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Test Procedure for §170.302.d Maintain Active Medication List APPROVED Version 1.1 September 24, 2010 Test Procedure for §170.302 (d) Maintain Active Medication List
This document describes the test procedure for evaluating conformance of complete EHRs or EHR
modules1 to the certification criteria defined in 45 CFR Part 170 Subpart C of the Final Rule for Health
Information Technology: Initial Set of standards, Implementation Specifications, and Certification Criteria
for Electronic Health Record Technology as published in the Federal Register on July 28, 2010. The
document2 is organized by test procedure and derived test requirements with traceability to the normative
certification criteria as described in the Overview document located at
http://healthcare.nist.gov/docs/TestProcedureOverview_v1.pdf. The test procedures may be updated to
reflect on-going feedback received during the certification activities.
The HHS/Office of the National Coordinator for Health Information Technology (ONC) has defined the
standards, implementation guides and certification criteria used in this test procedure. Applicability and
interpretation of the standards, implementation guides and certification criteria to EHR technology is
determined by ONC. Test procedures to evaluate conformance of EHR technology to ONC’s
requirements are defined by NIST. Testing of EHR technology is carried out by ONC-Authorized Testing
and Certification Bodies (ATCBs), not NIST, as set forth in the final rule establishing the Temporary
Certification Program (Establishment of the Temporary Certification Program for Health Information Technology, 45 CFR Part 170; June 24, 2010.)
Questions about the applicability of the standards, implementation guides or criteria should be directed to
ONC at [email protected]. Questions about the test procedures should be directed to NIST at
[email protected]. Note that NIST will automatically forward to ONC any questions regarding the
applicability of the standards, implementation guides or criteria. Questions about functions and activities
of the ATCBs should be directed to ONC at [email protected]. CERTIFICATION CRITERIA
This Certification Criterion is from the Health Information Technology: Initial Set of Standards,
Implementation Specifications, and Certification Criteria for Electronic Health Record Technology Final
Rule issued by the Department of Health and Human Services (HHS) on July 28, 2010.
§170.302 (d) Maintain active medication list. Enable a user to electronically record, modify, and retrieve a
patient’s active medication list as well as medication history for longitudinal care.
1 Department of Health and Human Services, 45 CFR Part 170 Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology, Final Rule, July 28, 2010. 2 Disclaimer: Certain commercial products are identified in this document. Such identification does not imply recommendation or endorsement by the National Institute of Standards and Technology.
Test Procedure for §170.302.d Maintain Active Medication List APPROVED Version 1.1 September 24, 2010
Per Section III.D of the preamble of the Health Information Technology: Initial Set of Standards,
Implementation Specifications, and Certification Criteria for Electronic Health Record Technology, Final
Rule where the maintain active medication list certification criterion is discussed:
“The reference to longitudinal care is intended to convey that the problem list must be
comprehensive in the sense that it must be capable of including entries provided over an
extended period of time. Consequently, for Complete EHRs and EHR Modules to be certified for
an ambulatory setting, they will need to be designed to enable the user to electronically record,
modify, and retrieve a patient’s problem list over multiple encounters. For an inpatient setting,
they will need to enable the user to electronically record, modify, and retrieve a patient’s problem
list for the duration of an entire hospitalization. This clarification was also requested in relation to
the medication list and medication allergy list certification criteria and we have not repeated our
“We clarify that for this certification criterion, and all other certification criteria, the term “retrieve”
means the retrieval of information directly stored and managed by Certified EHR Technology and
that it does not mean the retrieval of information from external sources, unless explicitly stated
otherwise. We also take this opportunity, in the context of our response regarding “longitudinal
care” above, to clarify that “medication history” is intended to include a record of prior
modifications to a patient’s medications.”
INFORMATIVE TEST DESCRIPTION
This section provides an informative description of how the test procedure is organized and conducted. It
is not intended to provide normative statements of the certification requirements.
This test evaluates the capability for a Complete EHR or EHR Modules to enable a user to electronically
record, modify, and retrieve a patient’s active medication list and medication history for longitudinal care.
The test procedure is not prescriptive about the method used to modify the problem list. For example,
modifying a medication list does not require modifying an existing instance of a medication. Modification can
be accomplished through discontinuing/inactivating an existing medication on the list and entering a new
Based on the text referenced above from the Final Rule, the longitudinal care requirement in this criteria
shall be evaluated in the context of the care setting supported by the EHR. Specifically, for EHRs
designed for an ambulatory setting, access to the medication information gathered during multiple patient
visits to a single Eligible Provider shall be available to the provider. There is no requirement that
medication information gathered by other providers or hospitals be accessible. For EHRs designed for an
inpatient care setting, access to medication information gathered during the current hospitalization
episode of care shall be available to users in the inpatient care setting. There is no requirement that
medication information gathered during prior hospitalizations or by Eligible Providers in the ambulatory
This test procedure is organized into three sections:
Test Procedure for §170.302.d Maintain Active Medication List APPROVED Version 1.1 September 24, 2010
Record - evaluates the capability to enter patient active medication data into the EHR to create the
The Tester enters the NIST-supplied patient active medications
Modify – evaluates the capability to modify patient medication data that have been previously entered
The Tester displays the patient active medication list data entered during the Record Patient
The Tester modifies the previously entered active medication data using NIST-supplied
medication data, for example, modifying a medication dose or frequency and discontinuing a
Retrieve – evaluates the capability to display the patient medication list data that have been
previously entered into the EHR, including the capability to display the patient medication list as
recorded during multiple ambulatory visits with the same provider or during a single inpatient visit
The Tester displays the patient active medication data entered during the test
The Tester displays the patient medication history, including modified medication data
The Tester validates that the displayed medication list data and medication history data are
accurate and complete, including the medication list data that were modified during the
For complete EHR or EHR modules targeted to the ambulatory setting, the following derived test
DTR170.302.d – 1 Electronically Record Patient Active Medication List in an Ambulatory
DTR170.302.d – 2 Electronically Modify Patient Active Medication List in an Ambulatory
DTR170.302.d – 3 Electronically Retrieve Patient Active Medication List and Medication
For complete EHR or EHR modules targeted to the inpatient setting, the following derived test
DTR170.302.d – 4: Electronically Record Patient Active Medication List in an Inpatient
DTR170.302.d – 5: Electronically Modify Patient Active Medication List in an Inpatient
DTR170.302.d – 6: Electronically Retrieve Patient Active Medication List and Medication
For complete EHR or EHR modules targeted to both settings, the following derived test requirements
Test Procedure for §170.302.d Maintain Active Medication List APPROVED Version 1.1 September 24, 2010
DTR170.302.d – 1 Electronically Record Patient Active Medication List in an Ambulatory
DTR170.302.d – 2 Electronically Modify Patient Active Medication List in an Ambulatory
DTR170.302.d – 3 Electronically Retrieve Patient Active Medication List and Medication
DTR170.302.d – 4: Electronically Record Patient Active Medication List in an Inpatient
DTR170.302.d – 5: Electronically Modify Patient Active Medication List in an Inpatient
DTR170.302.d – 6: Electronically Retrieve Patient Active Medication List and Medication
REFERENCED STANDARDS
NORMATIVE TEST PROCEDURES – AMBULATORY SETTING Derived Test Requirements
Electronically Record Patient Active Medication List in an Ambulatory Setting
Electronically Modify Patient Active Medication List in an Ambulatory Setting
Electronically Retrieve Patient Active Medication List and Medication History in
DTR170.302.d – 1: Electronically Record Patient Active Medication List in an Ambulatory Setting
Vendor shall identify a patient with an existing record in the EHR containing
patient medications entered during multiple ambulatory visits to the same
provider to be used for this test (for testing purposes at least three visits over a
Vendor shall identify the EHR function(s) that are available to: 1) select the
patient, 2) enter patient active medications, 3) modify patient medications, 4)
retrieve patient active medication list, and 5) retrieve medication history for
Tester shall select patient active medication data from NIST-supplied test data
Test Procedure for §170.302.d Maintain Active Medication List APPROVED Version 1.1 September 24, 2010 TE170.302.d – 1.02:
Using the EHR function(s) identified by the Vendor, the Tester shall select the
patient’s existing record and enter patient active medications data from the NIST-
supplied test data set TD170.302.d – 1
Using the NIST-supplied Inspection Test Guide, the Tester shall verify that the
patient active medication test data have been entered correctly and without
Using the data in the NIST-supplied Test Data set TD170.302.d – 1 Tester shall
verify that the patient active medication list test data are entered correctly and
Tester shall verify that the patient medication list data are stored in the patient’s
DTR170.302.d – 2: Electronically Modify Patient Active Medication List in an Ambulatory Setting
As defined in DTR170.302.d – 1, no additional information is required
Tester shall select patient medication test data from NIST-supplied test data set
Using the EHR function(s) identified by the Vendor, the Tester shall select the
patient’s existing record, shall display the patient active medication list data
entered during the DTR170.302.d – 1: Electronically Record Patient Active
Medication List in an Ambulatory Setting test, and shall modify the previously
Using the NIST-supplied Inspection Test Guide, the Tester shall verify that the
patient medication list data modified in TE170.302.d – 2.02 have been entered
Tester shall verify that the patient active medication data entered during the
DTR170.302.d – 1: Electronically Record Patient Active Medication List in an
Ambulatory Setting test are accessed and modified
Using the data in the NIST-supplied Test Data set TD170.302.d – 2, Tester shall
verify that the modified medication list data are stored in the patient’s record
Test Procedure for §170.302.d Maintain Active Medication List APPROVED Version 1.1 September 24, 2010 DTR170.302.d – 3: Electronically Retrieve Patient Active Medication List and Medication History in an Ambulatory Setting
As defined in DTR170.302.d – 1, no additional information is required
Using the EHR function(s) identified by the Vendor, the Tester shall select the
patient’s existing record and shall display the patient active medication data
entered during the DTR170.302.d – 1: Electronically Record Patient Active
Medication List in an Ambulatory Setting test and modified during the
DTR170.302.d – 2: Electronically Modify Patient Active Medication List in an
Using the EHR function(s) identified by the Vendor, the Tester shall select the
patient’s existing record and shall display the patient medication history
Using the NIST-supplied Inspection Test Guide, the Tester shall verify that the
patient active medication test list and the medication history test data display
Using the data in the NIST-supplied Test Data set TD170.302.d – 3a, Tester
shall verify that the patient active medication list data entered in the
DTR170.302.d – 1: Electronically Record Patient Active Medication List in an
Ambulatory Setting test display correctly and without omission
Using the data in the NIST-supplied Test Data set TD170.302.d – 3b, Tester
shall verify that the patient active medication list data entered in the
DTR170.302.d – 1: Electronically Record Patient Active Medication List in an
Ambulatory Setting test and modified in the DTR170.302.d – 1: Electronically
Modify Patient Active Medication List in an Ambulatory Setting test display
NORMATIVE TEST PROCEDURES – INPATIENT SETTING Derived Test Requirements
Electronically Record Patient Active Medication List in an Inpatient Setting
Electronically Modify Patient Active Medication List in an Inpatient Setting
Electronically Retrieve Patient Active Medication List and Medication History in
DTR170.302.d – 4: Electronically Record Patient Active Medication List in an Inpatient Setting
Test Procedure for §170.302.d Maintain Active Medication List APPROVED Version 1.1 September 24, 2010 Required Vendor Information
Vendor shall identify a patient with an existing record in the EHR to be used for
this test (for testing purposes over the duration of a hospital visit)
Vendor shall identify the EHR function(s) that are available to: 1) select the
patient, 2) enter patient active medications, 3) modify patient medications, 4)
retrieve patient active medication list, and 5) retrieve medication history for
Tester shall select patient active medication data from NIST-supplied test data
Using the EHR function(s) identified by the Vendor, the Tester shall select the
patient’s existing record and enter patient active medications data from the test
Using the NIST-supplied Inspection Test Guide, the Tester shall verify that the
patient active medication test data have been entered correctly and without
Inspection Test Guide IN170.302.d – 4.01:
Using the data in the NIST-supplied Test Data set TD170.302.d – 4, Tester shall
verify that the patient active medication list test data are entered correctly and
Tester shall verify that the patient medication list data are stored in the patient’s
DTR170.302.d – 5: Electronically Modify Patient Active Medication List in an Inpatient Setting
As defined in DTR170.302.d – 4, no additional information is required
Tester shall select patient medication test data from NIST-supplied test data set
Using the EHR function(s) identified by the Vendor, the Tester shall select the
patient’s existing record, shall display the patient active medication list data
entered during the DTR170.302.d – 4: Electronically Record Patient Active
Medication List in an Inpatient Setting test, and shall modify the previously
Test Procedure for §170.302.d Maintain Active Medication List APPROVED Version 1.1 September 24, 2010 TE170.302.d – 5.03:
Using the NIST-supplied Inspection Test Guide, the Tester shall verify that the
patient medication list data modified in the DTR170.302.d – 5: Electronically
Modify Patient Active Medication List in an Inpatient Setting test have been
Tester shall verify that the patient medication data entered during the
DTR170.302.d – 4: Electronically Record Patient Active Medication List in an
Inpatient Setting test are accessed and modified
Using the data in the NIST-supplied Test Data set TD170.302.d – 5, Tester shall
verify that the modified medication list data are stored in the patient’s record
DTR170.302.d – 6: Electronically Retrieve Patient Active Medication List and Medication History in an Inpatient Setting
As defined in DTR170.302.d – 4, no additional information is required
Using the EHR function(s) identified by the Vendor, the Tester shall select the
patient’s existing record and shall display the patient active medication data
entered during the DTR170.302.d – 4: Electronically Record Patient Active
Medication List in an Inpatient Setting and the DTR170.302.d – 5: Electronically
Modify Patient Active Medication List in an Inpatient Setting tests
Using the EHR function(s) identified by the Vendor, the Tester shall select the
patient’s existing record and shall display the patient medication history
Using the NIST-supplied Inspection Test Guide, the Tester shall verify that the
patient active medication test list and the medication history test data display
Using the data in the NIST-supplied Test Data set TD170.302.d – 6a, Tester
shall verify that the patient active medication list data entered in the
DTR170.302.d – 4: Electronically Record Patient Active Medication List in an
Inpatient Setting test display correctly and without omission
Using the data in the NIST-supplied Test Data set TD170.302.d – 6b, Tester
shall verify that the patient active medication list data entered in the
DTR170.302.d – 4: Electronically Record Patient Active Medication List in an
Test Procedure for §170.302.d Maintain Active Medication List APPROVED Version 1.1 September 24, 2010
Inpatient Setting test and modified in the DTR170.302.d – 5: Electronically Modify
Patient Active Medication List in an Inpatient Setting test display correctly and
TEST DATA
Test data is provided by NIST in this Test Procedure to ensure that the functional and interoperable
requirements identified in the criteria can be adequately evaluated for conformance, as well as to provide
consistency in the testing process across multiple ONC-Authorized Testing and Certification Bodies
(ATCBs). The NIST-supplied test data focus on evaluating the basic capabilities required of EHR
technology, rather than exercising the full breadth/depth of capability that installed EHR technology might
be expected to support. The test data is formatted for readability of use within the testing process. The
format is not prescribing a particular end-user view or rendering. No additional requirements should be
The Tester shall use and apply the NIST-supplied test data during the test, without exception, unless one
The Tester determines that the Vendor product is sufficiently specialized that the NIST-supplied
test data needs to be modified in order to conduct an adequate test. Having made the
determination that some modification to the NIST-supplied test data is necessary, the Tester shall
record the modifications made as part of the test documentation.
The Tester determines that changes to the test data will improve the efficiency of the testing
process; primarily through using consistent demographic data throughout the testing workflow.
The Tester shall ensure that the functional and interoperable requirements identified in the
criterion can be adequately evaluated for conformance and that the test data provides a
Any departure from the NIST-supplied test data shall strictly focus on meeting the basic capabilities
required of EHR technology relative to the certification criterion rather than exercising the full
breadth/depth of capability that installed EHR technology might be expected to support.
The Test Procedures require that the Tester enter the test data into the EHR technology being evaluated
for conformance. The intent is that the Tester fully controls the process of entering the test data in order
to ensure that the data are correctly entered as specified in the test procedure. If a situation arises where
it is impractical for a Tester to directly enter the test data, the Tester, at the tester’s discretion, may
instruct the Vendor to enter the test data, so long as the Tester remains in full control of the testing
process, directly observes the test data being entered by the Vendor, and validates that the test data are
entered correctly as specified in the test procedure. Ambulatory Setting Test Data TD170.302.d – 1: Record Active Medications – Ambulatory Setting Diabeta (glyburide) 2.5 mg tablet by mouth every morning
Test Procedure for §170.302.d Maintain Active Medication List APPROVED Version 1.1 September 24, 2010 Lipitor (atorvastatin calcium) 10 mg tablet by mouth daily Lasix (furosemide) 20 mg tablet by mouth 2 times per day Klor-Con (potassium chloride) 10 mEq tablet by mouth 2 times per day Erythromycin (erythromycin ethylsuccinate) oral suspension 400 mg by mouth every 6 hours TD170.302.d – 2: Modify Active Medications – Ambulatory Setting Discontinue Lipitor Modify the frequency of Lasix from 2 times per day to 1 time per day Modify the dose of Klor-Con from 10 mEq to 20 mEq
Diabeta (glyburide) 2.5 mg tablet by mouth every morning Lasix (furosemide) 20 mg tablet by mouth 1 time per day Klor-Con 20 mEq tablet by mouth 2 times per day
Erythromycin (erythromycin ethylsuccinate) oral suspension 400 mg by mouth every 6
TD170.302.d – 3a: Retrieve Active Medications – Ambulatory Setting
Diabeta (glyburide) 2.5 mg tablet by mouth every morning Lasix (furosemide) 20 mg tablet by mouth 1 time per day Klor-Con (potassium chloride) 20 mEq tablet by mouth 2 times per day Erythromycin (erythromycin ethylsuccinate) oral suspension 400 mg by mouth every 6 TD170.302.D – 3b: Retrieve Medication History - Ambulatory Setting
List of all Medications including those that have been discontinued
Diabeta (glyburide) 2.5 mg tablet by mouth every morning Lipitor (atorvastatin calcium) 10 mg tablet by mouth daily -- DISCONTINUED Lasix (furosemide) 20 mg tablet by mouth 1 time per day Klor-Con (potassium chloride) 20 mEq tablet by mouth 2 times per day Erythromycin (erythromycin ethylsuccinate) oral suspension 400 mg by mouth every 6
Test Procedure for §170.302.d Maintain Active Medication List APPROVED Version 1.1 September 24, 2010
Inpatient Setting Test Data TD170.302.d – 4: Record Active Medications – Inpatient Setting Norvasc (amlodipine) 5 mg tablet by mouth daily Macrobid (nitrofurantoin) 100 mg tablet by mouth daily Catapres (clonidine hydrochloride) 0.1 mg tablet by mouth 2 times per day Tazicef (ceftazidime pentahydrate) 2 grams intravenous piggy back (IVPB) every 8 hours Albuterol inhaler (albuterol sulfate) aerosol 2 puffs by oral inhalation every 4 hours prn for respiratory
Tylenol (acetaminophen) 325 mg tablet by mouth every 4 hours prn for fever greater than 38.3 C Milk of Magnesia (magnesium hydroxide) 30 ml by mouth once daily prn for constipation
TD170.302.d – 5: Modify Active Medications – Inpatient Setting Discontinue Macrobid Modify the frequency of Albuterol from every 4 hours prn to every 6 hours prn Modify the dose of Tylenol from 325 mg to 650 mg
Norvasc (amlodipine) 5 mg tablet by mouth daily Catapres (clonidine hydrochloride) 0.1 mg tablet by mouth 2 times per day Tazicef (ceftazidime pentahydrate) 2 grams intravenous piggy back (IVPB) every 8 hours Albuterol inhaler (albuterol sulfate) aerosol 2 puffs by oral inhalation every 6 hours prn 650 mg tablet by mouth every 4 hours prn for fever greater than
Milk of Magnesia (magnesium hydroxide) 30 ml by mouth once daily prn for constipation
TD170.302.d – 6a: Retrieve Active Medications – Inpatient Setting
Norvasc (amlodipine) 5 mg tablet by mouth daily Catapres (clonidine hydrochloride) 0.1 mg tablet by mouth 2 times per day Tazicef (ceftazidime pentahydrate) 2 grams intravenous piggy back (IVPB) every 8 hours Albuterol inhaler (albuterol sulfate) aerosol 2 puffs by oral inhalation every 6 hours prn for
Test Procedure for §170.302.d Maintain Active Medication List APPROVED Version 1.1 September 24, 2010
Tylenol (acetaminophen) 650 mg tablet by mouth every 4 hours prn for fever greater than
Milk of Magnesia (magnesium hydroxide) 30 ml by mouth once daily prn for constipation
TD170.302.d – 6b: Retrieve Medication History - Inpatient Setting
List of all Medications including those that have been discontinued
Norvasc (amlodipine) 5 mg tablet by mouth daily Macrobid (nitrofurantoin) 100 mg tablet by mouth daily -- DISCONTINUED Catapres (clonidine hydrochloride) 0.1 mg tablet by mouth 2 times per day Tazicef (ceftazidime pentahydrate) 2 grams intravenous piggy back (IVPB) every 8 hours Albuterol inhaler (albuterol sulfate) aerosol 2 puffs by oral inhalation every 6 hours prn for
Tylenol (acetaminophen) 650 mg tablet by mouth every 4 hours prn for fever greater than
Milk of Magnesia (magnesium hydroxide) 30 ml by mouth once daily prn for constipation
CONFORMANCE TEST TOOLS
Test Procedure for §170.302.d Maintain Active Medication List APPROVED Version 1.1 September 24, 2010
Document History Version Number Description Date Published
Updated to remove “Pending” from header
Removed “draft” from introductory paragraph
In the Informative Test Description section:
Changed the words “edit “and “change” to “modify”, page 3
Corrected some errors with Ambulatory/Inpatient Wording
Added the following statement, “The test procedure is not prescriptive about the method used to modify the problem list, for example, modifying a medication list does not require modifying an existing instance of a medication. Modification can be accomplished through discontinuing/inactivating an existing medication on the list and entering a new instance of the medication.”
In the Normative Test Procedure section:
Corrected numbering of test procedure and test references, pages 6-12
Corrected typographical errors with Ambulatory vs Inpatient wording, pages 6-12
Changed the word "Change" to "Modify", pages 10-11
Corrected numbering of test data, page 12
Deleted the following medication, “Esidrix” (v1.2
Safety and Health Rules at the MAGIC Site Version 4.2: Oscar Blanch Bigas, May 16th 2013Previous versions: Juan Cortina EMERGENCY PHONE NUMBERS: EXTERNAL HELP: 112 RECEPTION: 2500, 9 This document describes the safety and health procedures and rules at the MAGIC telescopes site. You must read it, make sure that you understand it completely, sign a printed copy o f the check list found
cacy in today’s study 2 Kahn SE. Glucose control in type 2 diabetes. Still worthwhile and worth is encouraging, but it is impossible to draw defi nitive pursuing. JAMA 2009; 301: 1590–92. Ray KK, Seshasai SR, Wijesuriya S, et al. Eff ect of intensive control of clinical conclusions from such a phase II study. Experience glucose on cardiovascular outcomes and death in patients with