results display as per  Pass  Fail AM 09.07 The system shall provide the ability to accept,
for this patient sorted by Appendix C, sorted by store in the patient's record, and display clinical
type of test (e.g. WBC, type of test. external source
HDL Cholesterol, etc.)
AM 14.05 The system shall provide the ability to filter or
sort results by type of test and test date.
4.18 Change the interval for The care plan for this  Pass  Fail AM 17.03 The system shall provide the ability to modify
lipid testing to annually patient can be modified. site-specific care plan, protocol, and guideline
documents obtained from outside sources.
for this patient.
Technology
4.19 Begin encounter Clinical documentation of  Pass  Fail AM 04.04 The system shall provide the ability to maintain
documentation: Patient patient-provided other dates associated with medications
indicates knee pain is information captured. as applicable.
limiting his activity. It is
FN 06.01 The system shall provide the ability to update
worse on the left than System allows entry of and display a patient-specific medication list
the right. non-prescription drug based on current medication orders or
He is taking Aleve for Aleve into medication prescriptions.
this. profile, and captures start FN 06.06 The system shall provide the ability to capture
date. and maintain, as discrete data elements, all
Add non-prescription current medications including over the counter
drug Aleve to and complementary medications such as
vitamins, herbs and supplements.
medication list, with
start date of 3 months AM 08.01 The system shall provide the ability to create
prior to today. clinical documentation or notes (henceforth
“documentation”).
documentation.
Technology
4.20 He developed a System allows entry of  Pass  Fail FN 06.01 The system shall provide the ability to update Any form of
recurrence of chest non-prescription drug and display a patient-specific medication list notification,
based on current medication orders or
pain which had Tums with dose and prescriptions. message or color
previously been frequency into medication coding is
AM 04.04 The system shall provide the ability to maintain
attributed to GERD and profile. other dates associated with medications
acceptable; pop up
controlled with Zantac including start, modify, renewal and end dates notification is not
150 mg a day. He Entry of Tums triggers as applicable. required.
started taking chewable drug interaction with FN 06.06 The system shall provide the ability to capture
Tums 750 mg several previously entered and maintain, as discrete data elements, all
times a day. Synthroid. current medications including over the counter
Add non-prescription and complementary medications such as
vitamins, herbs and supplements.
drug Tums, 750 mg
several times a day, to FN 12.01 The system shall provide the ability to check for
medication list. potential interactions between medications to
be prescribed/ordered and current medications
and alert the user at the time of medication
prescribing/ordering if potential interactions
exist.
FN 12.08 The system shall provide the ability to
prescribe/order a medication despite alerts for
interactions and/or allergies/intolerances being
present.
Technology
4.21 View current All current medications  Pass  Fail FN 06.02 The system shall provide the ability to display a Clarification –
medications list. display: view that includes only current medications. Medication lists must
 Actos 30 mg once be data lists and not
daily free text.
 Aleve
 Glucosamine
chondroitin
 Lipitor 20 mg a day
 Lisinopril 5 mg twice a
day
 Saw palmetto
 Synthroid 0.112 mg a
day
 Tums 750 mg several
times a day
 Zantac 150 mg a day
Generic drug names

would be acceptable.
4.22 Conduct follow up Notes from at least two  Pass  Fail AM 08.12 The system shall provide the ability to filter, This is intended to
actions related to previous visits (as entered search or order notes by associated diagnosis be the coded
within a patient record.
problem list: from appendix information) diagnosis and not
Diabetes – are available. free text in the body
 Find notes for this of a note.
patient with
associated
diagnosis
“Diabetes.”
Technology
4.23 Show how system Applicant demonstrates  Pass  Fail AM 11.19 The system shall provide the ability to create It is suggested that
provides the ability to this function. provider specific medication lists of the most Applicants have
commonly prescribed drugs with a default
create provider specific It is acceptable to either route, dose, frequency and quantity. saved a “favorites”
medication lists; list to show a look-up using list prior to their
include default route, physician preferences or inspection, and
dose, frequency and creating a new saved list. demonstrate that
quantity. items can be added
to this list.
4.24 Create prescription for System allows entry of  Pass  Fail AM 04.09 The system shall provide the ability to enter
“diabetes wonder drug.” uncoded medication. uncoded or free text medications when
medications are not on the vendor-provided
System alerts that no medication database or information is
interaction checking will be insufficient to completely identify the
performed against the medication.
uncoded medication. FN 07.01 The system shall provide the ability to alert the
user at the time a new medication is
prescribed/ordered that drug interaction,
allergy, and formulary checking will not be
performed against the uncoded medication or
free text medication.
FN 07.02 The system shall provide the ability to
prescribe/order uncoded and non-formulary
medications.
Technology
4.25 Patient‟s hypertension Medication list reflects that  Pass  Fail FN 06.03 The system shall provide the ability to exclude a Inactive medications
is not well controlled. Aleve is discontinued, and medication from the current medication list (e.g. must display in a
marked inactive, erroneous, completed,
He has been taking an reason for discontinuing. discontinued) and document reason for such medication list -
NSAID that may have action. either in a
contributed to this. He medication history of
will stop the Aleve. all medications
Enter medications list (active and inactive)
and discontinue Aleve; or in a separate list
capture the reason for of inactive
discontinuing this medications. It is
medication. not required that
current medications
and past
medications display
on the same screen.
4.26 Show identity of user Identity of user and date of  Pass  Fail AM 04.11 The system shall provide the ability to record Changes are to be
who made this change change to medication list the date of changes made to a patient's recorded at the level
medication list and the identity of the user who
to the medication list displays. made the changes. of the individual
and the date of medication.
changes. Date is recorded
automatically by the
If a different user is system. May not be
required to execute this key-entered.
step, login as that user. It is not specified
where this
information shall be
displayed; it could
appear in the GUI or
in the audit trail.
Technology
4.27 Hypothyroidism – System checks for drug-  Pass  Fail FN 06.06 The system shall provide the ability to capture Any form of
and maintain, as discrete data elements, all
 Renew Synthroid. drug, drug-allergy and
current medications including over the counter
notification,
drug-disease interactions. and complementary medications such as message or color
If interaction between Interaction with Tums vitamins, herbs and supplements. coding is
Synthroid and Diabetes displays. AM 11.07 The system shall provide the ability to reorder a
acceptable; pop up
does not appear, the Interaction with Diabetes prior prescription without re-entering previous notification is not
Applicant shall displays. data (e.g. administration schedule, quantity). required.
demonstrate how the FN 12.01 The system shall provide the ability to check for
system provides drug- potential interactions between medications to NOTE: Entry of non-
disease interaction be prescribed/ordered and current medications prescription
alerts using a different and alert the user at the time of medication medications as per
prescribing/ordering if potential interactions
combination. FN 06.06 is
exist.
important for
FN 12.10 The system shall provide the ability to check for interaction checking,
potential interactions between medications to
be prescribed and medication allergies listed in
associating
the record and alert the user at the time of symptoms with
medication prescribing/ordering if potential supplements.
interactions exist.
FN 13.01 The system shall provide drug-diagnosis
interaction alerts at the time of medication
prescribing/ordering.
4.28 View the rationale for Rationale is viewable.  Pass  Fail FN 12.05 The system shall provide the ability to view the
the drug interaction rationale for a drug interaction alert.
alert.
Technology
4.29 Override the alert. System accepts entry of  Pass  Fail FN 12.06 The system shall provide the ability to capture
Document reason for reason for overriding the and maintain at least one reason for overriding
any drug-drug or drug-allergy/intolerance
overriding the drug-drug allergy warning in a interaction warning triggered at the time of
interaction warning as a structured response. medication prescribing/ordering.
structured response. FN 12.07 The system shall provide the ability to enter a
An example of the structured response when overriding a drug-
reason is “combination drug or drug-allergy/intolerance warning.
taken previously.” Any
reason entered in a
structured response will
be acceptable for
verification purposes.
4.30 Proceed with renewal of Prescription is renewed.  Pass  Fail FN 12.08 The system shall provide the ability to
Synthroid. prescribe/order a medication despite alerts for
present.
4.31 View current All current medications  Pass  Fail AM 04.06 The system shall provide the ability to capture
medications list. display: medications entered by authorized users other
than the prescriber.
 Actos 30 mg once
daily FN 06.06 The system shall provide the ability to capture
 Diabetes wonder drug current medications including over the counter
 Glucosamine and complementary medications such as
chondroitin vitamins, herbs and supplements.
 Lipitor 20 mg a day FN 06.02 The system shall provide the ability to display a
 Lisinopril 5 mg twice a view that includes only current medications.
day
 Saw palmetto
day – renewed today
 Tums 750 mg several
times a day
Aleve does not display.
Technology
4.32 DJD Knees – Added to problem list.  Pass  Fail AM 03.09 The system shall provide the ability to maintain Examples of codes
a coded list of problems / diagnoses.
 Enter diagnosis Problem list entry must to capture the
“bilateral DJD capture concept of concept of
(knees)” Use “osteoarthritis of the osteoarthritis of the
whatever coding knees” in some way. knees include:
scheme is 715.96 or 715.98 or
appropriate 715.36
4.33 Save the note in System allows the note to  Pass  Fail AM 08.03 The system shall provide the ability to save a
progress as a draft. be saved in progress prior note in progress prior to finalizing the note.
to finalizing the note. PC 04.08 The system shall provide the ability to save a
note in progress prior to finalizing the note.
4.34 Order x-ray of knees. X-ray is ordered. Identity  Pass  Fail AM 12.01 The system shall provide the ability to order
of ordering provider is diagnostic tests, including labs and imaging
studies.
Demonstrate that captured. Order entry
system provides details are captured. AM 12.02 The system shall provide the ability to capture
the identity of the ordering provider for all test
instructions and/or orders.
prompts created by the Instructions and/or
user when ordering prompts demonstrated. AM 12.03 The system shall provide the ability to capture
appropriate order entry detail, including
diagnostic tests or associated diagnosis.
procedures. Note for Jurors: Content of
AM 12.04 The system shall have the ability to display user
Prompt advises that the the prompt may vary by
created instructions and/or prompts when
x-ray will expose the Applicant. ordering diagnostic test or procedures.
patient to radiation; for
example “A knee x-ray
exposes the patient to
0.75 mRads of
radiation.”
Technology
4.35 Order for knee x-ray is System allows association  Pass  Fail AM 03.07 The system shall provide the ability to associate Examples of codes
associated with a of order with problem. orders, medications, and notes with one or to capture the
more problems / diagnoses.
problem reflecting the concept of
diagnostic concept of Diagnosis/problem code or AM 03.08.01 The system shall provide the ability to associate osteoarthritis of the
orders and medications with one or more
osteoarthritis of the description must be codified problems / diagnoses.
knees include:
knees. captured in discrete data. 715.96 or 715.98 or
FN 09.01 The system shall provide the ability to require 715.36
problem / diagnosis as an order component.
FN 09.04 The system shall provide the ability to capture
and maintain, as discrete data, a
diagnosis/problem code or description
associated with an order of any (type including
prescriptions and medications ordered for
administration).
Technology
4.36 Review patient‟s All medications display  Pass  Fail AM 04.05 The system shall provide the ability to display Inactive medications
medication history (active and inactive): medication history for the patient. must display in a
profile.  Actos 30 mg once AM 04.06 The system shall provide the ability to capture medication list -
daily medications entered by authorized users other either in a
than the prescriber.
 Aleve (discontinued) medication history of
 Diabetes wonder drug FN 06.06 The system shall provide the ability to capture all medications
 Glucosamine current medications including over the counter
(active and inactive)
chondroitin and complementary medications such as
or in a separate list
 Lipitor 20 mg a day vitamins, herbs and supplements. of inactive
 Lisinopril 5 mg twice a medications. It is
FN 06.03 The system shall provide the ability to exclude a
day medication from the current medication list not required that
 Saw palmetto (e.g., marked inactive, erroneous, completed, current medications
discontinued) and document reason for such and past
 Synthroid 0.112 mg a action. medications display
day – renewed today
FN 06.01 The system shall provide the ability to update on the same screen.
 Tums 750 mg several and display a patient-specific medication list
times a day based on current medication orders or Medication history
 Zantac 150 mg tablet prescriptions.
includes all
a day medications
captured in the EMR
system including
prescription and non
prescription drugs.
Technology
4.37 Add a patient-specific Reminder added.  Pass  Fail AM 11.20 The system shall provide the ability to add Does not imply that
reminder to check reminders for necessary follow up tests based this must be an
on medication prescribed.
hepatic profile in 3 automated process.
months.
It is acceptable if the
system requires an
action by the user,
separate from the
action of prescribing
the medication, to
configure the system
to issue future
reminders related to
follow-up tests for
the medication.
4.38 Complete and sign off Note is retrieved from  Pass  Fail AM 08.04 The system shall provide the ability to finalize a Date and time must
note. Print a copy for “draft” status, updates to note, i.e. change the status of the note from in be system
progress to complete so that any subsequent
the patient. note are captured, and changes are recorded as such. generated and
note accepts sign off. recorded
AM 29.02 The system shall provide the ability to generate
Print preview is System captures identity reports consisting of all or part of an individual
automatically.
acceptable for of the user and date/time patient‟s medical record (e.g. patient summary).
verification. of finalization.
AM 30.02 The system shall provide the ability to generate
hardcopy or electronic output of part or all of the
individual patient‟s record.
Technology
Test Script Scenario #4 – Follow up:

In a continuation of scenario 4, we are now dealing with the follow up actions to the visit with the primary care physician.
4.40 Login as Dr. Butler and Login successful and
select record for patient record selected.
Theodore S. Smith.
4.41 Review outstanding Order displays; is  Pass  Fail AM 12.07 The system shall have the ability to provide a May include filters or
orders for x-rays (may identified as being for view of orders by like or comparable type, e.g., sorts.
all radiology or all lab orders.
be referred to as patient Theodore Smith,
“diagnostic imaging,” and is categorized by
“radiology,” “x-ray” or test/procedure description
however the system (e.g. “diagnostic imaging”
categorizes these). or “x-ray”).
4.42 Review status Status displays.  Pass  Fail FN 09.02 The system shall provide the ability to view Status may be
information for Description of status may status information for ordered services. electronically or
Theodore Smith‟s x-ray. vary by Applicant (for manually updated.
example, may be
“completed,” “in progress,”
“ordered”).
Technology
4.43 Receive x-ray report. Results entered into EHR;  Pass  Fail AM 09.01 The system shall provide the ability to capture Note that any
Link results to original X-ray report is displayed. and store external documents. mechanism for
order (order in step AM 09.04 The system shall provide the ability to receive, capturing the report
4.34). Enter results into Results are linked to the store in the patient‟s record, and display text- is acceptable: OCR,
based outside reports.
EHR. Review x-ray original order. PDF, image file of
report: AM 14.03 The system shall provide the ability to display report, etc.
 Knee x-rays show non-numeric current and historical test results It is acceptable if
as textual data.
severe arthritis with certain data received
total loss of joint AM 14.08 The system shall provide the ability to link through an interface,
results to the original order. if not relevant to the
space on the left.
end user, are not
Note that the x-ray displayed in the
report is to be provided application.
by the Applicant; Linking could be
CCHIT will not be accomplished by
providing results files changing the status
for these tests. of the order from
„pending‟ to
„completed‟.
4.44 Step removed.
Technology
4.45 Show how the system Clinical image can be  Pass  Fail AM 09.06 The system shall provide access to clinical The date/time stamp
can access clinical accessed; it is accessible images. They must be accessible from within may be the
the patient's chart and labeled and date-time
images. The image is from within the patient‟s stamped or included in a patient encounter date/time of image
to be provided by the chart. document. These images may be stored within creation or
Applicant, and will the system or be provided through direct acquisition, the
simulate the knee x-ray. Image is labeled and date- linkage to external sources. date/time of image
time stamped or, if stored importation/incorpor
Applicant is to either within the system, the ation into the
incorporate a link image is to be included in system, date/time of
containing a URL image a patient encounter the clinical
reference into the document. encounter with
patient‟s medical which the image is
record, or attach an The image could be associated, or
actual image file to the accessed through a link in manually entered by
medical record. the patient record. the user.
Either method is
acceptable; for
validation purposes, the
Applicant must open
and display the image
from within the patient
record to the jurors.
Technology
4.46 Associate this image Image can be associated  Pass  Fail AM 14.10 The system shall provide the ability to associate Through direct
with the x-ray report with the non-numerical one or more images with a non-numerical storage or links to
result.
from step 4.43. result. the data.
If the Applicant did not

attach the image in step
4.45 to the medical
record, use any other
image available in the
system to demonstrate
how the system
provides the ability to
associate images with
non-numerical results.
4.47 Add text annotation to System accepts and  Pass  Fail AM 14.09 The system shall provide the ability to enter a
the x-ray report from displays text note as free text comment to a result that can be seen
by another user who might subsequently view
step 4.43: “much worse annotation to the x-ray that result.
than before.” report from step 4.43.
4.48 Patient is to be referred Note accepts the  Pass  Fail AM 08.07 The system shall provide the ability to addend Date and time must
to Orthopedics. additional information and and/or correct notes that have been finalized. be system
Append the last the information is clearly AM 08.09 The system shall provide the ability to record generated and
progress note (from identifiable as new, for and display the identity of the user who recorded
addended or corrected a note, as well as other
step 4.38) to document example “addendum,” attributes of the addenda or correction, such as
automatically.
that the x-ray was “update,” “additional the date and time of the change.
abnormal and that the information,” etc.
patient was referred to Identity of user who
Ortho. addended the note, along
with date and time of
change are recorded and
displayed.
Technology
4.49 Demonstrate the The full content of the  Pass  Fail AM 08.08 The system shall provide the ability to identify Different approaches
retrieval of the modified note can be the full content of a modified note, both the to achieving the
original content and the content resulting after
completed (final) note identified, both the original any changes, corrections, clarifications, same result are
from step 4.38 that content and the content addenda, etc. to a finalized note. acceptable.
shows any resulting after the PC 01.11 The system shall provide the ability for a clinical
modifications or changes. or other authorized user to view the full content
addenda made to the of a finalized note. The full content of a
final note. This could be finalized note includes the finalized note and
demonstrated in a fashion any finalized modifications to that note including
finalized changes referred to as corrections,
If a different user is which is similar to that clarifications, addenda, etc. Finalizing is the act
required to execute which is seen in a word of publishing into the system in a way that
demonstrate this, login processing document with others may access information that has
as that user. “Final Showing Markup” changed.
selected.
4.50 Forward the results Results are forwarded to  Pass  Fail AM 14.07 The system shall provide the ability to forward a
from the knee x-rays to Dr. Alexander (will be result to other users.
Dr. Alexander. confirmed in a future step).
Technology
4.51 Patient wants to defer visit Medication administration  Pass  Fail FN 15.01 The system shall provide the ability to capture
to Orthopedics until after details are captured as medication administration details as discrete
vacation. Physician data, including;
discrete data. Clinical 1) the medication name and dose;
injects the knee with a documentation is available 2) date and time of administration;
mixture of Celestone and
for viewing. 3) route and site;
Marcaine. Capture 4) lot number and expiration data;
medication administration 5) manufacturer; and
details as discrete data: Note that “date and time of 6) user ID.
 Celestone Soluspan: administration” are not
1) dose: 1 ml = 6 mg provided; these would be
Betamethasone dependent upon the test
sodium phosphate date and time. These
(3mg) and should be the current date
betamethasone and time (now).
acetate (3mg)
3) route and site:
Intraarticular, right
knee
4) lot number and
expiration data:
068027 / 06-2010
5) manufacturer:
Schering Corp.
 Marcaine:
1) dose: 1 ml
Bupivicaine HCl 0.5%
Injection, USP (AKA
Sensorcaine)
3) route and site:
Intraarticular, right
knee
4) lot number and
expiration data:
PL2227 / 08-12
5) manufacturer:
AstraZeneca
Technology
4.52 Add a free text Free text comment is  Pass  Fail FN 04.01 The system shall provide the ability to capture,
comment associated associated with the maintain and display free text comments
associated with the problem/diagnosis.
with the problem problem/diagnosis.
bilateral DJD (knee): “x-
ray again at next visit.”
4.53 Logout as Dr. Butler Logout successful.
4.54 Login as Dr. Alexander. Login successful.
4.55 Receive notification that System notifies Dr.  Pass  Fail AM 14.04 The system shall provide the ability to notify the Examples of
results of knee x-ray for Alexander that new results relevant providers (ordering, copy to) that new notifying the provider
results have been received.
Theodore Smith are are available for review, as include but are not
available for review. forwarded to him in step limited to a
4.50. reference to the new
result in a provider
"to do" list or inbox.
4.56 Logout as Dr. Logout successful.
Alexander.
4.57 Login as Dr. Butler. Login successful. Patient
Select patient record for record selected.
Theodore S. Smith.
Technology
4.58 This step to be Medication history request  Pass  Fail IO-AM 9.15 The system shall provide the ability to send a
performed only by is sent; Theodore Smith‟s query for medication history to PBM or
pharmacy to capture and display medication list
applicants utilizing a historical medication from the EHR.
3rd Party ePrescribing information is received
Partner from payer and includes:
 Actos 30 mg once
Query the system for daily
Theodore S. Smith‟s  Lipitor 20 mg a day
medication history  Lisinopril 5 mg twice a
day
day
 Warfarin sodium 5 mg
daily
 Celebrex 200 mg once
daily
4.59 Step removed.
4.60 Step removed.
4.61 Step removed.
Technology
4.62 Record history: History updated with  Pass  Fail AM 08.01 The system shall provide the ability to create Any form of
patient-provided clinical documentation or notes (henceforth notification,
“documentation”).
 The patient called to information. message or color
report that he was AM 08.02 The system shall provide the ability to display coding is
documentation.
bitten by a mosquito System alerts to a cross acceptable; pop up
on the same leg just allergy with penicillin. AM 11.04 The system shall provide the ability to capture notification is not
below the knee that common content for prescription details required.
including strength, sig, quantity and refills to be
was injected. Note: When creating the selected by the ordering clinician.
prescription, checking
FN 12.01 The system shall provide the ability to check for
 The knee developed interactions, and reviewing potential interactions between medications to
pain and increased medication lists, any of the be prescribed and current medications and alert
swelling and there following will disqualify a the user at the time of medication ordering if
were red streaks hybrid product as not potential interactions exist.
running up and having sufficient workflow FN 12.10 The system shall provide the ability to check for
down the leg from integration: potential interactions between medications to
the site of the bite. be prescribed and medication allergies listed in
the record and alert the user at the time of
 Evidence that the user medication prescribing/ordering if potential
Create a prescription has to log in a second interactions exist.
for Ceftin, 500 mg by time to a separate
mouth twice daily for 7 application.
days #14 no refills.  Evidence that the user
(This prescription will must look up the
be sent electronically in patient again from a
step 4.65) separate patient list.
 Evidence that the user
must select the
prescribed drug more
than once, from
separate lists.
 Evidence that the user
must enter the
patient's medications
or allergies more than
once, in separate lists.
Technology
4.63 Override the warning System allows override of  Pass  Fail FN 12.08 The system shall provide the ability to
described in step 4.62. warning in step 4.62. prescribe/order a medication despite alerts for
present.
4.64 Document reason for System accepts reason (in  Pass  Fail AM 11.02 The system shall provide the ability to record This step may be
overriding the drug- structured response) and user and date stamp for prescription related completed
events, such as initial creation, renewal, refills,
allergy interaction displays. discontinuation, and cancellation of a simultaneously with
warning; for example prescription. step 4.63.
“The patient has FN 12.06 The system shall provide the ability to capture
tolerated this and maintain at least one reason for overriding
medication before.” any drug-drug or drug-allergy/intolerance
Override reason must interaction warning triggered at the time of
be entered in a medication prescribing/ordering.
structured response. FN 12.07 The system shall provide the ability to enter a
structured response when overriding a drug-
drug or drug-allergy/intolerance warning.
The text of the
structured response
may differ.
Technology
4.65 Complete the Prescription is created and  Pass  Fail AM 11.01 The system shall provide the ability to create
prescription and send it sent to the CCHIT Test prescription or other medication orders with
sufficient information for correct filling and
electronically to the Pharmacy electronically. dispensing by a pharmacy.
CCHIT Test Pharmacy. None of the disqualifying
FN 06.01 The system shall provide the ability to update
behaviors listed in 4.62 and display a patient-specific medication list
View patient‟s have occurred during based on current medication orders or
medication list in the steps 4.62, 4.63, 4.64, or prescriptions.
EHR. 4.65. IO-AM 09.06 The system shall provide the ability to send an
electronic prescription to a pharmacy
Setup Information: Patient‟s medication list in
 Pharmacy Name: the EHR application is
CCHIT Test updated and includes the
Pharmacy Two newly prescribed
 NCPDP ID: medication (Ceftin).
9123453
 Pharmacy Address:
200 S Wacker
Drive, Suite 3100,
Chicago, IL, 60606
 Prescriber
Registered with
CCHIT Pre-
Approved
ePrescribing
Network:
Dr. Internist E.
Butler MD.
Technology
4.66 When he called, the Entry of allergy to enalapril  Pass  Fail FN 12.11 The system shall provide the ability, when a
patient also indicated triggers a drug-allergy new allergy is documented, to check for a
potential interaction between the newly-
that he had had an alert with the previously documented allergy and the patient's current
allergic reaction to entered Lisinopril. medications, and alert the user if such
enalapril. interactions exist.
Enter allergy to
enalapril.
4.67 Show how potential System has the ability to  Pass  Fail FN 12.04 The system shall provide the ability to display, This is an “on
interactions relating to display potential on demand, potential drug-allergy interactions, demand” display, not
drug-drug interactions and drug diagnosis
items on the medication interactions at a time other interactions based on current medications, in response to any
list can be displayed than medication active allergies and active problems. medication being
now, as opposed to prescribing. The following prescribed at the
alerts that display interactions are shown: time.
during medication  Drug-drug interaction
ordering. between synthroid and This does not
tums require running an
 Drug-allergy algorithm or report.
interaction between Any method of
ceftin and penicillin displaying potential
 Drug-allergy interactions is
interaction between acceptable.
lisinopril and enalapril
4.68 Review encounter System provides the ability  Pass  Fail AM 08.11 The system shall provide the ability to filter,
notes; filter, search or to filter, search or order search or order notes by the provider who
finalized the note.
order by provider. notes by the provider who
finalized the note. (Notes
for this patient include
visits with Dr. Butler and
with Dr. Jones.)
Technology
4.69 Display all encounters Encounters display, and  Pass  Fail AM 31.04 The system shall have the ability to provide
for this patient: are first filtered by date of filtered displays of encounters based on
encounter characteristics, including date of
 Filter by date of service and then filtered service, encounter provider and associated
service; and by provider. Note that this diagnosis.
 Filter by provider. is two separate filters of
the same information.
4.71 Login as Office Login successful.
Manager.
4.72 The physician is Report displays, includes  Pass  Fail AM 29.01 The system shall provide the ability to generate
enrolled in a quality Jim Grayson and Chester reports of clinical and administrative data using
either internal or external reporting tools.
improvement initiative Pain. Report includes
and has been collecting patient name, age and AM 29.03 The system shall provide the ability to generate
reports regarding multiple patients (e.g.
data for submission on gender as requested. diabetes roster).
the quality measures
pertaining to heart Format of the output AM 29.04 The system shall provide the ability to specify
report parameters (sort and filter criteria) based
disease. determined by the on patient demographic data and clinical data
Applicant (e.g. printed (e.g. all male patients over 50 that are diabetic
Create a report that report, HL7 message, and have a HbA1c value of over 7.0 or that are
captures all patients delimited file, etc.). on a certain medication).
with a diagnosis of AM 39.01 The system shall provide the ability to export
coronary artery disease (extract) pre-defined set(s) of data out of the
with a prior MI system.
(diagnosis 410.11) who
are on a beta blocker,
including age and
gender.
Note: Report may be
created prior to the test.
4.73 Access patient record System provides ability to  Pass  Fail AM 01.04 The system shall provide a field which will
for Chester Pain; mark mark patient “exempt.” identify patients as being exempt from reporting
functions.
this patient “exempt
from reporting
functions.”
Technology
4.74 Run report (as in step Report displays, includes  Pass  Fail AM 01.04 The system shall provide a field which will
4.72) again. Jim Grayson. Chester identify patients as being exempt from reporting
functions.
Pain does not appear as
he is marked exempt from AM 29.01 The system shall provide the ability to generate
reports of clinical and administrative data using
reporting functions in step either internal or external reporting tools.
4.73.
4.75 Create an electronic An electronic file is  Pass  Fail AM 30.03 The system shall provide the ability to generate Any electronic file
version of a report for created that shows: hardcopy and electronic output by date and/or format is acceptable.
date range.
Joe Gardner that  The most recent visit;
shows: and
 The most recent  All visits in the past
visit; and three years.
 All visits in the past
three years. The report should display
the patient encounters or
Show a print preview of visits but does not need to
this report, to include the notes from
demonstrate that those visits.
hardcopy output can be
generated. A print preview is also
displayed.
4.76 Create a report that Report displays, includes  Pass  Fail AM 29.04 The system shall provide the ability to specify
captures all patients Theodore Smith, Joe report parameters (sort and filter criteria) based
on patient demographic data and clinical data
over the age of 20. Smith, Jim Grayson and (e.g. all male patients over 50 that are diabetic
Jennifer Thompson. and have a HbA1c value of over 7.0 or that are
Chester Pain does not on a certain medication).
appear as he is marked
exempt from reporting
functions in step 4.73.
4.77 Save the report System allows parameters  Pass  Fail AM 29.07 The system shall provide the ability to save
parameters from step to be saved. report parameters for generating subsequent
reports.
4.76.
Technology
4.78 Access the saved Report of patients over the  Pass  Fail AM 29.07 The system shall provide the ability to save Identifiers that shall be
report parameters from age of 20 displays; report parameters for generating subsequent removed are:
reports. 2. Postal address
step 4.76. Remove the includes Theodore Smith,
AM 30.04 The system shall provide the ability to export information, other than
identifiers and from the Joe Smith, Jim Grayson town or city, state and
structured data which removes those identifiers
report; run that report and Jennifer Thompson; listed in the HIPAA definition of a limited zip code;
again and export the Chester Pain does not dataset. This export on hardcopy and 3. Telephone numbers;
file. appear as he is marked electronic output shall leave the actual PHI data 4. Fax numbers;
exempt from reporting unmodified in the original record. 5. Electronic mail
functions in step 4.73. addresses;
6. Social security
Identifiers are removed for numbers;
each patient. File is 7. Medical record
exported. numbers;
8. Health plan
beneficiary numbers;
9. Account numbers;
10. Certificate/license
numbers;
11. Vehicle identifiers
and serial numbers,
including license plate
numbers;
12. Device identifiers
and serial numbers;
13. Web Universal
Resource Locators
(URLs);
14. Internet Protocol
(IP) address numbers;
15. Biometric identifiers,
including finger and
voice prints; and
16. Full face
photographic images
and any comparable
images.
Technology
4.79 Access the saved Report of patients under  Pass  Fail AM 29.08 The system shall provide the ability to modify
report parameters from the age of 20 displays; one or more parameters of a saved report
specification when generating a report using
step 4.76, and modify to includes Joe Gardner, that specification.
include only patients Emily Jones, Will Haynes,
under the age of 20. Alice Brown, Charlie
Green and David Carter.
4.80 Create and display a Report displays, and  Pass  Fail AM 29.06 The system shall provide the ability to produce
report of all patients includes Agatha Bloom. reports based on the absence of a clinical data
element (e.g., a lab test has not been
who have not had a Other patients as entered performed or a blood pressure has not been
blood pressure in the system by the measured in the last year).
measured in the past Applicant may also
12 months. display.
Technology
4.81 Generate reminder Based on the option the  Pass  Fail AM 23.09 The system shall provide the ability to The term
letters for patients who Applicant chooses to automatically generate reminder letters for 'automatically'
patients who are due or are overdue for disease
are due or overdue for demonstrate: management, preventive or wellness services. means that the
DTaP immunization system is able to
booster: A letter to either Emily generate patient
Jones or Will Haynes is recalls for all due or
Either automatically automatically generated overdue reminders
generate a letter to a and displayed, indicating for an individual
patient (either Emily that this patient is due for patient based on the
Jones or Will Haynes) a DTaP. current date,
that automatically regardless of
includes content Or: whether a user
specifying what initiates this action,
services are due; Letters are automatically or if the action
generated for Emily Jones triggered by pre-set
Or automatically and Will Haynes indicating parameters in the
generate a letter to all that these patients are due system.
patients who are due for a DTaP. An example would
for a specified service be generating a
(DTaP). letter to all patients
overdue for a
For verification screening
purposes use print mammography.
preview, or print and fax It is acceptable if the
to CCHIT proctor. output allows
generation of letters,
such as a mail
merge file.
Technology
4.82 To demonstrate how Guidelines that trigger the  Pass  Fail AM 23.05 The system shall provide the ability to modify
the guidelines that reminders can be the guidelines, criteria or rules that trigger the
reminders.
trigger the reminders modified; MMR is changed
would be modified, to be due at 15 months
change MMR to be due instead of 12 months.
at 15 months instead of
12 months.
step, please login as
this user.
4.83 Orthopedist requests Formal health record can  Pass  Fail AM 30.01 The system shall provide the ability to define
Theodore Smith‟s be defined for disclosure one or more reports as the formal health record
for disclosure purposes.
medical record. The purposes. The Applicant
report used as the shows the set of
formal health record for documents that are
disclosure purposes is defined as the formal
generated for Theodore health record.
Smith.
Technology
4.84 Document the Applicant documents the  Pass  Fail AM 30.06 The system shall have the ability to provide
disclosure of Theodore following information to support for disclosure management in
compliance with HIPAA and applicable law.
Smith‟s record. record the disclosure:
 The date of the
 The date of the disclosure;
disclosure / report:  The name of the
today person making the
 The name of the disclosure;
person making the
disclosure: Dr.
 The name of the
Alexander entity or person who
 Reported to: Dr. Dem received the protected
Bones, Orthopedics health information;
 Recipient‟s address:  The address of such
456 Anytime Lane, entity or person;
Annapolis MD 21405  The name of the
 Information disclosed: person making the
– Patient‟s name – disclosure;
Theodore Smith
 A brief description of
– Address – 2300
Commonwealth the information
Avenue, Anytown disclosed; and
MD 22222  A brief statement of
– Phone: 240-555- the purpose of the
1212 disclosure.
– date of birth:
11/08/1931 Free text (e.g. text note) or
– Medical record structured fields are
 Purpose of the sufficient to satisfy this
Disclosure: referral requirement.
4.85 Logout as Office Logout successful.
Manager.
4.86 Login as Dr. Alexander. Login successful. Patient
Select patient record for record selected.
Joe Smith (birthdate
3/23/1967).
Technology
4.87 Review medication list; System indicates that this  Pass  Fail FN 06.05 The system shall provide the ability to display
the patient takes no patient currently takes no that the patient takes no medications.
medications. medications. AM 04.10 The system shall provide the ability to enter or
further specify in a discrete field that the patient
takes no medications.
4.88 Dispense a sample of System allows for  Pass  Fail AM 11.12 The system shall provide the ability to identify Lot numbers and
Ceftin. Lot number is identification of sample medication samples dispensed, including lot expiration date could
number and expiration date.
F20457 and the dispensed; lot number be entered in free
expiration date is F20457 and expiration text or encoded.
November 2013. date November 2013
display.
Note that the medication

dispensed is a sample.
4.89 Logout as Dr. Logout successful.
Alexander.
Technology
Functionality requires that the EHR system supports multiple concurrent users through application, OS and database. The following steps will demonstrate
concurrent use requirements.
4.90 Login to the EHR Login successful.
system as Dr. Butler
and access and view
Theodore Smith‟s
patient record.
4.91 Keeping Dr. Butler‟s Login successful  Pass  Fail AM 40.01 The system shall provide the ability for multiple
session active and users to interact concurrently with the EHR
application.
open, login to the EHR
System as Dr.
Alexander and access
and view Theodore
Smith‟s patient record.
4.92 With both sessions The Applicant  Pass  Fail AM 40.02 The system shall provide the ability for
open, demonstrate that demonstrates that Dr. concurrent users to simultaneously view the
same record.
the users can view the Butler and Dr. Alexander
same patient record for are able to simultaneously
Theodore Smith. view the patient record for
Theodore Smith.
NOTE:
For instance, Applicant
could demonstrate a
networked EHR system
and show how multiple
users are able to
simultaneously access
the same patient
record using different
work stations. This
would require
additional set up by the
Applicant to
demonstrate this step.
Technology
4.93 With both sessions The Applicant  Pass  Fail AM 40.03 The system shall provide the ability for
open, demonstrate that demonstrates that Dr. concurrent users to view the same clinical
documentation or template.
the users can view the Butler and Dr. Alexander
same clinical are able to simultaneously
documentation: view the same clinical
 Dr. Butler accesses documentation.
and views clinical
documentation in
Theodore Smith‟s
patient record; and
 Dr. Alexander
accesses and
views clinical
documentation in
the same patient
record.
Technology
4.94 Dr. Butler begins Dr. Alexander is allowed to  Pass  Fail AM 40.04 The system shall provide protection to maintain
modifying an element see the patient record, but the integrity of clinical data during concurrent
access.
(e.g., progress note, is not permitted to modify
medication list, or the same element being
blood pressure) in modified by Dr. Butler.
Theodore Smith's Either record-level locking
patient record. Before (Dr. Alexander is blocked
that entry is complete, from making any changes
Dr. Alexander attempts to the record), field-level
to modify the same locking (Dr. Alexander is
element as Dr. Butler. blocked from changing
The system uses some only the element being
mechanism (e.g. modified by Dr Butler), or
record-level locking, another mechanism (e.g.,
field-level locking, or Dr. Alexander or Dr Butler
other protection) to receive a warning of the
maintain the integrity of conflict before they
clinical data when complete their entry) are
multiple users access acceptable.
and attempt to modify
the same element of
the same patient
record.
4.95 Logout Dr. Butler and Logout successful for both
Logout Dr. Alexander. users.
Technology
ADMINISTRATIVE scenario
ADM. Login as required. Login successful. If a different user
04 from the logged in
user is required to
execute any step,
please login as that
user.
ADM. Show where Applicant shows where in  Pass  Fail FN 07.03 The system shall provide the ability to maintain This functional
05 medication codes are the system codes are a coded list of medications including a unique requirement does
identifier for each medication.
maintained in the attached to medication list. not require a
system (e.g. in the user There is no requirement national system of
interface, database that the codes show in the coding for
table, etc.). GUI. The Applicant can medications.
simply show their tables
where a code is associated
with each medication.
Technology
ADM. At this step the proctor The template can be  Pass  Fail AM 08.20 The system shall provide the ability to Templates may
06 will provide you with a customized with an customize clinical templates. include any patient
data element to add to addition or removal. encounter note
or remove from a documentation tools
clinical template; that provide a pre-
customize the template set collection of
by adding or removing clinical findings or
that data element. fields, including
macros driven by
speech recognition
technology,
branching logic.
This list is not

necessarily all
inclusive of all the
technology that may
arrive in future.
Customization at the
level of clinical
content is
satisfactory.
ADM. Show how the system Providers associated with  Pass  Fail FN 03.01 The system shall provide the ability to capture
07 identifies providers this encounter can be and maintain, as discrete data elements, the
identity of all providers associated with a
associated with the identified, and include Dr. specific patient encounter.
patient encounter for Alexander, Nurse
Joe Gardner. Practitioner Ellen
Thompson, and Nurse.
ADM. Specify, using Applicant shows how the  Pass  Fail AM 34.02 The system shall provide the ability to specify This is meant as a
08 structured data, that system provides the ability the role of each provider associated with a means to define the
patient, such as encounter provider, primary
Dr. O‟Brien is the to specify the provider‟s care provider, attending, resident, or consultant provider role; display
primary care provider role. using structured data. of the data is not
for Jim Grayson. addressed.
Technology
ADM. Show how the alerts for System provides the ability  Pass  Fail AM 23.04 The system shall provide the ability to identify
09 disease management to identify criteria for criteria for disease management, preventive,
and wellness services based on clinical data
(for example, for disease management. (problem /diagnosis list, current medications, lab
Gestational Diabetes) values).
are setup (show the
setup of the rules to
trigger an alert).
ADM. Demonstrate how Applicant demonstrates  Pass  Fail AM 22.04 The system shall provide the ability to update
10 disease management process for updating disease management guidelines and any
associated reference material.
guidelines and disease management
associated material are guidelines and associated
updated. reference material.
ADM. Access directory of At a minimum, the system  Pass  Fail AM 27.02 The system shall provide the ability to maintain
11 users and show shall maintain a directory a directory which contains identifiers required
for licensed clinicians to support the practice of
identifiers required for of state medical license, medicine including at a minimum state medical
licensed clinicians to DEA, and NPI. license, DEA, and NPI.
support the practice of
medicine.
ADM. Show directory of System maintains a  Pass  Fail AM 27.04 The system shall provide the ability to create
12 clinical personnel directory of clinical and maintain a directory of clinical personnel
external to the organization who are not users
external to the personnel external to the of the system to facilitate communication and
organization who are organization who are not information exchange.
not users of the users of the system to
system. Applicant can facilitate communication
use examples provided and information exchange.
in set up data, or other
data as exists.
ADM. Show how the severity Applicant can show how  Pass  Fail AM 19.05 The system shall provide the ability to set the
13 level at which drug severity level can be set. severity level at which drug interaction warnings
should be displayed.
interaction warnings
appear to providers
can be set/changed.
Technology
ADM. Add VACCINE XYZ to Vaccine that was added is  Pass  Fail CH 13.01 The system shall provide the ability (at the This step applies
14 the system. Other data available in the user/administrative level) to add all new vaccine only to CHILD
products and antigens to the system‟s
as required to store the immunization database. immunization (tracking) data base. HEALTH
vaccine may be certification.
entered.
After entering the

vaccine to the system,
show this vaccine in
the immunization
database.
ADM. Logout as required. Logout successful.
15
Technology
THE FOLLOWING SCENARIO IS REQUIRED FOR CARDIOVASCULAR CERTIFICATION

This scenario involves a 66 year old male, Jim Grayson who is status post MI, CABG and CRT. He presents to the office in moderate respiratory distress; the
primary cardiologist is on vacation and the covering physician needs to review the patient‟s history as well as current and past lab results.
CV.01 Login as Dr. Green and Login successful
select patient record for
Jim Grayson.
Technology
CV.02 Display a default The default summary  Pass  Fail CV 12.01 The system shall provide the ability to display a Individual systems
summary screen of CV screen displays the summary screen (or screens) of CV-relevant may choose to
patient information when a patient record is
specific patient data for following CV specific viewed. The following constitutes a minimum list display more than
this patient. patient data when Jim of the types of patient information that shall be the minimum
Grayson‟s patient record is available through the summary view. requirements stated
viewed: 1) Problem List in this criterion.
2) Medications
3) Allergies
Category headings
Problem List: 4) Labs within the summary
 Hypertension; 5) Cardiovascular Tests and Procedures view may not be
 Hyperlipidemia; (Diagnostic) exactly as listed;
 Obesity; 6) Cardiovascular Tests and Procedures however all
(Therapeutic)
 Type II diabetes 7) Implants/Devices information of the
mellitus; types listed should
 Nicotine Dependence; be available from
 Class III CHF within this view.
 CAD; and
 Atrial Fibrillation.
Medications:
 Aldactone;
 Amiodarone;
 ASA;
 Coreg;
 Coumadin;
 Lasix;
 Lipitor;
 Lisinopril; and
 Metformin.
Expected result continues

below…
Technology
CV.02 …Expected result
cont‟d continued from above.
Allergies:
 No Known Allergies
Labs:
 Lab values from
06/01/2003 (entered as
in Appendix)
o Fasting Blood
Sugar (FBS) 222;
o HbA1C 10.2%;
o Total Cholesterol
(TC): 260;
o Triglycerides (TG):
310;
o LDL 182; and
o HDL: 30
 Lab values from today,

as imported in the
Ambulatory Test
Expected result continues

below…
Technology
CV.02 …Expected result
cont‟d continued from above.
Procedures:
 Cardiac Catheterization
(1/1/2000);
 PCI (1/1/2000);
 CABG (Coronary
Artery Bypass Graft)
(3/10/2000);
 Cardiac
Resynchronization
Therapy (CRT) w/ ICD
(6/2/2003)
Imaging:
 Exercise Nuclear
Stress Test
(7/10/2000);
 Echocardiogram
(7/10/2000; 6/1/2003)
Implants:
 CRT-D (6/2/2003)
Technology
CV.03 Demonstrate the ability Problem list is sorted to  Pass  Fail CV 08.01 The system shall provide the ability to configure The intent is that for
to configure the sorting display cardiac related the sorting/view of the diagnosis/problem list at different specialties,
the level of the specialty.
of the problem list at problems at the top of the the problem list
the level of user list. would display
specialty. differently. The
cardiac problems
If a different user is would be on the top
required to execute this of the problem list
step, login as that user when the
now. cardiologist signs in,
and if an orthopedist
signed in, he would
see orthopedic
problems at the top
of the list.
CV.04 Review CV specific risk CV specific risk factor  Pass  Fail CV 10.01 The system shall provide the ability to create a CV The intent of this
factor panel/display. . panel/display is available specific risk factor panel/display. This should criterion and test
include, but is not limited to the following:
for review, and includes: diabetes, hyperlipidemia, hypertension, history of step is to ensure
 Prior MI; Diabetes; cardiovascular disease, family history, tobacco that the items listed
Tobacco use; use. in the criterion are
Hypertension; displayed. Some
Hyperlipidemia; Family may be redundant
history with the summery
Family history is available; view (e.g., Diabetes,
will be reviewed in detail in if it is a risk factor
next step. may also be on the
problem list) but this
step is included to
ensure that there is
a display of each of
these items.
Technology
CV.05 Review family history. Family history is available  Pass  Fail CV 10.02 The system shall provide the ability to create a CV
for review and includes: specific family history panel/display. This should
include, but is not limited to the following: coronary
 Father died of disease, sudden death.
myocardial infarction
(MI) at age 55;
 Brother has coronary
artery disease (CAD)
and had a
percutaneous coronary
intervention (PCI) at
age 50;
 Sister had a coronary
artery bypass graft
(CABG) at age 60;
 Paternal aunt had
sudden coronary death
(SCD) at age 30.
CV.06 Search for cardiac Studies/procedures related  Pass  Fail CV 01.02 The system shall provide the ability to search for a
catheterization result to Jim Grayson based on particular study/procedure for a given patient
based on date or name of study/procedure
from 01/01/2000 by date or name of
procedure name or study/procedure are
date of procedure. available for review:
cardiac catheterization
01/01/2000.
CV.07 Review details of Details of previous cardiac  Pass  Fail CV 06.03 The system shall provide the ability to store the Physician ID type is
cardiac catheterization. catheterization are following data elements for cardiac catheterization not specified and
as discrete data:
available for review: 1) Date of procedure can be name, local
A scanned report or  Date of procedure 2) CPT coded test type (multiple selection system ID, national
attached file (e.g. pdf (01/01/2000) capability required) provider ID (NPI),
or other file) of the  CPT coded test type 3) Procedure name etc.
4) Type of intervention(s) (selected from
procedure data is (93510, 93543, 93545, customizable list of options; multiple selection
The data elements
acceptable. Discrete 93555, 93556) capability required) in this list represent
data must be PCI: 92982 5) ID of physician(s) performing procedure a minimum
demonstrated for  Type of intervention: (multiple input capability required) requirement rather
 Date of procedure Left Heart 6) Pressures (RA and LA – A wave, V wave, than a
Technology
 CPT coded test Catheterization; mean; Right and left pulmonary, wedge; RV and comprehensive list
type Angioplasty (acute LV – peak, early diastolic, end diastolic; PA, Ao of all discrete
(location) – peak, diastolic, mean
 Type of intervention PCI) 7) Saturations (IVC, SVC, RA, RV, PA, LA, LV, cardiothoracic
 ID of physician  ID of physician(s) Aortic, AV 02 difference, cardiac output, cardiac surgery data that
performing the /personnel involved index, and shunt fraction) may be available.
procedure with performing 8) LV Ejection Fraction
9) LV diastolic and systolic volume
 Pressures procedure. Items highlighted in
10) Narrative summary.
 Saturations ID#1; ID#2; ID#3 green are required
 LV diastolic and  Pressures (RA 4; LA: only for CV
systolic volume 7; RPW: 12; LPW: advanced reporting
 Narrative summary. 12RV: 15; LV: 120; PA: capability
AO Peak:120 certification.
Diastolic: 80 Mean:
100
Technology
CV.07 Expected result continued
cont‟d from above…
 Saturations (IVC: 70%;

SVC: 66%; RA: 66%;
RV: 68%; PA: 64%
 LV Ejection Fraction:
20%
 LV Diastolic Volume:
173 ml, Systolic
Volume: 120 ml
 Narrative summary:
Severe multivessel
CAD; 100% proximal
LAD-culprit vessel
Multiple tubular 80%
LCx stenosis in
proximal and mid
vessel
100% RCA lesion-RCA
fills from L to R
collaterals from LCx
CV.08 Show how the The cardiac catheterization  Pass  Fail CV 07.02 The system shall provide the ability to link
procedure data for the procedure is linked with procedure data with patient diagnosis.
cardiac catheterization the diagnosis of
is linked to the myocardial infarction (MI).
diagnosis of myocardial
infarction (MI).
Technology
CV.09 View final report of The final report of this  Pass  Fail CV 01.01 The system shall provide the ability to import The report may be a
cardiac catheterization procedure can be viewed (and/or directly enter) the final report of file of any type
studies/procedures from systems external to the
procedure done on through the UI. EHR attached to the
01/01/2000. patient record.
CV 02.01 The system shall provide access to view through
The report may include the the UI of the EHR the final report of
Physician ID type is
following data, that were studies/procedures imported from external not specified and
included in the Appendix sources (and/or directly entered into the EHR). can be name, local
(note that depending on system ID, national
the source of the data the provider ID (NPI),
display may differ): etc
 Provider ID#1, ID#2

and ID#3
 Procedure Date:
1/1/2000
 Procedure: left heart
catheterization with
PCI
Cardiac catheterization
findings include:
 Severe multivessel
CAD; 100% proximal
LAD-culprit vessel
 Multiple tubular 80%
LCx stenosis in
proximal and mid
vessel
 100% RCA lesion-RCA
fills from L to R
collaterals from LCx
Technology
CV.10 Export the final report The final report of the  Pass  Fail CV 03.01 The system shall provide the ability to export the
of cardiac cardiac catheterization final report of studies/procedures stored in the
EHR
catheterization procedure as viewed in the
procedure viewed in step above is exported.
the previous step.
For verification
purposes, a print
preview of the exported
file can be displayed (in
plain text or PDF) or
the file can be
exported, printed, and
faxed to the CCHIT
proctor.
Technology
CV.11 Review history of Details of previous stress  Pass  Fail CV 06.01 The system shall provide the ability to store the Items highlighted in
previous stress test. test are available for following data elements for a Stress Test as green are required
discrete data:
review. 1) Date of study only for CV
 Date of study 2) Test type advanced reporting
(7/10/2000) - list to include at least: Exercise treadmill, capability
 Test type (Exercise Exercise echo, Dobutamine echo, Exercise certification.
nuclear, Adenosine nuclear, Dobutamine nuclear,
Nuclear) Dipyridamole nuclear, Adenosine MRI,
 CPT = 93015 Dobutamine MRI, Adenosine PET/CT, CV.11 refers to an
 Result (abnormal) Dipyridamole PET/CT EF measured by a
 Total exercise time: 9 3) CPT coded test type stress test, therefore
minutes 4) Result: normal, abnormal, indeterminate the EF% will be
5) Total exercise time (where applicable)
 Resting heart rate: 92 6) Resting heart rate and BP higher than a regular
and BP: 146/90; 7) Peak heart rate and BP echocardiogram
 Peak heart rate: 190 8) Ejection Fraction (for modalities where it is (35% vs. 30% in
and BP: 190/100; measured) CV.22)
9) Interpreting physician
 Ejection Fraction 35%
10) Narrative summary.
 Interpreting physician:
Physician ID #1
“Abnormal stress test.
Physician of record
notified of results.”
CV.12 Review details of Details of surgery are  Pass  Fail CV 06.04 The system shall provide the ability to store the
previous cardiothoracic available for review: following data elements for cardiothoracic
surgeries as discrete data elements:
surgery.  Date of procedure 1) Date of procedure
(03/10/2000) 2) CPT coded test type (multiple selection
 CPT 33536 capability required)
 Procedure(s) 3) Procedure(s) performed (selected from
customizable list of options; multiple selection
performed (Coronary capability required)
Artery Bypass Graft 4) ID of physician(s) performing procedure
(CABG)) (multiple input capability required)
 ID of physician(s)
performing procedure
(ID #3)
Technology
CV.13 Review history of Details of EP procedure  Pass  Fail CV 06.02 The system shall provide the ability to store the
Electrophysiology (EP) are available for review; following data elements for invasive
Electrophysiology (EP) Procedures as discrete
procedures. the following will be stored data:
as discrete data elements: 1) Date of procedure
 Date of procedure 2) CPT coded test type (multiple selection
(06/02/2003) capability required)
3) Procedure(s) performed (selected from
 CPT code: 33249 customizable list of options; multiple selection
 Procedure(s) capability required)
performed (CRT by 4) ID of physician(s) performing procedure
way of EP. Device was (multiple input capability required)
implanted.)
 ID of physician(s)
performing procedure
(ID #2)
CV.14 Review history of Device data is linked to  Pass  Fail CV 06.05 The system shall provide the ability to store the Items highlighted in
implant/device data. procedure and can be following implant/device data elements as discrete green are required
data:
Device data should be reviewed. Device data 1) Date of implant/procedure only for CV
linked to procedure. includes: 2) CPT coded procedure type advanced reporting
 Date of 3) Procedure name capability
implant/procedure 4) Type of device (selected from customizable list certification.
of options)
(06/02/2003); 5) Product name (selected from customizable list
 CPT Code: 33249, of options)
93012 6) Device manufacturer (selected from
 Dual Chamber customizable list of options)
Pacemaker Implant 7) Product specifications (e.g. diameter, length)
8) Product serial number
 Types of device(s) 9) Manufacturer model number
 Generator CRT-D; 10) Leads type (for pacemaker)
St. Jude Medical; 11) Date removed
Model # 3207-36; 12) Physical location of device implant
13) Lead location
Ser# 412211 14) Pacing Threshold (V, msec)
 LV Lead; St. Jude 15) Sensing (mV)
Medical; Model 16) Impedance (ohms)
#1056T; Ser#; GXO- CV 07.01 The system shall provide the ability to link data
24401 regarding device implanted (captured in CV 06.05)
to the implantation procedure and display both
Technology
sets of data in surgical summaries and reports.
CV.14 Expected Result continued

cont‟d from above…
 RV Lead; St. Jude
Medical; Model #
7020; Ser# ADG-
11322
 RA Lead: St. Jude
Medical; Model #
1699TC; Ser# EPO-
14757
 Location: R anterior
chest
 Lead Location:
Standard
 Threshold: Atrial: 2.66v
/ 0.40 ms Ventricular:
1.64 v / 0.40 ms
 Sensing: Atrial: .50 mV
Ventricular 2.80 mV
 Impedence: Atrial 487
ohms Ventricular 554
ohms
Technology
CV.15 Review history of Previous Echocardiogram  Pass  Fail CV 06.07 The system shall provide the ability to store the Results must be
Echocardiogram from data is available to view: following data elements for an Echocardiogram as presented in defined
discrete data:
7/10/2000 admission. 1) Date of procedure fields; narrative text
 Date of procedure: 2) CPT coded test type (multiple selection including
Results are displayed 7/10/2000 capability required) quantitative results
in discrete fields versus  CPT code: 93303 3) Procedure name - list to include: transthoracic, is not acceptable. A
transesophageal, stress, ICE, IVUS, fetal (cardiac
large narrative text  Procedure name: narrative summary
only)
paragraphs. Transthoracic 4) M-mode measures must be included in
 M-mode: LVEDD - list to include: LVEDD, LVESD, Aortic root, a defined field
5.0mm; LVESD 3.6mm LA, RVDD, LV posterior wall thickness, septal indicating summary
LV posterior wall thickness data.
5) Doppler gradients
thickness: 1.0mm; - list to include: RV-RA systolic gradient, RA-
Septal thickness RV diastolic gradient, RV-PA systolic gradient, LA- Items highlighted in
1.0mm LV diastolic gradient, LV-Ao systolic gradient green are required
 Doppler gradients: 6) Left Atrial area only for CV
7) Aortic valve area
Aortic: 30mmHg; Mitral: 8) Mitral valve area
advanced reporting
4 9) LV diastolic volume capability
 LA area: 23 cm2 10) LV systolic volume certification.
 AV area: 3 cm2 11) LV mass
 MV area: 1.8 cm2 12) ID of interpreting physician(s)
13) Narrative summary
 LV diast vol: 173
 LV syst vol: 120
 LV mass: 116g
 ID of interpreting phys:
ID#3
Echocardiogram;
moderate systolic
dysfunction; 30%,
qualitative results
The results are displayed

in defined, quantitative
fields.
Technology
CV.16 Review details of Previous  Pass  Fail CV 06.08 The system shall provide the ability to store the Results must be
Electrocardiograms Electrocardiogram (ECG) following data elements for Electrocardiogram presented in defined
(ECG) as discrete data:
(ECG) from 3/1/2000 data is available to view: 1) Date and time ECG obtained fields; narrative text
admission.  Date & time obtained: 2) CPT coded test type (multiple selection including
3/1/2000; 13:30 capability required) quantitative results
Results are displayed  CPT code: 93010 3) Type of ECG performed ( is not acceptable. A
4) Date ordered
in discrete fields versus  Type: 12-lead 5) Interval (PR, QT, QTc, QRS Duration, P Axis,
narrative summary
large narrative text  Interval: PR: .12; QT: QRS Axis, T Axis) must be included in
paragraphs. .40; QTc: .5; QRS 6) ECG Interpretation a defined field
7) Ordering physician indicating summary
duration: .10; QRS 8) Reviewing physician
Axis: +80 degree data.
9) Date reviewed
 Interpretation: Sinus
rhythm w/ isolated Items highlighted in
PAC.Q waves noted in green are required
anterior precordial only for CV
leads. Poor R wave advanced reporting
progression; Rate capability
100bpm certification.
 Ordering physician: ID
#1
 Reviewing physician:
ID #2
 Date reviewed
3/1/2000
The results are displayed

in defined, quantitative
fields.
Technology
CV.17 Review Non invasive Previous non-invasive EP  Pass  Fail CV 06.09 The system shall provide the ability to store data Items highlighted in
EP Procedure from procedure data is available elements for non-invasive EP procedures, which green are required
would include ambulatory ECG monitoring, as well
6/2/2003 admission. to view: as remote transmission of data retrieved from only for CV
implantable devices. The following data elements advanced reporting
Results are displayed The results are displayed should be captured as discrete data: capability
in delineated fields in defined, quantitative 1) Date of procedure certification.
2) CPT coded test type (multiple selection
versus large narrative fields. capability required)
text paragraphs. 1) 06/02/2003 3) Procedure(s) performed (selected from
2) 93012 customizable list of options; multiple selection
3) 24-hour Ambulatory capability required)
ECG recording 4) ID of physician(s) signing off on procedure
(multiple input capability required)
4) Physician ID #1
CV.18 Review LDL and HDL LDL and HDL results are  Pass  Fail CV 08.02 The system shall provide the ability to document,
including target range. available for review. in structured fields, a target range for lab results, a
target maximum, or a target minimum for lab
Show how the system results, customized to patient for the following lab
provides the ability to Applicant can demonstrate values:
document target range how target range is 1) INR;
for this test customized customizable for this 2) Total Cholesterol;
3) LDL;
for this patient. patient. Initial target range 4) HDL
as presented in appendix 5) Triglycerides; and
LDL and HDL results data is LDL < 110 and HDL 6) HbA1c.
will include values >55. Customized target
entered from the range for Jim Grayson is
Appendix as well as saved.
results imported during
the Ambulatory Test
Script.
To demonstrate how
the target range is
customizable for this
patient, modify target
values for Jim Grayson
to LDL <90 and HDL
>60.
Technology
CV.19 Show how the system The system indicates that  Pass  Fail CV 09.01 The system shall provide the ability to indicate
provides the ability to these values for Jim when the patient is outside their custom target for
the following lab values:
identify lab values Grayson are outside his 1) INR;
outside custom target custom target values. 2) Total Cholesterol;
ranges. 3) LDL;
4) HDL
5) Triglycerides; and
Enter the following 6) HbA1c.
values for Jim
Grayson: LDL 95; HDL
40.
CV.20 Review an ECG (ECG file will be provided  Pass  Fail CV 13.01 The system shall provide the ability to display the 1. The EHR must
tracing. by CCHIT proctor to accurate (i.e. non-distorted) tracing from any ECG be able to
stored in the system or imported from another
vendor prior to certification system. receive and
testing.) store ECG files
from commercial
ECG tracing is displayed. ECG systems.
2. The EHR must
display these
ECG files as an
integral function
of the EHR
(without invoking
the originating
ECG
management
system).
3. The ECG must
display as a non-
distorted image:
measurement of
the length of any
number of
squares in the x-
axis direction will
equal the length
Technology
of the same
number of
squares in the y-
axis direction.
(Note: there are
five 0.2 sec
minor squares
per each 1 sec
major square in
the x-axis
direction.) The
image must
remain non-
distorted
regardless of the
aspect ratio of
the monitor (e.g.,
16:9 or 4:3).
Technology
CV.21 Transmit image Image is received. Image  Pass  Fail CV 15.02 The system will provide the ability to emergently 1. The EHR must
displayed in previous received is not visibly transmit specific patient data, reports, and be able to
accurate, clinically interpretable images to
step to proctor (proctor altered from the image alternate providers/facilities. transmit an ECG
will provide the stored in the system file (e.g. via fax
transmitted image to (stored image may have to or FTP server, or
Jurors). be redisplayed upon as an
receipt of transmitted attachment in an
Compare image image). Image must be email.) Saving
received to image readable, without the file externally
stored (from previous significant changes in and sending
step). scale, and does not require through an
modification or adjustment external email
on the receiving side. client is not
allowed as this
method
introduces the
possibility for
errors.
2. The ECG file
must be identical
to the file
originally sent to
the EHR from a
commercial ECG
management
system.
Technology
CV.22 Review Ejection Previous Ejection Fraction  Pass  Fail CV 04.01 The system shall provide the ability to capture the CV.22 refers to an
Fractions from previous data is available to view: following data elements for Ejection Fraction as EF measured by a
discrete data:
admissions. Both 1) Date of test; regular
quantitative and  1/1/2000; Angiogram; 2) Modality of test; echocardiogram.
qualitative results will 20% 3) Quantitative value as percent; and
display.  7/10/2000; 4) Qualitative value (narrative).
Echocardiogram; CV 05.01 The system shall provide the ability to retrieve and
Results from multiple moderate systolic display ejection fraction results from multiple
studies, including dysfunction; 30% studies/procedures/modalities in one view
(simultaneously), inclusive of EF (quantitative or
Ejection Fraction, date  6/1/2003; qualitative), date and modality.
and modality are Echocardiogram; 15%
viewable
simultaneously. The results from multiple
studies/procedures are
displayed in one view
(simultaneously).
CV.23 Graphically display Ejection fraction results  Pass  Fail CV 05.02 The system shall provide the ability to graphically
ejection fraction results from multiple display ejection fraction results from multiple
studies/procedures/modalities in one view
reviewed in the studies/procedures/ (simultaneously).
previous step (may be modalities can be
combined with the graphically displayed in
previous step). one view.
CV.24 Logout as Dr. Green. Logout successful.
Technology
Test Script Scenario 3B – Interoperability Testing – Clinical Documentation

3.06 The following actions are conducted by the CCHIT Test Proctor:
1. CCHIT Test Proctor emails patient summary documents to the Applicant.
 Patient summaries will be selected from a set of pre-built test cases; basic demographic information will match existing patient charts that have been
created by the Applicant for use in this Test Script
2. CCHIT Test Proctor shares inspection checklists with Juror
 Checklists will describe document content to look for in Applicant‟s EHR, based on the content of the documents generated.
3. CCHIT Test Proctor selects patient record to update.
 Patient record will be selected from a set of pre-built test cases; basic information will be updated in the following sections: medications and allergies.
 Applicant transmits patient summary file to CCHIT Test Proctor.
4. CCHIT validates the document for xml coding and compliance, proper use of coded terminologies and vocabularies, and updated content information
3.07 Login as required. Login successful.
Technology
3.08 Receive the HITSP The HITSP C32 file is  Pass  Fail IO-AM 10.10 The system shall provide the ability to display The data is
C32 file from Proctor. received. HITSP C32/CCD documents and file them as structured,
intact documents in the EHR.
exchanged using a
Match the patient The document is filed in Summary patient record content information standard format,
summary file to the the appropriate chart by will include: patient demographics, medication filed (not thrown
correct chart in the matching the patient list, medication allergy list, away), and
EHR. Store the file as registration information displayed, but
an intact document in contained in the document discrete data import
that chart. to the appropriate test is not required.
patient chart in the system.
Display the content of It is acceptable to
the HITSP C32 The system displays the display calculated
document. The correct narrative (human age of patient rather
required display readable) information than date of birth.
elements are: contained in the HITSP
 Patient Name, Birth C32 document. For further
Date, and Gender; guidance, see the
and The required display CCHIT Certified
 Section labels (title) elements are: 2011
and associated  Patient Name, Birth Interoperability
narrative text for Date, and Gender from Testing Guide.
the patient the Registration
demographics, Information HITSP C32
medication list, module; and
medication allergy  Section labels (title)
list. and associated
narrative text for
patient demographics,
medication list,
medication allergy list.
Technology
3.09 Applicant will notify the Applicant may generate  Pass  Fail IO-AM 10.20 The system shall provide the ability to For further
proctor as to what HITSP C32 v2.3 or HITSP generate and format patient summary guidance, see the
documents per the following specifications:
version of patient C32 v2.5 documents. CCHIT Certified
summary will be HITSP C32 (v2.3 or v2.5) 2011
generated by their The following sections of Summary patient record content information Interoperability
system. the summary patient will include: patient demographics, Testing Guide.
record will be updated: medications, medication allergies
Before the patient medications, allergies. Generated xml documents must demonstrate
summary document is use of industry-standard
generated, the CCHIT Once the file is received, vocabularies/terminologies.
Proctor will select a CCHIT will validate the xml The intent is to test the Required (R) fields,
pre-existing patient compliance, use of correct including the product coded terminology for
the medication and medication allergy.
from the system and coded terminologies and
request the applicant to vocabularies, and verify
open the record, verify that the updated content
the demographic information is present in
information and then the generated document.
add information to the
record before creating
the document.
The updated patient

summary is generated
by the Applicant and
transmitted to the
CCHIT Proctor.
Technology
3.10 Validate the patient File is validated by CCHIT  Pass  Fail IO-AM 10.20 The system shall provide the ability to For further
summary file and contains no xml generate and format patient summary guidance, see the
successfully for xml coding errors. CCHIT Certified
coding compliance and HITSP C32 (v2.3 or v2.5) 2011
correctness based Structured entries, Summary patient record content information Interoperability
upon the version of the narrative text and specified will include: patient demographics, Testing Guide.
document generated. coded terminologies are medications, medication allergies
required for the following Generated xml documents must demonstrate
patient summary sections: use of industry-standard
patient demographics, vocabularies/terminologies.
medication list, medication The intent is to test the Required (R) fields,
allergy list; including the product coded terminology for
3.11 Verify that the File is validated by CCHIT  Pass  Fail IO-AM 10.20 The system shall provide the ability to Vocabularies
generated patient to demonstrate correct generate and format patient summary  C32
summary demonstrates usage of coded Medications:
use of industry- terminologies and HITSP C32 (v2.3 or v2.5) RxNORM/NDC
standard vocabularies vocabularies. Summary patient record content information  C32 Allergies:
and coded will include: patient demographics, RxNORM, UNII
terminologies. Structured entries, medications, medication allergies
narrative text and specified Generated xml documents must demonstrate
coded terminologies are use of industry-standard
required for the following vocabularies/terminologies.
patient summary sections: The intent is to test the Required (R) fields,
patient demographics, including the product coded terminology for
medication list, medication
allergy list.
Technology
3.12 Verify that the File is displayed by CCHIT  Pass  Fail IO-AM 10.20 The system shall provide the ability to Structured entries,
generated patient using a stylesheet, and the generate and format patient summary narrative text and
summary contains the updated patient summary specified coded
updated content information is verified by HITSP C32 (v2.3 or v2.5) terminologies are
information. examining the narrative Summary patient record content information required for the
text for the following will include: patient demographics, following patient
sections: medications, medication allergies summary sections:
Generated xml documents must demonstrate patient
 Patient Demographics use of industry-standard demographics,
(Name, date of birth, vocabularies/terminologies. medication list,
and gender) The intent is to test the Required (R) fields, medication allergy
 Medication List including the product coded terminology for list;
 Medication Allergy List
Narrative text and
specified coded
terminologies are
required (structured
entries are optional)
for the following
patient summary
sections:
immunizations,
problem list,
procedures, and
diagnostic test
results
3.13 Logout as required. Logout successful.
Technology
Appendix A –
Previous visit entries for Joe Smith, bd 01 July 1998. Appendix information is to be entered as previous visits for this patient at this practice.
Problem List – includes asthma
06/15/2000
 PCV Immunization given (Applicant to scan consent document for the administration of this immunization; scanned document must be indexed with an
associated date of 06/15/2000 and a document type of “consent.”)
07/12/2003
 Immunizations (Applicant to scan consent document for the administration of these immunizations; scanned document must be indexed with an associated
date of 07/12/2003 and a document type of “consent.”)
o DTaP
o MMR
o IPV
 Height 42”, weight 41.5 lbs
04/01/2007
04/02/2008
02/01/2009
 Height 56”, weight 70 lbs
 Allergies to Penicillin
Data from two visits outside this practice

03/10/2005
 Height 46”, weight 49 lbs (this data obtained from a visit outside this practice)
04/03/2006
Technology
 Height 48.3”, weight 52 lbs (this data obtained from a visit outside this practice)
Technology
Previous visit entries for Emily Jones

 November 1 – 3, 2008 – birth and related incidents
o Birth weight 8 lbs 7 oz, ht 22”
o Immunizations
 Hep B
 December 2, 2008 – 1 month visit
o Wt 9 lbs 8 oz, ht 22”
o Immunizations
 Hep B
Previous visit entries for Will Haynes

 November 4, 2008 – birth and related incidents
o Birth weight 8 lbs 11 oz, ht 21”
o Immunizations
 Hep B
 December 4, 2008 – 1 month visit
o Wt 9 lbs 12 oz, ht 21”
o Immunizations
 Hep B
For Child Health Certification:

There must be a patient record for Charlie Green, male, with date of birth two days before inspection date.
There must be a patient record for Alice Brown, female, with date of birth ten days before inspection date.
Technology
Appendix B
Previous visit entries for Jennifer A. Thompson, birthdate 4/10/1978 – Appendix information is to be entered as previous visits for this patient at this practice.
For reference:
o LMP – test date minus 29 weeks
o EDD – test date plus 11 weeks
 6 months ago – visit date is test date minus 24 weeks
o Allergies
 NKDA
o Problem list
 Pregnancy
o U/S for anatomy and placenta. No anomalies seen; size consistent with EGA.
o Problem list
 Gestational Diabetes
 1 month ago – visit date is test date minus 4 weeks
o Lab results
 HgA1C 6.2
Record of Blood Sugar Data (to be entered into EHR during step 2.03)
Note that if an interface is used to enter the blood sugar information into the EHR, values may differ from those appearing in this appendix; this would meet the
criterion.
Date Fasting Post Breakfast Post Lunch Post Dinner
Yesterday (Y) 98 130 133 137
Y minus 1 106 98 120 110
For use in Scenario 2, create an order set called “Diabetes One”. The order set must include orders for RhoGAM, HgbA1c and nutrition referral.
Technology
Appendix C
Previous visit entries for Theodore S. Smith, bd 11/08/1931. Appendix information is to be entered as previous visits for this patient at this practice.
Past Medical History/Problem List: His past medical history is positive for type 2 diabetes, elevated cholesterol, hypertension, GERD, BPH, Hypothyroidism, and
arthritis.
He has had appendicitis (resolved with an appendectomy on September 12, 2004), cholecystitis (resolved with a cholecystectomy), and a cataract (resolved with a
left cataract extraction).
There are at least two prior visits for this patient. Previous Visit One problems included diabetes and hypertension; in this visit the provider was Dr. Jones. Previous
Visit Two problems included diabetes, hypertension and GERD; in this visit the provider was the Dr. Butler.
Allergies: He is allergic to Penicillin G and Sulfamethoxazole.
Medications: He is currently on Lipitor 20 mg a day, Zantac 150 mg a day, Actos 30 mg once daily, Synthroid 0.112 mg a day, glucosamine chondroitin, saw
palmetto, and lisinopril 5 mg twice a day (0 refills remaining for lisinopril).
Labs and vital signs to be preloaded as would have been entered during previous patient visits at this practice (i.e. into the patient record as data
elements):
NOTE that LOINC Codes have been provided for Cholesterol, HDL and LDL to facilitate step 4.15.
 Visit 04/14/2003
o CBC: WBC 9.8, RBC 3.67, HGB 10.9, HCT 33.2, MCV 90.7, MCH 29.7, MCHC 32.7, PLT 304, Neut 75, Lymph 10, Monos 5, Eos 5, Baso 1
3 months ago 6 months ago 9 months ago 1 year ago LOINC CODE
Glucose 185 180 136 128
LDH 151 141 148 152
Cholesterol 172 163 203 287 14647-2
HDL 57 47 62 48 14646-4
LDL 96 98 116 193 13457-7
HGBA1 8.6 10.5 10.1 9.3
Technology
Appendix G
Previous visit entries for Jim Grayson, bd 09 March 1943. Also includes set up data required for advanced reporting capability certification (these data elements are
highlighted in green in the test steps.) Appendix information is to be entered as previous visits for this patient at this practice.
Patient is a Caucasian male who returns for follow-up of CHF.
He has sustained previous MI's (Anterior STEMI 2000), has undergone coronary artery bypass graft in 2000 and cardiac resynchronization therapy in 2003.
Current conditions list:
1) CHF (Class III) ICD9 428.0
2) Multivessel CAD ICD9 414.01
3) Paroxysmal Atrial Fibrillation ICD9 427.31
4) Obesity (BMI 33.2) ICD9 278.00
5) Type II DM ICD9 250.00
6) Nicotine Dependence ICD9 305.1
7) Hypertension
8) Hyperlipidemia
Patient's current meds: Aldactone 25mg qAM; Amiodarone 200mg qAM (w/food); ASA 325mg qAM; Coreg 12.5mg BID; coumadin 5mg qPM; Lasix 20mg BID; Lipitor
20mg qPM (atorvastatin); Lisinopril 20mg qAM; Metformin 1000mg BID,
Family History:
 Father died of myocardial infarction (MI) at age 55;
 Brother has coronary artery disease (CAD), and had percutaneous coronary intervention (PCI) at age 50;
 Sister had coronary artery bypass graft (CABG) at age 60;
 Paternal aunt had sudden coronary death (SCD) at age 30.
Previous visits:
01/01/2000
Persistent post MI angina and congestive heart failure with severe left ventricular systolic dysfunction; specifically, an Ejection Fraction of 20% (modality=Angiogram).
Patient presented with MI on the anterior wall of his heart (ICD-9 CM code 410.11) resulting in a cardiac catheterization procedure (angioplasty or acute PCI).
Catheterization procedure details and findings include:
 CPT codes: Left Heart Cath: 93510, 93543, 93545, 93555, 93556. PCI: 92982. EDC: 93010
 Procedure performed by the following cardiologist users: ID#1, ID#2, ID#3
Technology
 Pressures:
 RA: 4
 LA: 7
 Right Pulmonary Wedge (RPW): 12
 Left Pulmonary Wedge (LPW): 12
 RV: 15
 LV: 120
 PA: AO Peak: 120 Diastolic: 80 Mean: 100
 Saturations:
 IVC: 70%
 SVC: 66%
 RA: 66%
 RV: 68%
 PA: 64%
 Left Ventricular Ejection Fraction: 20%
 Left Ventricular Diastolic Volume: 173mL Systolic Volume: 120 mL
 Narrative summary: Severe multivessel CAD; 100% proximal Left Anterior Descending (LAD)-culprit vessel; Multiple tubular 80% Left Circumflex (LCx) stenosis in
proximal and mid vessel; 100% RCA lesion-RCA fills from L to R collaterals from LCx
03/10/2000
Patient underwent coronary artery bypass surgery (CABG – coronary bypass graft) due to persistent Angina Pectoris (Class III) in the setting of multivessel CAD and
Severe LV Systolic Dysfunction
 Performed by Physician ID #3
 CPT code 33536
 ECG Data
 Date ordered: 3/1/2000
 The date and time obtained 3/1/2000; 13:30
 Type: 12-lead
 Interpretation: Sinus rhythm with isolated PAC. Q waves noted in anterior precordial leads. Poor R wave progression. Rate 100 bpm
 Interval (PR: .12 QT: .40, QTc: .5 QRS Duration: .10, QRS Axis: +80 degree)
 Ordering physician: Cardiologist ID #2
 Reviewing physician: Cardiologist ID #1
Technology
 Date reviewed 3/1/2000

 CPT code: 93010
07/10/2000
Patient returns for routine CV follow-up No Angina, No CHF: clinically stable EF re-assessed to determine Risk post OP of Sudden Coronary Death
 EF assessed via Echocardiogram
 Procedure name: Transthoracic
 M-mode: LVEDD 5.0mm; LVESD 3.6mm LV posterior wall thickness: 1.0mm; Septal thickness 1.0mm
 Doppler gradients: Aortic: 30mmHg; Mitral: 4
 LA area: 23
 AV area: 3 cm2
 MV area: 1.8 cm2
 LV diast vol: 173
 LV syst vol: 120
 LV mass: 116g
 ID of interpreting phys: ID#3
 Narrative summary: Echocardiogram; moderate systolic dysfunction; 30%, qualitative results
 Exercise Nuclear (Myoview), results: abnormal
 Total exercise time: 9 minutes
 Resting heart rate and BP: 146/90; 92
 Peak heart rate and BP: 190/100; 190
 Ejection Fraction 35%
 Interpreting physician: Physician ID #1
 Narrative summary: “Abnormal stress test. Physician of record notified of results.”
 CPT Codes: 93015
06/01/2003
Patient returns now with clinical signs/symptoms of CHF.
 Laboratory reveals FBS (fasting blood sugar) 222mg/dL HbA1C =10.2% TC (Total Cholesterol) =260mg/dL TG (triglycerides) 310mg/dL, LDL 182, HDL 30
 Target range for this patient for LDL is < 110 and for HDL is > 55
 Echocardiographic EF of 15% indicates worsening left ventricular systolic dysfunction
Technology
06/02/2003
Patient underwent cardiac resynchronization therapy (CRT) w/ICD
 Performed by Physician ID #2
 Implant placed in Right Anterior Chest : Device was implanted with the following product specifications:
 Generator – St. Jude Medical (CRT-D)
 model # 3207-36
 SN# 412211
 LV Lead -St Jude Medical
 model #1056 T
 SN # GXO-24401
 RV Lead - St Jude Medical
 model # 7020
 SN #ADG-11322
 RA Lead -St Jude Medical
 model #1699 TC
 SN # EPO -14757
 Lead Location: standard
 Threshold
 Atrial: 2.66 v / 0.40 ms
Ventricular: 1.64 V / 0.40 ms
 Sensing: Atrial: .50mV
Ventricular: 2.80 mV
 Impedence: Atrial: 487 ohms
Ventricular: 554 ohms
 CPT code: 33249
 Patient was monitored via 24-hour Ambulatory ECG Recording (CPT: 93012), by Physician ID #1
Previous visit entries for Chester Pain, bd 01/29/1945

Diagnoses - 414.0, 410.11, 428
Medications: Aspirin 325 mg by mouth once daily; Metoprolol 100 mg one tablet by mouth twice daily

CCHIT Certified 2011 Ambulatory EHR Test Script 20100326

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CCHIT Certified 2011 Ambulatory EHR Test Script April 7, 2010

CCHIT Test Scripts

April 7th, 2010

Product (NUMBER CODE ONLY):_________________________ Date: __________________________

Evaluator: _________________________________________ Signature: _______________________

Test Environment Setup Parameters for Script Execution

For ePrescribing steps:

There must be a patient record for Joe Smith

There must be a patient record for Joe Smith

Telephone: 301-555-1212 (home)

There must be a patient record for Emily Jones

There must be a patient record for Will Haynes

There must be a patient record for Jennifer A. Thompson

Patient ID: PID#00000111

There must be a patient record for Theodore S. Smith

There must be a patient record for David Carter

There must be a patient record for Jim Grayson

There must be a patient record for Chester Pain

There must be a patient record for Agatha Bloom

Address: 742 Evergreen Terrace, Springfield IL 62701

Agatha‟s most recent blood pressure reading is from 10 January 2006.

Test Script Scenario #1 – Summary:

Note that the correct

This step applies

Signature may either be

1.69 Exit Charlie Green‟s Logout successful.

Test Script Scenario #2 – Summary:

The indication that the

A report may satisfy this

Test Script Scenario 3A – Interoperability Testing – Laboratory Results

Test Script Scenario #4 – Summary:

Problem list must be

Generic drug names

Aleve does not display.

4.39 Logout as Dr. Butler. Logout successful.

Test Script Scenario #4 – Follow up:

If the Applicant did not

Note that the medication

This list is not

After entering the

THE FOLLOWING SCENARIO IS REQUIRED FOR CARDIOVASCULAR CERTIFICATION

Expected result continues

 Lab values from today,

Expected result continues

 Saturations (IVC: 70%;

 Provider ID#1, ID#2

CV.14 Expected Result continued

The results are displayed

The results are displayed

Test Script Scenario 3B – Interoperability Testing – Clinical Documentation

3.07 Login as required. Login successful.

The updated patient

Data from two visits outside this practice

Previous visit entries for Emily Jones

Previous visit entries for Will Haynes

For Child Health Certification:

Allergies: He is allergic to Penicillin G and Sulfamethoxazole.

 Date reviewed 3/1/2000

Previous visit entries for Chester Pain, bd 01/29/1945

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Product (NUMBER CODE ONLY):_ Date: __

Evaluator: ___________________ Signature: _