3 steps to gathering EHR requirements for a new medical practice

A new medical practice has many decisions to make, with the selection of an EHR vendor as one of the top priorities. A new practice has no existing processes or established ways of charting patient records. However, the clinicians, administration and office staff will likely come with experience in patient care and documentation. The benefit of a new medical practice is that there are no old systems to do away with, so there should be better user buy-in.

New medical practice EHR step 1

The first step will require you to assess your practice goals, financial budget and technological systems and capabilities. It is important to establish a practice mission from which you will be able to base much of your decision making on. A psychologist office that specializes in post-traumatic stress in war veterans may have a mission that follows: The purpose of the clinic is to provide compassionate and evidenced based care to people dealing with post-traumatic stress syndrome, particularly those of violence and war, to empower their own healing and autonomy.

Recommended Reading: EHR Selection Survival Guide - Support your selection of a new medical practice EHR

For this clinic, the EHR system will need an easy interface for the clinician, as well as access to evidenced based outcome tools, patient education handouts and a patient access portal to support their autonomy and care. By identifying your practice goals, you can identify many of your EHR system requirements.

New medical practice EHR step 2

Next, you must ensure that you establish all legal and ethical guidelines required by your profession and by your insurance companies. This is important to uphold professional licenses and in order to get reimbursed for your services. You may need to contact professional organizations, as well as federal and commercial insurance companies.

New medical practice EHR step 3

Finally, be sure to consult your newly established clinical and office team. Ask what they find important and necessary for successful patient care with successful documentation. They will have the most hands on experience (provided they are experienced clinicians). Most importantly, they will be able to tell you what they don’t want, so you can avoid systems that will cause future frustration.

After these steps, you should have a more clear idea of what your EHR system should look like.

In general, an EHR system should:

  • Support clinical documentation and clinical reports
  • Carry over patient demographics, billing and insurance information for each encounter
  • Interface with billing software as well as for sharing information with other providers, pharmacies and laboratories
  • Provide ongoing member support and training
  • Meet all federal requirements for documentation
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Amy Vant

About the author…

Amy Vant is a doctor of physical therapy and clinical director for an outpatient physical therapy clinic in the United States. She has experience utilizing and implementing many forms of medical documentation through various healthcare practice venues. Amy enjoys writing about healthcare administration strategies, including electronic health record systems.

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Amy Vant

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