EHR EMR / EHR Requirements and System Features List By Kashish Arora EHR 4 comments June 20, 2024 Accurate electronic health records are literally a matter of life and death, and sifting through the many EMR/EHR features can feel overwhelming. EMR and EHR software collect and standardize the information needed for managing patients’ medical records and treatment, so choosing the right system based on your specific EMR requirements is vital. Get our EHR/EMR Software Requirements Template What This Article Covers Importance Needs Analysis Key Requirements Charting Electronic Prescriptions Medical Billing Telehealth Communication Result Management Clinical Workflow Management Technical Requirements Integration and Extensibility Meaningful Use System Selection Conclusion Importance So what’s the big deal? Aren’t all EHR and EMR systems pretty much the same? The short answer is not at all! The long answer is that each medical practice is unique — an occupational therapy clinic won’t have the same needs as a behavioral medicine provider. There may be an EHR/EMR system broad enough to serve both adequately, but selecting a specialized platform tailored to your practice can cut down on costs, improve adoption and result in better overall patient care. Identifying your organization’s specific needs will help you select the right solution to meet those needs and provide better patient care. Needs Analysis To identify what your practice needs from an EHR or EMR, you need to ask yourself some guiding questions. You will have to consider various issues before deciding which system to buy, and considering these questions beforehand can help refine your request for proposal to ensure you find the perfect solution for your medical software needs. Some of the questions you should consider asking include: 1. What are your goals for implementing an EMR or EHR? Why are you searching for an EMR or EHR? If you’re upgrading to a more robust system, your requirements will look very different from a practice buying its first EMR. Having clear goals like, “I want to be able to do more from my device” or “I want to centralize all my practice’s tasks into a single system” will help narrow down solutions that definitely aren’t an excellent fit. Naming the specific inefficiencies you’d like to solve is a good way to identify your company’s purchase goals. 2. Who will use the system? How many users? A small family practice and a hospital won’t have the same needs, and many vendors price systems on a per-user basis. Knowing how many users and who those users are is vital information to provide vendors to ensure a good match. 3. Does the system need to interface with other software solutions? Do you use a separate system to schedule patients? What about a billing system? A legacy EHR? Data security software? A customizable dashboard to review multiple files at the same time? None of the above? EMRs can be especially limited in their interoperability while EHRs have restricted integration capabilities. Keeping in mind each system’s potential, identify what you need to connect to well in advance to prevent frustration down the line. 4. Do you need to access the system on mobile, desktop or both? Many software systems offer mobile apps today — in fact, some only offer mobile interfaces! Identifying how you want to access the system is crucial. Once you’re able to find an answer to this question, finalizing your pick will become extremely easy. 5. What are your performance and support expectations? The current market condition makes it imperative to ascertain how a product vendor prepares to provide your practice with a high-quality support system. Defining your expectations will aid in gauging your anticipated performance standards for reaching an optimal solution. 6. What is your budget for this purchase? Budgeting is advantageous for future investment and expenditure. Since buying a new solution can demand significant cash, ascertaining a cap-off price will help you adhere to the company’s spending limit. Asking vendors about subscription, implementation and maintenance costs in advance will save you from unexpected expenses. You should also ask prospective vendors some questions before settling on a match to ensure you have all the relevant information upfront. Some questions to ask EHR vendors are: Select the Right Software with the Free Lean Selection Book You should also ask questions of the prospective vendors before you settle on a match to make sure you have all the relevant information upfront. Some questions to ask EHR vendors are: Is the software optimized for mobile devices? What systems does the software integrate with? What implementation time frame can we expect for an organization of our size? How does the platform streamline workflows? What customization features does the platform include? Are they add-on EHR/EMR capabilities? What security features does the system use to maintain HIPAA compliance? Do you offer data migration services? If so, do they cost extra? Do you offer training support? What kinds? What are the upfront vs. continual costs? Is the software updated regularly? Will this affect our access? Armed with these questions and the answers you gleaned from the first section, you’re ready to take on our EMR requirements list. Get our EHR/EMR Software Requirements Template Key Requirements Functional EHR software requirements refer to the capabilities at the system’s core. Most platforms will offer some version of these capabilities, but not necessarily all, so it’s essential to know what your practice needs and find out what the specific solution offers when you first conduct research. 1. Charting The most basic function of EMR and EHR platforms is medical charting. With EMRs, you can document and access patients’ medical histories with your practice over time. EHRs take this function a step further, promoting interoperability. With an EHR, you can access and share patient information across organizations to get a complete view of treatments, medications, allergies and family history. 2. Electronic Prescriptions EHR platforms send medication prescriptions to patients and pharmacies electronically. E-prescribing enables physicians to submit an Rx directly to the pharmacy of their patients’ choice so they can pick up their medications at a time and place that suits their needs. It makes it more efficient for physicians to prescribe, search and view medications digitally. Practice Fusion’s e-prescribing module. This feature gives providers the opportunity to reconcile old medication files swiftly while also preventing drug errors and duplicate therapies. It also offers decision support features that help alert providers of possible risk trends and aid in decision-making. Dose Calculator Clinical Decision Support Health History Computerized Provider Order Management (CPOM) Benefit Verification and Formulary Price Estimator Refill 3. Medical Billing When it comes down to it, there’s no denying that health care organizations are businesses and medical billing is an important process. Like any other business, you need to be able to manage your revenue efficiently to be successful. Medical billing enables invoicing staff to reduce record-keeping hassles for generating superbills more efficiently and in less time. View billing reports, including accounts receivable, claim accuracy, claim categories and insurance aging, using Kareo Billing. This functionality provides health care professionals with a better system to automate billing procedures, eradicate paper-based superbill errors and reduce physical file maintenance costs. Medical Billing Codes Eligibility Checks Rejection and Denial Management Electronic Superbills Claims Submission and Management Insurance Coverage Patient Payments Get our EHR/EMR Software Requirements Template 4. Telehealth Advancements in technology have changed the way patients access quality care today. The advent of telehealth functionality is a classic example of how technology enables better communication among physicians and patients at a distance. Manage patients in virtual waiting rooms and view daily appointments in list format using Amwell’s telehealth clinician telehealth dashboard. To ensure optimal patient engagement, telehealth facilitates powerful virtual care capabilities to provide effective collaboration among various health care professionals from across the globe. This functionality supports swift information exchange, seamless treatment progress tracking and streamlined care plan monitoring for excellent remote care delivery to patients. Audio/Video/Text Consultation Clinician Directory Patient Consent and Intake Provider Collaboration Virtual Waiting Room Secure Recordings Virtual Walk-in Urgent Care Clinic 5. Communication What makes an EHR an EHR is its capability to communicate with a variety of sources outside the practice. Patient portals are more than just helpful today. Patient-centric portals enable patients to access their medication records, lab results, appointment schedules and educational resources. They can do this via an in-system portal or through software integration with a third party like Google Health. Allow patients to view lab results and messages in MyQuest’s patient portal. Instead of wasting patient and physician time on minor ailments or commuting to the physical office, patients can simply message their physician via their EHR’s secure direct messaging system. Physicians can advise patients on medication changes and minor health problems or let them know an issue is severe enough to warrant an in-person visit. While some organizations may require a separate patient scheduling system, EHRs offer enough scheduling functionality to meet many practices’ needs. Patient Portal Appointment Scheduling Secure Direct Messaging (SDM) E/M Coding Insurance Verification Telehealth Get our EHR/EMR Software Requirements Template 6. Result Management Managing patient treatment plans, receiving test results and tracking progress over time are crucial to successful care. There are various EMR features that facilitate result management. Immunization registries are federal databases that collect vaccination records on citizens with the goal of high vaccination coverage. They consolidate medical data on patients from multiple health care providers in order to identify those who are due or late for vaccines regardless of their provider. If an EHR system can’t connect to these databases, patient data is more difficult to access later for important CDC studies or tasks like college enrollment. Charting capabilities found in each system also contribute to how easily a physician can access patient records. Subjective, objective, assessment and plan (SOAP) note functionality is a huge benefit to practices as they communicate with interdisciplinary teams to treat patients. Along the same lines, computerized provider order entry (CPOE) can streamline practice workflows and balance workloads. Both these capabilities foster communication, accuracy and value-based care. Clinical Summaries Lab Orders Lab Results Immunization Registries Integration SOAP Notes Problems List CPOE Enabled Prescription Templates Demographic Management Care Management 7. Clinical Workflow Management What makes a health care organization run successfully is its administrative staff. Improving efficiency and productivity by reducing operational workload can help your business gain significant traction. Clinical workflow management enables you to reduce potential medical errors with resources that can provide optimal organizational outcomes and patient satisfaction. Diet Management Follow-up Reports/Recall Tracking Document Management and Faxing Medication Management Health Care Plans Reminders Orders and Lab Management Referral Management Technical Requirements You should also look for technical architectural features. These include security certifications, performance reporting, data management, deployment and more. You must always check the application’s scalability and fault tolerance architecture while buying an EMR. The solution you are trying to implement can provide you a broad spectrum of benefits only when it’s horizontally and vertically scalable. In addition, the fault tolerance capabilities enable the system to recover from failures immediately. Medical compliance capabilities and data security are vital to keep in mind when purchasing an EHR. Almost all will be HIPAA compliant and come with ICD-10 or ICD-11 support. There are plenty of other types of security and certifications to look out for in order to get the best system for your practice. Some will be ONC-ATCB compliant, meaning they have been certified by an additional regulatory body. Some will also be CCHIT certified. How your system is accessed is another thing to consider. Users can install EHR systems into their private servers (called on-premise) or via a software-as-a-service (SaaS) cloud-based EHR. Some deployments will offer mobile web apps that users can access remotely. Another aspect to keep in mind is whether the EHR can integrate with other software. Can this EHR integrate with one or even multiple practice management software offerings if you operate a large multi-location practice or hospital? What about medical billing software? Finding out what interoperability capabilities you need beforehand can help ensure practice-wide implementation. Document Upload and Storage ONC-ATCB ICD-10 or ICD-11 Support Mobile Web App Deployment Environment Implementation Services Chat and Instant Message Options E-signature APIs Clinical Exchange Document Data Importing/Exporting Integration and Extensibility System integration enables users to access medical records across solutions seamlessly. Whether you’re looking for treatment notes or prescription histories, this functionality can scour for accurate files swiftly, saving you time and effort. Some advantages that come with system integration include: Improve data quality Standardize information-keeping formats Eliminate data silos Streamline information acquisition Access a clean archive repository Enhance data management When looking for an ideal integration solution, look for the following tools: Calendar Integration Data Exchange and Interoperability Platform Integration Clinical Device Integration Inventory Management Software Integration Laboratories Integration Medical Scheduling Software Integration Patient Data Export Payment Processing Platforms Integration Prescription Management Software Integration Reporting and Analytics Software Integration Telemedicine and Telehealth Software Integration Meaningful Use Meaningful use incentives are another vital EHR requirements consideration. Utilizing the capabilities of a certified EHR system to demonstrate meaningful use results in fewer penalties and more money back in your pocket. Promoting Interoperability Programs, instituted by the Centers for Medicare and Medicaid Services (CMS), requires eligible professionals (EPs) and eligible hospitals to report on four core categories as of 2022 to demonstrate meaningful use: Electronic Prescribing Health Information Exchange Provider to Patient Exchange Public Health and Clinical Data Exchange Selecting EHR software with ONC-ATCB certification ensures your system has the necessary features to meet meaningful use requirements and empowers you to do so. Get our EHR/EMR Software Requirements Template System Selection Don’t let the volume of EMR and EHR software features overwhelm you — this is an overall list, and every practice will find different features necessary. Using this EHR requirements template can help you evaluate which EHR capabilities are most important to you. Once you’ve identified your EHR system requirements, you can generate an RFP to send to the vendors who best deliver those EMR features. Based on the information you receive, you’re ready to create a shortlist and compare offerings — use our EHR/EMR comparison matrix and pricing guide to guide your evaluation. After selecting a shortlist of best-fit platforms, it’s time to ask for a personalized price quote and demos. Most platforms are priced based on which features users need, so you will be ready for this step. Take the system for a spin with a trial or demo to evaluate the interface’s user-friendliness for yourself. Conclusion Selecting a new application isn’t a simple task. Thoroughly defining the EHR and EMR requirements checklist, however, eases the process immensely. Now you should be armed with the knowledge to find your perfect software match and continue providing excellent care to your patients! What do you look for in an EHR/EMR? Let us know in the comments! Kashish AroraEMR / EHR Requirements and System Features List06.20.2024