Stage
   Description
     
7
  
  • The hospital has a paperless EMR environment. Clinical information can be readily shared via Continuity of Care (CCD) electronic transactions with all entities within health information exchange networks (i.e., other hospitals, ambulatory clinics, sub-acute environments, employers, payers and patients). This stage allows the health care organization to support the true sharing and use of health and wellness information by consumers and providers alike. Also at this stage, HCOs use data warehousing and mining technologies to capture and analyze care data, and improve care protocols via decision support.
     
6
  
  • Full physician documentation/charting (structured templates) are implemented for at least one patient care service area.
  • A full complement of radiology PACS systems is implemented (i.e. all images, both digital and film-based, are available to physicians via an intranet or other secure network.)
     
5
  
  • The closed loop medication administration environment is fully implemented in at least one patient care service area. The eMAR and bar coding or other auto-identification technology, such as radio frequency identification (RFID), are implemented and integrated with CPOE and pharmacy to maximize point-of-care patient safety processes for medication administration.
     
4
  
  • Computerized practitioner/physician order entry (CPOE) for use by any clinician added to nursing and CDR environment.
  • Second-level of clinical decision support related to evidence-based medicine protocols implemented.
  • If one patient service area has been implemented CPOE and completed previous stages, this stage has been achieved.
     
3
  
  • Clinical documentation installed (e.g. vital signs, flow sheets, nursing notes, care plan charting, and/or the electronic medication administration record (eMAR) system are scored with extra points and are implemented and integrated with the CDR for at least one service in the hospital.
  • First level of clinician decision support is implemented to conduct error checking with order entry (i.e. drug/drug, drug/food, drug/lab, conflict checking normally found in the pharmacy).
  • Some level of medical image access from picture archive and communication systems (PACS) is available for access by physicians via the organization's intranet or other secure networks.
     
2
  
  • Major ancillary clinical systems feed data to clinical data repository (CDR) that provides physician access for retrieving and reviewing results.
  • CDR contains a controlled medical vocabulary (CMV) and the clinical decision support system and rules engine for rudimentary conflict checking.
  • Optional for extra points. Information from document imaging systems may be linked to the CDR.
     
1
  
  • Laboratory, pharmacy and radiology installed.
     
0
  
  • Some clinical automation may exist.
  • Laboratory and/or pharmacy and/or radiology not installed.