| Feature | Description |
| Electronic Medical Records | |
| Patient demographics | Manages the input and maintenance of patient information including demographics, insurance, contacts, referrals, notes and more. |
| Consents & Authorizations | Manages the capture and tracking of patient authorizations, including electronic signatures and standard authorization forms. May include advance directives like "do not resuscitate" orders. |
| Chief Complaints (CC) | Allows the provider to detail the symptoms, problem, condition, diagnosis, physician-recommended return or other factor that is the reason for a medical encounter. |
| History of Present Illness (HPI) | Allows the provider to enter a history of the present illness categorized by location, quality, severity, duration, timing, context, modifying factors and associated symptoms. |
| Constitutional Exam | Provides a process flow and data collection for a constitutional exam; including height, weight, blood pressure, pulse, respiration, and general appearance. |
| Past, Family, and Social History (PFSH) | Provides for the collection of all aspects of past, family and social history. Data collected includes illnesses, surgeries, injuries, and prior treatments, among others. |
| Review of Symptoms (ROS) | Allows for the reporting or denial of symptoms in all pertinent systems. Most systems include an ability to deny all symptoms or make use of defaults to enter data by exception. |
| Clinical Notes | Support for the clinical notes, such as standard subjective, objective, assessment, and plan (SOAP) method of documenting a patient encounter in the patient's chart. |
| E&M Coding Advice | Automatically generates E&M codes based on information collected during CC, ROS, etc. Maximizes billing potential by eliminating errors, omissions and down-coding. |
| Image / X-ray Store | A repository for information that is presented to the clinic from outside sources, as well as a place to store images from charts, x- rays, lab results and any other type of graphical information. |
| Graphics & Drawing | Allows the provider to draw on anatomical diagrams or digital pictures and include them in the patient record. Pre-drawn objects should be available to quickly illustrate conditions. |
| Medication tracking | Enables the provider to enter all of the patient’s current medications and allergies. For existing patients, the medication list from the previous encounter will be displayed for updating. |
| Medication Formulary | Offers a database of available pharmaceuticals, enabling the provider to check for drug interactions, dosages and disease/drug efficacy. |
| Medication Interactions | Allows the provider to check for drug-drug, drug-allergy and drug- food interactions before they prescribe. Automatically checks prescriptions and posts alerts for known interactions. |
| Allergies & Intolerances | Captures and stores lists of medications and other agents to which the patient has had an allergic or other adverse reaction in a standard coded form. |
| Immunization Tracking | Tracks immunizations that have been administered and integrates to local registries to import and export immunization records. |
| E-Prescribing | A bi-directional interface that allows the provider to communicate with the pharmacists to submit prescriptions, answer questions and request additional information or refills. |
| Lab orders & Results | Enables the provider to electronically submit lab orders and review results. Typically integrates with lab companies like Lab Corp and Quest. |
| Health protocol alerts | Automatically reminds the provider to perform a particular test or inform the patient of pertinent information relating to their condition or case. Parameters should be customizable. |
| Duplicate Therapy Check | Double checks all orders and patient instructions to check for duplicative therapies. |
| Clinical Decision Support | Presents a series of alternate treatment options by indication to support the provider's decision making process. Some systems provide a patient-ready overview of options. |
| Patient Instructions | Generates custom patient instructions by merging pre-built instructions with case-specific notations. These can be printed and sent home with the patient to support their care. |
| Referrals | Generates consult and referral letters or electronic submissions to introduce a patient, support billing, return results or thank other providers. |
| Letters & Excuses | Automatically generates permission slips for the patient, such as Authorization for Absence, Return to Duties or Care Certificates. Letters are printed as well as noted in the chart. |
| Patient Education | Provides an encyclopedia of articles on various conditions and treatment options for patients to read for further education. Articles can be printed or presented over the web. |
| Patient Portal | Provides patients with web-based access to their health records, education, and supports home-monitoring and self-testing for chronic conditions (ex: diabetes testing). |
| Ad hoc Reporting | Offers a range of pre-built and custom reports to meet payer and regulatory requirements, monitor patient health and improve the efficiency of the provider organization. |
| Practice Management | |
| Patient Scheduling | Allows administrative staff to schedule physicians, mid-levels and resources such as rooms. |
| Patient Data Validation | Allows providers to validate patient demographic data and risk assessment to manage payment risk and take necessary precautions, such as requiring up-front payment. |
| Patient Messaging | Prompts staff with patient-specific messages to be relayed during visits or to be printed on the patient's billing statements. |
| Eligibility Inquiry | Automatically verifies the patient's eligibility for receiving benefits with the insurance company using a standard electronic data interchange (EDI) connection. |
| ICDM-9 Coding | Includes International Classification of Diseases (ICD-9) codes to enable rapid code lookup and maintain up-to-date codes. |
| CPT/Dx Coding | Includes Current Procedural Terminology (CPT) codes and associated licenses to enable rapid code lookup and maintain up to date codes. |
| Claim Scrubbing | Automatically reviews claims for errors or data omissions to reduce denials and re-work. For example, this module should review ICD-9 and CPT codes to ensure validity. |
| Narrative reports | Allows the provider to draft a narrative by leveraging all data that is captured during an appointment as well as all demographic data to support claim submission. |
| CMS-1500 Claims | Allows staff to process and submit claims based on Center for Medicare Services form 1500 for ambulatory care. |
| UB-04 (inpatient) | Allows staff to process and submit claims based on the UB-04 form for inpatient or hospital services. |
| Clearinghouse Submission | Allows the provider to submit claims to a wide range of payers via established claims clearinghouses, typically by using electronic data interchange (EDI) protocols. |
| Direct-to-carrier submission | Allows the provider to submit claims directly to payers rather than using a clearinghouse. May use electronic data interchange (EDI) protocols or other secure transmission technologies. |
| ERA Support | Integrates and displays electronic remittance advice (ERA) messages that describe the actions that a payer took on a claim, such as amounts paid, denied, adjusted, etc. |
| Claim Status | Allows the provider to check on the status of a claim with just a simple electronic query from the system, which checks with the payer or clearinghouse for status. |
| Re-bills / Tracers | Also known as tracer claims, re-bills, second submissions, or duplicate billings, this function allows claims to be resubmitted due to non-payment by the payer. |
| Batch posting | Allows staff to quickly and easily post a large batch of insurance payments to multiple claims and multiple patients at once. Adjusted balances are then available for further billing. |
| ERA Posting | Automatically posts payments electronically to the practice management system through electronic remittance advice (ERA) messaging. |
| Code-level Posting | Automatically posts payments by CPT code so that payments can be matched effectively to procedures. |
| Credit card processing | Allows staff to accept credit card payments and process them immediately. Separates payments made for claims from those made for non-insurance, point-of-sale items. |
| Claims reporting | Provides a detailed analysis of all claims by pending, suspended, and waiting status. Allows staff to prioritize billing and accounts receivable activities. |
| Superbill | Allows staff to quickly generate and print superbills individually or in batch for all scheduled appointments. Formats should be customizable so that the practice can generate its layouts. |
| 3rd Party Printing | Integrate the billing system with a third-party printing service that will print and mail bills on behalf of the provider to reduce administrative work for the staff. |
| Custom Billing Plans | Allows staff to set up and administer custom billing arrangements for individual patients or groups of patients where necessary. Uses those custom plans to manage receivables as well. |
| Billing Dashboard | Provides a summary view of all billing statistics, including dollar values of outstanding claims, accounts receivable balances by payer and aging of all receivables. |
| Finance Charges | Calculates and adds finance charges for patient accounts that carry an outstanding balance past standard payment term periods. Allows staff to waive charges on an exception basis. |
| Dunning Letters | Automatically generates dunning letters that can be printed and sent to patients with outstanding balances that are past due. |
| Ad hoc Reporting | Offers a range of pre-built and custom reports to meet payer and regulatory requirements, monitor patient health and improve the efficiency of the provider organization. |
| Technology, Security, & Certification | |
| HIPAA Compliant | Compliant with the Health Insurance Portability and Accountability Act (HIPAA) of 1996 requirements for privacy, security, transactions and code sets. |
| CCHIT Certified | Certified to meet Certification Commission for Healthcare Information Technology (CCHIT) requirements. Current level to meet is CCHIT 2011 |
| Custom Templates | Allows the provider and staff to define custom templates for all forms and workflows so that the EMR can be modified to meet the provider's preferred processes. |
| Audit Trail | Tracks an extremely granular record of all data entered and exported from the system. |
| HL7 Support | Support for the Health Level 7 (HL7) standard, which is a de facto standard for communication between various systems employed in the medical community. |
| SSL Security | Employs the Secure Sockets Layer (SSL) protocol and digital certificates to manage the security of message transmissions in a network or over the Internet. SSL meets HIPAA requirements. |
| Tablet PC / Stylus and PDA | Allows the provider to interact with the EHR through a touch screen or stylus (electronic pen) interface rather than having to use a keyboard and mouse. |
| Voice Recognition | Allows provider to speak into a microphone connected to the workstation. Information can be entered verbally and automatically converted to text and stored electronically. |
| Wireless Support | Enables physicians and provider staff to access the EMR application through wireless laptops, tablet PCs or personal digital assistants (PDAs). |
| Back-up & Recovery | Automatic backup of all data within the system on a nightly basis, as well as the ability to restore that data in the event of a system failure. |
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