Selecting an EMR/EHR Software System: Clinical Documentation Considerations

Last week, we highlighted some of the clinical management features you should consider before deciding on an EMR or practice management software system. Today, we'll outline a few important clinical documentation considerations.

1. Does the software system have a web-based patient interviewing software that can be incorporated into a note?

2. Does the EMR have an integrated transcription solution with macros, carbon copy, and distribution features, and full line-count reporting?

3. Is there a scanning solution integrated with the EHR/EMR?

4. Can the user annotate, mark-up, and sign scanned documents (e.g., ophthalmology or dermatology)?

5. Does the IT system have a demonstrated ability to eliminate transcription using templates and/or speech recognition?

6. Can the EMR user print the entire patient record?

7. Does the system have the ability to provide real-time billing updates and notification back into Practice Management System without any manual intervention (e.g., changes to insurance, situational data elements, and special billing functions)?

8. Does the EMR feature automated tasks to remind physicians of missing charges and to complete reconciliation features to the Practice Management System?

9. Can the user carry forward review of systems, problem list, medication, etc., from the patient's last visit?

10. Does the EHR have the ability to flexibly document conditions including expanding details (severity, location, etc.) for each clinical finding?

11. Can the user document the patient visit using pre-built templates?

Stay tuned for more "advice" later this month, when we'll outline some other important considerations when shopping around for your medical software system.