An electronic health record (EHR) or electronic medical record (EMR) allows your practice to input, recall, and track patient data electronically, replacing paper medical records. But EHRs are more than just digital versions of paper records. Here are the basic and advanced features and functions of EHRs that you should keep in mind when implementing, improving, or upgrading an EHR.
Basic EHR Features and Functions
Like a paper medical record, EHRs document patient information and medical histories. This documentation serves multiple functions, including providing a comprehensive record of patient care to support future decision-making, facilitating continuity of care across visits and clinicians, and providing support for diagnoses, care plans, and medication or other orders. However, the core EHR functions go beyond those of a paper medical record. The basic features and functions of EHRs include the following:
- Manage patient information: Capture and manage patient demographics, patient history, problem lists, medication lists, clinical documents, laboratory and test results, clinical notes, and external clinical documents.
- Guide patient care: Capture and manage patient-specific care plans, provide appropriate guidelines and protocols, and support clinical decision-making.
- Facilitate communication and education: Generate and record patient-specific instructions, support secure electronic communication between providers and between patients and providers, and identify appropriate educational or support resources for patients, families, and caregivers.
In 2003, the Institute of Medicine laid out eight core functions of an EHR, which include the following:
- Health information and data
- Results management
- Order entry/management
- Decision support
- Electronic communication and connectivity
- Patient support
- Administrative processes
- Reporting and population health management
The Centers for Medicare and Medicaid Services’ (CMS) Promoting Interoperability (PI) programs, which provide incentives for adopting and using EHRs, have four core requirements that go beyond the Institute of Medicine’s basic EHR functions. These include:
- Coordination of care through patient engagement
- Health information exchange
- Public health reporting
- Reporting on quality measures.
While all EHRs can perform these core functions, ease of use and adaptability vary. When selecting an EHR, you should consider the user interface for basic features and functions that you will use every day. For example, how easy is it to access patient history relevant to the current complaint? An intuitive user interface that allows for easy recall of pertinent information and fast documentation will ease the transition to an EHR. Improving EHR usability to increase productivity is vital if you’re replacing or optimizing an EHR.
Advanced EHR Features and Functions
The promise of EHRs goes far beyond digitizing paper medical records. With their built-in analytic capabilities, EHRs can help your practice adhere to guidelines-based care, seamlessly place and manage orders, improve your quality scores, and reduce errors.
Many EHRs include Clinical Decision Support (CDS) tools that can assist you in making decisions about patient care. Built-in CDS tools provide you with critical information about medications as you prescribe them, like recalls, interactions, and allergies. EHR-based CDS tools can also automatically provide clinical guidelines, alert you to deviations from guidelines-based care, and even support accurate diagnoses. Using these CDS tools can also help reduce medical errors, making patient care safer, and reducing your liability. For example, EHRs can flag possible medication errors like interactions or inappropriate dosages, and they can alert you to deviations from guidelines-based care.
EHRs also facilitate computerized physician order entry (CPOE) for medications, laboratory tests, radiology, physical therapy, and other frequent orders. Using these EHR capabilities, you can eliminate handwritten or faxed orders, save time, and reduce misunderstandings or lost orders.
Many quality improvement and pay-for-performance programs, such as the Quality Payment Program (QPP), require regular reporting of quality metrics. EHRs simplify such reporting by reducing data entry needs and internally tracking your performance over time. Additionally, EHRs provide automatic, patient-specific reminders for preventive services like vaccinations and cancer screenings, which are commonly tracked as part of quality improvement programs. Using an EHR can help you increase your quality scores by encouraging the timely provision of preventive services, accurately tracking patient progress toward care goals, and allowing you to see your progress toward quality benchmarks in real-time.
Finally, optimize EHRs to be customized to your workflow and practice needs. With some EHRs, you can create EHR templates to simplify regular tasks like managing your office’s schedule, reviewing quality data, or managing orders. Similarly, order management and order sets allow you to quickly order common medications or tests for patients with similar conditions.
How the Right EHR Can Streamline Your Workflow
With the right EHR, you can streamline your EHR workflow, improving efficiency and saving your office time and money. Built-in and custom EHRs tools can help you analyze the flow of patients through your office and the flow of patient information within your practice so you can identify bottlenecks and pain points. For example, managing laboratory, test, and medication orders frequently require significant staff time. With a user-friendly EHR, orders and results can be managed electronically, and you can easily identify delays or bottlenecks in scheduling follow-up visits.
EHRs also help streamline your coding and billing workflow. Compared to paper records, EHRs capture a more complete, accurate list of diagnoses and procedure codes in real-time, helping to ensure complete billing and reducing requests for additional information. The right EHR may also include rules-based clinical, administrative, and financial coding assistance to ensure completeness, accuracy, and timely reimbursement.
Should You Use EHR Speech Recognition?
EHRs can work with speech recognition software to allow you to dictate notes directly into the EHR without the need for transcription. If you currently dictate notes and use transcription services, speech recognition software can save you money. Pairing an EHR with speech recognition can also improve efficiency in your practice and facilitate high-quality care by ensuring complete and timely documentation. However, speech recognition software is not perfect and requires double-checking, so it may not be worthwhile if you use dictation infrequently. It also often doesn’t capture the discrete data element points needed for quality programs, E&M coding, and analytics.
How TempDev Can Help
TempDev offers a wide array of NextGen EHR consulting services to help you implement and customize your NextGen EHR, including EHR reporting solutions and templates, workflow optimization, and training. TempDev consultants can also help you improve practice workflows.
Call us at 888.TEMP.DEV, or contact us here to get started implementing or improving your EHR.