MedInformatix EHI Export

EHI Export Background

Under the ONC Health IT Certification Program (Program), Health IT Developers are subject to Conditions and Maintenance of Certification requirements as part of the 2015 Edition Cures Update. Included in these requirements is the Assurances Condition and Maintenance of Certification which requires Certified Health IT that electronically stores Electronic Health Information (EHI) to certify to the Cures Update § 170.315(b)(10) EHI Export criterion. Health IT developers certifying to this criterion must provide their customers with the capability to efficiently export single and multi-patient EHI in a secure and timely manner. The EHI export file must be in an electronic and computable format. Developers must include a publicly accessible hyperlink of the export’s format.

WHAT IS EHI?

Electronic Health Information (EHI) refers to “electronic protected health information” (ePHI) to the extent that it would be included in a designated record set as defined in 45 CFR 164.501. EHI does not include psychotherapy notes as defined in 45 CFR 164.501 or information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding. The EHI definition represents the same ePHI that an individual would have the right to access under the HIPAA Privacy Rule (For additional information about the definition of EHI, please review ONC’s Understanding Electronic Health Information (EHI) fact sheet) .

DOCUMENTATION OVERVIEW

This document outlines MedInformatix’ s EHI export file format and describes the structure and syntax of how the EHI is exported, but not the EHI itself. Use the export format documentation to process EHI after it has been exported by the product.

EXPORT FORMATS

MedInformatix supports the following export formats for the EHI exported by the B.10 EHI Export solution:

Clinical Data – C-CDA R2.1

Clinical Data is represented using the Consolidated Clinical Document Architecture (C-CDA) R2.1 format which supports USCDI (United States Core Data for Interoperability) V1 Data Classes and Data Elements.

Other elements may exist which are part of C-CDA requirements but not listed in the USCDI, like Advance directive, reason for referral, etc.

Reference information:

C-CDA R2.1 Companion Guide

C-CDA R2.1 Sample

USCDI V1

Discrete Data - CSV

Discrete Data includes MedInformatix pre-defined designated record set supplemental data which includes clinical and non-clinical data supporting patient care. It is comprised of 27 data tables exported in a Comma-separated values (CSV) format. If data is not present, then no data exists for the patient in question. The Table Name corresponds to the file names exported.

CSV – Comma-separated values is a text file format that uses commas to separate values. Converts objects into a series of character-separated value (CSV) strings and saves the strings to a file. It stores tabular data (numbers and text) in plain text.

Data tables contain Practice Management (PM) elements, Electronic Medical Record (EMR) elements, Auditing events and QPP elements.

LIST OF EXPORTED SQLTABLES AS CSV

File Name Description
APPOINTMENTS.CSV Patient Appointments (PM)
Balance.CSV Patient Balance (PM)
CLACTIVITYLOG.CSV Chart Activity (Audit)
CLALLRGY.CSV Patient Allergies (EMR)
CLAUTHRZ.CSV Patient Authorizations (PM/EMR)
CLCLAIM.CSV Patient Claims (PM)
CLCNOTES.CSV Patient Collection Notes (PM)
CLDISPENSE.CSV Patient Vaccines (EMR)
CLDOCTOR.CSV Patient Doctors (PM/EMR)
CLFAMILY.CSV Family History (EMR)
CLINBOXLOG.CSV Patient Inbox Import Log (Audit)
CLLAB.CSV Patient Labs (EMR)
CLMAIL.CSV Patient Messages (PM/EMR)
CLMASTER.CSV Patient Demographics (PM/EMR)
CLORDER.CSV Patient Orders (EMR)
CLPCP.CSV Patient Providers (EMR)
CLPHARMACY.CSV Patient Pharmacies (EMR)
CLPNOTES.CSV Patient Clinical Notes (EMR)
CLPROBLM.CSV Patient Diagnosis (EMR)
CLPROBLMHIST.CSV Patient Diagnosis History (EMR)
CLRXHIST.CSV Patient Medication History (EMR)
CLVITAL.CSV Patient Vital Sign History (EMR)
CLVNOTES.CSV Patient Account Notes (EMR)
GUARANTOR.CSV Patient Guarantor (PM)
PAYMENTS.CSV Patient Payments (PM)
Statements.CSV Patient Statements (PM)
zQualityPayCharge.CSV Patient QPP (Quality Payment Program) MIPS (Merit Based Incentive Payment System) Codes (QPP)

The Appointments files is a list of all patient appointments, regardless of status. An example of the record is provided below the data element descriptions.

Data Element Description
Company Top-level organization code used in all company-specific tables.
Account Patient's account number.
MRN Patient’s medical record number.
Appt Date Scheduled date of the appointment.
ApptTime Scheduled time of the appointment.
Book Resource the appointment is scheduled for, such as a provider or modality.
Reason Appointment Reason Code
Appt Description Appointment Reason Description, such as New Patient Exam, Lab Test, or Diagnostic Imaging Test.
Allotted Amount of time allocated for the appointment in minutes.
Tag Date Date the patient is set as “ready for service”
Tag Time Time the patient is set as “ready for service”.
Room Time Time the patient is taken into a treatment room.
Finish Time Time the patient’s appointment is set as complete.
Status The status of the appointment.
Appt Flag The appointment flag associated with the status of the appointment.
Create Date Date when the appointment was scheduled.
Create Time Time when the appointment was scheduled.
Appt Referral The referring provider code.
User Name Name of the user who scheduled the appointment.
Facility Location where the appointment was scheduled.
Anesthesia Used Anesthesia flag, indicating whether or not it was used.
Note General notes related to the appointment.
Appt ID Per Company, a unique ID for each appointment.
Arrival Time Time the patient is set as “arrived”.
Flag User The user who flagged the appointment.
Reason User The user who set the final Appointment Reason code.
Stat Is the appointment a STAT appointment.
Eligibility Patient’s general insurance eligibility status.
Reason Code Appointment Reason Code.
Reason Desc Appointment Reason Description.

Record Example Appointments:

Company,Account,MRN,Appt Date,ApptTime,Book,Reason,Appt Description,Allotted,Tag Date,Tag Time,Room Time,Finish Time,Status,Appt Flag,Create Date,Create Time,Appt Referral,User Name,Facility,Anesthesia Used,Note,Appt Id,Arrival Time,Flag User,Reason User,Stat,Eligibility,Reason Code,Reason Desc

MAIN,M100000,100000,05/10/1980,10:15 AM,Computed Tomography,CT Calcium Scoring,CT Calcium Scoring,20.0,,,,,N,Unbilled,05/10/1980,12:30 PM,,Paul,RADIOLOGY FACILITY FIVE,N,,637375,,,,,No Insurance,CT1008,CT Calcium Scoring

Data Element Description
Company Top-level organization code used in all company-specific tables.
Account Patient's account number.
MRN Patient’s medical record number.
Account Balance Total account balance.
Insurance Due Amount of total account balance owed by insurance.
Patient Due Amount of total account balance owed by the patient.
Copay Per Visit Do Not Use
Unpaid Deductible Deductible amount applied to a charge.

Record Example Balance:

Company,Account,MRN,Account Balance,Insurance Due,Patient Due,Copay Per Visit,Unpaid Deductible

MAIN,M100000,100000,2263.7800,140.6600,71.3000,0.0000,0.0000

Data Element Description
Company Top-level organization code used in all company-specific tables.
Account Patient's account number.
MRN Patient’s medical record number.
Event ID Unique ID for each logged activity.
Timestamp Date & time when the activity event occurred.
Time Zone Not used.
Group Event Group.
Code Event Code.
Description Event description, providing context for the event.
User Name Name of the user who logged the event.
Status Status of the event

Record Example CLACTIVITYLOG:

Company,Account,MRN,Event Id,Timestamp,Time Zone,Group,Code,Description,User Name,Status

MAIN,M100000,100000,560036,8/17/2018 2:52:09 AM,,CHART,Open,,Supervisor MedInformatix,Y

Data Element Description
Company Top-level organization code used in all company-specific tables.
Account Patient's account number.
MRN Patient’s medical record number.
Allergy Substance a patient is allergic to.
Allergy Stated Substance a patient is allergic to.
Reaction Patient’s reaction to the allergy.
Severity Severity of the allergic reaction, often categorized as mild, moderate, severe, or other levels.
Allergy Type Specifies the type of allergy, whether it is a medication allergy, food allergy, environmental allergy, or another category.
Reported Date Date when the allergy was reported.
Entry User Name of the user who entered the allergy information.
Active Indicates whether the allergy is currently active (e.g., still relevant) or inactive.
Delete User User who removed the allergy, if applicable.
Delete Date Date when the allergy was deleted, if applicable.
Delete Reason Reason for deleting the allergy, if applicable.
Composite Allergy ID A unique identifier that may be used to link multiple allergies associated with the same patient or event.
Source Source of the allergy information, such as internal, or external source.
Concept Type Category of the allergy concept.

Record Example CLALLRGY:

Company,Account,MRN,Allergy,Allergy Stated,Reaction,Severity,Allergy Type,Reported Date,Entry User,Active,Delete User,Delete Date,Delete Reason,Composite Allergy Id,Source,Concept Type

MAIN,M100000,100000,Ampicillin,Ampicillin,Hives,Moderate,,05/10/1980,Ronald Smith,Y,,,,6402,Internal,

Data Element Description
Company Top-level organization code used in all company-specific tables.
Account Patient's account number.
MRN Patient’s medical record number.
Valid From Date from which the authorization is valid.
Valid Thru Date until which the authorization is valid.
Provider Healthcare provider or facility authorized for specific procedures or services.
Referred By Healthcare provider that referred the patient for authorization, if applicable.
Auth No Authorization number.
Status Status of the authorization, indicating whether it is active, expired, or for other purposes.
Ins Carrier Insurance carrier associated with the authorization.
Procedure Description Description of the specific medical procedure or service authorized.
Appt Authorization Description of the specific Appointment Reason authorized.
Create User Name of User who created the authorization record.
Create Date Date when the authorization record was created.
Change User User who last changed the authorization record.
Change date Date of last change to the authorization record.
Auth Id A unique identifier for the authorization record.
Appt No Appointment number linked to the authorization, if applicable.
# Allowed Number of authorized procedures or services allowed under the authorization.
# Appt Set Number of appointments scheduled as part of the authorization.
# Appt Used Number of appointments completed under the authorization.

Record Example CLAUTHRZ:

Company,Account,MRN,Valid From,Valid Thru,Provider,Referred By,Auth No,Status,Ins Carrier,Procedure Description,Appt Authorization,Create User,Create Date,Change User,Change Date,Auth Id,Appt No,# Allowed,# Appt Set,# Appt Used

MAIN,M100000,100000,06/22/2015,06/22/2015,[Any],,,R,MEDICARE,,Office Visit Established Patient 30 Min.,Meredith,01/04/2022,,,3731,1362748,1,2,0

Data Element Description
Company Top-level organization code used in all company-specific tables.
Account Patient's account number.
MRN Patient’s medical record number.
Claim Id Unique identifier for each patient claim, used for tracking and reference.
Diag 1 First diagnosis code associated with the claim.
Diag 1 Description Description of the first diagnosis.
Diag 2 Second diagnosis code associated with the claim.
Diag 2 Description Description of the second diagnosis.
Diag 3 Third diagnosis code associated with the claim.
Diag 3 Description Description of the third diagnosis.
Diag 4 Fourth diagnosis code associated with the claim.
Diag 4 Description Description of the fourth diagnosis.
Accident Indicates whether the claim is related to an accident or injury.
Pre Auth Prior Authorization number.
Referral Referring Provider.
Primary Insurance Patient's primary insurance provider.
Secondary Insurance Patient's secondary insurance provider.
Tertiary Insurance Patient's tertiary insurance provider.
Benefits Assignment Information about whether the patient has assigned their insurance benefits to a healthcare provider or facility.
Admit Date Date of admission if the claim is associated with hospitalization.
Admit Type Type of admission (e.g., emergency, scheduled).
Appt Number Appointment number linked to the claim.
Emergency Indicates whether the claim is related to an emergency medical situation.
EPSDT Refers to the Early and Periodic Screening, Diagnostic, and Treatment program, which is a Medicaid program for children. This field may indicate participation in the program.
Facility Healthcare facility associated with the claim.
Fee Type Fee Schedule Fee Type.
Ins Form Insurance claim form used for processing the claim.
Hospital Date From Start date for hospitalization.
Hospital Date To End date for hospitalization.
Incident Date From Start date of the incident or event related to the claim.
Incident Date To End date of the incident or event.
Partial Disability Date From Start date for partial disability related to the claim.
Partial Disability Date To End date for partial disability.
Total Disability Date From Start date for total disability related to the claim.
Total Disability Date To End date for total disability.

Record Example CLCLAIM:

Company,Account,MRN,Claim Id,Diag 1,Diag 1 Description,Diag 2,Diag 2 Description,Diag 3,Diag 3 Description,Diag 4,Diag 4 Description,Accident,Pre Auth,Referral,Primary Insurance,Secondary Insurance,Tertiary Insurance,Benefits Assignment,Admit Date,Admit Type,Appt Number,Emergency,EPSDT,Facility,Fee Type,Ins Form,Hospital Date From,Hospital Date To,Incident Date From,Incident Date To,Partial Disability Date From,Partial Disability Date To,Total Disability Date From,Total Disability Date To

MAIN,M100000,100000,1,R50.9,"Fever, Unspecified",,,,,,,,,,Self Pay,,,Y,,,,,,,,,,,,,,,,

Data Element Description
Company Top-level organization code used in all company-specific tables.
Account Patient's account number.
MRN Patient’s medical record number.
Msg Date Date when the collection note was created.
Msg Text Content of the collection note, which may include information related to billing, payment, or financial matters.
User Name of user who created or entered the collection note.
Msg Id Unique identifier for each collection note message.
Active Indicates whether the collection note is active or inactive.
Last Edit User Name of user who made the most recent edit to the collection note.
Last Edit Date Date of the last edit to the collection note.

Record Example CLCNOTES:

Company,Account,MRN,Msg Date,Msg Text,User,Msg Id,Active,Last Edit User,Last Edit Date

MAIN,M100000,100000,09/26/2014,"Called ref doc, retro autho obtained. 123ABC789, eff date 9/1/2014.",MedInfo Support,0000000002,Y,,

Data Element Description
Company Top-level organization code used in all company-specific tables.
Account Patient's account number.
MRN Patient’s medical record number.
Dispense ID A unique identifier for each vaccine dispensing event, used for tracking and reference.
Vaccine Date Date on which the vaccine was administered to the patient.
Vaccine Time Time at which the vaccine was administered.
Drug Name Name of the vaccine administered.
Dosage Dosage amount of the vaccine administered.
Route Method of administration (e.g., intramuscular, oral) of the vaccine.
Site Specific site on the patient's body where the vaccine was administered.
Type Type or category of vaccine administered (e.g., flu vaccine, COVID-19 vaccine).
Expiration Date Expiration date of the vaccine administered.
Lot Number Lot number of the vaccine.
Manufacturer Manufacturer that produced the vaccine.
Note Additional notes related to the vaccine administration.
User Name of user who entered the vaccine record.
Status Status of the vaccine record
Reaction Any adverse reactions or side effects experienced by the patient after vaccine administration.
Delete User User who marked the vaccine record as deleted.
Delete Date Date when the vaccine record was marked as deleted.
Facility Healthcare facility where the vaccine was administered.
Drug Id A unique identifier for the vaccine administered.
CVX The Code Set for vaccine administered, a standardized code for identifying vaccines.
Unit Of Measure Unit of measurement for the vaccine dosage (e.g., milliliters, micrograms).
Source Source of the vaccine
Tx Status Treatment or vaccination status (e.g., complete, in progress).
Tx Date Date associated with the treatment status.
Physician Code for healthcare provider responsible for administering the vaccine.
VFC Code A code related to the Vaccines for Children program, which provides vaccines to eligible children.
Prior Dx Reason Reason for administering the vaccine based on the patient's prior diagnosis.
Refuse Reason Reason for refusing the vaccine.
Entry Date Date the vaccine record was entered.

Record Example CLDISPENSE:

Company,Account,MRN,Dispense Id,Vaccine Date,Vaccine Time,Drug Name,Dosage,Route,Site,Type,Expiration Date,Lot Number,Manufacturer,Note,User,Status,Reaction,Delete User,Delete Date,Facility,Drug Id,CVX,Unit Of Measure,Source,Tx Status,Tx Date,Physician,VFC Code,Prior Dx Reason,Refuse Reason,Entry Date

MAIN,M100000,100000,5030,01/04/2012,17:51,"DTaP, 5 pertussis antigens",1,INTRADERMAL,Structure of intervertebral foramen of f,V,2012-02-28,2,"Immuno-U.S., Inc.",,Ronald Smith,Y,,,,MEDINFORMATIX MAIN OFFICE,,106,SZ,Internal,,,MD4,Not VFC eligible,,,9/1/2018 5:54:45 PM

Data Element Description
Company Top-level organization code used in all company-specific tables.
Account Patient's account number.
MRN Patient’s medical record number.
Doctor Code for the healthcare provider.
Name Name of the healthcare provider.
Office Name of the doctor's facility.
Street Address Street address of the facility.
City City of the facility.
State State of the facility.
Zip ZIP code of the facility.
Phone Contact phone number for the facility.
Email Email address of the healthcare provider.
Direct Address Direct Mail address of the healthcare provider.
Charge Percent Not used.
Allowed Percent Not used.
Copay Percent Not used.

Record Example CLDOCTOR:

Company,Account,MRN,Doctor,Name,Office,Street Address,City,State,Zip,Phone,Email,Direct Address,Charge Percent,Allowed Percent,Copay Percent

MAIN,M100000,100000,OFF_ADAVIS,Dr Albert Davis,MEDINFORMATIX,5777 W CENTURY BLVD STE 1700,LOS ANGELES,CA,90045,310/348-7367,,,100,100,100

Data Element Description
Company Top-level organization code used in all company-specific tables.
Account Patient's account number.
MRN Patient’s medical record number.
Relationship Familial relationship of the individual with the patient (e.g., mother, father, sibling).
First Name First name of the family member.
Middle Name Middle name of the family member.
Last Name Last name of the family member.
Address Address of the family member.
City City of the family member.
State State of the family member.
Zip ZIP of the family member.
Country Country of the family member.
Email Email address of the family member.
Phone Phone number of the family member.
Problem Description of the medical condition, problem, or disease relevant to the family member's history.
Code A specific code associated with the family member's medical condition or problem.
Age The age of the family member at age of the problem, if known.
Entry User The name of the user who entered the family history information.
Entry Date The date when the family history information was entered.
Rec ID Unique identifier for each family history record.

Record Example CLFAMILY:

Company,Account,MRN,Relationship,First Name,Middle Name,Last Name,Address,City,State,Zip,Country,Email,Phone,Problem,Code,Age,Entry User,Entry Date,Rec ID

MAIN,M100000,100000,Sister,AVA,,NEWMAN,1 MAIN,LONG BEACH,CA,90805,USA,,,No current problems or disability,160245001,,Timothy Applegate,10/17/2023,abb479e8-bd7b-43e4-9b0c-3ef541a01a0d

Data Element Description
Company Top-level organization code used in all company-specific tables.
Account Patient's account number.
MRN Patient’s medical record number.
File Location Location of the imported file within the system.
Chart Display Name Name of type of document imported.
File Name Name of the imported file.
Entry User User who imported the file into the patient's chart.
Entry Date Date when the file was imported to the patient's chart.
Active Indicates if the file was imported or deleted.

Record Example CLINBOXLOG:

Company,Account,MRN,File Location,Chart Display Name,File Name,Entry User,Entry Date,Active

MAIN,M100000,100000,C:\temp\CHECKLIST FOR DECEASED.doc,Diagnostic Reports,100000_011019_10_59_54_2.DOC,"Albert Davis, MD~",01/10/2019,Y

Data Element Description
Company Top-level organization code used in all company-specific tables.
Account Patient's account number.
MRN Patient’s medical record number.
Order Order number or identifier associated with the lab test.
Observation Id A unique identifier for each lab observation or result, predates LOINC.
Value Numerical or qualitative value of the lab test result.
Units Units of measurement for the lab test result (e.g., milligrams per deciliter, micrograms per milliliter).
Comment Additional comments or notes related to the lab test result.
Ref Range Reference range or normal values for the lab test, indicating what is considered within normal limits.
Abnormal Indicates whether the lab result is abnormal or outside the reference range.
Status Status of the lab result (e.g., final, preliminary, pending).
Source Source or laboratory that conducted the lab test.
Source Flag A flag or marker indicating specific conditions or details about the lab result.
Loinc Code A standardized code from LOINC (Logical Observation Identifiers Names and Codes) used to identify the lab test.
Test Date Date when the lab test was conducted.
Results Date/td> Date when the lab test results were available.
Load Date Date when the lab result was loaded into the system.
Entry User User or healthcare professional responsible for entering or recording the lab result.
Delete User User who marked the lab result as deleted, if applicable.
Delete Date Date when the lab result was marked as deleted, if applicable.
Delete Reason Reason for marking the lab result as deleted, if applicable.
Target Value A target or goal value for the lab test result, if applicable.
Doc Document or report associated with the lab result, if available.
Reviewed Indicates whether the lab result has been reviewed by a healthcare provider.

Record Example CLLAB:

Company,Account,MRN,Order,Observation Id,Value,Units,Comment,Ref Range,Abnormal,Status,Source,Source Flag,Loinc Code,Test Date,Results Date,Load Date,Entry User,Delete User,Delete Date,Delete Reason,Target Value,Observe Id,Doc,Reviewed

MAIN,M100000,100000,"UA, Complete",Specific Gravity,1.015,,,1.001-1.035,,F,QUEST,M,5811-5,06/22/2015,06/22/2015,06/22/2015,MEDINFO,MedInfo Support,,,,SPEC GRAV,,Reviewed by MC

Data Element Description
Company Top-level organization code used in all company-specific tables.
Account Patient's account number.
MRN Patient’s medical record number.
Msg Date Date on which a message was sent or received.
Msg Date Time Timestamp indicating both the date and time of a message.
From User User or sender of the message.
To User User or recipient of the message.
Msg Name Name or title of the message, which could describe its purpose or content.
Msg Text Text or content of the message itself.
Send Status Message's status, indicating if it was successfully sent or received, or if there were any issues with delivery.
Appt No Appointment Number - A reference to an appointment associated with the message, if relevant.
Msg Id Message Identifier - A unique identifier for the message, often used for tracking and reference.
File Name The name of any attached files or documents associated with the message.
Chart Display Name Name or label used to display patient information or medical charts.
Attachment Information about any attachments, such as file type or size.
External Name Name of an external entity or source if the message is related to external data.
External Type Type or category of the external entity or source.
Workstep A step or stage in a workflow or process, often relevant in healthcare or business contexts, if collected.
Provider Name Name of the healthcare provider or professional associated with the message or data, if collected.

Record Example CLMAIL:

Company,Account,MRN,Msg Date,Msg Date Time,From User,To User,Msg Name,Msg Text,Send Status,Appt No,Msg Id,File Name,Chart Display Name,Attachment,External Name,External Type,Workstep,Provider Name

MAIN,M100000,100000,10/17/2023,10/17/23 08:24:46,Timothy Applegate,Ronald Smith,"NEWMAN, ALICE",please see her when you can,Not Read,,A1619,,,,,,[New],

Data Element Description
Company Top-level organization code used in all company-specific tables.
Account Patient's account number.
MRN Patient’s medical record number.
Doctor Patient's primary healthcare provider.
Last Name Patient's last name.
Middle Name Patient's middle name.
First Name Patient's first name.
Address Street 1 Patient's primary street address.
Address Street 2 Patient's secondary street address.
City Patient's city.
State Patient's state.
Zip Patient's ZIP code.
Home Phone Patient's home telephone number.
Work Phone Patient's work telephone number.
Cell Phone Patient's mobile phone number.
Date Of Birth Patient's date of birth.
Sex Patient's birth sex (e.g., male, female).
Email Patient's email address.
Patient Type Customer-defined insurance classification (HMO, PPO, MEDICARE, etc.).
Fee Type Customer-defined name of the Fee Schedule used for determining charge and allowed amounts (STANDARD, MEDICARE, SELF PAY, etc.).
Drug Type Drug formulary code, legacy.
Referral Referral Source
Student Indicates whether the patient is a student.
Marital Status Patient's marital status (e.g., married, single, divorced).
Last Pay Date of the patient's last payment or financial transaction.
Last Visit Date of the patient's last healthcare visit.
Next Visit Date of the patient's next healthcare visit, if scheduled.

Record Example CLMASTER:

Company,Account,MRN,Doctor,Last Name,Middle Name,First Name,Address Street 1,Address Street 2,City,State,Zip,Home Phone,Work Phone,Cell Phone,Date Of Birth,Sex,Email,Patient Type,Fee Type,Drug Type,Referral,Student,Marital Status,Last Pay,Last Visit,Next Visit

MAIN,M100000,100000,Dr Albert Davis,NEWMAN,JONES,ALICE,1357 AMBER DR,,BEAVERTON,OR,97006,555/723-1544,555/777-1234,555/777-1234,05/01/1970,F,sales@MedInformatix.com,MEDICARE,STANDARD,U,,N,Unknown,,02/22/2022,

Data Element Description
Company Top-level organization code used in all company-specific tables.
Account Patient's account number.
MRN Patient’s medical record number.
Order Date Date when the order was placed.
Order Time Time at which the order was placed.
Description Description of the order, including details about the medical test, procedure, or service ordered.
Stat Indicates whether the order is considered "stat" or urgent, often requiring immediate attention.
Status Status of the order, indicating whether it is pending, in progress, or completed.
Dept Department or unit within the healthcare facility responsible for fulfilling the order.
Location Specific location within the healthcare facility where the order is to be carried out.
Done By Healthcare professional or staff member responsible for carrying out or fulfilling the order.
Done Date Date when the order was completed or fulfilled.
Done Time Time at which the order was completed or fulfilled.
Expected Expected timeframe for completing the order.
ICD The International Classification of Diseases (ICD) code associated with the order, often used for diagnostic coding.
Prov Healthcare provider who placed the order.
ID Unique identifier for the order.
Order Set Name Name of the order set.
Status User User responsible for updating the order status.
Status Date Date when the order status was updated.
Status Time Time at which the order status was updated.
Refuse Status Indicates the status of the order if it has been refused.

Record Example CLORDER:

Company,Account,MRN,Order Date,Order Time,Description,Stat,Status,Dept,Location,Done By,Done Date,Done Time,Expected,ICD,Prov,ID,Order Set Name,Status User,Status Date,Status Time,Refuse Status

Main,M100000,100000,06/22/2015,10:25 AM,Referral to Community Health Hospital IP,N,Not Yet Handled,REF,,,,,06/22/2015,,Supervisor MedInformatix,0001973518,,"Albert Davis, MD~",,,N

Data Element Description
Company Top-level organization code used in all company-specific tables.
Account Patient's account number.
MRN Patient’s medical record number.
Ref Name The name of the referring provider, often a healthcare professional or physician who referred the patient for specific medical services or treatment.
Ref Type The type or category of the referring provider (e.g., primary care physician, specialist, examples: Cardiology, Pulmonology, referring facility).
Ref Code A code or identifier associated with the referring provider, which may be used for tracking and reference.
Phone Number The contact phone number for the referring provider.
Email The email address of the referring provider.
Address Street 1 The primary street address of the referring provider's office or location.
Address Street 2 A secondary street address or additional address details, if applicable.
City The city where the referring provider is located.
State The state or region where the referring provider's office is located.
Zip Code The ZIP or postal code of the referring provider's office location.

Record Example CLPCP:

Company,Account,MRN,Ref Name,Ref Type,Ref Code,Phone Number,Email,Address Street 1,Address Street 2,City,State,Zip Code

Main,M100000,100000,"DAVIS, ALBERT",Referral,DAVI2472R000001,555/555-1002,,2472 ROCKY PLACE,,BEAVERTON,OR,97006

Data Element Description
Company Top-level organization code used in all company-specific tables.
Account Patient's account number.
MRN Patient’s medical record number.
Pharmacy Name Name of the pharmacy where the patient gets their prescriptions filled.
Address Street 1 Primary street address of the pharmacy.
Address Street 2 Secondary street address or additional address details.
City City where the pharmacy is located.
State State where the pharmacy is located.
Zip ZIP code of the pharmacy's location.
Phone Contact phone number for the pharmacy.
Fax Fax number for the pharmacy.
EPCS EPCS (Electronic Prescription of Controlled Substances)- Indicates whether the pharmacy is enabled to receive electronic prescriptions for controlled substances.
NCPDP NCPDP (National Council for Prescription Drug Programs) - A unique identifier used in the pharmacy industry.
Store Id Store identifier for the pharmacy.
Guid Guid (Global Unique Identifier) - A unique identifier.
Pharmacy NPI Pharmacy NPI (National Provider Identifier) - The NPI number specific to the pharmacy.
Pharmacy Online Indicates whether the pharmacy provides online services for prescription refills or other services.
Pharmacy Retail Indicates whether the pharmacy operates as a retail pharmacy, where patients can fill prescriptions.
Pharmacy 24 Hour Indicates whether the pharmacy operates 24 hours a day.
Pharmacy DME Pharmacy DME (Durable Medical Equipment) - Indicates whether the pharmacy provides durable medical equipment in addition to medications.
Pharmacy Status Status of the pharmacy (e.g., active, inactive).

Record Example CLPHARMACY:

Company,Account,MRN,Pharmacy Name,Address Street 1,Address Street 2,City,State,Zip,Phone,Fax,EPCS,NCPDP,Store Id,Guid,Pharmacy NPI,Pharmacy Online,Pharmacy Retail,Pharmacy 24 Hour,Pharmacy DME,Pharmacy Status

Main,M100000,100000,Medi-Blue Rapid Clinic,2165-B1 Northpoint Parkway,,Santa Rosa,CA,95407,7076445578,7076465100,0,2455142,,{1E196DD3-7A44-4F69-BE64-5D3603D3AB82},,,,,,Active

Data Element Description
Company Top-level organization code used in all company-specific tables.
Account Patient's account number.
MRN Patient’s medical record number.
Msg Date The date when the clinical note message was created or recorded.
Msg Text The content of the clinical note message, which may include information related to the patient's medical condition, treatment, or other clinical details.
User The user or healthcare professional who created or entered the clinical note.
Msg Id A unique identifier for each clinical note message, used for tracking and referencing.
Visit Date The date of the patient's clinical visit or appointment related to the clinical note.
Provider The healthcare provider or physician associated with the clinical note.
Appt No The appointment number or identifier linked to the clinical note, if applicable.
Active Indicates whether the clinical note is currently active and relevant or if it has been marked as inactive or completed.

Record Example CLPNOTES:

Company,Account,MRN,Msg Date,Msg Text,User,Msg Id,Visit Date,Provider,Appt No,Active

MAIN,M100000,100000,06/22/2015,The patient was found to have fever and Dr Davis is suspecting Anemia based on the patient history. So Dr Davis asked the patient to closely monitor the temperature and blood pressure and get admitted to Community Health Hospitals if the fever does not subside within a day.,MedInfo Support,0000000100,06/22/2015,MEDINFO,,Y

Data Element Description
Company Top-level organization code used in all company-specific tables.
Account Patient's account number.
MRN Patient’s medical record number.
Diagnosis ICD Code. ICD-10 since 2015.
Mapped Diagnosis Mapped or standardized diagnosis code that may be used for reporting and data exchange. The typical code is ICD-9.
Diagnosis Description Description of the diagnosis, providing additional details about the medical condition.
Note Notes or comments related to the diagnosis, providing context or additional information.
Reported Date Date when the diagnosis was reported or documented.
Onset Date Date when the patient's symptoms or condition began.
Provider Healthcare provider or physician responsible for diagnosing the patient.
External Provider Information about an external provider or specialist associated with the diagnosis.
Status Status of the diagnosis (e.g., active, resolved, chronic).
Approximate Onset An approximation of the onset date when the exact date is not known.
Rank The ranking or priority of the diagnosis in cases where multiple diagnoses are recorded.
Accident Indicates whether the diagnosis is related to an accident or injury.
Managed By Information about the healthcare professional or team responsible for managing the patient's diagnosis.
Case Id Unique identifier associated with the patient's diagnosis case, often used for reference and tracking.
Entry Date Date when the diagnosis record was entered into the system.
Snomed SNOMED CT code associated with the diagnosis, a standardized clinical terminology system.
Snomed Description Description or label associated with the SNOMED CT code.
Managed Managed: Indicates whether the diagnosis is actively managed or treated.

Record Example CLPROBLM:

Company,Account,MRN,Diagnosis,Mapped Diagnosis,Diagnosis Description,Note,Reported Date,Onset Date,Provider,External Provider,Status,Approximate Onset,Rank,Accident,Managed By,Case Id,Entry Date,Snomed,Snomed Description,Managed

MAIN,M100000,100000,E03.9,244.9,"Hypothyroidism, Unspecified",,12/31/2006,12/31/2006,Betty Gomez,DY,Controlled,,3,N,,,01/12/2022,83986005,Severe hypothyroidism (disorder),Y

Data Element Description
Company Top-level organization code used in all company-specific tables.
Account Patient's account number.
MRN Patient’s medical record number.
Diagnosis Code or identifier for the patient's diagnosis, often using standardized coding systems (e.g., ICD-10 code).
Mapped Diagnosis Mapped or standardized diagnosis code that may be used for reporting and data exchange. The typical code is ICD 9.
Diagnosis Description Description of the diagnosis, providing additional details about the medical condition.
Note Notes or comments related to the diagnosis, providing context or additional information.
Reported Date Date when the diagnosis was reported or documented.
Onset Date Date when the patient's symptoms or condition began.
Provider Healthcare provider or physician responsible for diagnosing the patient.
External Provider Information about an external provider or specialist associated with the diagnosis.
Status Status of the diagnosis (e.g., active, resolved, chronic).
Approximate Onset An approximation of the onset date when the exact date is not known.
Rank The ranking or priority of the diagnosis in cases where multiple diagnoses are recorded.
Accident Indicates whether the diagnosis is related to an accident or injury.
Managed By Information about the healthcare professional or team responsible for managing the patient's diagnosis.
Case Id Unique identifier associated with the patient's diagnosis case, often used for reference and tracking.
Entry Date Date when the diagnosis record was entered into the system.
Snomed SNOMED CT code associated with the diagnosis, a standardized clinical terminology system.
Snomed Description Description or label associated with the SNOMED CT code.
Managed Indicates whether the diagnosis is actively managed or treated.

Record Example CLPROBLMHIST:

Company,Account,MRN,Diagnosis,Mapped Diagnosis,Diagnosis Description,Note,Reported Date,Onset Date,Provider,External Provider,Status,Approximate Onset,Rank,Accident,Managed By,Case Id,Entry Date,Snomed,Snomed Description,Managed

MAIN,M100000,100000,E03.9,244.9,"Hypothyroidism, Unspecified",,12/31/2006,12/31/2006,Betty Gomez,DY,Controlled,,3,N,,,01/12/2022,83986005,Severe hypothyroidism (disorder),Y

Data Element Description
Company Top-level organization code used in all company-specific tables.
Account Patient's account number.
MRN Patient’s medical record number.
Rx Id A unique identifier for the prescription or medication record.
Rx Date Date when the prescription was issued.
Drug Name Name of the medication prescribed to the patient.
Prescription Prescription details, including dosage, strength, and other relevant information.
Instructions Instructions for the patient regarding how to take the medication.
Dispense Amount of medication dispensed to the patient.
# Refills Number of allowed refills for the prescription.
End Supply Date Date when the medication supply is expected to run out.
Source Source or origin of the prescription (e.g., prescribing physician or healthcare facility).
Drug Id An identifier associated with the medication (MEDID).
Active Flag Indicates whether the prescription is active.
Stop Reason Reason for stopping or discontinuing the prescription.
Stop Date Date when the prescription was stopped or discontinued.
Provider Healthcare provider or physician who prescribed the medication.
User Name Name of the user who recorded the prescription.
Co Sign User Name Name of the user who co-signed or approved the prescription.
Substitution Aka Dispense as written Y/N
Med Substitution This field indicates whether a substitution was made for a prescribed medication.
Patient Type This field categorizes the patient based on their status or type.
Substitution Flag Indicator that denotes whether a medication substitution was made.
Original Rx Date Original date when the prescription was initially issued.
Comply Indicates whether the patient is complying with the prescribed medication regimen.
Days Supply Number of days the medication supply is expected to last.
Dx Code Diagnosis code associated with the prescription.
CSA Schedule Controlled substance schedule associated with the medication.
Route User Name User name associated with the prescription route.
Route Date Date when the prescription route was recorded.
Stop User Name User name associated with the prescription stoppage.
Route Alt Fax Alternative fax information related to the prescription route.
Route Status Status of the prescription route.
Dispense Measure Unit of measurement for the dispensed medication.
Benefit Loop Information about benefits or coverage related to the prescription.
RXCUI A unique identifier associated with the prescription, often used in healthcare records.
Auto Expire Date The date when the prescription is set to automatically expire.
External Doctor Information about an external doctor or provider related to the prescription.
Route Route or method of administration for the medication.
Site Administration site for the medication.
Lot No Lot number associated with the medication.
Expiration Date Date when the medication is set to expire.
Admin By Healthcare professional or user responsible for medication administration.
Renewal Request GUID Unique identifier associated with medication renewal requests.
Pharmacy Pharmacy associated with the prescription.
Pharmacy Status Status of the pharmacy related to the prescription.
Pharmacy Note Notes or comments related to the pharmacy and prescription.
Pharmacy Reference A reference associated with the pharmacy and prescription.
Pharmacist Name of the pharmacist responsible for dispensing the medication.
Rx Route Transaction Id Unique identifier for the prescription route transaction.
Admin Time Time at which the medication was administered.
As Needed Indicates whether the medication is to be taken "as needed."
Long Term Indicates whether the medication is for long-term use.
Original Rx Id Identifier of the original prescription, if applicable.

Record Example CLRXHIST:

Company,Account,MRN,Rx Id,Rx Date,Drug Name,Prescription,Instructions,Dispense,# Refills,End Supply Date,Source,Drug Id,Active Flag,Stop Reason,Stop Date,Provider,User Name,Co Sign User Name,Substitution Flag,Substitution,Patient Type,Substitution Flag1,Original Rx Date,Comply,Days Supply,Dx Code,CSA Schedule,Route User Name,Route Date,Stop User Name,Route Alt Fax,Route Status,Dispense Measure,Benefit Loop,RXCUI,Auto Expire Date,External Doctor,Route,Site,Lot No,Expiration Date,Admin By,Renewal Request GUID,Pharmacy,Pharmacy Status,Pharmacy Note,Pharmacy Reference,Pharmacist,Rx Route Transaction Id,Admin Time,As Needed,Long Term,Original Rx Id

MAIN,M100000,100000,5931,06/22/2015,Aranesp (in polysorbate),Aranesp 500 mcg/mL (in polysorbate) injection syringe,Once a week,1,0,6/22/2015 12:00:00 AM,Prescribed in Office,545587,Y,,01/01/1900,Ronald Smith,Ronald Smith,,Y,,,,06/22/2015,,,,0,,,,,,ML,0,731241,,,,,,,,,,,,,,,,False,False,

Data Element Description
Company Top-level organization code used in all company-specific tables.
Account Patient's account number.
MRN Patient’s medical record number.
Date Taken Date when the vital signs were recorded or measured.
Provider Healthcare provider or medical professional responsible for taking and recording the vital signs.
BP Patient's blood pressure reading, which typically includes two values.
BP Description How was Blood Pressure taken other than seated position, if not indicated. E.g., Supine right arm, large cuff left arm.
BPS The systolic blood pressure value, which represents the pressure in the arteries when the heart beats.
BPD The diastolic blood pressure value, which represents the pressure in the arteries when the heart is at rest between beats.
Weight (lb) Patient's weight measured in pounds.
Height (in) Patient's height measured in inches.
Temperature Patient's body temperature reading.
Temp Description Description of the temperature measurement, such as "oral," "axillary," or "rectal."
Pulse Patient's pulse or heart rate, measured in beats per minute.
Resp Patient's respiration rate, measured in breaths per minute.
Resp Description Description of the respiration rate measurement.
BMI Patient's body mass index, which is a calculation based on weight and height.
Glucose Patient's blood glucose level, which is often measured for diabetic or glucose monitoring.
O2SAT Patient's oxygen saturation level, typically measured using pulse oximetry.
Inhaled O2 Amount of inhaled oxygen, if applicable.
Waist The measurement of the patient's waist circumference.
Entered Date and time when the vital sign data was entered into the system.
Recorded Date and time when the vital sign data was originally recorded.
Age Patient's age at the time when the vital signs were recorded.

Record Example CLVITAL:

Company,Account,MRN,Date Taken,Provider,BP,BP Description,BPS,BPD,Weight (lb),Height (in),Temperature,Temp Description,Pulse,Resp,Resp Description,BMI,Glucose,O2SAT,Inhaled O2,Waist,Entered,Recorded,Age

MAIN,M100000,100000,06/22/15 21:53:37,"Albert Davis, MD~",145/88,,145,88,194.0078,69.6850,100.4,,80,18,,28.09,,95,36,,,06/22/15 21:53:37,45

Data Element Description
Company Top-level organization code used in all company-specific tables.
Account Patient's account number.
MRN Patient’s medical record number.
Msg Date Date when the account note message was created or recorded.
Msg Text Content of the account note message, which may include information related to the patient's account, financial matters, or other relevant details.
User User or staff member who created or entered the account note.
Msg Id A unique identifier for each account note message, used for tracking and referencing.
Active Indicates whether the account note is currently active and relevant or if it has been marked as inactive or completed.

Record Example CLVNOTES:

Company,Account,MRN,Msg Date,Msg Text,User,Msg Id,Active

MAIN,M100000,100000,04/02/2018,Billing Note ,Timothy Applegate,0000000006,Y

Data Element Description
Company Top-level organization code used in all company-specific tables.
Account Patient's account number.
MRN Patient’s medical record number.
Guarantor Last Name Last name of the guarantor, who is typically an individual responsible for the patient's financial obligations, such as a family member or legal guardian.
Guarantor Middle Name Middle name of the guarantor, if applicable.
Guarantor First Name First name of the guarantor.
Guarantor Address Street 1 Primary street address of the guarantor.
Guarantor Address Street 2 Secondary street address or additional address details, if applicable.
Guarantor City City where the guarantor is located.
Guarantor State State or region where the guarantor resides.
Guarantor Zip ZIP or postal code of the guarantor's location.
Guarantor Phone Contact phone number for the guarantor, often used for communication and billing purposes.

Record Example GUARANTOR:

Company,Account,MRN,Guarantor Last Name,Guarantor Middle Name,Guarantor First Name,Guarantor Address Street 1,Guarantor Address Street 2,Guarantor City,Guarantor State,Guarantor Zip,Guarantor Phone

MAIN,M100000,100000,NEWMAN,JONES,ALICE,1357 AMBER DR,,BEAVERTON,OR,97006,

Data Element Description
Company Top-level organization code used in all company-specific tables.
Account Patient's account number.
MRN Patient’s medical record number.
Pay Date Date when the payment was made.
Entry Date Date when the payment record was entered into the system.
Payor Code Code or identifier associated with the entity or payor making the payment (e.g., insurance company, patient, third-party payer).
Pay Description Check, Check number, Credit Card, Cash
Pay Amount Amount of the payment made.
Entry User User or staff member who recorded the payment.
Pay Id Unique identifier for each payment, used for tracking and referencing.
Check Id Unique identifier associated with the payment check, if applicable.
Check Description Description of the payment check, or method used for payment.
Charge Id An identifier associated with the charge or service for which the payment is made.
Pay Location Location or facility where the payment was processed or received.
Insurance Carrier Name of the insurance carrier or company associated with the payment if it is related to insurance reimbursement.

Record Example PAYMENTS:

Company,Account,MRN,Pay Date,Entry Date,Payor Code,Pay Description,Pay Amount,Entry User,Pay Id,Check Id,Check Description,Charge Id,Pay Location,Insurance Carrier

MAIN,M100000,,09/01/2020,09/01/2020,INS1,Primary Insurance Payment,48.0000,"Albert Davis, MD~",5174,548,123,19778,LOCKBOX,

Data Element Description
Company Top-level organization code used in all company-specific tables.
Account Patient's account number.
MRN Patient’s medical record number.
Charge Id An identifier associated with the specific charge or service on the patient's statement.
Service Date From Starting date for the service period covered by the statement.
Service Date To Ending date for the service period covered by the statement.
CPT Bill The Common Procedural Terminology (CPT) code associated with the billed service.
Modifier Modifier code applied to the CPT code, if necessary, to provide additional information about the service.
Description Description of the service or charge.
Charge Amount Amount billed for the service.
Credits Any credits applied to the patient's account, which may include refunds or adjustments.
Balance Current balance on the patient's account, reflecting the amount owed.
Responsible Responsible party or entity for the charges, which may include the patient, insurance company, or another payer.
Billed Total amount billed for the services on the statement.
Episode A reference to the medical episode or case associated with the services on the statement.
Deny Code Denial code or reason provided by an insurance company for services not covered or approved.
Pay Ins 1 Payment received from the first insurance company.
Pay Ins 2 Payment received from the second insurance company, if applicable.
Pay Guarantor Payment received from the patient or guarantor.
Adjustments Any adjustments made to the statement, which may include corrections or write-offs.
Write Offs The amount of charges that have been written off and are no longer expected to be collected.
Charge Allowed The amount allowed by insurance or other payers for the services.
Copay The copayment amount, if applicable.
Deductible The deductible amount, if applicable.
On Account Amounts that are currently on the patient's account.
ICD The International Classification of Diseases (ICD) code associated with the diagnosis for the services provided.
Facility Code A code associated with the healthcare facility where the services were provided.
Rendering Doctor The healthcare provider who rendered the services.
Service Provider The healthcare provider or entity that provided the services.
Entry User The user or staff member who recorded the statement information.
Bill Date 1 The first billing date associated with the statement.
Bill Date 2 The second billing date, if applicable.
Last Paid The date of the last payment received.
Claim No The claim number associated with the statement for insurance processing.
Patient Responsibility Date The date when the patient's responsibility for the charges is determined.
Bill Status The status of the billing or statement, indicating whether it is pending, paid, denied, or another status.

Record Example STATEMENTS:

Company,Account,MRN,Charge Id,Service Date From,Service Date To,CPT Bill,Modifier,Description,ChargeAmount,Credits,Balance,Responsible,Billed,Episode,Deny Code,Pay Ins 1,Pay Ins 2,Pay Guarantor,Adjustments,Write Offs,Charge Allowed,Copay,Deductible,On Account,ICD,Facility Code,Rendering Doctor,Service Provider,Entry User,Bill Date 1,Bill Date 2,Last Paid,Claim No,Patient Responsibility Date,Bill Status

MAIN,M100000,100000,19778,6/22/2015 12:00:00 AM,6/22/2015 12:00:00 AM,99201,,"OFFICE/OUTPATIENT VISIT,NEW",48.0000,0.0000,0.0000,1,B,1,,48.0000,0.0000,0.0000,0.0000,0.0000,48.0000,0.0000,0.0000,0.0000,R50.9,OFFICE1,MD1_OFC1,MD1_OFC1,Supervisor MedInformatix,9/4/2018 12:00:00 AM,,9/1/2020 12:00:00 AM,3311,9/4/2018 12:00:00 AM,Billed

Data Element Description
Company Top-level organization code used in all company-specific tables.
Account Patient's account number.
MRN Patient’s medical record number.
XACDATE Date associated with the quality and payment charge codes, indicating when these codes are relevant or applicable.
CPT Current Procedural Terminology (CPT) code used to represent specific medical procedures or services provided.
ENTRYDATE Date when the quality and payment charge codes were entered into the system.
USERCODE The user or staff member responsible for entering the quality and payment charge codes.
REASONS Reasons or explanations associated with the quality and payment charge codes, providing context for their use.
MEASURE Measure or metric associated with the quality and payment charge codes, indicating the specific aspect of healthcare quality or payment they pertain to.

ZQUALITYPAYCHARGE Record Example:

COMPANY,ACCOUNT,MRN,XACDATE,CPT,ENTRYDATE,USERCODE,REASONS,MEASURE

MAIN,M100000,10000,2019-03-11 00:00:00.000,G8427,2019-03-11 00:00:00.000,MEDINFO,NULL,DM 130

Document Repository Data

MedInformatix exports all electronic documents.

It displays the practice designated sections for chart management. The Document repository supports various standards, anything text related will be exported as a PDF. Any other extension is in its original format without modification.

Export formats supported:

Portable Document Format (PDF) is the most common format. This format is generally seen as the standard format for creating and sharing documents online. It is a versatile file format used for diverse types of documents. It can be used for both straightforward and elaborate papers, containing text, images, illustrations, and multimedia like videos and audio.

Some examples of MedInformatix files which may reside within the Document Repository are BMP, JPG, TIF, GIF, PDF, DOC, XLS, MPG, AVI, etc.

Syntax: Filename, Date and Provider.