Electronic Health Records Services

The Vendor is required to provide software as a service (SaaS) solution for electronic health records (EHR) to meet the needs, business practices, security, and reporting requirements of supporting agencies.
- General requirements
•    Be a comprehensive, secure, cloud-based electronic health record (EHR) 
•    Support integration with external systems through well-documented, standardized APSs to enable bidirectional data exchange. 
•    All necessary integrations will be documented using interface control documents (ICD). 
•    Support integration with custom in-house applications including the ability to send, receive, and synchronize data. 
•    Provide real-time updates of outpatient and inpatient medical records to users and connected systems as data or system states change. 
•    Have the ability to provide patients with real-time discharge summaries in a format that can be shared with community staff. 
•    Provide robust data and records management capabilities, including secure storage, retrieval, auditability, and comprehensive reporting functionality. 
•    Support batch exports as well as reversible and audited changes in bulk customizable by role. 
•    Integrate with azure active directory federation services and support multifactor authentication. 
•    All APIs shall use industry standard authentication and authorization mechanisms to integrate with external systems 
•    Maintain SOC 2 compliance to ensure security and confidentiality standards. 
•    Include verbose change logs and auditing that can be exported to an external SIEM. 
•    Auditing should include changes to records as well as administration events. 
•    Include alerting and protect against the creation of duplicate patient charts. 
•    Include bi-directional interfaces with external systems to include but not limited to updating patient demographic information (i.e. Name, identification number, location, parent or legal guardian contact information), youth picture, medical and mental health alerts, medication lists, completion of pertinent screenings and treatments (dates), etc.,
•    Enforce role-based access controls to restrict system functions and data access based on assigned user roles. 
•    Capture and categorize documentation based off user role (nurse notes, provider notes, clinical notes, external notes, etc.). 
•    Allow users to view, create, update and manage patient EHR data in accordance with applicable privacy, security and regulatory requirements. 
•    Support the importing of external files (e.g., lab results, radiology, etc.) in all relevant and commonly used file formats required for system operations. 
•    Allow exporting of selected data and reports using standard file formats. 
•    Have an internal electronic medication administration record (EMAR) system and module that interfaces with the vendor pharmacy allowing for effective administration and tracking of medications. 
•    Have an internal electronic treatment administration record (ETAR) allowing for effective administration and tracking of treatments 
•    Have the ability for authorized users to electronically sign documents 
•    Be mobile friendly, providing full functionality and usability on supported mobile devices. 
•    Be compatible with and support integration with peripherals, including but not limited to biometric devices, bar code scanning, and signature pads. 
•    Interface with third-party vendor systems to receive and process medical data, including x-rays, lab results and immunizations. 
•    Create a task list for pending orders and a way to reconcile orders when completed.
•    Have enhanced security measures for protected health information in compliance with applicable privacy and statutory and regulatory requirements. 
•    Track a youth’s internal and external location and duration of time detained through integrations with existing, homegrown systems. 
•    Generate a claim or bill, capturing all service, patient and provider information, based on medical services a youth receives provided by agency. 
•    Develop and configure customizable forms to capture data according to user or organizational requirements.
- Outpatient care
•    Ability to receive test results in real time from the vendor laboratory, using industry standard interfaces, with the ability to “flag” or notify designated users when the system receives the results (normal or abnormal). 
•    Automatic flagging of abnormal results (e.g., lab results haven't been reconciled, etc.) or newly received results to alert authorized users for timely review and action.
•    Alerting of users to missing information or prolonged inactivity on a record to ensure timely completion of tasks (e.g., missing exams, drug allergies, imaging not received, etc.). 
•    The ability to create “sticky notes” or “pop ups” on the patient’s appointment summary screen to share pertinent information related to a scheduled appointment. 
•    The ability to create, edit, and delete appointments to include:
o    Tracking of appointments specific to each facility, workflow, and clinic type. 
o    Tracking of when an appointment is rescheduled, not acknowledged, or deleted. 
o    Color-coded appointments for easier identification of acuity or task needing to be completed.
o    Ability for super users to create new appointment types and names. 
o    Ability to set recurring appointments (hourly, daily, weekly, monthly, annually). 
o    Appointment to follow the patient if they are transferred to another facility in the agency. 
o    External appointment reminders (set a day in advance).
•    Ability to generate patient summary sheets that compile selected data points (e.g., risk factors, medical alerts, etc.) from existing records for reporting, sharing, printing, review, and analysis. 
•    Comprehensive referral management capabilities to ensure efficient tracking, updating (e.g., prepopulating, etc.) and notification of referrals. 
•    Tracking of internal and external referrals. 
•    Automatic date, time stamp, and signature of the EHR notes and verbal orders author. 
•    Creating customized encounter and progress notes and templates, based on established agency health services standing orders and protocols or oversets of common patient complaints such as physical assessments, allergies, etc.
•    Capturing patient health care trends in longitudinal and graph form such as variations in height, weight, vital signs, blood sugars, etc. using a flowsheet. 
•    Creating and maintaining patient-specific problem lists using preloaded icd-10, nursing codes, and psychiatric diagnostic codes.
•    Allowing users to create, manage, print, export and monitor custom health profiles (e.g., diet, physical, etc.) with the ability to flag profiles and generate alerts when a defined condition is met. 
•    Creating an electronic treatment administration record (ETAR) that is integrated within the system’s EMAR to track scheduled treatments. 
•    Generating and recording patient specific education resources that can easily be reviewed and printed. 
•    Populating and completing tasks once certain nursing and diagnosis codes are selected (i.e., labs, follow-up appointments, routine standing orders, transfer assessment, physical, referrals, etc.) That can be viewed by multiple users. 
•    The ability to enter “in house” lab results (COVID, influenza, urine dip, pregnancy, or strep test) and for these to convert to the flow sheet. 
•    Allowing authorized users to edit, delete, modify, and distribute notes, while logging all actions with the identity of the user who performed the change. 
•    Creating, reviewing, or amending information regarding a change in the status of a problem. 
•    Categorizing youth into a “special” population and clinic based on diagnosis (i.e., chronic conditions, pregnancy, etc.), prescribe an evidenced-based treatment plan, and track the care received. 
•    Creating integrated plans of care (IPOC) for acute care office visits based on diagnosis, abnormal results, charting, etc. 
•    Pre-developed evidence-based templates and educational material available for the treatment of chronic conditions (diabetes, asthma, hypertension, seizure disorder, etc.) that are in alignment with national and correctional health care standards. 
•    Identifying and tracking patients with specific health conditions or risk factors based on diagnosis, abnormal vitals, labs, etc.
- Pharmacy and medication management
•    Electronic prescribing controlled substances (EPCS) capability for submission of controlled substance orders to a pharmacy. 
•    Have customizable ordering of medications, i.e., medication taper, sliding scale, etc. 
•    Allow a nurse to enter orders for a prescription from a physician or mid-level provider, with the ability to alert providers (via text, email) to validate and authenticate the order and complete the prescribing process. 
•    Identify potential drug to drug interactions during the medication ordering process and generate an alert requiring acknowledgement by the ordering staff prior to order completion. 
•    Identifies and sends an alert to designated staff related to a pre-defined administration of routine (prn) medications. 
•    Routinely maintains and updates medication prescribing guidelines. 
•    The ability to create customizable templates for medication management visits i.e. discharge, admission, medication refills, etc. 
•    Receives medication data electronically from the pharmacy for both new and refill orders. 
•    Maintain an EMAR that supports online and offline medication administration with automatic data synch upon network restoration, integrates with electronic prescribing systems to auto-populate medication orders, includes a biometric or bar code scanning based authentication option, allows authorized nurses to view and update records and supports secure upload and storage or patient photographs. 
•    Alerts nursing staff or send reminders related to medication expiration or when a patient’s medication is nearly depleted. 
•    Contains a bi-directional interface with the state immunization online registry (SIMON) to view, import and update youth vaccine administration records (EVAR). 
•    Creation of a patient medication compliance report. 
•    Documents vaccine administration and tracks and sends alerts when subsequent vaccines are due. 
•    As part of discharge planning the ability for a provider to prescribe and the nurse to print prior to discharge.