Surgery EMR Software

Best Surgery Clinic EMR Software Buyer's Guide 2024

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by Oliver Hudson
Last Updated: Dec 17, 2024

What is Surgery Clinic EHR Software?

Surgery clinics have to juggle a lot of tasks at the same time and require electronic medical record software that helps to make the workflow seamless. Surgeons require Electronic Health Record Software (EHR) that can support the three stages of surgery; pre-op, intra-op, and post-op, within one software discretely, yet at the same time integrated with labs, diagnostic, and monitoring devices.

Features of Surgery Clinic Software Interface – To conduct effective surgical procedures, surgeons must know every detail of the patient’s health. A seamless lab interface offered by the software will automatically enable up-to-date patient files.

Customized Templates– Surgery clinic Electronic Medical Record (EMR) Software needs to have SOAP note templates that cover all three aspects of a surgery clinic; pre-op, intra-op, and post-op. This will enable accurate point-of-care charting for quick review.

Device Integration– It is essential for intra-op charting that surgery clinic electronic medical records have device integration to monitor patient vitals.

Surgery Clinic EMR Software System – The top Surgery Clinic Software should also have connectivity with diagnostic devices. This enables the EHR Software to raise red flags and alerts in case of allergic reactions, or emergency aid.

Referral Program – A lot of surgical procedures are referred to as surgeons. The surgery clinic Electronic Health Records software should have a strong Secure Messaging portal to import patient files, as well as export files after the surgery has been conducted.

ICD/CPT Codes – Surgery-specific ICD-10 and CPT codes declutter the electronic medical record software, enabling accurate, eligible claims for a faster billing process.

Dictation Support – Intra-op EMR Software should have dictation support to enable surgeons to take down point-of-care charting without using their hands. This saves time, ensures accurate charting, and doesn’t distract from the surgery.

What You Need To Know About Surgery Clinic EMR Software

Overview

Surgery Clinic Electronic Medical Records Software commonly referred to as Surgery EHR Software represents the electronic method of storing medical records for patients. Using specially designed software, physicians and other medical professionals can store anything ranging from patient demographics to extensive clinical information about patients, such as medical history, social history, lab reports, and more.

EMR Software by Specialty

Since all medical providers (MDs, DOs, PAs, NPs, LCSW, OT, etc.) work distinctly based on their background and medical specialty, EMR Software must accommodate the unique style and documentation requirements. Examples of such specialty-specific features include the ability to annotate images or the capability to store before/after photos for Pain Management specialists and Dermatology specialists respectively. Similarly, other specialties such as Pediatrics, Oncology, Podiatry, Ophthalmology, Neurology, Nephrology, Dialysis Centers, Rheumatology, and Chiropractic Care require their unique set of specialty-specific features to simplify adoption.

Meaningful-Use

Since the introduction of the HITECH Act, healthcare IT has undergone a massive transition starting from the widely recognized Meaningful Use program to what is now known as MACRA, the Medicare EHR Incentive Program. The Meaningful Use program has transformed and now formed part of the four components of the new Merit-Based Incentive Payment System (MIPS), which itself is a fundamental part of MACRA.

For some medical practices, the transition from paper-based records to EMR Software (Electronic Medical Records Software) has not been a simple one. Regardless, realizing that the benefits of utilizing ONC Certified EMR Software far outweigh the hassle and challenges associated with it – ensuring a viable future, most practices today have successfully transformed their clinical and administrative operations to EMR Software.

EMR Software Benefits

Aside from ensuring tangible financial incentives and profitability, practices converting to EMR / EHR Software have seen the following benefits:

EMR Software Requirements by Practice Size

Just like a medical specialty, EHR Software requirements also depend on the size of the medical practice. From solo-provider clinics to large multi-provider, multi-specialty clinics, every practice has unique inherent challenges that must be addressed by the EMR Software vendor.

Small or Solo Provider Practices

A small doctor’s office not only has a limited number of staff members but their EMR Software budgets are also extremely low compared to a large enterprise such as a hospital. Due to these budgetary constraints, many providers simply choose to employ Free EMR Software or choose an affordable EHR Software vendor with a low fixed monthly fee. Cloud-based access is one such important requirement so that these providers can access patient charts even from home when needed.

Medium-Sized Practices

These practices usually consist of 5 to 10 medical providers often belonging to the same medical specialty. Their requirements are more stringent, and their budget is also considerably large. Aside from specialty-focused requirements (EHR Software by Specialty), these practices also require unique features such as interoperability, dedicated customer support, multi-device support as well and extensive reporting functionality to keep an eye on the overall performance of the practice.

Large practices

Larger group practices generally comprise more than fifteen or often twenty medical providers. These practices usually provide medical services that fall under various medical specialties (Orthopedics, Pain Management, Surgery, Chiropractic Medicine, Family Medicine, etc.). Therefore, these practices require support for multiple users to access the system simultaneously, as well as for the Scheduling software to accommodate multiple locations, providers, and resources such as Dialysis Chairs, procedure room allocation, etc. These practices also keep replacing or adding staff members and need a scalable solution.

Hospitals or enterprise organizations

EHR software companies such as Epic, Cerner, Allscripts, NextGen, Athenahealth, IMS by Meditab, eClinicalWorks, Meditech, McKesson, MEDHOST, etc. usually target and provide solutions for larger corporations like Hospitals, ACOs, PCMH, IPAs, CINs (Clinically Integrated Networks), Public Health Departments, etc.

These customers have the most elaborate list of requirements, which are usually documented in the form of an RFI or RFP to assess and shortlist vendors that can meet them. The requirements consist of features like inventory management modules, interface with local labs (LIS), machines, and diagnostic equipment along with drug dispensing (pharmacy management software) and electronic medication administration records (EMAR), etc.

These entities also require the EHR software also need to integrate with multiple other software and medical devices.

Why does your practice need EMR Software?

Since the introduction of Meaningful Use, most healthcare practices simply have little or no choice but to convert their practice operations to EHR software. However, most providers today select the EHR software of their choice that best suits their specific needs and must perform an extensive search to evaluate all available options before they find one that is suitable. Most potential EHR Software buyers in the market today have the following in common:

  1. Do not know what they are looking for
  2. Know exactly what they want but don’t know where to start or find it
  3. Relying on advice from colleagues using EMR software already

Although #3 is ideal, every provider and practice workflow is unique and therefore what works for one provider may not suit the other. “One size fits all” simply doesn’t apply in the world of healthcare IT. Software experts and industry specialists are an ideal source of information, and advice and ultimately ensure that the right decision is made.

What to Look For in a Potential EMR Software?

EMR software includes several types of software based on specific applications or functionalities:

Cloud-based EMR software

Small doctor offices benefit the most from Cloud-based EMR Software technology since minimum to no upfront cost or maintenance is required and accessing the EHR Software is possible from any location given the availability of internet access. This type of EMR software is also device-independent in most cases and can be accessed using devices such as Smartphones (Android & iOS), iPhones, iPads, laptops, and desktop computers.

Mac EMR Software

Apple dominates the digital device and computer market in the US today, so it is no surprise that many providers are specifically looking for their EMR Software vendor to support the Mac operating system (Mac EMR Software). Not all Vendors today work on a Mac device, so looking for a vendor with native support for Mac devices is essential to ensure that the software performs on existing hardware at the practice and does not require more investment in computer systems.

ONC-ATCB Certified EMR Software Vendors

This is the most significant requirement for most software buyers today as the software must comply with the standards and guidelines set by the Office of the National Coordinator (ONC). The online repository details all software vendors and details related to their respective compliance with the measures set by the ONC (Click here). Software that complies with these standards has undergone rigorous testing and confirmed at a benchmark level defined by the federal body. The software testing done during this exercise checks all areas of the EMR Software system from Patient Portal access to the way the EHR Software communicates with other programs and entities like labs, Pharmacies (via e-Rx), hospitals, HIEs, etc.

Surgery Clinic EHR software

Electronic health records software (EHR) for certain specialties such as neurosurgery or reconstructive surgery must provide robust tools to document the clinical workflow of surgeons such as specifying the area of concern (for example joint pain) and it should also provide specialty-specific templates and reporting features.

 

Integrated Practice Management Software

With competition rising in healthcare IT, EMR software providing integrated Practice Management software as part of their overall software package easily outperforms rivals with standalone EHR Software including those that may provide specialty-specific EHR software. EMR Software companies with integrated Practice Management solutions often tend to provide extensive reporting capabilities to track practice performance and manage business operations better.

Integrated Medical Billing Software

Medical practice has several needs for software systems to streamline operations across the board. One such important area is billing for services rendered and communications with insurance companies. Medical Billing Software, therefore, works best when integrated with Electronic Health Records software. All clinical documentation seamlessly conforms to the required standard and forms a financial document that can be electronically sent to payers (insurance carriers) to verify and process at their end. This simplifies the operations and ensures all parties are on the same page when it comes to the financial health of the enterprise. Medical billing software helps practices and medical billing managers generate claims, and patient statements, verify patient eligibility, and more. This software is ideal for practices that want to handle billing in-house and can integrate with EMRs.

Security

An EMR Software must ensure the security and safety of patient records while ensuring privacy and HIPAA compliance for patient/doctor communication (Patient Portal). This is a paramount concern for physicians and HIPAA compliance should be guaranteed at all times by the EHR Vendor. Most Vendors today (Epic, Cerner, Athenahealth, AdvancedMD, PrognoCIS, Modernizing Medicine, eClincalWorks, etc.) are aware of the importance of HIPAA compliance and have taken steps to ensure the safety of patient records security in every section of the EHR Software using advanced tools like data encryption technologies to enhance the security of the EMR software.

Greenway Patient Portal

Greenway Patient Portal

Specific Services

One of the decisions your practice will have to make is whether you want just EMR software or one with integrated Practice Management for billing and scheduling. There are advantages to having both together but there have been cases where some practices only go for one if they had unique requirements that a vendor could not fulfill, or they had already paid a hefty amount for PM software and weren’t looking to replace it yet.

Ease of Use and Training

Doctors are not IT professionals, and though some might be tech-savvy, it would be egregious to expect them all to be experts on EHR software. Ease of use is essential to make the transition from paper to electronic smooth, as well as day-to-day practice to go along without a hitch. If the software is too complicated and hard to understand, it’s a waste of precious time and needlessly aggravating. Some vendors offer free training while others don’t; make sure you ask for training if your practice needs it.

Specialty Specific

Not all specialties are created equal, so why must their software be generic? Basic EHR software works well and is good for general practice and most specialties, but doctors have complained about specialty specific not being available in the market. The specialty software has inbuilt recording systems that make specialty practices function efficiently. Only a few vendors provide specialty-specific software, so there aren’t many to choose from. But more vendors are cottoning on to the demand and there should be more options shortly.

Support

Support is a major issue most practices have with their current vendors. A good support team can make small glitches to major roadblocks easy to maneuver while a bad one will just make things worse. Some vendors provide support as part of the plan you’re already paying for, while others charge extra for support. Scout the market, read reviews, or ask if there will be a special support team assigned to each practitioner and whether you’ll be charged for the service.

Hidden Cost

There are varying price lists out there, some offer free services, while others charge an arm and a leg for specialty services. Either way there will be hidden costs that you might get to know about later. Fix your budget and talk to vendors you interview about hidden costs within the contract and whether services such as training and support are free.

Mobility

Smartphones have changed the dynamics of mobile usage. Handheld devices are easy to carry around and can be used for any number of uses. Most people are ditching the cumbersome PC for a handheld device. Doctors mostly use iPads or Tablets in the examination room to take down patient symptoms, check history and note down the prescription, so the vendor must have a mobile application that is synced with all the mobile devices being used in the practice.

AdvancedMD mac EMR electronic medical record mobile

AdvancedMD mac EMR

Market Trends to Be Aware Of

Like anything else, the EMR software industry is also subject to constant changes. From new technology to legalities and governing bodies, everything is constantly changing. Here are some of the changes I think it would do well for you to keep track of.

Cloud-Based Services

Recent research found that only 25% of practitioners are interested in a web-based model and only 50% are willing to have it as an initial model that eventually transitions to cloud-based. Cloud-based EMR software cuts down on steep upfront costs for client servers and can be hosted on any device that has a web browser. It’s no surprise that more and more vendors are transitioning to cloud-based software because the industry demands are changing.

Meaningful Use Changes

At a recent healthcare conference Andy Slavitt, the administrator of the Centers for Medicare & Medicaid Services declared that Meaningful Use was over, and would be replaced by the end of this year with something better. But a deeper look into the claims revealed that meaningful use would very much still be there, only much improved.

The new measures aim to make the reporting and benchmark for reaching the required reports much easier and laxer than under Meaningful Use, along with other changes.