i) Progress Note Entry
Free text entry of encounter. Customizable specialty or disease specific templates, use of MEDCIN technology to encode notes, integration with voice recognition and standard transcription, data entry by proxies, data input by patients (e.g., Instant Medical History), tablet computer entry (clicking/inking/handwriting recognition), pictures, annotation.
ii) Integrated Patient Management or Interface for Patient Scheduling.
iii) Other Data Modules - Ability to scan documents and images into EMR. Voice Recognition Software for Dictation, Handwriting recognition for pen-based input. Interfaces for spirometry, vitals, EKG, endoscopy, phone messages/automated results reporting to patients.
iv) Patient call log for nurse and physician to document calls, with an audit trail.
v) Health Maintenance - Ability to customize for mammograms, PAP smears, Lipid, INR, Statins LFT monitoring at user-defined intervals and to track when they are due.
vi) Order entry for labs and imaging with CPT and ICD9 codes (bidirectional lab interfaces are rare)
vii) Laboratory and Radilogy Interface -HL7 standard, no extra charge for this with flags for abnormals.
viii) Prescription Management - Allergy alert with manual override. Meds List active long term PRN and per problem. Send Rxs directly to Pharmacy. Insurance Formulary. Frequent updates to medication database with side effects and customizable patient handouts. (Patient education hand outs, customized for your practice)
ix) E/M coding with regularly updated ICD and CPT codes automatically generated for encounter (depends on how data is entered – usually available only with templates, few “smart parsers” for free text)
x) Consult letters and tracking for pending consults
xi) Communications - Ability to enter data using handheld. Remote access to EMR using secure connection (Ability to look up patient demographics, H&P,labs from your home PC)
xii) Back up : ability to backup to tape, CD, RAID, NSD, incremental, offsite with reliable Disaster recovery
xiii) HIPAA compliance