According to the National Alliance for Health Information Technology (NAHIT), the “official” definition of electronic medical records (EMR) software is:
An electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one health care organization.
There are two key pieces to this definition:
- EMR software helps to manage the creation, organization, and retrieval of electronic patient records.
- EMR software does not enable you to share electronic records with other organizations (unlike electronic health records, or EHR, software).
A typical EMR solution allows physicians and clinicians to easily manage:
- Patient Charts – create patient charts electronically at the point of care that include demographics, clinical health histories, allergy information, medications, immunization records, progress notes, lab results, and more
- ePrescriptions – generate and send prescriptions to pharmacies electronically
- Lab Orders – electronically create and send orders for lab work, medical tests, and consultations
- Billing – capture all evaluation and management (E & M) codes at the point of care to ensure complete invoices and eliminate downcoding
NOTE: The phrases “electronic medical records software” and/or “EMR software” are often used interchangeably with “electronic health records software” and/or “EHR software”. It is important to understand that there is a major difference in these two types of software.
How is EMR and EHR software different?
NAHIT states that the major difference between EMR and EHR software is that EHR software can be managed and shared “across more than one health care organization.” An EHR solution enables multiple electronic medical records from different practices to be collected and shared amongst practices.
In addition, there are some functional differences between the two. EHR software includes most EMR functionality, as well as features that enable patients to securely access their own medical records and, in some cases, even add/edit information in them.
Additional software to consider
There are other types of medical software that are similar to EMR software and/or can easily be integrated with EMR software.
- Medical Practice Management software manages functions such as appointment scheduling, billing, claims processing and other administrative tasks for medical practices. Many vendors offer integrated EMR and medical practice management solutions.
- Healthcare Management software is more comprehensive than MPM software and integrates clinical, operational, and financial functions of a medical practice. It manages typical MPM functions as well as processes like financial auditing and regulatory compliance.
- Medical Transcription software enables physicians/clinicians to transcribe clinical notes for patients using voice dictation. Transcription is occasionally offered as a feature of an advanced ERM solution.
What features are included in EMR Software?
There are numerous variations of basic and advanced EMR solutions available. The keys to find the one that will fit best with your practice are to:
- Determine if you need/want an integrated solutions (medical practice management and EMR)
- Determine if you need/want to share records with external organizations (EHR or “EMR” that has external interfaces)
- Determine if you need/want a solution that is designed for your practice or specialty (many specialty-specific solutions exist)
Once you’ve decided on the factors above, you’ll want to identify and compare the top 15 – 20 features that are critical to your practice. Regardless of your specifics, be sure to evaluate solutions that are HIPPA compliant and CCHIT / ONC-ATCB certified. Below are some basic and advanced features found in EMR solutions:
- Alerts and reminders
- Amend encounter
- Appointment management
- Billing and invoicing (or interfaces)
- Chart management
- Claims management
- Drug allergy and drug-to-drug interaction
- Medication and recall tracking
- Physician order entry
- Anatomical designation
- Investigation questionnaire
- Medication tracking
- Mobile and wireless access
- Patient self-assessment
- P4P (pay for performance) management
- Practice patterns and standards
- Scheduling interface
- Tablet/Touch screen
- Voice recognition and voice records
Other features that may be included in an EMR solution include:
- Clinical care and decision support
- Clinical flow sheets
- Clinical pathways integration
- Document scanning and management
- HL7 lab interface
- Patient portal and education
- Prescription drug database
- Template management