EMR

Features

Features and functions include …
A bridge between unstructured and structured data.

Practice Management

Scheduling
Registration
Appointments
Phone Messages
General questions
Eligibility
Authorization
Referrals
CoPay
Patient Portal

EMR

persistent data
Demographics
Advance Directives
General History
Risk Factors
Exams/Tests
Family History
– immediate family
– relatives
Genetic Risks
Social/Lifestyle History
Environment/Stress
– living conditions
– social patterns
– neighborhood, diet
– psychological
Surgical History
Allergies
– food
– drugs
Vitals History
Smoking Status
Medications List
Immunizations
Problem List
Lab Results

Patient Engagement
– patient portal
– patient preferences
– patient specific education
– reminders

event data
Patient Narrative
Physician Narrative

WORKFLOW: nurse sees patient
Review/Update History
Vitals
Chief Complaint (CC)
History of Present Illness (HPI)
History (Hx)
Review of Systems (ROS)

WORKFLOW: doctor takes over here
Physical Exam (PE)
Diagnosis (Dx)
Prescription (eRx)
Service Performed (SP)
Service Ordered (SO)
Testing
Plan & Patient Instruction (Plan)
Referral Authorization
SOAP
E&M Guidelines
Fee Sheet
Coding

WORKFLOW: sign note, close note, submit to Billing
Integrate PHRs/FHRs
Patient Portal
CMS Quality Reporting
Electronic Syndromic Surveillance
Interoperability

Pediatrics
well-child visits
support of growth chart analysis
immunization tracking
immunization forecasting
weight-based drug dosing

Practice Management

Checkout
Claims Processing
Planning
Patient Education
Charge Capture
Billing
Claims processing
Accounts Receivable