Dermatology Coding Alert

Using this list will ensure you don't miss out on an important component

You wouldn't buy shoes that don't fit, and the same thing goes for an electronic health records (EHR) system. Since features and functionalities differ in each EHR package, be sure to determine which ones are most important for your practice.

Look for these critical features when you're system- shopping:

•  Expandability. Find out whether the EHR system will be able to handle a growing number of patients, as well as additional providers and locations should your practice expand.

•  Integration. Your EHR system should mesh with other systems such as your practice management and billing software, especially if they're from another vendor. You should also be able to integrate into hospital EHR and registration systems, and with other physicians' EHR systems in the future.

•  Customized template. Make sure the documentation template is customized to fit your practice's specific needs, says Catherine Brink, CMM, CPC, CMSCS, president of Healthcare Resource Management in Spring Lake, N.J.

Avoid systems with "pattern documentation" in which the template is formatted to prompt the provider for answers to E/M services that are not medically necessary, Brink says. "EHR should be formatted for the specialty of the provider to  avoid pattern documentation and allow the provider to code correctly for the E/M service rendered," she says.

•  Ability to incorporate new technology. You'll want to ensure that your EHR software is capable of incorporating newer technologies as they emerge, such as the ability to securely e-mail patients' appointment reminders.

•  Privacy and compliance assurance. Ask whether your system will meet the standards of the Health Insurance Portability and Accountability Act (HIPAA), says Pati Trites with Advocates for Documentation Integrity and Compliance in Augusta, Mich.

•  Ease of use. The system should allow you to move quickly from screen to screen and should not seem to be convoluted and difficult to navigate. All of the employees at your practice should be able to use the system easily, including physicians, billing personnel and medical office receptionists.

•  Robust audit and entry capabilities. You want a system that "a robust audit system," Trites says. Some EHR systems will allow you to keep records "open" indefinitely, meaning that staff members can keep making invisible changes to the visit notes for months or even years. Other systems will allow you to turn the audit trail on and off, so changes can happen off the radar.

If a Medicare auditor asks to see the audit trail, you don't want him to see that documentation hasn't been completed for claims you submitted months ago, Trites says. You should also look for the ability to keep track of who documented what parts of the encounter, the ability to accurately reflect the time of documentation, and the ability to correctly perform an amendment or addendum to the medical record, Trites says.

•  Reliable backup system. If you lose all of your data during an emergency or power outage, your EHR software won't do you a bit of good. Test the backup system, ask questions such as how the information can be restored and how quickly it can be restored, and consider off-site storage of the backups.

•  Security. Ensure that the software program you choose has the capability of password protection and that you can control the password and security settings rather than the vendor. Security levels help control what information people can have access to. This should include the ability to limit access of various groups of physicians, secretaries and nursing staff to specific areas of the chart.

•  Multi-specialty functionality. Some practices may need the ability to input records across various specialties. If you need this feature, be sure that the system allows you to cross-pollinate patient records with various aspects of the treatment such as appointment schedule, prescription writing, lab results and medical history.

•  Scanning or other paper management option. You'll need a way to convert from paper to electronic formats. Be sure the EHR system you choose either has the ability to scan documents into the system or allows you to add that function via a third-party provider.

•  Ability to order and track lab and other services. Look for a system that has the "ability to order and receive results for in-house laboratory tests and x-rays," says Ian S. Easton, PhD, past president of the American College of Medical Practice Executives and current department head of applied technology for Coastal Georgia Community College in Brunswick, Ga.

•  Prescription-writing option. Most EHR systems allow you to write and refill prescriptions, print one or multiple prescriptions at a time, and keep track of expired prescriptions and medications that did not work for a patient.

Others go so far as to check medications against the patient's known allergies, indicate drug interactions, and provide clinical decision support with medication names and dosages. Easton recommends finding a system that allows you to print, fax or e-mail prescriptions.

•  Specialty-specific extras. If you're part of a specialty-specific practice, you may want to add other features. For example, a pediatric office may want to purchase an EHR system that allows growth charting and immunization tracking and reminders.