Like any software, while the specifics vary between vendors, there are necessary minimum requirements for medical office software, aka medical office management or medical practice management software. These systems help medical practices and healthcare providers administer more efficient, streamlined healthcare that improves patient satisfaction while bettering their bottom line.
Here’s a short list of key medical office software functions:
- Identify patients and maintain electronic patient records
- File patient demographics
- Manage lists of problems
- Store patient histories and medication lists
- Maintain clinical notes
- Record external clinical documents
- Manage protocols, individualized care plans and other guidelines
- Generate instructions specific to the patient
Here are the most common medical office software features you’ll come across when evaluating for the medical software that benefits you the most:
Identify patients and maintain electronic health records
Self-explanatory. By its very nature, medical office software should maintain electronic health records for every patient.
File patient demographics
Captures demographic information. When it is clinically relevant, the demographics can be tracked over time.
Manage lists of problems
Creates lists of problems specific to each patient.
Manage medication lists
Creates a list to store medications each patient takes.
Manage patient history
This stores all medical, family and social history, including any externally available clinical history and and patient reported history. This includes the health records you find in an electronic health records (EHR) software as well as the medical records present in an electronic medical records (EMR) software (yes, there’s a difference between the two systems).
Maintain clinical notes
This allows you to addend, authenticate and transcribe documentation for clinical notes.
Capture clinical documents
Allows you to include any clinical documentation from previous physicians and other external sources.
Manage protocols, individualized care plans and other guidelines
Provides the tools needed to put together a patient-specific care plan and other protocols to keep in mind during treatment.
Generate instructions specific to the patient
Self-explanatory. This can be used for pre- and post-procedural needs as well as post-discharge instructions.
Patient care orders
This allows you to track orders based on the input from other providers.
Order diagnostic tests
Send away orders for diagnostic tests as needed.
Manage order sets
Provides sets based on system prompt or user input.
Present latest and all test results to personnel to review, filter and compare.
Maintain all patient decisions via authorizations as needed.
Support for assessments
Allows you to go through prompts to support care plans and protocol when capturing information.
Support for protocol and guidelines
Allows the use of appropriate protocols and guidelines for managing certain kinds of conditions.
Support for drug interaction identification
Issues warnings for drug interactions when ordering medications.
Individualized dosing and warnings
Issues warnings and identifies patient-specific appropriate dosing based on conditions when ordering medications.
Accurate specimen collection
Providers are alerted in real time to support specimen collection.
Alerts for preventive care
When making clinical decisions, identifies individualized reminders, screening exams and other services for routine preventive care standards. It can also notify the patient when certain tests are overdue as well as monitor when the patient has taken action as a result.
Supports insurance company portals
Supports the communication between the medical practice and an insurance provider for payment authorization of insurance claims.
Medical billing and coding software
Supports medical coding and billing services, including the submission of bills to patients and insurance providers. Medical billing software features should also manage receiving authorization for billing payments as well as general medical coding. This feature may include most of the components offered in a standalone web-based medical billing software.
Clinical task assignment
Supports the delegation of tasks to the necessary parties.
Supports linking tasks to patients or other parts of the EHR. It can also track tasks to ensure the party has completed it within an appropriate amount of time.
Communication between providers
Allows a secured electronic connection between all providers to respond to actions in care, such as referral, as well as to document offline communication and generate messages as needed.
Communication with pharmacy
Supports secure bidirectional electronic communication between pharmacies and physicians.
Communication with family and patient
Allows response to communication between patients/family and providers. This can also allow the delivery of support and educational resources for patients and families for certain medical conditions or other diagnoses.
Quality medical software authenticates users before allowing access.
Manages access control permission sets to EHR users. It enables security to grant authorizations within certain contexts as needed, maintaining HIPAA compliance at all times.
Secure data exchange
Ensures the full security of any EHR data transfer or exchange.
Enforces privacy rules according to the appropriate jurisdiction.
Retaining Data and Destruction
Ensures the availability of data and can destroy health record information according to the standards of the organization. This includes retaining EHR data and documents as legally required, retaining documents unaltered, ensuring availability for the legal period of time, and destroying EHR data systematically according to policy after the retention period.
Management of workflow
Supports workflow functions such as setting up work queues, system interfaces and personnel, among others.
Demographics of providers
Displays current practitioners, their demographic information, as well as information to determine how much access they have for the EHR software security system.
Demographics of patient
Allows interactions with other modules to maintain updated information according to recordkeeping standards.
Stores the residence of the patient for administration of services, transporting the patient, and as is required for public health reporting.
Provides information in a way to de-identify them as required locally.
Appointment scheduling software
Allows interactions with other modules to generate an optimal scheduling system by planning out patient care.
Generation of reports
Generates reports according to ad hoc report standards.
Health record output
Lets users define records for disclosure.
Offers specialized views based on clinical protocols, business rules, as well as situation-specific values.
Clinical coding assistance governed by rules
Provides a way for relevant patient data to be available for coding procedures, diagnoses, as well as outcomes.
Administrative and financial coding assistance governed by rules
Supports the assistance of administrative and financial coding based on unstructured text as well as structured data within the documentation.
Authorization for service
Allows interactions with other modules to allow the practitioner to create requests, appeals and responses as needed for service authorization, including prior referrals, previous authorizations as well as pre-certifications.
Assistance with service claims and requests
Supports interaction with other modules to create treatment care attachments for submitting other information in support of other requests.
Reimbursement claims and encounter reports
Allows interaction with another module to support the creation of encounter reports and claims for cases of reimbursement.
Store patient/provider relationships
Tracks how many providers have treated a single patient.
As you can see, medical office software offers a ton of functionality to healthcare organizations and the office managers who help everything run. From saving time by automating tasks to managing patient relationships better, medical practices can find a whole host of benefits after adopting medical software.