November 9, 2009

Signs of the Times
By Alice Shepherd
For The Record
Vol. 21 No. 21 P. 12

Whether it’s assimilating into an EMR environment or improving chart deficiency rates, digital signature technologies are proving their worth to healthcare organizations.

According to the Association for Information and Image Management, more than 75 million pages of medical forms are processed daily at a cost of $125 million. With increasing pressure to reduce costs while increasing efficiency and patient satisfaction, healthcare providers are turning to digital signature technologies to complement EMR systems and other forms of automation already in place. A wide variety of digital signature applications exist to meet every type of organization’s needs.

Pen and Paper Go High Tech
Until recently, when patients arrived at Brandon Healthcare, a family practice in Brandon, Fla., they were asked to complete new patient paperwork or update their existing records, each of which needed to be retrieved from storage. A nurse would then document the patient complaints and vital signs and forward that data to the physicians, who in turn added handwritten notes detailing condition, diagnosis, treatment, and office charges. All this information was then returned by the patient to the billing clerk, who coded it and entered it into the computer system. Finally, at the end of the business day, the office manager checked all the codes for errors before sending the data to a clearinghouse for billing to the appropriate insurance company.

A little more than one year ago, Computer Associates and Rover Technology Fusions developed a beta proof-of-concept workflow system designed for medical practices that utilizes the Rover INK’s enterprise software solution based on Anoto digital pen-and-paper technology. Since implementation, each Brandon Healthcare doctor can see an additional three to four patients per day, with registration taking less than two minutes to verify handwritten forms as opposed to 12 minutes to key data into an EMR. As a result, Brandon’s patient records are stored electronically with fewer errors. The original papers are scanned to preserve the patients’ handwritten documents as backup documentation and then shredded, eliminating paper files and storage requirements.

Using the digital pen, patients complete registration paperwork (eg, demographics, past medical history, allergies, medications), printing on customized forms with Anoto’s patented dot pattern. George Brick, MD, Brandon’s president, explains that “As patients check off yes/no questions or print their answers on the forms, the pen’s tiny camera stores an image of what is being written. The pen is just a little thicker than a ballpoint pen and writes as smoothly as any good ballpoint. Patients are very intrigued with how the pen works, and none have resisted using it.”

Once the forms, which are made of real paper, are completed, the pen is docked on a computer station in the front office. From there, the information is uploaded and becomes instantly accessible to the doctor who will meet with the patient. The pen is also used by the nurse to collect the patient’s vital signs. Again, the pen is docked and the information instantly uploaded to be available to the doctors.

As doctors examine their patients, they pull up the electronic file to view all the relevant information. They then chart the patient history and make exam notations using the digital pen. Once again, the pen is docked and all information is integrated into the EMR, while treatment methods are confirmed and matched to the proper billing codes. Each physician has a pen in his or her exam room, as well as a docking station.

“Physicians have been slow to accept EMRs because of the difficulty of typing and using pull-down menus while talking to the patient,” says Brick. “Our digital pen-and-paper system allows us to keep taking notes while maintaining very good eye contact with the patient. We like to face our patients, not a computer screen. We have customized our forms, so we can ask any question we want. While most EMR systems only provide yes/no questions and typing, the pen lets me elaborate and write additional information, which is uploaded to the chart. The application digitizes the information into the EMR and also stores my handwritten notes for future reference. There are currently over 100 EMR systems on the market, and one of the reasons they haven’t caught on is that physicians are concerned about usability. We’re sold on the digital pen and paper.”

The software populates answers to yes/no questions in paragraph form. For example, if the physician checks “yes” for chest pain and “no” for shortness of breath, the information in the EMR reads, “The patient complains of chest pain not associated with shortness of breath.”

The pen recharges itself while docked to upload information. In addition, overnight docking reenergizes it with a complete charge for the following day.

“The efficiency of digital pen and paper is phenomenal,” says Brick. “It’s very gratifying to capture so much patient data so quickly without errors. I don’t want to spend less time with patients in order to see more. With this technology, I can spend the same amount of time with my patients as I normally would while seeing more per day and being much more efficient. Even the registration module alone could really streamline registration at hospitals, emergency rooms, radiology facilities, and walk-in clinics. Rather than having staff spend their time typing, information could be uploaded into EMR systems in two to three minutes.”

Click to Sign
In Manhasset, N.Y., North Shore University Hospital began using Meta Health Technology’s PowerSign electronic signature technology about three years ago. Physicians use it to place their signatures on medical record documents, whether they are dictated reports or handwritten notes that have been scanned to permit electronic signing. Here, no pen is used to sign. Once a physician has reviewed the report, he or she clicks “electronic signature,” and the signature is officially placed.

Although used occasionally by nurse practitioners, the system is geared toward physician chart completion. “When we saw the electronic signature technology, we thought it would be a great way to simplify our process in the department and make it easier for the physicians to complete their medical records,” says Elizabeth Heller, RHIA, North Shore’s HIM director.

From within the hospital, physicians access the network with their log-in and password. To place signatures remotely via the Internet, they use electronic tokens in combination with a password. “The tokens are HIPAA compliant,” says Heller. “They are about 2 inches long by an inch wide with a little screen that shows a set of numbers. The numbers change every 60 seconds. The system relates the numbers to the password and grants access.”

Since it’s so easy to click “electronic signature,” what happens if a physician signs a document in error? “The application has the capability for correction,” says Heller. “If a physician signs something and later realizes it was incorrect, the document can be updated and signed again. However, the original version of the document is saved. In fact, if someone were to make changes on several occasions, each version would be saved.”

Initially, some physicians were skeptical, fearing that the new technology might be cumbersome to use. “When we showed them how easy it was to use, they accepted it quite readily,” says Heller. “The chairman of our medical records committee travels quite a bit and commented on how the technology works from anywhere in the world with Internet access.”

The hospital’s more than 3,000 physicians were all trained one on one. “As they came into medical records to complete their charts, we intercepted them, did a little mini-training, and gave them their tokens,” says Heller. “The process took about six months.” The hospital’s rollout was phased, beginning with about 100 of the most active physicians and then proceeding alphabetically. Some training was also done in the physicians’ offices to ensure completion by the date mandated for the switch to e-signature.

Heller’s advice is to begin rolling out e-signature technology with the most active, most computer-savvy physicians who are likely to champion the product and promote it to their peers. “In a large institution, a phased rollout in controlled numbers is most effective because you can train as you proceed and make sure physicians are using the system correctly,” she says. “Big-bang rollouts often overlook the need for thorough training and sufficient staff to monitor and manage the system.”

Leadership support is another crucial element to successful implementation. “The administration has to notify the physicians that they will need to learn how to use the new tool and that it will no longer be acceptable to complete their medical records manually,” says Heller. “If you give them a choice, they have no reason to use it. You also need good IT support. Our IT department played a very large role in installing and rolling out the system and setting up the electronic tokens.”

The technology is helping North Shore create an efficient documentation process. “Electronic signature technology makes it easier for physicians to access their charts and sign them off,” says Heller. “It can also decrease your delinquency numbers. As a result of increased efficiency, the medical records department was able to reassign one staff member to other duties.”

Patients Love Tablets and Kiosks
Several years ago, Florida Hospital Fish Memorial in Orange City was asked to pilot NCR Healthcare’s eClipboard e-signature tablets for the Adventist Health System. Interfacing with the hospital’s Cerner EMR, the signature application first asks registrars to enter their patient account number. Then, the patient’s name and address appear on the screen to confirm identity. Next, the application brings up the forms—such as privacy, consent, and financial documents—patients or their representatives need to sign. After signing each form with the stylus, the patient clicks “next” and proceeds to the subsequent one. When all forms are signed, patients have the option of asking for a paper copy, which few do. The system also asks if an interpreter was used, in which case staff have to document who the interpreter was and cosign the consent.

“Patients have adapted to the tablets very well,” says patient access manager Barbara Wagner. “By now, everyone is used to signing similar tablets with similar electronic pens in the process of shopping or banking. We also explained to them that it protects their privacy because there is no paper.”

The tablets also work well for bedside registration. “We have mobile computer carts with a scanner so we can do bedside registration and the patients can complete all their paperwork on the e-sig tablets,” says Wagner. “[This month], we will add the capability to take a payment on that tablet so we never have to leave the room with a credit card.” The hospital added bands across the back of the tablets where patients can slide their hand to avoid dropping the units. This is particularly important in the emergency department (ED), where patients can be shaky.

Another e-signature technology that has proven successful at Fish Memorial is NCR’s MediKiosks stationed in the outpatient lobby, where patients can verify demographics and sign paperwork without having to wait for staff. “Once patients are in the system, they can complete this validation of data and sign all forms themselves on subsequent visits,” explains Wagner. “They type in their name or swipe a credit card at the kiosk to identify themselves. The system then brings up the patient’s demographics so they can verify their address, phone number, insurance, next of kin, and the like. They can make corrections to some of those entries but not to insurance or guarantor information. When corrections are necessary, a staff member reviews them and electronically signs as a witness. Scheduled patients are also asked to acknowledge that they have come for their appointment, and the system brings up the necessary forms for signature. When the signatures are complete, patients can pay any required copay at the kiosk or pay at the registration desk if they prefer. By that time, registration has activated their encounter and has their bracelet and labels ready, and they can proceed to their department. The information from the kiosks and tablets imports into the Cerner EMR wirelessly via a CVM server.”

The hospital expected that the most resistance to the kiosks would come from older patients, but that was not the case. Some patients in their 30s don’t want to use the system, while others in their 80s and 90s embrace it. In fact, Wagner has noticed that sometimes people would rather wait for a kiosk to open than go inside and see a registrar.
A staff member has been assigned as a liaison to help people use the kiosk for the first time. “We showed a lady in her 90s how to use the kiosk, and she immediately noticed that her phone number was wrong,” says Wagner. “She was surprised that she had never noticed the error when registering with a staff member.”

To encourage the use of kiosks, proper placement is essential. “Another hospital placed its kiosk over to the side, where it was not in the flow of patients, and very few people were using it,” says Wagner. “Here, people immediately step to the kiosks as they walk to our check-in desk because the kiosks are within a few feet of the desk.”

One change that was made to the kiosks after initial deployment was to add a tilt hinge. “Some people needed it at a certain angle to sign,” says Wagner. “Tilting the screen also affords additional privacy, although the kiosks are already in little booths.” She recommends using standing kiosks rather than desks, where people might linger and cause lines to build. However, the hospital is planning to install a kiosk at desk level for people using wheelchairs that cannot be raised. Meanwhile, two signature tablets have been adapted to be a mini-kiosk for these patients.

When creating storyboards for the e-signature tablets, Wagner says it’s important to bring up the patient’s identifying information immediately after the staff enter the patient’s account number. That way, staff can verify the patient’s identity before having him or her sign the forms. This is particularly important in the ED, where account numbers are created rapidly, to avoid pulling up the wrong patient.

As a result of increased efficiency, Wagner was able to reassign one staff member from registration to the ED, and a full-time scanning position was eliminated because of reduced paper volume.

As healthcare organizations move toward adopting EMRs to better manage information, they are looking for simple solutions that enhance efficiency, save money, and increase patient satisfaction. Digital signature technologies are proving to be a viable option.

— Alice Shepherd is a southern California-based business-to-business journalist specializing in healthcare topics.