Well, to start with, an electronic medical record (EMR) is a digital version of traditional paper-based medical record for an individual and it represents a medical record within a single facility, like a doctor’s office or a clinic. It contains general information related to patients such as treatment and medical history.
As we know them EMR/EHR are the storehouse of patient medical information and they act as a central repository connecting a number of clinical modules around hospital settings that generate & capture patient data. A number of EMRs come packed with various modules such as clinical decision support, computerized physician order entry, PACS, Laboratory information system, e-Prescriptions, etc.
Understanding the requirements for the development of EMR system
Now there are numerous modules of EMR and they are all considered pretty important for the making of EHR system for websites as well as mobile apps.
Just as mentioned above, software for electronic health records tends to have their own key points that are not meant to be disregarded. Basically, there are two key requirements, which are: physician work list requirements & charting capabilities within the software itself.
Keep note that each of the EMR/EHR software must be able to help physician keep records of all medical records, varying from:
- Patient data and health conditions
- Vitals & measurements
- Patient data & health conditions
- Surgery histories
- care plans
- outstanding lab or radiology results
It should be ensured that the physician, as s/he deals with electronic medical records, is able to access it with complete ease. Also the charting capabilities which are present in each system contributes to how easily the records can be accessed by a physician. These may include:
- online check-ins
- chart searches
- follow up appointment reminders
- electronic provider order entries
- plan note documentations
- objective assessments
- prescription templates
Often the systems are evaluated largely on the basis of these two key requirements. And then there are functional requirements as well that need to be evaluated. They may include, however are not limited to:
- appointment management
- electronic remittance advice
- insurance claim validation and insurance verification
- electronic provider schedules
- lab order tracking
- lab result sharing
- billing management
- allergy assessments
- assessments of dangerous drug interactions
Then comes reporting part. So there will be many who generate clinical quality reports & financial analysis. Also there are many systems offering the ability to even customize reports. So, report capabilities may comprise of:
- Ad-hoc reports
- e-prescription reports
- CPOE reports
- document management
- custom reports
Then, there are technical requirements as well that need to be considered, where it is crucial to follow all law & regulations under HIPAA, HITECH & ONC-ATBC. Complying to them will ensure there are no illegal activities taking place – mainly when some malfunction occurs due to technology and you failed to catch that timely. Besides, you must also look at how the system deploys, like are they going to offer host installation – IE the system is installed off-site – or is it going to be installed directly into the system – on-premises installation?
Here, are the modules for an EMR Software:
- Patient management and listing
- Alert & Notifications
- Hospital/Clinic Management & customizations possible at clinical level
- Multi-user based system, with user access mechanism for different staff members
- In Adherence to HIPAA standards
- In adherence to HL7 standards
- Compliant to ICD9/10
- Work Scheduling Management System
- Document Management System
- Patient charting module and SOAP notes
- Accounting module
- Payer Management
- Billing Management and Claim Generation (EDI 837)
- Comprehensive Appointment & Scheduling
- Can be integrated with clearing houses (on requirement basis)
- Subscription-based access mechanism
- In-built DICOM Viewer facility (on-requirement basis only)
- Activity Log Tracking & Monitoring
- Interoperability-ready modules for Lab and Radiology Integration
- Record demographics, vitals, insurance, smoking status, allergies, medications, immunizations, conditions, social history, family history, and many other crucial information
Next, let’s head to exploring features of EMR software.
What are the vital features of an EMR/EHR system?
This is solely for patient and this portal portal give users (patients) access to:
- Lab results
- Forms to download
- Educational materials
- Discharge summaries
- Recent doctor visits
Patient portal functionality includes:
- Appointment scheduling
- Contact information update form
- Benefits & coverage checks
- Prescription refill request form
- Secure e-mail exchange with providers
A set of procedures need to be followed in every medical practice. Thus, having EHR/EMR software that understands the order of operations and guides users to function them, save a lot of time for the current users as well as the trainees or new joiners. In some cases, EMR/EHR software also offer customizable work-flows thus keeping everyone & everything on track. Like, you reminder emails can be automated as well as reminders can be set for phone calls to patients and to send test results.
In the medical arena, charts play a big-big role, in fact, an EMR software/system incapable of charting in real-time leads to stress, burnout, and inaccurate/incomplete charts. For instance, if a chart is not timely prepared, doctors need to stay after shifts, or maybe chart from their home, or need to come in even during off-days, so to complete the documentation. Thus, this feature is crucial in every EMR/EHR system.
- Besides, it would be further helpful, if the chart offers this voice recognition feature too. This wouldn’t just save time, but also help in many other ways too.
- EMR system also offers customizable templates and this way your charts will be featuring the fields you require and not the ones you don’t, this will save time & training.
- With charts, it is also possible to track vital signs over multiple encounters. Also, there are charts that automatically display percent changes, this way you will know at a glance that the patient’s BP is 12% lower than it was two months ago.
- Being able to chart on tablets is crucial too, as at the time you require to chart away from your desktop. Or else, you will need to input the information later on manually. With programmable keyboard shortcuts charting time can be saved.
An EMR system makes the payment receiving a lot faster, painless, as well as integrated. Like, it includes:
- It is a lot easier having the information & data from charts onto bills.
- Sending bills can easier with the system
- The software helps in taking payments and integrates easily with a system that is taking payments.
- The system can integrate with payment software.
To make the bill creation effortless, a program auto-fill a bill mentioning services from the chart. It may even allow you to view the bill & chart simultaneously.
Having a software that is helpful in complying with evaluation & management document standard is pretty helpful. Thus, it can be ensured that healthcare payers are in the loop about for what & how much they have to pay out.
So, the information may vary from:
- Diagnosis and treatment codes
- Reason for the encounter and relevant history
- Complete and legible medical records
- Patient’s progress, response to and changes in treatment, and revision of diagnosis
- Appropriate health risk factors
- Prior diagnostic test results
- Physical exam findings
- Assessment, clinical impression, or diagnosis
- Date and legible identity of the observer
- Medical plan of care
It is vital that the EMR system also offers e-prescriptions so that you can print & transmit prescriptions electronically. Besides, it enables immediate & automatic notifications of potential drug allergy and interactions.
Same as e-prescriptions, the ability to electronically monitor analysis, delivery, a degree of certainty & results of samples seamlessly and then integrate that information with charts can be greatly helpful. It offers two-way communication with labs, easy access to explanatory information & research on lab results. Just see which lab/s the software integrates with.
Ensure your Compliance
Health Insurance Portability and Accountability Act (HIPAA)
Health Level 7 International (HL7)
Food and Drug Administration (FDA),
U.S. Department of Health and Human Services (HHS)
HITECH’s Meaningful Use Stage 1 and 2 (MU-1 & MU-2
Cloud hosting is immensely popular nowadays among the health institutions. Being able to access records from any location has unleashed us from the premises.
Advancement in virtualization, computing power, and high-speed connectivity makes cloud hosting feasible, while encryption makes it secure. Cloud technology is system and cheaper to integrate, maintain & update. Besides, it gets easier to have access to information everywhere.
What are the benefits of an EMR/EHR System?
Well, there are a number of advantages of using an EHR framework in the hospitals and clinics. Here, we have mentioned a few:
- Well tested and quality assured product
- Near to zero maintenance and complete maintenance support
- Reduced Development time as well time to market
- Ready for SaaS or PaaS models
- Modular framework to support ‘Plug & Play’ system
- Robust foundational Architecture for any customizations
These benefits of EMR help in producing a huge increase in health-related safety of patients & patient welfare. Besides, electronic medical records & patient care are synonymous in that, as such systems easily enable constraints to be placed upon end users’ access to specific patient information.
Put EMR / EHR System on Mobile Platform
No doubt that EMR mobile applications will boost the efficient of the system as mobile apps enables departments & staff members to access the required information/data/reports on the go from anywhere through the mobile devices. Thus, developing EHR mobile application is an good idea.
How to find the right EMR/EHR software developer?
Now there are a number of Medical software development companies which make this kind of system, and it will prove to be a daunting task to mention them all here. So, it is vital to keep few things in mind as you initiate the search.
- First, as you are choosing a vendor – do a lot of research, like go through the surveys, reviews, etc. This allows easy and fast elimination of the ones with poor reviews or the ones that appear sketchy. There could be a mismatch in priority if the medical software development firm is dealing with hospitals that are a different size than yours – it can be smaller or larger. This way, you can receive the best services for the amount you pay.
- So, as you succeed in bringing down the list to top 10 or 15, then it gets easier figuring out which firm you can rely on with your data. Then, it is time to pen down a request for a proposal. This way the development firm gets to know about your company/hospital and the information they need – like top criteria for EMR system & what your organization focuses on primarily.
- Once you receive the response from the developer, you can invite the top companies to visit your hospital. Then you can know how their system works and performs. Also, hand out a rating form to your employees if you are keen to have their input prior to taking the big decision. Ensure it is done prior to each demo in this way it is ensured that the audience can follow & understand the system easily. Also, they can give their feedback easily on a particular developer.
- Further, you must be talking to references as well for each developer. Get contacts of other firms who have a past experience of working with a particular developer. This helps in gaining some extra and crucial information & opinions before you finalize a EMR Software Developer. Being thorough with questioning is vital as references are often likely to give positive reviews as compared to people you know are likely to give an honest opinion if in case the development services are not that extraordinary.
There can be questions like – Would choose the developer again? How satisfied are you with our decision to go for services of this Healthcare IT Solution provider company? How disruptive was the installation of the system? Are you looking for relatively low disruption (as the ones who take three days for installation are not viable)? What about the costs for system maintenance?
EMR system is greatly helpful in streamlining the process of keeping health records & medical records up-to-date. However, often the expense and time of development and implementation of a system exceed how much you are investing in at first glance. Thus, it is integral to have a thorough look at them as this makes all the information gathered by you valuable.
Well, EMR software is going to immensely impact your day-to-day proceedings. Hence, it is vital that you take care of a lot of aspects while choosing a EMR System development firm to get an EMR system created.