C798 check list

About the Checklist TR S AF E R Self-Assessment ] Computerized Provider Order Entry wy with Decision Support >About the Checklist >Table of Contents >Team Worksheet >About the Practice Worksheets >Practice Worksheets The Checklist is structured as a quick way to enter and print your self-assesment. Your selection on the checklist will automatically update the related section of the corresponding Recommended Practice Worksheet. The Domain associated with the Recommended Practice(s) appears at The Recommended Practices(s) for the topic appear below the associated Domain. November 2016 the top of the column. Recommended Practices for Domain 1 — Safe Health IT The EHR supports and uses standardized protocols for exchanging data with other systems. systems, virus and malware protection software, H Established and up-to-date versions of operating application software, and interface protocols are used. System-to-system interfaces support the standard clinical vocabularies used by the connected applications. and tested to ensure that both coded and free-text data elements are transmitted without loss of or changes to information content. u System-to-system interfaces are property configured consistent with its complexity and with the importance of the accuracy, timeliness, and reliability of the data that traverses the interface. m The intensity and the extent of interface testing is n At the time of any major system change or upgrade that affects an interface, the organization implements procedures to evaluate whether users (clinicians or administrators) on both sides of the interface correctly understand and use information that moves over the interface. 1 Changes to hardware or software on either side of the o interface are tested before and monitored after go-live. There is a hardware and software environment for interface testing that is physically separate from the live environment. restart the exchange of data across the interface in an n Policies and procedures descnbe how to stop and orderly manner. established for managing and monitoring key m Security procedures, including role-based access, are designated aspects of interfaces and data exchange. Worksheet 1.1 Worksheet 1.2 Worksheet 1.3 Worksheet 1.4 Worksheet 1.5 Worksheet 1.6 Worksheet 1.7 Worksheet 1.8 Worksheet 1.9 Worksheet 1.10 F in dua'tyeas & C Implementation Status . Partially i Not in some areas implemented G C = Select the level of @ c = implementation achieved by your organization for each Recommended Practice. Your Implementation Status will be reflected on the Recommended Practice Worksheet in this PDF. To the right of each Recommended Practice is a link to the Recommended Practice Worksheet in this PDF. The Worksheet provides guidance on implementing the Practice. SAFER Self-Assessment | Computerized Provider Order Entry with Decision Support 4 of 45

K} g Self-Assessment Ly SAF E R Computerized Provider Order Entry | Checklist . with Decision Support >Table of Contents ‘ > About the Checklist >Team Worksheet ‘ > About the Practice Worksheets >Practice Worksheets Recommended Practices for Domain 1 — Safe Health IT Implementation Status Fully Partially Not in all areas in some areas implemented Coded allergen and reaction information (or "no Worksheet 1.1 (o @ @ known allergies" [NKA]) are entered and updated in the EHR prior to any order entry. Evidence-based order sets are available in the Worksheet 1.2 (o C C EHR for common tasks and conditions and are updated regularly. 13 User-entered orderable items are matched to, or can Worksheet 1.3 (o @ ™ be looked up from, a list of standard terms. The EHR can facilitate both cancellation and Worksheet 1.4 (o @ @ 1.4 acknowledgment of receipt of orders for laboratory, radiology, and pharmacy. CDS alerts are displayed in the relevant clinical Worksheet 1.5 (o C C context. 16 CDS incorporates current best practices and Worksheet 1.6 (o C C | guidelines from authoritative sources (e.g., national organizations, medical specialty professional associations). Recommended Practices for Domain 2 — Using Health IT Safely Implementation Status Fully Partially Not in all areas in some areas implemented Clinicians are trained and tested on CPOE Worksheet 2.1 (o C & 2.1 operations before being issued login credentials. Clinicians are engaged in implementing, reviewing, Worksheet 2.2 (o C C and updating CDS. CPOE is used for ordering all medications, Worksheet 2.3 (o @ ™ diagnostic tests, and procedures for which CPOE is available. There is minimal use of free-text order entry. Worksheet 2.4 C (o) ® Orders are entered and stored in standardized, coded form. Order entry information is electronically Worksheet 2.5 (3 @ @ communicated (e.g., through the computer or mobile messaging) to the people responsible for carrying out the order. November 2016 SAFER Self-Assessment | Computerized Provider Order Entry with Decision Support 5 of 45

e . SAF E R éecl)fr-gzzs’zzr??zted Provider Order Entry ‘ Checklist with Decision Support >Table of Contents ‘ > About the Checklist >Team Worksheet ‘ > About the Practice Worksheets >Practice Worksheets Recommended Practices for Domain 2 — Using Health IT Safely Implementation Status Fully Partially Not in all areas in some areas implemented Questions presented to the user by CPOE or CDS Worksheet 2.17 (@ C ) 2.17 are unambiguous. CPOE and CDS implementation and use are Worksheet 2.18 (@ @ -~ supported by usability testing based on best practices from human factors engineering. Critical patient information is visible during the order Worksheet 2.19 (o C C entry process. The clinician is informed during the ordering process Worksheet 2.20 (@ C C when additional steps are needed to complete the order being requested. Use of abbreviations and acronyms is minimized and Worksheet 2.21 (@ @ ) standardized. Additional safeguards (e.g., double checking by a Worksheet 2.22 (o @ G second specialist) are implemented in the EHR before high risk medications are prescribed. Recommended Practices for Domain 3 — Monitoring Safety Implementation Status Fully Partially Not in all areas in some areas implemented Key metrics related to CPOE and CDS (e.g., Worksheet 3.1 (o @ -~ override rates) are defined, monitored, and acted on to optimize safety and use. November 2016 SAFER Self-Assessment | Computerized Provider Order Entry with Decision Support 7 of 45