EMR has the following modules:
- Security
- Auditing
- Patient Scheduling
- Patient Registration
- Prescriptions
- Clinical Documentation
- System Management
- HL7 ADT Receiver Interface
- Patient Scheduling Exporter
- Reporting
- Insurance Clearinghouse
In any software solution, security is the most important part. There are specific laws that must be followed when healthcare medical records are handled by software and humans. The application layer will handle all security requirements. Roles will also be used that will allow a Role access to specific parts of the software.
Auditing (logging) must be performed with each user action and automated system function. The method is which the auditing information will be story is yet to be determined.
A patient scheduling model is needed to allow the user to schedule a patient for a visit at some point of time in the future. The patient will make an appointment and the software user will enter the patient into the schedule and provide the patient with the date and time of the appointment. The software user should be able to assign the patient to a specific resource which will most like always be a Physician though it could in theory also be a device such as an MRI unit.
Patient registration is the first step in the EMR workflow. A patient must be registered into the system before anything else can be done. No patient no activity.
Gathering all information possible from the patient is critical. Standard information such as name and address is needed as well as many other types of information such as allergies, employment information and even insurance information. This patient registration module will be required to capture any and all information required by the users of the software.
E-prescribing has been described as the solution to improved patient safety. It is estimated that approximately 7,500 deaths occur each year in the United States due to medication errors. These errors are predominately due to hand-writing illegibility, wrong dosing, missed drug-drug or drug-allergy reactions. With approximately 2.5 billion prescriptions written annually, which constitutes one of the largest paper-based processes in the United States, the writing of prescriptions can be streamlined and efficient by using an e-prescribing system.
Hospitals need a documentation system that can communicate with existing information systems and databases, both within the hospital and outside, gather together all the relevant patient data and make it automatically available to clinicians for inclusion in their clinical documents.
General system management functions must be developed that will allow specific roles
or users the ability to perform all system management functions which are to include:
Adding new software users, Creating custom roles, Adding users to roles, Adding
users to tasks, Resetting passwords, Viewing security logs, Setting all system configurable
values, Perform maintenance tasks,
This module helps in exporting Appointment Schedules in different formats.
During an encounter, patient data collected through EMR is stored in a relational database. EMR offers an ad hoc report writer for tailoring information to specifically address business needs. Reports can be exported to other systems.
This module helps electronically claim insurance from insurance companies. Although doctors and dentists are not required to use a clearing house to submit claims, clearing houses help speed up the process because they prescreen submissions so that mistakes can be corrected more quickly.