Electronic notes (MU2)

MU Requirements

Per ONC

Taken from ONC Final Rule:File:2014 Edition Cert Federal Register.pdf

(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/policy-researchers-implementers/2014-edition-final-test-method

Status

Analyzed - Bradymiller 11:26, 16 December 2012 (UTC)

Code completed by ZH Healthcare and committed to sourceforge on 2/28/2013.

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 at numerous notes (note this approach requires identifying the individual notes that meet the search criteria).
• Plan to search in the Custom Reports screen using a method that requires no modifications to the form code itself. On my reading through the certification, it appears ok to include the form section labels in the search. So, perhaps can simply wrap each note output with a specific div class in the Custom Report and then only search those items with a specific Search field at top (and make it clear it is only searching the patient forms). (DONE)
• Finished code to allow searching of patient notes/forms has been committed to sourceforge:

• http://github.com/openemr/openemr/commit/bc7ad1cdc82244ef1b5eedddb7f53efcb1e9c5eb

• Instructions on searching patient notes/forms is on the Patient Note and Form Searching wiki page.

Testing Report

Electronic Notes passed the Health IT test procedures and no inconsistencies found.

Here is the test report. File:Electronic Notes.pdf

‎ – Meaningful Use Stage 2 Testing of OpenEMR

Documents

• Electronic Notes process:File:Electronic notes process.pdf

Forum Threads

Sourceforge discussion on this item

Links

• OpenEMR Certification Stage II Meaningful Use Main Project Page