EMR Technology Checklist

Transcription

1 Patient Accessibility/Scheduling/Account Maintenance: Able to interact with schedule through an online portal pre register VIP status to move patient to the front of the line Access and pre registration Online results retrieval Statement and account / billing resolution Referral Source: Referral date External referral source Referral note (template, reason for seeking service, risk assessment) Patient Registration (Office Based): Patient Search Demographics Name (aliases) Date of birth Social security number Custom search fields (MRN, chart number, etc.) Other patient demographics Gender (M, F, transgender, other) Race and ethnicity Street address City State County Zip Code Phone (home, work, cell) Mark as primary call number (or do not call) 1

2 Patient Registration (Office Based) cont.: Emergency contact name Emergency contact phone Relationship to patient School attending Special needs: translator, mobility impaired, etc. Language Auto populate city state from zip code entry Address checking functionality Notes / alerts HIPPA signature date Consents signed (ROI, POA, informed consent, insurance billing) Retain name and address history Alert if duplicate SSN entered Set required fields Alert mailing address fields Print individual face sheet Batch print face sheets Label printing Record last updated name and date Custom data fields for mandated data reporting Date of death Deactivate / Reactivate patient account Merge duplicate patient records Insurance / Eligibility: Primary Insurance Secondary and tertiary Insurance Start and end dates for insurance 2

3 Insurance / Eligibility: Retain insurance history Subscriber information (name, contact, group and ID number) Eligibility verified date and verified by whom (name, user ID) Verify eligibility electronically (if pre registered) Verify eligibility real time Run eligibility schedule batch Task list to work new patient eligibility, lost eligibility Robust eligibility data detail, specifies primary, secondary, co pays (variable for urgent care), deductibles, health spending accounts (HSA) Alert authorization needed View scanned and stored insurance cards and photo ID s Appointment Scheduling: Patient search: name (alias name), DOB, MRN, SSN, etc. Multiple schedule views (full day, week, by providers and locations) Multiple appt. types and time allotments Online Monitoring / Viewing of schedules at other clinic sites showing check in / Wait times Cancelation reason and canceled by whom (client, provider, parent, etc.) Comments field Mark appointment time arrived, no show or canceled on schedule Double book on schedule 3

4 Appointment Scheduling: Customize schedule by clinic / provider (master schedule for each provider) Run standard reports on schedule information (cancel, no show, service types) Schedule follow up or recurring appointments Block scheduling with clinician based on license or area of expertise (e.g. children only) See patient statement balance during appointment scheduling Alert for insurance eligibility during appointment scheduling Other scheduling alerts (e.g. do not call, mail, or call after 4 p.m. only) Patient Check in / Check out: Sort / view site schedule by locations, days, patients, appt. times, providers View and change arrival status (scheduled, arrived, cancelled, no show) Scan insurance cards View co pays, balances outstanding Easily update demographics, insurance contacts, etc. Accept and receipt co pays / payments (credit and debit cards) Balance daily cash payments View / add scheduling and reminder call notes View patient alerts (e.g. don t schedule without provider approval ) Print next appointment notice 4

5 Provider Desktop and Schedule: View patient appt. details on daily schedule (time, appt. type, service, etc) View appt. status per patient (arrived, canceled, no showed) Interactive schedule: click patient name on schedule, opens patient electronic chart Click to view patient demographics summary from desktop Alerts for open tasks (unsigned notes, unsubmitted charges, lab results, etc.) Provider Task List: Interactive task list: Click on task list item opens item to be done (view lab results, sign chart note) Generate a task (by provider or system) Assign task priority Reassign a task Add a comment to a reassigned task Mark task done deletes from list Save and view task history Chart / Notes: Create note templates for service type (Urgent Care) Templates driven by problem (reason for visit) Decision support and alerts Speed of entry: Allow dictation directly into note template, pen based, keyboard Electronically sign note Allow/prompt second electronic signature for supervision co signature 5

6 Chart / Notes cont.: Allow and track addendums to signed note Dictation software embedded in EMR Dragon / voice recognition software embedded in EMR View all treatment notes in chart view Sort mechanisms for treatment notes in chart view View scanned documents in chart (ROIs, hospital discharge summaries, lab results, etc.) Generate system task to review / co sign note Treatment Plan: Create treatment plan templates (Urgent Care) Assign problems / diagnoses Assign goals w/ start and completion dates Assign plans w/ start and completion dates Alert if treatment plan is not completed Patient History: Social Medical Family Prescriptions (Rx): Drug name Dosage Form Route of administration Number dispensed 6

7 Prescriptions (Rx): Number of refills Start date Expiration date Patient instructions Pharmacy instructions Prescriber (name, license, & DEA numbers) Electronic signature for Rx Electronic transmission of Rx Fax Rx Print Rx Display transmission queue Drug allergy tracking alerts Drug interaction alerts Searchable drug formulary Searchable pharmacy directory Assign pharmacy to patient Patient drug information Physician drug favorites list linked to diagnosis Alert if payor approval is required for some atypical drug regimens Nurse/MA documentation: Triage with templates and decision support Vital Signs: Blood Pressure Temperature Height Weight Assign drug allergies, symptoms, severity, first identified 7

8 Nurse/MA documentation cont.: Assign food or substance allergies, symptoms, severity, first identified Ancillary Orders and Results: Interface with laboratories, diagnostics, and hospitals Electronically submit or fax orders Alert if order does not return File results to specific tests ordered in the patient record, presentation of data (graphic, tabular, trending) Prompt for results protocols (normal values) Generate task for abnormal results Digital X ray Integration: Imaging transfers directly to imaging module in EMR Image viewing and results retrieval across platforms and remote Link between images and provider report Billing: Charge coding review Set up fee schedule with billed rate and expected reimbursement by payer Format electronic claims Electronic errors scrubbing Night batch claims Transmit electronic claims to clearing house Time/date stamp on claims runs Contract management Capitation budgets, funds, and allocations 8

9 Billing cont.: Report on claims run Resubmit failed claims run Print paper claim Claim submission status update in real time Post electronic remittances, write offs, rejections to line item invoice Send denials to rejections work queue Assign a denial cause to rejections for tracking Resubmit rejected claims Track resubmitted claims on client account Track payment plans Produce patient statements, with balances by aging history Retain patient statement history ability to consolidate, including guarantors Aging & collections tracking & work queues Denials management workflow Payer claim EDI eligibility, claim submission, status, remittance advice Provider Credentials: Provider name Provider NPI number Provider license number Provider DEA number Provider competencies Record and track provider license, NPI, and DEA effective / expiration dates Integration with credentialing systems (e.g. NAQH) Ability to freeform additional fields if needed 9

10 Reporting: Management reports (scheduling, billing, productivity, number of patients seen, hours of service, etc.) on a facility level Clinical outcomes reporting by diagnosis, treatment modality, age, gender, etc. Mandated reporting (PQRI, etc.) Ability to run ad hoc queries quality and outcomes Upload data / reports to Excel Export data to warehouse Ability to build and populate real time dashboards Able to access reports across desktop and mobile platforms Interface w/ corporate systems: accounting, payroll, etc. Certified: ONC Which organization has certified your product? 10