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.

Considering an EMR or EHR Software System? Clinical Management Features to Consider

If you are thinking about buying an electronic medical record (EMR) or electronic health record (EHR) software system for your physician practice, make sure you do your homework. Even the most affordable medical software systems require a few thousand dollars of your money, making it important that the software you select meets your expectations.

Following are some of the clinical management features you should consider before deciding on a medical or practice management software system. If the EMR or EHR vendor doesn't discuss one of these features, it's a good idea to ask them yourself.

1. Does the EMR software have the ability to enter all demographic and registration information in Practice Management System and transfer it to EHR without any data entry needed into EHR?

2. Can the user customize the patient demographic fields to display any number of Practice Management System fields to the clinician?

3. Can the physician or medical support staff quickly and easily switch from one patient record to another?

4. Is it possible to organize the screen and to customize tabs or modules according to user preferences?

5. Does the EHR software have the ability to display a patient summary or “face” sheet, including patient demographics, problems, medications, allergies, health maintenance, encounter listing, patient tasks, recent encounters, patient picture, and personal profile?

6. Will the EMR display and manage health maintenance alerts including chronic disease reminders per patient?

7. Does the EHR system notify to physician of critical lab and other test results for immediate attention, with a prioritization alert?

In Office Medication Dispensing

8. Does the medical software system check each orderable item for medical necessity and duplication?

9. Can the physician fax or electronically transmit prescriptions to the patient's pharmacy?

10. Will the EMR automatically alert the user when a prescription conflicts with a documented allergy, or when one prescription medication conflicts with another?

11. Does the EMR/EHR have the ability to easily search and report on prescribed medications in case of a drug recall?

12. Is the EMR/EHR software recommend best practice(s) based on current medical literature?

The right electronic medical records software system can save a physician practice time and money, while also improving patient outcomes. But it's important to ask the right questions when doing your homework. Later this month, we'll outline clinical documentation features to consider.

Have we missed any important clinical management features? Post a comment.