Get started by identifying what functions you want the new system to perform. We’ve provided a description of the most common medical record and practice management functions. We will help you assess which features are best suited to your practice along with other factors such as ease of use to determine which software package is right for your organization. Below are a few of the categories of features that are typical in such systems. So, whether you are a sole practitioner, multiple physician office or small hospital, we are there to assist.
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.
Touchscreen Interface
Similar to an iPhone, the user can simply touch the screen with their fingers to use the application rather than having to use a stylus or electronic pen.
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 inter-actions, dosages and disease/drug efficacy.
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 (e.g. diabetes
testing).
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.
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 pre-cautions, 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.
Payor Contract Management
Manages the key terms of contracts with payers so that billing staff can cross check commitments from payers while processing claims.
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.
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 (i.e. collections) 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.