HL7 Electronic Health Record System Functional Model, Release 2.1.1
2.1.1-ballot - Normative Ballot

Publication Build: This will be filled in by the publication tooling

## Artifacts Summary

This page provides a list of the FHIR artifacts defined as part of this implementation guide.

### Overarching Section

The Overarching Section contains Conformance Criteria that apply to all EHR Systems and consequently must be included in all EHR-S FM compliant profiles. These criteria are grouped under a single Function.

All functions within the Overarching Section have an identifier starting with “OV”.

OV.1 Overarching Criteria (Function) | Overarching criteria are those that apply to all EHR Systems.

### Care Provision Section

The Care Provision Section contains those functions and supporting Conformance Criteria that are required to provide direct care to a specific patient and enable hands-on delivery of healthcare. The functions are general and are not limited to a specific care setting and may be applied as part of an Electronic Health Record supporting healthcare offices, clinics, hospitals and specialty care centers. The functions in this section are organized in general flow of an encounter; however, it is recognized that encounter flow varies considerably in different care settings and scopes of practice. All functions within the Care Provision Section have an identifier starting with “CP”.

CP.1 Manage Clinical History (Header) | Manage the patient's clinical history lists used to present summary or detailed information on patient health history.
CP.1.1 Manage Patient History (Function) | Manage medical, procedural/surgical, mental health, substance use, social and family history. This includes pertinent positive and negative histories, patient-reported or externally available patient clinical history.
CP.1.2 Manage Allergy, Intolerance and Adverse Reaction List (Function) | Manage patient-specific allergy, intolerance and adverse reaction lists.
CP.1.3 Manage Medication List (Function) | Create and maintain patient-specific medication lists.
CP.1.4 Manage Problem List (Function) | Create and maintain patient-specific problem lists.
CP.1.5 Manage Health-Related Factors List (Function) | Manage patient-specific health-related factors.
CP.1.6 Manage Immunization List (Function) | Create and maintain patient-specific immunization lists.
CP.1.7 Manage Medical Equipment, Prosthetic/Orthotic, Device List (Function) | Create and maintain a patient-specific list of medical equipment, medical prosthetic, orthotic, and/or implantable devices.
CP.1.8 Manage Patient and Family Preferences (Function) | Capture and maintain patient and family preferences.
CP.1.9 Manage Adverse Events (Function) | Capture and maintain adverse events.
CP.2 Render externally-sourced Information (Function) | Render documentation and data that has been captured from multiple external sources.
CP.2.1 Render externally-sourced Clinical Documents (Function) | Render clinical documentation that has been captured from multiple external sources.
CP.2.2 Render externally-sourced Data (Function) | Render data that has been captured from multiple external sources.
CP.2.3 Render Emergency Medical System Originated Data (Function) | Render emergency medical data that has been captured from multiple external sources.
CP.2.4 Render externally-sourced Clinical Images (Function) | Render clinical images that has been captured from multiple external sources.
CP.2.5 Manage Patient-Originated Data (Function) | Capture and explicitly label patient-originated data, link the data source with the data, and support provider authentication for inclusion in patient health record as well as subsequent rendering of the information as part of the health record.
CP.3 Manage Clinical Documentation (Header) | Clinical Documentation must be managed including the capture of the documentation during an encounter, maintenance and appropriate rendering.
CP.3.1 Conduct Assessments (Function) | Create and maintain assessment information.
CP.3.2 Manage Patient Clinical Measurements (Function) | Capture and manage patient clinical measures, such as vital signs, as discrete patient data.
CP.3.3 Manage Clinical Documents and Notes (Function) | Create, addend, amend, correct, authenticate, maintain, present and close, as needed, transcribed or directly-entered clinical documentation and notes.
CP.3.4 Manage Patient-Specific Care and Treatment Plans (Function) | Provide templates and forms for clinicians to use for care plans, guidelines and protocols during provision of care and care planning.
CP.3.5 Acknowledge/Amend Other Provider Documentation (Function) | Review and indicate or amend other caregiver notes as permitted.
CP.4 Manage Orders (Function) | Provide the ability to manage clinical orders and results including medication, non-medication, diagnostic tests, blood products, other biologics and referrals, using order sets as appropriate.
CP.4.1 Use Order Sets (Function) | Use Order Set templates to facilitate order entry by rendering the appropriate orders based on provider request, input or system configuration.
CP.4.2 Manage Medication Orders (Function) | Create prescriptions or other medication orders with detail adequate for correct filling and administration. Provide information regarding compliance of medication orders with formularies. Provide drug utilization review functionality including alerts regarding drug interactions and allergies.
CP.4.2.1 Medication Interaction and Allergy Checking (Function) | Provide alerts for potential medication interactions and medication allergy reactions.
CP.4.2.2 Patient-Specific Medication Dosing and Warnings (Function) | Render medication dosing and warnings related to a medication order based on patient-specific parameters.
CP.4.2.3 Medication Order Efficiencies (Function) | Provide the tooling necessary to increase the efficiency of medication ordering.
CP.4.2.4 Medication Alert Overrides (Function) | Capture the alerts and warnings for medications being overridden and reasons for the override.
CP.4.3 Manage Non-Medication Patient Care Orders (Function) | Enable the origination, documentation, capture, transmission, tracking and maintenance of non-medication patient care orders.
CP.4.4 Manage Orders for Diagnostic/Screening Tests (Function) | Enable the origination, documentation, transmission, tracking and maintenance of orders for diagnostic tests.
CP.4.5 Manage Orders for Blood Products and Other Biologics (Function) | Communicate with appropriate sources or registries to manage orders for blood products or other biologics.
CP.4.6 Manage Orders for Referral (Function) | Enable the origination, documentation and tracking of referrals between care providers or healthcare organizations, including clinical and administrative details of the referral, and consents and authorizations for disclosures as required.
CP.5 Manage Results (Function) | Present, annotate, and route current and historical test results to appropriate providers for review. Provide the ability to filter and compare results.
CP.5.1 Manage Results of Diagnostic Tests (Function) | Enable the receipt and display of results for diagnostics tests.
CP.6 Manage Medication, Immunization and Treatment Administration (Header) | Provide the functionality required to support the management of medication and immunization administration.
CP.6.1 Manage Medication Administration (Function) | Present providers with the list of medications that are to be administered to a patient, necessary administration information, and capture administration details.
CP.6.2 Manage Immunization Administration (Function) | Capture and maintain discrete data concerning immunizations given to a patient including date administered, type, manufacturer, lot number, and any allergic or adverse reactions. Facilitate the interaction with an immunization registry to allow maintenance of a patient's immunization history.
CP.6.3 Manage Treatment Administration (Function) | Provide the functionality required to support the management of treatment administration and documentation. (Treatment defined as the administration or application of remedies to a patient for a disease or injury; medicinal or surgical management; therapy).
CP.7 Manage Future Care (Header) | Provide the functionality to manage treatment and care planning through presentation of guidelines and protocols as well as managing recommendations for future care.
CP.7.1 Present Guidelines and Protocols for Planning Care (Function) | Present organizational guidelines for patient care as appropriate to support planning of care, including order entry and clinical documentation.
CP.7.2 Manage Recommendations for Future Care (Function) | Document and support the management of the disposition process for a patient by managing recommendations for future care.
CP.8 Manage Patient Education & Communication (Header) | Provide the functionality to effectively communicate with the patient regarding their care and document the communication as part of the patient's medical record.
CP.8.1 Generate, Record and Distribute Patient-Specific Instructions (Function) | Generate and record patient-specific instructions related to pre- and post-procedural and post-treatment/discharge requirements.
CP.9 Manage Care Coordination & Reporting (Header) | Provide the functionality required to coordinate care with other providers and report care provided.
CP.9.1 Produce a Summary Record of Care (Function) | Render a summarized review of a patient's episodic, and/or comprehensive EHR, subject to jurisdictional laws and organizational policies related to privacy and confidentiality.
CP.9.2 Capture Health Service Report Information (Function) | Support the creation of health service reports to authorized health entities that a provider may be required to generate (e.g., the creation of an oncologist's report that must be submitted to a national cancer registry).

### Care Provision Support Section

The Care Provision Support Section focusses on functions required to support the provision of care to a specific patient to enable hands-on delivery of healthcare. This section is organized generally in alignment with Care Provision Section. For example, CP.4 (Manage Orders) is supported directly by CPS.4 (Support Orders). This alignment is designed to assist in finding related support functions related to care provision functions but is not expected to be 100% matched as some Care Provision Functions do not require matching Support functions or vice-versa.

All functions within the Care Provision Support Section have an identifier starting with “CPS”.

CPS.1 Record Management (Header) | Manage the patient record including all patient demographics, identifiers and other information to support the provision of care.
CPS.1.1 Manage a Patient Record (Function) | Manage a single logical record for each patient.
CPS.1.2 Manage Patient Demographics (Function) | Manage patient demographic information.
CPS.1.3 Capture Quick Registration (Function) | Capture a registration, either directly entered or received from an external system, without complete supporting demographics, in order to facilitate patient care before the full registration is complete.
CPS.1.4 Capture Referral Request (Function) | Enable the receipt and processing of referrals from care providers or healthcare organizations, including clinical and administrative details of the referral, and consents and authorizations for disclosures as required.
CPS.1.5 Manage Patient Encounter (Function) | Manage patient encounter information, including tele-health encounters, and support follow-up encounters.
CPS.1.6 Subject to Subject Relationship (Header) | Information about the relationships between patients and others facilitate healthcare delivery and appropriate access to health information.
CPS.1.6.1 Related by Genealogy (Function) | Provide information on relationships by genealogy.
CPS.1.6.2 Related by Insurance (Function) | Support interactions with other systems, applications, and modules to provide information on an insured person's relationships. Examples of relationships include domestic partner, spouse, and guarantor of payment.
CPS.1.6.3 Related by Living Situation (Function) | Provide information on relationships by living situation. Examples of living situations include college dormitory, military deployment, in same household.
CPS.1.6.4 Related by Other Means (Function) | Provide information on patient relationships that are represented other than by genealogy, insurance or living situation.
CPS.1.7 Preferences, Directives, Consents and Authorizations (Function) | Capture and manage patient preferences, advance directives, consents and authorizations.
CPS.1.7.1 Support for Patient and Family Preferences (Function) | Support the integration of patient and family preferences into clinical decision support.
CPS.1.7.2 Manage Patient Advance Directives (Function) | Capture and maintain patient advance directives.
CPS.1.7.3 Manage Consents and Authorizations (Function) | Create, maintain, and verify patient decisions (such as informed consent for treatment or disclosure).
CPS.2 Support externally-sourced Information (Function) | Capture and maintain a variety of information from multiple external sources.
CPS.2.1 Support externally-sourced Clinical Documents (Function) | Incorporate clinical documentation (computable and scanned) from external (to the system) sources.
CPS.2.2 Support externally-sourced Clinical Data (Function) | Incorporate discrete clinical data from external sources and support communication/presentation of data captured from medical and non-medical devices and entities.
CPS.2.3 Support Emergency Medical System Originated Data (Function) | Provide the ability to capture and maintain patient information from an external Emergency Medical System (EMS).
CPS.2.4 Support externally-sourced Clinical Images (Function) | Incorporate clinical images from external sources and support communication/presentation of images from medical and non-medical devices and entities.
CPS.2.5 Support patient-originated Data (Function) | Capture and explicitly label patient-originated data, link the data source with the data, and support provider authentication for inclusion in patient health record.
CPS.2.6 Support Patient Health Data Derived from Administrative and Financial Data and Documentation (Function) | Capture and explicitly label patient health data derived from administrative or financial data; and link the data source with that data.
CPS.2.7 Support Patient Data Derived from Eligibility, Formulary and Benefit Documentation for Electronic Prescribing (Function) | Capture and explicitly label patient data derived from eligibility, formulary and benefit information; and link the data source with that data.
CPS.2.8 Support Medical Device Originated Data (Function) | Support collection and presentation of data captured from medical and medication monitoring devices.
CPS.3 Support Clinical Documentation (Header) | Standard assessments, guidelines and prompts are provided to facilitate decision support for the optimization of patient care based on specific medical conditions.
CPS.3.1 Support for Standard Assessments (Function) | Support the establishment, updates and use of assessment forms that will assist in the development of and adherence to care plans, guidelines, and protocols at the point of information capture.
CPS.3.2 Support for Patient Context- Driven Assessments (Function) | Offer prompts based on patient-specific data at the point of information capture for assessment purposes.
CPS.3.3 Support for Standard Care Plans, Guidelines, Protocols (Function) | Support the use of appropriate standard care plans, guidelines, protocols, and/or clinical pathways for the management of specific conditions.
CPS.3.4 Support for Context-Sensitive Care Plans, Guidelines, Protocols (Function) | Identify and present the appropriate care plans, guidelines, protocols, and/or clinical pathways for the management of patient-specific conditions that are identified in a patient clinical encounter.
CPS.3.5 Support for Research Protocols Relative to Individual Patient Care (Function) | Provide support for the management of patients enrolled in research protocols.
CPS.3.6 Support Self-Care (Function) | Provide the patient with decision support for self-management of a condition between patient/provider encounters.
CPS.3.7 Capture Guidelines and Standards from External Sources (Function) | Capture practice guidance from a variety of “trusted” external sources.
CPS.3.8 Manage Documentation of Clinician Response to Decision Support Prompts (Function) | Capture the decision support prompts and manage provider actions to accept or override decision support prompts.
CPS.3.9 Clinical Decision Support System Guidelines Updates (Function) | Capture and maintain updates of clinical decision support system guidelines and associated reference material.
CPS.3.10 Support for Identification of Potential Problems and Trends (Function) | Identify conditions of clinical interest, identify trends that may lead to significant problems, and provide prompts for clinical decision support.
CPS.3.11 Support Other Encounter and Episode of Care Documentation (Function) | Where not covered above, provide the means to manage and organize the documentation of the health care needed and delivered during an encounter/episode of care.
CPS.3.12 Manage Health Information Record Quality (Function) | Support grammatical and lexical integrity of the health record by providing medical spelling, thesaurus and grammar ready assistance during clinical documentation as well as enabling shortcuts for pre-defined text.
CPS.4 Support Orders (Header) | Support for Orders is required to ensure that appropriate decision support and safety checks are conducted by the system at the time of ordering as well as at the time of dispensing medications or immunizations.
CPS.4.1 Manage Order Set Templates (Function) | Maintain order set templates based on preferred standards, provider preferences, organizational policy or other criteria.
CPS.4.2 Support for Medication and Immunization Ordering (Function) | Provide functionality to alert providers to potential medication and immunization ordering errors (such as wrong patient, wrong drug, wrong dose, wrong route and wrong time).
CPS.4.2.1 Support for Medication Interaction and Allergy Checking (Function) | Identify medication interaction warnings at the time of medication or immunization ordering, or prescribing, as well as at the time of dispensing.
CPS.4.2.2 Support for patient-specific Dosing and Warnings (Function) | Identify and present appropriate dose recommendations based on known patient conditions and characteristics at the time of medication ordering and dispensing.
CPS.4.2.3 Support for Medication Ordering Efficiencies (Function) | Provide the tooling necessary to support efficient medication ordering.
CPS.4.2.4 Support for Medication Recommendations (Function) | Offer recommendations and options in medication treatment protocols as well as supporting medication monitoring on the basis of patient diagnosis, patient characteristics, or therapeutic guidelines and protocols.
CPS.4.2.5 Support for Medication Reconciliation (Function) | Review a patient's medication information (from more than one source) and reconcile conflicts.
CPS.4.3 Support for Non-Medication Ordering (Function) | Facilitate provider review and validation of order information to make it pertinent, effective and resource-conservative at the point of order entry.
CPS.4.4 Support Orders for Diagnostic/Screening Tests (Header) | This function has not been defined and is captured here as a place-holder for potential further development of the Functional Model and to maintain alignment with the corresponding CP section.
CPS.4.5 Support Orders for Blood Products and Other Biologics (Header) | This function has not been defined and is captured here as a place-holder for potential further development of the Functional Model and to maintain alignment with the corresponding CP section.
CPS.4.6 Support for Referrals (Header) | Evaluate patient information for referral indicators.
CPS.4.6.1 Support for Referral Process (Function) | Evaluate referrals within the context of a patient's healthcare data.
CPS.4.6.2 Support for Referral Recommendations (Function) | Evaluate patient data and recommend patient referral based on specific criteria.
CPS.4.6.3 Support for Electronic Referral Ordering (Function) | Enable the transmission of electronic referral orders from the EHR-S.
CPS.5 Support for Results (Function) | Evaluate results and notify provider and patient of results within the context of the patient's healthcare data.
CPS.6 Support Treatment Administration (Header) | Alert providers to potential administration errors (such as wrong patient, wrong drug, wrong dose, wrong route and wrong time) in support of safe and accurate medication and immunization administration and support administration workflow.
CPS.6.1 Support for Medication Administration (Function) | Alert providers to potential administration errors (such as wrong patient, wrong drug, wrong dose, wrong route and wrong time) in support of safe and accurate medication administration and support medication administration workflow.
CPS.6.2 Support for Immunization Administration (Function) | Alert providers to potential administration errors (such as wrong patient, wrong drug, wrong dose, wrong route and wrong schedule) in support of safe and accurate immunization administration and support immunization administration workflow.
CPS.6.3 Support for Safe Blood Administration (Function) | Facilitate real-time checks for potential blood administration errors.
CPS.6.4 Support for Accurate Specimen Collection (Function) | Facilitate real-time checks to ensure accurate specimen collection.
CPS.7 Support Future Care (Header) | Support for Future Care is necessary to enable the planning of future care according to appropriate healthcare guidelines.
CPS.7.1 Access Healthcare Guidance (Function) | Provide pertinent information from available evidence-based knowledge, at the point of care, for use in healthcare decisions and care planning.
CPS.8 Support Patient Education & Communication (Header) | Support for appropriate communication with the patient or the patient representatives.
CPS.8.1 Patient Knowledge Access (Function) | Provide the ability to access reliable information about wellness, disease management, treatments, peer support groups, public health education materials, and related information that is relevant for a specific patient.
CPS.8.2 Patient Education Material Updates (Function) | Receive and validate formatted inbound communications to facilitate, and/or perform updating of patient education material.
CPS.8.3 Patient Reminder Information Updates (Function) | Receive and validate formatted inbound communications to facilitate updating of patient reminder information from external sources such as Cancer or Immunization Registries.
CPS.8.4 Support for Communications Between Provider and Patient, and/or the Patient Representative (Function) | Facilitate communications between providers and patients, and/or the patient representatives.
CPS.8.5 Patient, Family and Care Giver Education (Function) | Facilitate access to educational or support resources pertinent to, and usable by, the patient or patient representative.
CPS.8.6 Communication with Personal Health Record Systems (Function) | Statement: Enable and manage communication between EHR Systems and PHR Systems.
CPS.9 Support Care Coordination & Reporting (Header) | Support exchange and reporting of information between participants in patient-centered care.
CPS.9.1 Clinical Communication Management and Support (Function) | Support exchange of information between participants in patient-centered care as needed, and the appropriate documentation of such exchanges. Support secure communication to protect the privacy of information as required by jurisdictional law.
CPS.9.2 Support for Inter-Provider Communication (Function) | Support exchange of information between providers as part of the patient care process, and the appropriate documentation of such exchanges. Support secure communication to protect the privacy of information as required by jurisdictional law.
CPS.9.2.1 Manage Consultation Requests and Responses (Function) | Provide a means to capture and manage requests for consultation and responses.
CPS.9.2.2 Support for Provider to Professional Communication (Function) | Manage communications to professionals (e.g., coroners, medical examiners, law enforcement) for health care events.
CPS.9.2.3 Support for Provider -Pharmacy Communication (Function) | Provide features to enable secure bi-directional communication of information electronically between practitioners and pharmacies or between practitioner and intended recipient of pharmacy orders.
CPS.9.3 Health Record Output (Function) | Support the definition of the formal health record, a partial record for referral purposes, or sets of records for other necessary disclosure purposes.
CPS.9.4 Standard Report Generation (Function) | Provide report generation features using tools internal or external to the system, for the generation of standard reports.
CPS.9.5 Ad Hoc Query and Rendering (Function) | Provide support for ad hoc query and report generation using tools internal or external to the system. Present customized views and summarized information from a patient's comprehensive EHR subject to jurisdictional laws and organizational policies related to privacy and confidentiality. The view may be arranged chronologically, by problem, or other parameters, and may be filtered or sorted.
CPS.9.6 Information View (Function) | Support user-defined information views.
CPS.10 Manage User Help (Function) | Support the ability to manage the configuration, and/or customization of appropriate user help that is context sensitive and may include the exchange of live online chat.

### Administration Support Section

The Administrative Support Section focusses on functions required in the EHR-S to support the management of the clinical practice and to assist with the administrative and financial operations. This includes management of resources, workflow and communication with patients and providers as well as the management of non-clinical administrative information on patients and providers. All functions within the Administrative Support Section have an identifier starting with “AS”.

AS.1 Manage Provider Information (Header) | Maintain, or provide access to, current provider information.
AS.1.1 Manage Provider Registry or Directory (Function) | Provide a current registry or directory of practitioners that contains data needed to determine levels of access required by the system.
AS.1.2 Manage Provider's Location Within Facility (Function) | Provide provider location or contact information on a facility's premises.
AS.1.3 Provider's On Call Location (Function) | Provide provider location or contact information when on call.
AS.1.4 Manage Provider's Location(s) or Office(s) (Function) | Provide locations or facility contact information for the provider in order to direct patients or queries.
AS.1.5 Team/Group of Providers Registry or Directory (Function) | Provide access to a current directory, registry or repository of information on teams or groups of providers according to scope of practice, organizational policy, and/or jurisdictional law.
AS.1.6 Provider Caseload/Panel (Function) | Provide access to a provider's caseload or panel information.
AS.1.7 Manage Practitioner/Patient Relationships (Function) | Identify relationships among providers treating a single patient, and provide the ability to manage patient lists assigned to a particular provider.
AS.1.8 Support for Provider Credentialing (Function) | Manage Provider Credentialing Information
AS.2 Manage Patient Demographics, Location and Synchronization (Function) | Capture and management of patient administrative information across locations in order to support care, including directories, and/or registries.
AS.2.1 Synchronize Patient Demographic Data (Function) | Support interactions with other systems, applications, and modules to enable the maintenance of updated demographic information in accordance with realm-specific recordkeeping requirements.
AS.2.2 Manage Patient's Location Within Facility (Function) | Provide the patient's location information within a facility's premises.
AS.2.3 Manage Patient's Residence for the Provision and Administration of Services (Function) | Provide the patient's residence information for the provision and administration of services to the patient, patient transport, and as required for public health reporting.
AS.2.4 Manage Patient Bed Assignment (Function) | Support interactions with other systems, applications, and modules to ensure that the patient's bed assignments within the facility optimize care and minimize risks e.g., of exposure to contagious patients.
AS.2.5 Manage Patients in Healthcare Programs (Function) | Capture and manage patient participation in healthcare programs.
AS.2.6 Manage Patient Privacy Consent Directives (Function) | Provide the ability to record and manage patient-specific privacy consent directive consistent with privacy policies.
AS.3 Manage Personal Health Record Interaction (Header) | Provide the system support in managing the interaction with a patient's PHR.
AS.3.1 Manage Information Exchange with Patient PHR (Function) | Support the ability to capture, and/or have interactions with patient PHR systems to enable the creation and maintenance of demographic, clinical and administrative information.
AS.3.2 Manage Legal and Other Related PHR files (Header) | Manage legal and other related electronic documents that allow or restrict the use or disclosure of the Personal Health Record Account Holder's information.
AS.3.2.1 Manage Consents and Authorizations from a PHR (Function) | Maintain the Consents and Authorization directives/statements from the patient's PHR.
AS.3.2.2 Manage PHR End-of-Life Documents and Other Advance Directives (Function) | Manage Personal Health Record electronic documents that provide the patients direction for end-of-life care and manage other types of Advance Directives.
AS.4 Manage Communication (Header) | Support communication to enable the exchange of information internally and between healthcare and non-healthcare organizations.
AS.4.1 Manage Registry Communication (Function) | Enable the exchange of structured demographic and clinical information with registries (e.g., local disease-specific, notifiable, patient, provider, organization, and health services registries) for patient monitoring and subsequent epidemiological analysis.
AS.4.2 Support for Communications Within an Organization (Function) | Facilitate communications regarding patient data and status within a health care organization.
AS.4.3 Support for Communications Between Organizations (Function) | Facilitate communications regarding patient orders, data and status between organizations.
AS.4.4 Support for Provider-Employer Communications (Function) | Provide support for capturing employment information, and/or special work related requirements (e.g., flyers, divers, firemen, transportation workers) to assist in medical disposition choices and notifications, and support communication to employers.
AS.5 Manage Clinical Workflow Tasking (Header) | Create, schedule, update and manage tasks with appropriate timeliness.
AS.5.1 Clinical Task Creation, Assignment and Routing (Function) | Creation, assignment, delegation, and/or transmission of tasks to the appropriate parties.
AS.5.2 Clinical Task Assignment and Routing for Medication Management & Administration (Function) | Assignment, delegation, and/or transmission of tasks for Medication Orders and Prescription Management.
AS.5.3 Clinical Task Linking (Function) | Linkage of tasks to EHR components, patients, and/or a relevant part of the electronic health record.
AS.5.4 Clinical Task Status Tracking (Function) | Track tasks to facilitate monitoring for timely and appropriate completion of each task.
AS.6 Manage Resource Availability (Header) | Manage the availability of healthcare resources to support the provision of care.
AS.6.1 Manage Facility Demographics (Function) | Maintain facility demographic information.
AS.6.2 Manage Healthcare Resource Availability Information (Function) | Support the collection and distribution of local healthcare resource information, through interactions with other systems, applications, and modules, to enable planning and response to extraordinary events such as local or national emergencies.
AS.6.3 Manage Healthcare Resource Scheduling (Function) | Support interactions with other systems, applications, and modules to provide the necessary data to a scheduling system for optimal efficiency in the scheduling of patient care, for either the patient or a resource/device.
AS.6.4 Support Triage Categorization (Function) | Provide support for prioritizing patients based upon acuity, wait time, and practitioner load.
AS.6.5 Support Waiting Room Management (Function) | Provide support to waiting room management.
AS.6.6 Support Patient Acuity and Severity Determination (Function) | Provide the data necessary to support and manage patient acuity and severity determination for illness/risk-based adjustment of resources.
AS.7 Support Encounter/Episode of Care Management (Header) | Manage and document the health care needed and delivered during an encounter/episode of care.
AS.7.1 Manage Presentation Filters (Function) | Present specialized views based on the encounter-specific values, clinical protocols and business rules.
AS.7.2 Support Encounter Documentation (Function) | Provide assistance in assembling data, supporting data collection and processing output from a specific encounter.
AS.7.3 Support Financial Reporting (Function) | Provide clinical data to support administrative and financial reporting.
AS.7.4 Support Remote Healthcare Services (Function) | Support remote health care services such as tele-health and remote device monitoring by integrating records and data collected by these means into the patient's record for care management, billing and public health reporting purposes.
AS.7.5 Manage Transitions of Care and Discharged Patients (Function) | Provide a means to manage outstanding patient issues after the encounter, for transits of care and discharge.
AS.8 Manage Information Access for Supplemental Use (Header) | Support extraction, transformation and linkage of information from structured data and unstructured text in the patient's health record for care management, financial, administrative, and public health purposes.
AS.8.1 Support Rules-Driven Clinical Coding (Function) | Make available all pertinent patient information needed to support coding of diagnoses, procedures and outcomes.
AS.8.2 Support Rules-Driven Financial & Administrative Coding (Function) | Provide financial and administrative coding assistance based on the structured data and unstructured text available in the encounter documentation.
AS.8.3 Support Integration of Cost/Financial information into Patient Care (Function) | Support interactions with other systems, applications, and modules to enable the use of cost management information required to guide users and workflows.
AS.8.4 Manage Healthcare Facility Performance Information (Function) | Support the import or retrieval of data necessary to review available quality, performance, and cost measurements regarding healthcare facilities.
AS.8.5 Support for Provider Training (Function) | Provide the ability to clinician and staff training requirements and document proficiency.
AS.9 Manage Administrative Transaction Processing (Header) | Support the creation (including using external data sources, if necessary), electronic interchange, and processing of transactions listed below that may be necessary foradministrative management during an episode of care.
AS.9.1 Support Financial Plan Enrollment (Function) | Support interactions with other systems, applications, and modules to facilitate enrollment of uninsured patients into subsidized and unsubsidized health plans, and enrollment of patients who are eligible on the basis of health, and/or financial status in social service and other programs, including clinical trials.
AS.9.2 Support Financial Eligibility Verification (Function) | Support interactions with other systems, applications, and modules to enable eligibility verification for health insurance and special programs, including verification of benefits and pre-determination of coverage.
AS.9.3 Support Service Authorizations (Function) | Support interactions with other systems, applications, and modules to enable the creation of requests, responses and appeals related to service authorization, including prior authorizations, referrals, and pre-certification.
AS.9.4 Support Service Requests and Claims (Function) | Support interactions with other systems, applications, and modules to support the creation of health care attachments for submitting additional clinical information in support of service requests and claims.
AS.9.5 Support Financial Claims & Encounter Reports (Function) | Support interactions with other systems, applications, and modules to enable the creation of claims and encounter reports for reimbursement.

### Population Health Support Section

The Population Health Support Section focuses on those functions required of the EHR to support the prevention and control of disease among a group of people (as opposed to the direct care of a single patient), usually with something(s) in common, e.g., reside in the U.S., have diabetes, are under the age of 5, are treated by the same care provider, have pneumonia and are in a long-term care facility, etc. This section includes functions to support input to systems that perform medical research, promote public health, & improve the quality of care at a multi-patient level. Population health data must be managed carefully to avoid inadvertently breaching patient privacy and confidentiality. Individual patients may be identifiable within a population or aggregate based on information other than patient identifiers, e.g., age plus location, and/or based on a combination of public and population-based information. This section specifically addresses requirements related to patient privacy and consent for use of patient information for secondary uses, and/or reporting. All functions within the Population Health Support Section have an identifier starting with “POP”.

POP.1 Support for Health Maintenance, Preventative Care and Wellness (Header) | Evaluate patient information to provide alerts, notifications and reminders regarding health, preventative care and wellness.
POP.1.1 Present Alerts for Preventative Services and Wellness (Function) | Identify patient-specific suggestions/reminders, screening tests/exams, and other preventative services in support of routine preventative and wellness care.
POP.1.2 Present Notifications and Reminders for Preventative Services and Wellness (Function) | Evaluate and notify patient, and/or provider of those preventative services, tests, or behavioral actions that are due or overdue.
POP.2 Support Population-Based Epidemiological Investigation/Surveillance (Header) | Support for population-based internal and external epidemiological investigations of clinical health of aggregate patient data for use in identifying health risks from the environment, and/or population in accordance with jurisdictional law.
POP.2.1 Support for Epidemiological Investigation/Surveillance Data Collection (Function) | Support for Person-Level and Aggregate-Level Queries to Generate Population Cohorts, and/or Aggregates to be used in epidemiologic investigations and reports.
POP.2.2 Support for Epidemiologic Data-Analysis (Function) | Support for Cohort Person-Level and Aggregate-Level Data Content and Analysis
POP.2.3 Support for Cohort and Aggregate Data Sharing (Function) | Support cohort and aggregate-level population data sharing within an organization, and/or with other organizations.
POP.3 Support for Notification and Response (Function) | Upon notification by an external, authoritative source of a health risk within the cared-for population, alert relevant providers regarding specific potentially at-risk patients with the appropriate level of notification.
POP.4 Support for Monitoring Response Notifications Regarding a Specific Patient's Health (Function) | In the event of a health risk alert, evaluate whether expected actions have been taken, and execute follow-up notification otherwise.
POP.5 Donor Management Support (Function) | Manage population-based information regarding potential human-product donors, and/or recipients.
POP.6 Measurement, Analysis, Research and Reports (Header) | Support the capture and subsequent export or retrieval of data necessary for the measurement, analysis, research and reporting.
POP.6.1 Outcome Measures and Analysis (Function) | Support the capture and subsequent export or retrieval of data necessary for the reporting on patient outcome of care by population, facility, provider or community.
POP.6.2 Quality, Performance and Accountability Measures (Function) | Support the capture and subsequent export or retrieval of patient, and/or population data necessary to provide quality, performance, and accountability measurements for which providers, facilities, delivery systems, and communities are held accountable.
POP.6.3 Support for Process Improvement (Function) | Support the capture and subsequent export or retrieval of data necessary to support process improvement measures and related initiatives.
POP.6.4 Support for Care System Performance Indicators (Dashboards) (Function) | Capture, determine and render data necessary to support health care organizational performance monitoring and improvement.
POP.7 Public Health Related Updates (Function) | Receive and validate formatted inbound communications to facilitate updates to the system's public health reporting guidelines.
POP.8 De-Identified Data Request Management (Function) | Provide patient data in a manner that meets applicable requirements for de-identification.
POP.9 Support Consistent Healthcare Management of Patient Groups or Populations (Function) | Provide the ability to identify and consistently manage healthcare over time and across populations or groups of patients that share diagnoses, problems, functional limitations, treatment, medications, and demographic characteristics that may impact care ( e.g., population management, disease management, wellness management or care management).
POP.10 Manage Population Health Study-Related Identifiers (Function) | Manage information that identifies key elements of a research or population study.

### Record Infrastructure Section

The Record Infrastructure Section consists of functions common to EHR System record management, particularly those functions foundational to managing record lifecycle (origination, attestation, amendment, access/use, translation, transmittal/disclosure, receipt, de-identification, archive…) and record lifespan (persistence, indelibility, continuity, audit, encryption). RI functions are core and foundational to all other functions of the Model (CP, CPS, POP, AS). Note extensive reference to RI functions in Overarching Criteria. RI functions may be implemented within the architecture of a single system or across a tightly coupled suite of systems (applications).All functions within the Record Infrastructure Section have an identifier starting with “RI”.

RI.1 Record Lifecycle and Lifespan (Header) | Manage Record Lifecycle and Lifespan
RI.1.1 Record Lifecycle (Function) | Manage Record Lifecycle
RI.1.1.1 Originate/Retain Record Lifecycle Event (Function) | Originate and Retain Record Entry (1 instance)
RI.1.1.1.1 Evidence of Record Entry Originate/Retain Event (Function) | Maintain Evidence of Record Entry Originate/Retain Event
RI.1.1.2 Amend (Update) Record Lifecycle Event (Function) | Amend (Update) Record Entry (1 instance)
RI.1.1.2.1 Evidence of Record Entry Amendment Event (Function) | Maintain Evidence of Record Entry Amendment Event
RI.1.1.3 Transform/Translate Record Lifecycle Event (Function) | Transform/Translate Record Entries (1 or more instances)
RI.1.1.3.1 Evidence of Record Entry Translate Event (Function) | Maintain Evidence of Record Entry Translate Event
RI.1.1.4 Attest Record Lifecycle Event (Function) | Attest Record Entries (1 or more instances)
RI.1.1.4.1 Evidence of Record Entry Attestation Event (Function) | Maintain Evidence of Record Entry Attestation Event
RI.1.1.5 Access/View Record Lifecycle Event (Function) | Access/View Record Entries (1 or more instances)
RI.1.1.5.1 Evidence of Record Entry View/Access Event (Function) | Maintain Evidence of Record Entry View/Access Event
RI.1.1.6 Report (Output) Record Lifecycle Event (Function) | Report (Output) Record Entries (1 or more instances)
RI.1.1.6.1 Evidence of Record Entry Output/Report Event (Function) | Maintain Evidence of Record Entry Output/Report Event
RI.1.1.7 Disclose Record Lifecycle Event (Function) | Disclose Record Entry Content (1 or more instances)
RI.1.1.7.1 Evidence of Record Entry Disclosure Event (Function) | Maintain Evidence of Record Entry Disclosure Event
RI.1.1.8 Transmit Record Lifecycle Event (Function) | Transmit Record Entries (1 or more instances)
RI.1.1.8.1 Evidence of Record Entry Transmit Event (Function) | Maintain Evidence of Record Entry Transmit Event
RI.1.1.9 Receive/Retain Record Lifecycle Event (Function) | Receive/Retain Record Entries (1 or more instances)
RI.1.1.9.1 Evidence of Record Entry Receive/Retain Event (Function) | Maintain Evidence of Record Entry Receive/Retain Event
RI.1.1.10 De-Identify (Anononymize) Record Lifecycle Event (Function) | De-Identify (Anononymize) Record Entries (1 or more instances)
RI.1.1.10.1 Evidence of Record Entry De-Identification Event (Function) | Maintain Evidence of Record Entry De-Identification Event
RI.1.1.11 Pseudonymize Record Lifecycle Event (Function) | Pseudonymize Record Entries (1 or more instances)
RI.1.1.11.1 Evidence of Record Entry Pseudomynization Event (Function) | Maintain Evidence of Record Entry Pseudomynization Event
RI.1.1.12 Re-identify Record Lifecycle Event (Function) | Re-Identify Record Entries that were previously de-identified or pseudonymized (1 or more instances)
RI.1.1.12.1 Evidence of Record Entry Re-Identification Event (Function) | Maintain Evidence of Record Entry Re-Identification Event
RI.1.1.13 Extract Record Lifecycle Event (Function) | Extract Record Entry content to produce subsets, derivations or aggregations (1 or more instances)
RI.1.1.13.1 Evidence of Record Entry Extraction Event (Function) | Maintain Evidence of Record Entry Extraction Event
RI.1.1.14 Archive Record Lifecycle Event (Function) | Archive Record Entries (1 or more instances)
RI.1.1.14.1 Evidence of Record Entry Archive Event (Function) | Maintain Evidence of Record Entry Archive Event
RI.1.1.15 Restore Record Lifecycle Event (Function) | Restore Record Entries from archive (1 or more instances)
RI.1.1.15.1 Evidence of Record Entry Restore Event (Function) | Maintain Evidence of Record Entry Restore Event
RI.1.1.16 Destroy/Delete Record Lifecycle Event (Function) | Destroy/Delete Record Entries (1 or more instances)
RI.1.1.16.1 Evidence of Record Entry Destruction Event (Function) | Maintain Evidence of Record Entry Destruction Event
RI.1.1.17 Deprecate Record Lifecycle Event (Function) | Deprecate Record Entries (1 or more instances)
RI.1.1.17.1 Evidence of Record Entry Deprecation/Retraction Event (Function) | Maintain Evidence of Record Entry Deprecation/Retraction Event
RI.1.1.18 Re-activate Record Lifecycle Event (Function) | Re-activate Record Entries (1 or more instances)
RI.1.1.18.1 Evidence of Record Entry Re-Activation Event (Function) | Maintain Evidence of Record Entry Re-Activation Event
RI.1.1.19 Merge Record Lifecycle Event (Function) | Merge Record Entries (2 or more instances)
RI.1.1.19.1 Evidence of Record Entry Merge Event (Function) | Maintain Evidence of Record Entry Merge Event
RI.1.1.20 Unmerge Record Lifecycle Event (Function) | Unmerge Record Entries previously merged (2 or more instances)
RI.1.1.20.1 Evidence of Record Entry Unmerge Event (Function) | Maintain Evidence of Record Entry Unmerge Event
RI.1.1.21 Link Record Lifecycle Event (Function) | Link Record Entries (2 or more instances)
RI.1.1.21.1 Evidence of Record Entry Link Event (Function) | Maintain Evidence of Record Entry Link Event
RI.1.1.22 Unlink Record Lifecycle Event (Function) | Unlink Record Entries (2 or more instances)
RI.1.1.22.1 Evidence of Record Entry Unlink Event (Function) | Maintain Evidence of Record Entry Unlink Event
RI.1.1.23 Add Legal Hold Record Lifecycle Event (Function) | Add Legal Hold to Record Entries (1 or more instances)
RI.1.1.23.1 Evidence of Record Entry Legal Hold Event (Function) | Maintain Evidence of Record Entry Legal Hold Event
RI.1.1.24 Remove Legal Hold Record Lifecycle Event (Function) | Remove Legal Hold from Record Entries (1 or more instances)
RI.1.1.24.1 Evidence of Record Entry Legal Hold Removal Event (Function) | Maintain Evidence of Record Entry Legal Hold Removal Event
RI.1.1.25 Verify Record Entries (Function) | Verify Record Entries (1 or more instances)
RI.1.1.25.1 Evidence of Record Entry Verification Event (Function) | Maintain Evidence of Record Entry Verification Event
RI.1.1.26 Encrypt Record Entries (Function) | Encrypt Record Entries (1 or more instances)
RI.1.1.26.1 Evidence of Record Entry Encryption Event (Function) | Maintain Evidence of Record Entry Encryption Event
RI.1.1.27 Decrypt Record Entries (Function) | Decrypt Records Entries (1 or more instances)
RI.1.1.27.1 Evidence of Record Entry Decryption Event (Function) | Maintain Evidence of Record Entry Decryption Event
RI.1.2 Record Lifespan (Header) | Manage Record Lifespan
RI.1.2.1 Manage Record Entries (Function) | Manage/Persist Record Entries (Multiple instances)
RI.1.2.2 Manage Record Entries for Legal Hold (Function) | Manage/Preserve Record Entries for Legal Hold (Multiple instances)
RI.1.3 Record States (Header) | Manage Record States
RI.1.3.1 Manage Record Pending State (Function) | Manage Record Entries during the various states of completion.
RI.1.3.2 Manage Record Entry Amended, Corrected and Augmented State (Function) | Manage Record Entries amended, corrected or augmented after finalization (or signature/attestation).
RI.1.3.3 Manage Record Entry Succession and Version Control (Function) | Manage successive Record Entry versions over time.
RI.1.3.4 Manage Record Entry Retraction (Function) | Remove a record entry from view if it is deemed erroneous and cite the reason.
RI.1.4 Record Completeness (Function) | Manage Record Completeness
RI.2 Record Synchronization (Function) | Manage Record Synchronization
RI.3 Record Archive and Restore (Function) | Manage Record Archive and Restore

### Trust Infrastructure Section

The Trust Infrastructure (TI) Section consists of functions common to an EHR System infrastructure, particularly those functions foundational to system operations, security, efficiency and data integrity assurance, safeguards for privacy and confidentiality, and interoperability with other systems. TI functions are core and foundational to all other functions of the Model (Care Provision, Care Provision Support, Population Health, Administrative Support and Record Infrastructure). Note extensive reference to TI functions in Overarching Criteria. TI functions may be implemented within the architecture of a single system or across a tightly coupled suite of systems (applications).All functions within the Trust Infrastructure Section have an identifier starting with "TI".

TI.1 Security (Header) | Manage EHR-S security.
TI.1.1 Entity Authentication (Function) | Authenticate EHR-S users, and/or entities before allowing access.
TI.1.2 Entity Authorization (Function) | Manage set(s) of EHR-S access control permissions.
TI.1.3 Entity Access Control (Function) | Manage access to EHR-S resources.
TI.1.3.1 Emergency Access Control (Function) | Manage emergency access to EHR-S resources.
TI.1.4 Patient Access Management (Function) | Manage a patient's access to personal health information.
TI.1.5 Non-Repudiation (Function) | Limit an EHR-S user's ability to deny (repudiate) data origination, transmission or receipt by that user.
TI.1.6 Secure Data Exchange (Function) | Secure all modes of EHR data exchange.
TI.1.7 Secure Data Routing (Function) | Route electronically exchanged EHR data only to/from known and authenticated destinations/sources (according to applicable healthcare-specific rules and relevant standards).
TI.1.8 Patient Privacy and Confidentiality (Function) | Enable the enforcement of the applicable jurisdictional and organizational patient privacy rules as they apply to various parts of an EHR-S through the implementation of security mechanisms.
TI.1.8.1 Redact Patient Identifying Information (Function) | Maintain patient identities and conditions invisible to the public and other providers who do not have “need to know” on public tracking screens.
TI.1.8.2 Protect Individual Patient Identity (Function) | Flag patient identity as confidential to others.
TI.1.9 System Operation Measurements (Function) | Manage the change of status of an external facility.
TI.1.10 Service Availability (Function) | Manage the ability to access, render and determine information related to Service Level Agreement.
TI.1.11 Trusted Information Exchange Environment (Function) | Maintain a Trusted Information Exchange environment to enable common security measures among participants in the health information exchange.
TI.2 Audit (Function) | Audit Key Record, Security, System and Clinical Events
TI.2.1 Audit Triggers (Function) | Manage Audit Triggers
TI.2.1.1 Record Entry Audit Triggers (Function) | Manage Record Entry Audit Triggers
TI.2.1.2 Security Audit Triggers (Function) | Manage Security Audit Triggers
TI.2.1.2.1 Security Event Security Audit Trigger (Function) | Manage Audit Trigger initiated to track Security event.
TI.2.1.2.2 User Authentication to the System (Start user session) Security Audit Trigger (Function) | Manage Audit Trigger initiated to track user authentication to the system (start user session).
TI.2.1.2.3 User Authentication (System Prompt for Password Change) Security Audit Trigger (Function) | Manage Audit Trigger initiated to track user authentication (system prompt for password change).
TI.2.1.2.4 User Request to Change Password Security Audit Trigger (Function) | Manage Audit Trigger initiated to track user request to change password.
TI.2.1.2.5 User Log Out (End user session) Security Audit Trigger (Function) | Manage Audit Trigger initiated to track user log out (end user session).
TI.2.1.2.6 User Access (Successful) Security Audit Trigger (Function) | Manage Audit Trigger initiated to track user access (successful).
TI.2.1.2.7 User Attempts to Access Data (Unsuccessful – Access Denied) Security Audit Trigger (Function) | Manage Audit Trigger initiated to track user attempts to access data (unsuccessful – access denied).
TI.2.1.2.8 Extraordinary User Access (Break the Glass) Security Audit Trigger (Function) | Manage Audit Trigger initiated to track extraordinary user access (break the glass).
TI.2.1.2.9 User Permissions (Authorization) Security Audit Trigger (Function) | Manage Audit Trigger initiated to track user permissions (authorization).
TI.2.1.3 System Audit Triggers (Function) | Manage System Audit Triggers
TI.2.1.3.1 System Event System Audit Trigger (Function) | Manage Audit Trigger initiated to track system events.
TI.2.1.3.2 System Started System Audit Trigger (Function) | Manage Audit Trigger initiated to track system started event.
TI.2.1.3.3 Back Up Started System Audit Trigger (Function) | Manage Audit Trigger initiated to track back-up started event.
TI.2.1.3.4 Back Up Completed System Audit Trigger (Function) | Manage Audit Trigger initiated to track back-up completed event.
TI.2.1.3.5 Back Up Recovery Started System Audit Trigger (Function) | Manage Audit Trigger initiated to track back-up recovery started event.
TI.2.1.3.6 Back Up Recovery Completed System Audit Trigger (Function) | Manage Audit Trigger initiated to track back-up recovery completed event.
TI.2.1.3.7 Batch Job Started System Audit Trigger (Function) | Manage Audit Trigger initiated to track batch job started event.
TI.2.1.3.8 Batch Job Completed System Audit Trigger (Function) | Manage Audit Trigger initiated to track batch job completed event.
TI.2.1.3.9 Maintenance Started System Audit Trigger (Function) | Manage Audit Trigger initiated to track maintenance started event.
TI.2.1.3.10 Maintenance Completed System Audit Trigger (Function) | Manage Audit Trigger initiated to track maintenance completed event.
TI.2.1.3.11 Resource Usage System Audit Trigger (Function) | Manage Audit Trigger initiated to track resource usage event.
TI.2.1.3.12 System Maintenance Events -Local Access System Audit Trigger (Function) | Manage Audit Trigger initiated to track system maintenance events -local access.
TI.2.1.3.13 System Maintenance Events -Remote Access System Audit Trigger (Function) | Manage Audit Trigger initiated to track system maintenance events -remote access.
TI.2.1.3.14 System Maintenance - EHR or Clinical Software System Audit Trigger (Function) | Manage Audit Trigger initiated to track system maintenance - EHR or clinical software.
TI.2.1.3.15 System Maintenance - Codes, Vocabulary, Knowledge, Rules System Audit Trigger (Function) | Manage Audit Trigger initiated to track system maintenance of codes, vocabulary, knowledge and rules.
TI.2.1.3.16 Data Corruption System Audit Trigger (Function) | Manage Audit Trigger initiated to track data corruption events.
TI.2.1.4 Clinical Audit Triggers (Function) | Manage Clinical Audit Triggers
TI.2.1.4.1 Clinical Alerts Clinical Audit Trigger (Function) | Manage Audit Trigger initiated to track clinical alerts.
TI.2.1.4.2 Acknowledgements of Clinically Significant Report Changes Clinical Audit Trigger (Function) | Manage Audit Trigger initiated to track acknowledgement of clinically significant report changes.
TI.2.1.4.3 Disable Decision Support Alerts Clinical Audit Trigger (Function) | Manage Audit Trigger initiated to track disabling of decision support alerts.
TI.2.2 Audit Log Management (Function) | Manage Audit Log
TI.2.2.1 Audit Log Indelibility (Function) | Manage Audit Log Indelibility
TI.2.3 Audit Notification and Review (Function) | Notify of Audit Events, Review Audit Log
TI.3 Registry and Directory Services (Function) | Enable the use of registry services and directories to uniquely identify, locate and supply links for retrieval of information related to: patients and providers for healthcare purposes; payers, health plans, sponsors, and employers for administrative and financial purposes; public health agencies for healthcare purposes, and- healthcare resources and devices for resource management purposes.
TI.4 Standard Terminology and Terminology Services (Header) | Support semantic interoperability through the use of standard terminologies, standard terminology models and standard terminology services.
TI.4.1 Standard Terminology and Terminology Models (Function) | Employ approved standard terminologies to ensure data correctness and to enable semantic interoperability (both within an enterprise and externally).Support a formal standard terminology model.
TI.4.2 Maintenance and Versioning of Standard Terminologies (Function) | Enable version control according to scope of practice, organizational policy, and/or jurisdictional law to ensure maintenance of utilized standard terminologies. This includes the ability to accommodate changes to terminology sets as the source terminology undergoes its natural update process (new codes, retired codes, redirected codes). Such changes need to be cascaded to clinical content embedded in templates, custom formularies, etc., as determined by existing policy.
TI.4.3 Terminology Mapping (Function) | Map or translate one terminology to another as needed by local, regional, national, or international interoperability requirements.
TI.5 Standards-Based Interoperability (Header) | Provide automated health care delivery processes and seamless exchange of clinical, administrative, and financial information through standards-based solutions.
TI.5.1 Application, Structured-Message, and Structured-Document Interchange Standards (Header) | Support an EHR system's ability to operate seamlessly with systems that adhere to recognized application interchange standards. These systems include other EHR systems, subcomponents of an EHR system, or other (authorized, non-EHR) systems.
TI.5.1.1 Application Interchange Standards (Function) | Support the ability to operate seamlessly with other systems by using applications, and/or structured messages and documents that adhere to interchange standards.
TI.5.1.2 Structured-Document Interchange Standards (Function) | Support the management of structured documents.
TI.5.1.3 Structured-Message Interchange Standards (Function) | Support the management of structured messages.
TI.5.2 Interchange Standards Versioning and Maintenance (Function) | Support various versions of an interchange standard.
TI.5.3 Standards-Based Application Integration (Function) | Integrate applications in a standards-based manner.
TI.5.4 Interchange Agreements (Function) | Support the use of Interchange Agreements to specify the rules, responsibilities, expectations, and methods by which Interchange Agreement partners may exchange information.
TI.5.5 System Integration (Function) | Support the integration of the EHR system with related systems.
TI.6 Business Rules Management (Function) | Manage the ability to create, update, delete, view, and version business rules including institutional preferences. Apply business rules from necessary points within an EHR-S to control system behavior. An EHR-S audits changes made to business rules, as well as compliance to and overrides of applied business rules.
TI.7 Workflow Management (Function) | Support workflow management functions including both the management and set up of work queues, personnel lists, and system interfaces as well as the implementation functions that use workflow-related business rules to direct the flow of work assignments.
TI.8 Database Backup and Recovery (Function) | Provide for the ability to backup and recover the EHR system.
TI.9 System Management Operations and Performance (Function) | Manage the change of status of an external facility and the ability to access, render and determine information related to Service Level Agreement.
TI.10 Standard or Preferred Clinical Models and Clinical Model Services (Header) | Employ approved standard clinical models and clinical model service to ensure data correctness and to enable semantic interoperability (both within an enterprise and externally). Support sets of formal standard clinical models and/or clinical model services.
TI.10.1 Standard or Preferred Clinical Models (Function) | Employ approved standard or Preferred Clinical Models to ensure structured data correctness and to enable semantic interoperability (both within an enterprise and externally). Support a standard or Preferred Clinical Models model.
TI.10.2 Maintenance and Versioning of Standard or Preferred Clinical Models (Function) | Enable version control according to scope of practice, organizational policy, and/or jurisdictional law to ensure maintenance of utilized standard or preferred clinical models. This includes the ability to accommodate changes to clinical models as the source clinical model undergoes its update process. Such changes need to be cascaded to clinical content embedded in templates, custom formularies, etc., as determined by existing policy.
TI.10.3 Clinical Model Mapping (Function) | Map or translate one clinical model to another as needed by local, regional, national, or international interoperability requirements.

### Other

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Overarching | The Overarching Section contains Conformance Criteria that apply to all EHR Systems and consequently must be included in all EHR-S FM compliant profiles. These criteria are grouped under a single Function. All functions within the Overarching Section have an identifier starting with “OV”.
Care Provision | The Care Provision Section contains those functions and supporting Conformance Criteria that are required to provide direct care to a specific patient and enable hands-on delivery of healthcare. The functions are general and are not limited to a specific care setting and may be applied as part of an Electronic Health Record supporting healthcare offices, clinics, hospitals and specialty care centers. The functions in this section are organized in general flow of an encounter; however, it is recognized that encounter flow varies considerably in different care settings and scopes of practice. All functions within the Care Provision Section have an identifier starting with “CP”. Example: For example, when a child presents with symptoms of common cold, a Direct Care EHR-S Function will enable the doctor to record that event. Additionally, Clinical decision-support functions within the Direct Care EHR-S section will alert the provider that a vaccination is due and will offer contraindication alerts for the medication given to the child who has symptoms of a cold.
Care Provision Support | The Care Provision Support Section focusses on functions required to support the provision of care to a specific patient to enable hands-on delivery of healthcare. This section is organized generally in alignment with Care Provision Section. For example, CP.4 (Manage Orders) is supported directly by CPS.4 (Support Orders). This alignment is designed to assist in finding related support functions related to care provision functions but is not expected to be 100% matched as some Care Provision Functions do not require matching Support functions or vice-versa. All functions within the Care Provision Support Section have an identifier starting with “CPS”.
Administration Support | The Administrative Support Section focusses on functions required in the EHR-S to support the management of the clinical practice and to assist with the administrative and financial operations. This includes management of resources, workflow and communication with patients and providers as well as the management of non-clinical administrative information on patients and providers. All functions within the Administrative Support Section have an identifier starting with “AS”.
Population Health Support | The Population Health Support Section focuses on those functions required of the EHR to support the prevention and control of disease among a group of people (as opposed to the direct care of a single patient), usually with something(s) in common, e.g., reside in the U.S., have diabetes, are under the age of 5, are treated by the same care provider, have pneumonia and are in a long-term care facility, etc. This section includes functions to support input to systems that perform medical research, promote public health, & improve the quality of care at a multi-patient level. Population health data must be managed carefully to avoid inadvertently breaching patient privacy and confidentiality. Individual patients may be identifiable within a population or aggregate based on information other than patient identifiers, e.g., age plus location, and/or based on a combination of public and population-based information. This section specifically addresses requirements related to patient privacy and consent for use of patient information for secondary uses, and/or reporting. All functions within the Population Health Support Section have an identifier starting with “POP”.
Record Infrastructure | The Record Infrastructure Section consists of functions common to EHR System record management, particularly those functions foundational to managing record lifecycle (origination, attestation, amendment, access/use, translation, transmittal/disclosure, receipt, de-identification, archive…) and record lifespan (persistence, indelibility, continuity, audit, encryption). RI functions are core and foundational to all other functions of the Model (CP, CPS, POP, AS). Note extensive reference to RI functions in Overarching Criteria. RI functions may be implemented within the architecture of a single system or across a tightly coupled suite of systems (applications).All functions within the Record Infrastructure Section have an identifier starting with “RI”. Example: Care Provision (CP) and Care Provision Support (CPS) functions are invoked by Actors taking Actions (i.e., caregivers documenting care provision). Most all Actions taken to support individual health or to provide healthcare are captured by the EHRS and persistently evidenced in the EHR record. For example, CP immunization administration functions create EHR record entries which must be persisted over time. These same entries form the basis for transmittal to central immunization registries.
Trust Infrastructure | The Trust Infrastructure (TI) Section consists of functions common to an EHR System infrastructure, particularly those functions foundational to system operations, security, efficiency and data integrity assurance, safeguards for privacy and confidentiality, and interoperability with other systems. TI functions are core and foundational to all other functions of the Model (Care Provision, Care Provision Support, Population Health, Administrative Support and Record Infrastructure). Note extensive reference to TI functions in Overarching Criteria. TI functions may be implemented within the architecture of a single system or across a tightly coupled suite of systems (applications).All functions within the Trust Infrastructure Section have an identifier starting with "TI". Example: Care Provision (CP) and Care Provision Support (CPS) functions must operate in a secure electronic environment. For example, Trust Infrastructure functions provide a secure environment for the CP immunization registration query function. Subsequently a CP function reports (transmits) the child's immunization event in a secure manner via another TI exchange function. TI functions also transparently provide other essential services, such as periodic backups of a child's health record and an audit trail of all accesses to that record.

### Structures: Resource Profiles

These define constraints on FHIR resources for systems conforming to this implementation guide.

FMFunction | This StructureDefinition represents the base EHR-S FM Function type
FMHeader | This StructureDefinition represents the base EHR-S FM Header type
FMSection | This StructureDefinition represents the base EHR-S FM Section type
FunctionalModel | This StructureDefinition represents the base EHR-S FunctionalModel type

### Structures: Extension Definitions

These define constraints on FHIR data types for systems conforming to this implementation guide.

requirements-actors | Requirements Statement Actors
requirements-change-info | Requirements or Statement Criteria Change Indicator
requirements-dependent | Requirements Statement Criteria is dependent
requirements-example | Requirements Statement Example

### Terminology: Value Sets

These define sets of codes used by systems conforming to this implementation guide.

Requirement Change Indicators | Requirement Change Indicators

### Terminology: Code Systems

These define new code systems used by systems conforming to this implementation guide.

Change Info | Requirement Change Indicator