Last Updated | August 17, 2022
Overview: Custom Patient Record-Keeping Software: 5 Essential Components
Gone are the days when healthcare organizations relied on a one-size-fits-all approach while choosing patient record-keeping software.
This approach doesn’t work today.
That’s because off-the-shelf electronic health records (EHRs) no longer serve the needs of different practices with unique workflows.
While an off-the-shelf EHR may be able to provide for a general practitioner, it does not fit the workflows of specialist medical practitioners like dentists, cardiologists, physiotherapists, and oncologists.
Healthcare practices and professionals have unique workflows and using a generic purpose EHR software does not provide all features and thus does not meet their needs. Such software only causes practitioners frustration and reduces productivity and practice efficiency.
That’s why there is a need to adopt a better approach to developing better software solutions.
If you (as a healthcare practitioner) want to make care delivery efficient and align your overall workflow, you have to move beyond generic record-keeping software and invest in a customized EHR system.
A bespoke EHR for your specialty, clinic or healthcare practice will be much more effective at boosting the efficiency of your practice and optimizing your internal workflows.
So, if you want to gain maximum results from your investment, you need to invest in customized patient record-keeping software. This type of software will give you the advantage of freely choosing components as per your needs. In this way, you can get as many components in your EHR software as you need.
You can learn about some of the essential components below.
However, before you get down to those details, the first thing you need to find out is what information customized patient record-keeping software will help you store.
What Information Is Stored In Custom Patient Record-Keeping Software?
Be it a generic patient record-keeping software or a customized one, the basic information they store is the same.
They all hold a patient’s past medical history maintained by the clinicians over time. Plus, they store clinical data related to the care of that particular individual, such as demographics, vital signs, problems, progress notes, medications, immunizations, radiology reports, and laboratory data.
However, with a customized EHR, you can get additional features for expanding information storage, such as custom health history questionnaires, physical health examination templates based on your specialty, patient call log, and much more.
The information stored in the EHRs largely depends on your specialty practice. If you are a general practitioner, not all your patients walk in with x-ray or charts, so you do need to store x-ray reports.
But, every patient walking into a dental practice carries charts or x-rays, so dental professionals can add advanced charting and imaging tools in their documentation workflow to quickly and efficiently store and access such information.
Likewise, there is a possibility to store a huge amount of data chunks in your customized EHR software for which you can get different modules like:
- Treatment cycles
- Execution calendar for managing crucial events
- Drug administration
- Comprehensive embryology management and so on.
Interestingly, customized record-keeping software empowers you to store information and complete documentation just the way you want, allowing you to focus on providing better patient care and achieving the best possible results.
However, there are some essential components you will need to make sure to add to your custom EHR software.
5 Components of Custom Patient Record Keeping Software
In healthcare app development services, user experience (UX) (in this case, patient experience) with the software is extremely important. Therefore, your custom patient record-keeping software must have all the components and templates that make up an interactive healthcare UX design.
To ensure a great experience with customized software, you can get it built with some advanced components like:
- AI-Assisted Note-taking
As a healthcare practitioner, you often spend a lot of time taking notes about patients and then inserting them into the EHR. With a customized EHR, no longer will you need to do that.
Peter Liu (a researcher at Google Brain) in his study has proposed his recently developed language modeling to the healthcare industry. His proposed AI-powered tool can predict the content of new patient notes based on existing health records. With this powerful tool, Peter aims to help clinicians eliminate the need to rely on assistants and tackle dictation or write-up tasks.
His AI tool with error-checking or auto-completion features will provide clinicians with a strong clinical assistive note-taking model to minimize errors and boost efficiency.
In your custom-made EHR software, you can also add an AI-assisted note-taking feature to automate the note-writing process. This way, you can relieve yourself of this tedious task.
However, you must know that Peter has just proposed this tool. So, it may not essentially be available for the software you choose. Therefore, you must talk to your vendor and confirm if you can add this to your custom record-keeping software now or later.
- Scanning and Integration
Opting for customized record-keeping software gives you the freedom to add any components to it.
Another essential component you need to have in your system is the ability to scan documents and integrate with other systems to streamline data flow.
Your customized and comprehensive EHR can have a scanning interface to help you scan patient paper charts, upload scans of documents and images, record dictation, and pull up any data from EKGs, CT scans, and so on directly into the system.
As for the data integration solutions for healthcare, you can go for HL7 data integration to integrate medical diagnostic systems with your record-keeping software and get a real-time and holistic view of a patient.
- Patient Call Log
Your telephone line is a lifeline between you and your patients. However, keeping a record of every incoming and outgoing call can be a cause of frustration for your clinical staff and have ripple effects on your practice efficiency.
But, with customizable EHR software leaving everything at your disposal, you can add an advanced patient call log feature to your software.
The call log screen in your custom-built EHR can help you keep a record of every call throughout the practice. Likewise, when you are on a call with a patient, it can automatically pull up and provide you with patient data associated with their number.
Let’s say a patient is calling in for a prescription refill. The log screen of your customized software will give you instant access to the patient’s current medication list for you to approve or add a new refill without switching the screen. This way, within a few clicks, you can revert to the patient while still on the call.
With this proper call documentation, you can go a long way in assessing the individual patient situations and providing accurate diagnoses.
- Prescription Management System
Another component your EHR should have is a prescription management system. A prescription management system can help address the issue of non-adherence to medication.
Once you have this system set up as part of your customized EHR, you get the ability to closely track and monitor patient prescription refills, usage, side effects, and adherence.
This system simplifies prescription management for both providers and patients even after patients get discharged. Plus, it reduces the risk of prescription loss and updates the information after every patient visit.
Having such a robust prescription management system in the EHRs can facilitate a reliable method to give patients new prescriptions and reduce errors.
- A Strong Backup System
It does not suffice if your customized EHR has all the above components and no backup system.
When a small technical malfunction occurs with a server experiencing a meltdown, you can lose all your medical records within an eyeblink.
So, to avoid catastrophic data loss, you need to make sure to get an automated backup feature in your record-keeping software.
A strong backup system is the backbone of how you manage to get the most out of your bespoke record-keeping software, so make sure your system is set to backup data automatically.
Unlike ready-made record-keeping software, customized software gives you the freedom to choose this feature among different options that include:
- Tap backup system
- Disk backup
- Online/ cloud backup
One of the best configuration options is to have a cloud-based backup. It is connected to the Internet and preserves your patient information within servers run by the vendor. This makes it a better solution to retrieve data and software in the event of failure.
The Way Forward
With all that customized software offers you, you get the idea that generic record-keeping software does not suffice for specific purposes of different practices.
Every healthcare practice has unique workflow needs, so they need specialized record-keeping software that features essential components and leaves out unnecessary ones to make record-keeping practice easier.
For your healthcare practice to achieve efficiency, you must harness the right features that can essentially make your workflow streamlined.
You can hit this goal with custom patient record-keeping software that allows you to choose the features and components at your disposal.
What is the most used patient medical records software?
Among an extensive range of patient medical records software, Epic EHR ranks as the most used software with a market share of 34%, followed by two other software- Cerner and MEDITECH- holding shares of 23% and 14%, respectively.
How much does patient record-keeping software cost?
The typical costs for patient record-keeping software are based on monthly charges that can be anywhere between $300-$700, plus they have a one-time upfront cost ranging from $2,000-$33,000.
Some other software may provide you with a pricing model consisting of a one-time licensing fee ranging from $2,000 to $25,000 with an additional monthly cost for support and software maintenance.
How do you store data in patient record-keeping software?
Patient record-keeping software is usually the prime target of hackers, so patient health and financial information must be stored in them in a way that ensures protection.
To ensure this security, you need to consider the following practices for storing data:
- Develop data documentation standards and train staff to follow them
- Carefully consider how records will be organized in the software
- Scan all the existing paper records and schedule the time to integrate them into the EHR. You can do this in many ways by harnessing EHR system integration using Epic EHR integration health care, Allscripts EHR integration, or Cerner HL7 integration– depending on the record-keeping software you use.
- Encrypt all patient records in the software to meet privacy standards for HIPAA compliance software development
- Verify the records accurately by each provider who has treated the patient
HL7 vs FHIR standards: which ones make data sharing easier?
HL7 and FHIR standards define how healthcare information can be exchanged among various EHR systems used by different healthcare providers.
HL7 standards support data transfer using HL7 message examples, and they need to be written by a programming team and then integrated with your system to exchange data.
However, Fast Healthcare Interoperability Resources (FHIR) do not need to be written and are smarter than HL7. They come as an application that facilitates fast interoperability among EHRs and makes data sharing easier than HL7 standards.
How do I choose an EHR for my clinic?
There are lots of EHR software for clinical practices. To choose one for your clinic, get to know your requirements and telemedicine startup costs offered by different EHR vendors.
Once you shortlist EHR vendors, you will learn that the best EHRs are offered by Epic and Cerner companies.
Now, when it comes to deciding between these two EHRs, you can search for Cerner vs Epic pros and cons. This will help you understand the difference between the features of these software and costs and which one can fit your budget.