Alerts -- Alerts are most important for specialists who deal with urgent or critical issues, (e.g. Cardiologists).

• Notification of required annual or follow-up testing.
• Notification of required medication renewal.
• Notification of prescription refills requested by the patient.
• Notification of drug interactions.
• Notification of possible reactions due to allergies.
• Notification of abnormal laboratory results.

Appointments/Billing (PM) -- The Practice Management system can be integrated with the EHR, or can be a separate component. If you plan on purchasing ONLY an EHR, do not check this feature, which can include each of the following:

• Creation of the SuperBill within the EMR that is automatically sent to the billing software via Electronic Data Interchange (EDI).
• Creation of the SuperBill within the EMR that is manually entered into the billing software.
• Ability to identify the status of all SuperBills.
• Ability to interface to the Clearinghouse used for billing.
• Ability to interface to insurance companies for submission of a bill.
• Ability for a coding tool to suggest ways to correct up-code encounter documentation to receive a higher level of reimbursement.
• Tools to create, change, confirm or cancel an appointment.
• Tools to send a reminder to the patient via email.
• Tools to handle the scheduling for individual healthcare providers.
• Tools to schedule specific rooms in the practice for specific purposes.

Customized Templates -- For many physicians, implementing an EHR will be easier if you utilize templates judiciously. Two concepts to keep in mind are that some EHRs will come with a wide variety of pre-loaded templates, and other systems will allow you to easily incorporate your own templates into their structure.

If you are new to practice, having pre-loaded templates can be a tremendous time saver. If you have developed templates over the course of years of practice, you will want to be able to incorporate your own.

Decision Support -- Decision Support is one of the critical features required by the Federal Government in order to take advantage of the HITECH Act's stimulus funding. Features included within decision support can include each of the following:

• Standards of Care support tools within the EHR customized to the practice.
• Customized order sets based on a patient's diagnosis.
• Quality measures linked to an order set.
• Treatment protocols using pre-defined order sets.
• The ability to prompt the physician for PQRI-related coding, when applicable to the patient's diagnosis or procedure.
• Access to the internet and favorite sites to review the newest information on standards of care.

Document Management -- The ability to scan multiple documents belonging to one patient and automatically assign them to the patient's EMR.

Additional features that relate to document management include:

• The ability to receive a fax via the computer and assign it to the appropriate reviewer.
• The ability to send a fax of patient information via the computer to a requestor.
• The ability to automatically date stamp a document at time of receipt and at time of viewing to create an audit trail.
• The ability to upload a document directly from the internet and assign it to the appropriate reviewer or place it in the patient's EMR.
• The ability to prioritize documents so the most important are handled first.
• The ability to respond to a subpoena and/or a patient request with a specific set of documents.
• The ability to view all faxed or uploaded documents in one location relating to an individual patient.

Documentation Ease -- Some of the more sophisticated programs use algorithms which allow future reports to be modeled after past reports, while others utilize rather rigid templates.

There are advantages to each methodology, and some of the more rigid templates allow for more structured reporting and E&M coding capabilities. However, reports produced by programs of this nature may appear rather stilted and "cookie cutter."

The EHR Companies will tell you that they can help you produce medical reports quickly. We recommend testing this feature on some sample patients, to determine which style is most suitable to you.

Methods that are utilized to help ease the documentation burden include:

• Voice Recognition such as Dragon Medical
• Handwriting Recognition Tools
• Use of "QuickNotes" or "normal" encounter documentation that automatically populates the fields.
• Photos/Drawings
• The ability to create a "sticky" or "post-it" note on a document.
• Automatic generation of a consultation or progress note with the practice information on it.

Dragon Medical -- The world's leading speech recognition solution series designed specifically for physicians. By eliminating physicians' sole reliance on typing, clicking and scrolling, something that 67 percent of doctors surveyed cited as a concern ("time associated with reliance on keyboard and mouse to document within an EHR"), healthcare providers can allocate more time toward patient care instead of reporting. Because most doctors speak at least three times faster than they type, speech recognition software can improve physician productivity by up to 25 percent, as compared to a non-speech-enabled system.

e-Prescribing -- e-Prescribing is one of the most basic features of a modern Electronic Health Record, and unless you do not anticipate writing prescriptions (such as will be the case for Physical Therapists and Chiropractors), we strongly recommend purchasing a software program that has robust e-Prescribing features.

If you are new to healthcare information technology, you may be interested in a stand-alone e-Prescribing system, at least for your entry into the field. However, a stand-alone e-Prescribing system will not allow you to prove "meaningful use" as referenced in the HITECH Act.

Sophisticated e-Prescribing systems will not only transmit the prescription to your chosen pharmacy, it will also permit for allergy checking, drug-drug interaction checking, dosage checking. Similarly, you may be allowed to utilize multiple formularies, an important feature if you accept a variety of different insurance plans.

Additional features include utilizing G-Codes, confirming that you are using an e-Prescribing system, as well as the providing of reports to ensure that you receive the proper incentive payments from the Federal Government which are available to e-Prescribing physicians.

E&M Coding -- Most modern EHRs provide sophisticated algorithms to ensure that you are coding at the proper level, based upon the documentation that you have provided for each encounter. In many systems recommendations are further provided to suggest additional documentation which could be undertaken to allow you to code at the next higher level.

This can be a particularly important feature if you see a large number of office based patients, such as would be the case for Family Physicians, Internal Medicine Physicians and Pediatricians.

Health Maintenance -- Health Maintenance Guidelines are available from birth to death for healthy individuals as well as for a large number of disease states.

These can be particularly helpful for physicians who may be incentivized by various third parties to provide, and prove that they are providing high quality care, as well as for those physicians who truly wish to follow the guidelines provided by various organizations.

Issues that may be addressed in the Health Maintenance Guidelines include:

• Immunizations / Vaccinations
• Cholesterol levels
• Glucose levels / A1C
• Blood Pressure
• Colorectal cancer screening
• Bone mineral density>
• PAP Smear
• Mammograms
• Prostate Cancer Screening

Internal Messaging -- Tremendous increases in efficiency can be obtained by utilizing an internal and/or external messaging system effectively.

From notifications of patients in the waiting room, to notices from the hospital, information can be transmitted in an immediate and unobtrusive fashion, and yet delivered to just the right people, at the right time, in a convenient fashion.

Interfaces -- A modern EHR can interface with a bewildering assortment of other organizations and pieces of equipment.

Standards include the ability to send and receive information from pharmacies, radiology facilities, hospitals, and laboratories.

In addition, interfacing to other EHR programs in other physicians' offices is now possible. Utilizing technology such as can be seen in the "Integrating the Healthcare Enterprise" (or IHE), it is hoped that the medical information you document in your office will be readily available to your patients' other healthcare providers, across town or across the country, almost instantly. Interfaces of this nature are being developed as of 2009, but are not yet fully developed on a nationwide scale.

Nonetheless, interfaces can be a critical and expensive component of many implementations. You should carefully consider which laboratories, radiology facilities and hospitals your patients visit, and determine how to get your technology to "speak" with them.

And, in addition to interfacing with other organizations, there is the issue of interfacing with various pieces of equipment. Many EHRs can receive blood pressure and other vital information from patients as they examine themselves at home. Similarly, EKGs, stress tests, electric goniometers, and countless other pieces of equipment are now able to input their readings directly into the patient record, without human interaction.

Mobility -- A modern physician does not need to be in their office in order to "see" patients. Using an iPhone, for instance, you can view your schedule, see the laboratory results on your patients, see a summary of their patient record or just about any other information you may need.

A slightly larger footprint associated with mobility would be using a wireless network within the office, walking from room to room with a laptop and/or tablet computer.

The concept of mobility also includes the ability to access your entire Electronic Health Record, usually in a SaaS (Software as a Service) model, from any Internet connection.

Yet another aspect of mobility includes the ability to provide "virtual" office visits to your patients. In an increasing number of situations, third party payors are reimbursing physicians for these virtual office visits in which a patient provides information to you via phone and/or the Internet and you provide treatment to them.

Outsourced Billing -- Many offices realize that they are most efficient when they do what they were trained best to do, and that is to provide medical care. Medical billing is a specialty all by itself, and physicians can be more productive and earn a higher net income by outsourcing this task to an expert in the field.

Indications that you should strongly consider an outsourced billing solution include:

• You see patients covered by a wide variety of insurance types
• You have a small multi-specialty group
• You practice in a high rent district
• You have difficulty hiring qualified employees
• Salaries are high in your geographic area
• Your collection ratio is below industry average
• You are a new practice and want to concentrate on other issues
• You do not have enough space in your office

An outsourced billing service should provide the following:

• Integration with an EMR
• Generation and submission of electronic and paper claims
• Confirmation of receipt of claims and resubmission of lost claims
• Posting payments and remittance advice received from payers, including scanning paper remittance advice into a practice management application for online reference
• Following up on unpaid claims and denied claims and working to secure payment for them
• Access to the latest coding and insurance rules to help prevent denial recurrences
• A comprehensive reporting solution that at a minimum provides monthly reports, but ideally real-time reports as needed of patient panel size, A/R, claim status, collections and key performance metrics
• Reviewing key performance metrics and notifying you proactively if performance is not consistent with targets/benchmarks
• Committed billing and collections experts that work in partnership with you to maximize revenue
• Specially trained staff that can proactively seek opportunities to help you improve practice performance

Patient Portal -- Patient Portals allow patients to access your EHR from outside of the office. This can have tremendous advantages, both in terms of efficiency as well as in terms of quality of care.

From an efficiency standpoint, patients are able to schedule and modify appointments, review and pay their bills online, and request prescription refills. Doing so saves your staff time, and thus saves you money.

Possibly more importantly, a more robust portal can allow for "virtual office visits" in which you can interact with your patient via a secure email system, providing medical care. For instance, patients in remote locations can take their blood pressure and monitor their glucose readings, and populate the EHR with this information. You can then guide them to the proper care, providing medications as needed. An increasing number of insurance companies are reimbursing physicians for this type of care.

Amongst the major benefits are your ability to undertake these virtual office visits at your convenience, rather than when your patient is in your office.

Robust Workflow -- Workflow is one of the most difficult, and unfortunately, one of the most important concepts to understand when shopping for an EHR. We will start by providing a dictionary definition, but that probably will not be sufficient. "Workflow - The flow or progress of work..."

A few examples should assist. As an Allergist, it may be important for you to have a timer included within your patient flow in order to allow patients to leave the waiting room 20 minutes after their injection. As a Cardiologist, you will need to have the ability to move patients from the examining room to the stress test lab, and back. Dermatologists need to be able to bill for a large number of simultaneous procedures. Endocrinologists frequently require home glucose monitoring capability. An Infection Disease Specialist should have access to updated world literature from within the EHR. A multi-specialty office must have the ability to offer customizable workflow capabilities to each of the various specialties within the office. Many lower end products have a hard-wired workflow which may be suitable for a specific specialty, but may not be modifiable for others.

We strongly recommend that you very carefully visualize having patients walk through your office, envisioning the various activities they will perform, and the various locations they will visit. Make sure that the programs you consider are capable of handling each of the diverse actions.

Some specific capabilities of a robust workflow include:

• The ability to create an assignment for each staff member and track it to completion.
• The ability to create practice specific letters, forms and reports.
• The ability to view all incoming faxes and other uploaded documents in one location, or to be able to segregate them so that only certain subsets are available for viewing by various staff members.

Role-based Security -- There are different security requirements for Software as a Service (SaaS) installations in comparison to Client/Servers. You must ensure that you remain HIPAA compliant at all times. Interfaces with outside entities must be taken into consideration.

Role-based security may not be a critically important feature for a solo Chiropractor, but would be considered essential for an infectious disease specialist in Los Angeles.