Health Information Compliance Alert

Check this handy list to compare different systems.

Finding an electronic medical records (EMR) system that fits your practice is as important as finding a pair of shoes that doesn’t pinch your toes or give you blisters. Features and functionalities differ in each EMR, so you need to determine which ones are most important for your practice.

Use this checklist to ensure the systems you review have these critical features:

• Expandability. Find out whether the EMR system will be able to handle a growing number of patients, as well as additional providers and locations should your practice expand.
• Integration. Your EMR 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 EMR and registration systems, and with other physicians’ EMR systems in the future.
• Customized template. Make sure the documentation template is customized to fit your practice’s specific needs. 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.
• Ability to incorporate new technology. You’ll want to ensure that your EMR 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).
• 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 with thorough auditing functionality. Some EMR 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 payer 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. 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.
• Reliable backup system. If you lose all of your data during an emergency or power outage, your EMR 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 EMR 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.
• Prescription-writing option. Most EMR 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. You should also look for 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 EMR system that allows growth charting and immunization tracking and reminders.