1. Patient Charting
This function documents the patient’s visit by providing templates or forms for inputting patient visit information such as vitals, complaints, History and Present Illness, Review of Sytems, Physical Exam, etc. In most systems this is done via drop-down boxes, pick lists, hand-writing recognition and/or voice recognition.
2. Order Communication Systems
This function communicates with external systems such as Laboratories, Pharmacies, Imaging Centers and Hospitals via HL7 interfaces. This function assists the physician in sending out lab requests, prescriptions, imaging requests and submitting visit charges and diagnosis codes to the back office/billing system. Often referred to as Computerized Physician Order Entry (CPOE)
3. Clinical Decision-Making Support Systems
This function helps physicians in their decision-making by automatically providing recommendations, reminders and alerts to the provider. These recommendations are based off the information that the physician enters regarding the patient and matches that against a database (what database?) and the patient’s health maintenance profile. This function also assists the doctor with coding and diagnosis. Most EMR systems will provide physicians with a recommended CPT code based off of Evaluation & Management (E/M) rules thereby allowing doctors to bill payers at the highest possible rate for the services performed.
4. Document/Image Management
This function provides offices with a way to manage the flow of paper coming into their office, ie patient intake forms, referring physician letters, faxes, lab reports, etc. and provides physicians with a way to manage images such as x-rays, MRI’s, ultrasound and, in some programs, audio/video clips.
5. Patient Portal
This function enables patients to access their health record from any computer in the world with a secure internet connection, granted they provide a username and password. Automated features include appointment scheduling, Rx refill requests, record access, electronic intake forms and outcome assessments and patient education. This can also be used for provider-to-provider communication where patients can grant access rights to their electronic medical record.
6. Statistics and Reporting
This function allows providers to create reports from their database for statistical purposes. This feature becomes especially helpful in the event of drug recalls, health maintenance reminders and disease management.
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