Understanding Features & Functions of an EHR

EHRs are more than just digital versions of paper records. EHR functions and features can help your practice run more efficiently, freeing you to focus on what matters most, your patient’s health. EHRs can also help you share data with patients and other providers to help make care more coordinated and integrated. Here are the EHR functions and features your practice should know about when purchasing, implementing, improving, or upgrading your EHR system.

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 functions and features EHRs include the following: 

The Institute of Medicine and the Centers for Medicare and Medicaid Services (CMS) have both detailed the core functions of EHRs to help hospitals and practices make purchasing decisions. Under Stage 3 of the EHR Incentive Programs, which provide incentives for adopting and using EHRs, CMS laid out the following objectives for EHR functions:

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: 

While all certified EHRs can perform these core functions, ease of use, adaptability, and customizability vary. When selecting an EHR, your practice should consider the user interface for basic functions and features that your staff 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 and everyday usage of an EHR. Improving EHR usability to increase productivity is vital if you're replacing or optimizing an EHR.

User-friendly EHR systems are less likely to cause physician burnout and more likely to lead to greater patient, provider, and staff satisfaction. By selecting a user-friendly EHR, like NextGen, you can save your practice from expensive customization, training, and data conversions down the road.

EHRs also vary in the degree to which you can create custom templates and other interfaces to support unique practice types. For example, Federally Qualified Health Centers and Community Health Centers face unique patient flow and billing challenges. EHRs that allow for custom template development can help support your unique workflows without requiring your staff to become experts in EHR management. Third-party developers like TempDev can help you customize your EHR system to meet your needs.

Advanced EHR Features and Functions

The promise of EHRs goes far beyond digitizing paper medical records. With their built-in analytic capabilities, EHRs help support improvements in your operational performance. They can help your practice adhere to guidelines-based care, seamlessly place and manage orders, improve your quality scores, and reduce errors.

Many EHRs, like NextGen, include Clinical Decision Support Tools to help providers make decisions about patient care. For example, built-in Clinical Decision Support tools give your providers critical information about medications as they prescribe them. This includes safety information like recalls, interactions, and allergies.

These EHR-based tools can also automatically provide clinical guidelines to providers based on the diagnoses they enter into the system. This helps providers stay up to date on the latest guidelines, even for conditions they encounter infrequently. Your EHR system can also alert providers to deviations from guidelines-based care. Clinical Decision Support tools can even suggest diagnoses from symptoms and test results, reducing time-to-diagnosis and diagnostic errors.

Using these tools can help reduce medical errors. This makes patient care safer, improving your practice’s quality scores and reducing your liability. For example, your EHR can flag possible medication errors like interactions or inappropriate dosages, and it 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, saving time. Electronic ordering also reduces the chances of misunderstandings and lost orders, ensuring that patients can get lab work and tests completed timely.

Many quality improvement programs and pay-for-performance programs require regular reporting of quality metrics. For example, the Medicare Quality Payment Program (QPP) requires annual reporting from participating providers. Joining these programs can improve your finances through bonus payments, but your practice must be able to produce high scores consistently on a wide variety of metrics. EHRs simplify quality reporting by reducing data entry needs. Reporting and dashboard functions also let you keep track of your performance in real-time. That way, you can address any lagging quality metrics before the end of the reporting year.

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 and accurately tracking patient progress toward care goals.

Finally, your practice can optimize your EHR for your workflow and practice needs. With some EHRs, like NextGen, you can create EHR templates to simplify regular tasks. For example, order management and order sets allow you to order common medications or tests quickly for patients with similar conditions. You can also create templates to help you aggregate and review quality data. Third-party developers like TempDev have even created templates to help your practice run flu and COVID-19 vaccine clinics without opening individual patient charts.

How the Right EHR Can Streamline Your Workflow

With the right EHR, you can streamline your EHR workflows, 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, your staff and providers can manage orders and results electronically. Your practice can also 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. This helps your practice ensure complete billing and reduce requests for additional information. The right EHR may also include rules-based clinical, administrative and financial coding help to ensure completeness, accuracy and timely reimbursement. With an integrated EHR and Practice Management Billing System, you can automate simple billing processes and reduce late and denied payments.

Should You Use EHR Speech Recognition? 

EHRs can work with speech recognition software to allow your providers to dictate notes directly into the EHR without the need for transcription. If your providers 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. EHR vendors, such as NextGen, also offer mobile dictation solutions so physicians can dictate their notes from their smart phone from anywhere.

However, speech recognition software is not perfect. Results must be double-checked to ensure accuracy. If your practice does not currently use dictation services, adding speech recognition functions to your EHR may not be worthwhile. Using dictation rather than provider data entry can also miss key documentation requirements. If your providers are not interacting with your EHR system during office visits, built-in alerts and CDS systems cannot provide diagnostic, coding, and documentation support. Your practice may also miss key data for quality reporting, E&M coding, or analytics when providers dictate notes after visits.

How TempDev Can Help with EHR Functions

TempDev offers a wide array of NextGen EHR consulting services to help you implement and customize your NextGen EHR. These include EHR reporting solutions and templates, customization, project management, and training. TempDev consultants can also help you assess and redesign your workflows to get more out of your NextGen system.

Call us at 888.TEMP.DEV or contact us here to get started implementing or improving your EHR.