Any piece of information that is required for a complete patient record can be placed in the Electronic Health Record: complaint, histories, physical, review of systems, plan, vitals, prescription, etc. In addition to documenting a patient's encounter, ConcurMDEHR has the ability to run reports identifying complete but un-reviewed labs; allows the physician to consult schedules to check expected patient loads, and many other features described below. The key to entering all of this information into a patient's record in a timely manner is the use of pre-built specialty templates.

Specialty Templates

ConcurMDEHR makes use of "templates" to simplify data entry in the EHR. A template is a framework of the information that a physician uses most often. The information is entered into the computer and is stored so that it can be quickly retrieved for future use. Another important factor is that, by giving the users multiple ways to enter information into the system, clinicians with little or no computer skills can quickly adapt to the new technology. ConcurMDEHR has extensive pre-built specialty templates for Oncology/Hematology, ENT (Ear, Nose and Throat), OB/GYN, Family Practice and Internal Medicine. Clinicians can easily edit and modify the templates themselves to meet their more specific needs.

Vital Signs

All vital signs (weight, pulse, height, blood pressure, etc.) are displayed as a line graph relative to dates of previous encounters. This makes it easy to identify unhealthy trends or patterns in vital sign data. Vital Sign Monitor can be interfaced into the system.

Injection Management

ConcurMDEHR provides a means for specifying injection dosages, units, location, lot numbers, and more; as well as the ability to run reports and print other information related to these injections.

Writing Prescriptions

The EHR application has the ability to check past and current medications, drug allergies, etc. The physician in just a few point and clicks can prescribe the medication, dosage, frequency, number of refills and instructions, and print it out for the patient.

Advantages to Writing Prescriptions in ConcurMDEHR:

• Ability to set default dosages, frequencies, refills, etc. for medications
• Ability to bring an old prescription forward into the current encounter, whether modified or just re-prescribed, much faster than by traditional paper methods
• Ability for physicians to securely transmit electronic prescriptions to pharmacies
• Ability for physicians to fax prescription information to pharmacies in conjunction with commercially available products that can be purchased separately

Clinical Documentation Reuse

The information required in the EHR application is stored in the system in chronological order. The clinician can quickly navigate to previous categories of information within the medical record. In cases where patients have chronic ailments, conditions that do not change much with respect to time, the physician can quickly pull portions of previous medical records forward into the current patient encounter and speed the process of documenting the medical record.

Evaluation and Management (E&M)

Periodically, the government performs audits where they check charges for "E&M" services rendered and compare those charges to the supporting medical record documentation to insure compliance with these regulations. By using templates and reusing portions of the past medical records, the physician can quickly build the necessary documentation to justify his services. Also, since much of the information needed to estimate the level of care is available in an electronic format and many of the guidelines can be 'automated', ConcurMD can offer the feature of estimating the level of care and provide documentation recommendations for moving to a higher level of care.

Medical Necessity Management and Coding

ConcurMD has a built-in Coding System. As health insurers revise policies and the coding changes, the physician's practice has the ability to make those changes in the ConcurMD system. When the physician, nurse, or other employee orders a procedure or service, the software can provide hints as to what diagnoses is considered necessary for a given procedure, patient and insurer. And equally, by selecting a diagnosis, ConcurMD will hint at what procedure or service a health insurer considers medically necessary. This is made possible because the ConcurME suite is fully integrated on a single data base for the Electronic Health Record, the Laboratory Information System and the Practice Management module.

Messaging

ConcurMD provides a messaging system, which works in unison with the EHR. Users of ConcurMD are able to send electronic messages back and forth to each other regarding patients. All correspondence can be saved as a part of the patient's permanent medical record.