Electronic notes (MU2)

MU Requirements

Per ONC

Taken from ONC Final Rule

(9) Electronic notes. Enable a user to electronically record, change, access, and search electronic
notes.

Per NIST/ONC Final Test Methods

See http://www.healthit.gov/sites/default/files/170.314a9electronic_notes_2014_tp_approvedv1.2.pdf

Proposal

Everything is fulfilled except for the searching of notes, which needs to be(taken from the final test methods):

IN170.314(a)(9) – 4.01: Using the Tester selected single words and groups of words the Tester shall verify that the specific data (word or phrase) used for searching the electronic notes are found if the word or phase exists within the note
 The tester shall verify that only note text is searched (e.g. if browser-based or third-party application (e.g. MS Word, Adobe Acrobat) search capabilities are used to accomplish this test, the search should not result with text contained within the EHR or note headers or template and only contain text within the patient-specific note
 If the EHR technology accomplishes by searching across multiple notes (although only search of a single note is required), the result must identify individual note(s) in the result set that meet the search criteria
IN170.314(a)(9) – 4.02: Using the specific search data in the provided test data, the Tester shall verify that the specific data (word or phrase) used for searching the electronic notes are not found if the word or phase does not exist within the note
 The tester shall verify that only note text is searched (e.g. if browser-based or third-party application (e.g. MS Word, Adobe Acrobat) search capabilities are used to accomplish this test, the search capability must not include text contained within the EHR or note headers or template and only contain text within the patient-specific note
 If the EHR technology accomplishes by searching across multiple notes (although only search of a single note is required), the search capability must include individual note(s)

Thus, we need a search method to search only notes (ie. can not rely on the browser search since this searches things outside of the note). Per above, can have something that simply searches the note that is being looked at or focused on or at numerous notes (note this approach requires identifying the individual notes that meet the search criteria).

Links

• OpenEMR Certification Stage II Meaningful Use Main Project Page