It looks like my previous post about Digital Signatures in an EMR drew quite a bit of interest looking at the stats. Really this isn’t surprising. How long have we been signing things electronically at Walmart. Longer than I can remember honestly. Sure, Walmart is worth billions of dollars, but the technology isn’t that expensive. The real advantage that Walmart has is a great legal team.
Setting the legal items aside, the technology of a digital signature is not rocket science by any means. In fact, it’s the legal questions that are harder mostly because there just hasn’t been much case law that has dealt with it. Just as a thought, I would highly suggest that whoever reads about this talks with a good legal team before implementing it.
Of course, reading the comments from my previous post made me realize that what we’re doing is really quite innovative. I’m not just talking about digital signatures. For more than two years now we’ve been collecting patients health history form in our Health Center and intake questionnaire in our counseling center electronically. These forms don’t require the patient or client to leave a signature. It’s basically just capturing information. I think most people can see why it’s valuable to have a health history form captured electronically. In our case it makes all of the necessary clinical information available in one place without dealing with the time consuming and inaccurate scanning. Even more significant for us as a state institution was the ability to do aggregate reporting on the type of patients we were seeing. How many other people can find out things like 20% of your patients have a family history of heart disease (not our actual number)?
I know there are a number of EMR companies out there that have a whole patient portal where this kind of stuff is done, but I’ve never seen any that use a kiosk at the doctor’s office to collect this information. If you are an EMR vendor that has this feature, please leave a comment. I think we’d all love to know who else does it.
Looking at it now, capturing digital signatures for HIPAA privacy forms, consents, etc is just the next step in ridding ourselves of paper. In fact, this addition means that our patients can bypass the front desk completely. They check in on the computer, fill out their necessary forms and then are directed to have a seat. This notifies the nurse that they have arrived and they are ready to be seen. No face to face contact. Privacy at its best.
Well, I got a few questions and comments in my digital signature post that prompted this post. I’ll do my best to answer them here.
Chris Kozloski said, “I like the idea. A kiosk for registration that they could fill out the paperwork online and sign the blocks on the screen would be really neat.”
See my notes above. It’s not just an idea. We’ve been having them fill out the paperwork for two years now. We also have the technology to do the signatures. Just waiting for the other signature pads to arrive and we’ll be implementing it.
One thing I’m not sure most people think about is how the computer will know which forms need to be filled out by the patient. I think that’ll have to be the topic for my next post.
Craig Briars asked, “What software are you using to do this with?”
This is a good question. We are using Medicat EMR. It’s an EMR that is focused on the College Health community, but could be used in a general practice if needed. I’m not sure how it is in a general practice, but I know that they have a ton of features that make it a solid choice for College Health offices interested in EMR.
Medicat has integrated it’s software with topaz signature pads. Medicat uses the Topaz software to capture the signature. It’s actually quite neat how the signature is captured and stored in the database. We did find that the LCD signature pads with the back light were the best. The cheap $100 topaz signature pads just wouldn’t capture my signature if I did it quickly. Plus, if it isn’t LCD, then I don’t know which part of the signature it missed so that I can correct it.
So here is a question for you. I have seen people who refuse to sign a digital signature pad. They don’t like the idea of their signature being electronically stored.
How are you all dealing with that situation, or have you had to deal with that situation to that point?
This would obviously concern the advanced directives sheet and forms of this nature. These form, of course would require a signature, as they are legal documents. I am assuming that you are completely paperless?
Sorry for the second post but I had a thought after I hit submit on the first one.
Chris,
People refusing to sign a digital signature pad is definitely a problem to consider. We are still new into this arena and I should say that the majority of our patients are in the 18-30 range and they are more open to the concept of digital signatures. However, I expect that we will meet with this problem soon enough.
We’ve combatted this problem in a couple ways. First, is that the signature is a required field and you can’t finish check in without doing something. Of course, someone could just draw a house or an X and it would accept it as their signature.
The second check we have is that our nursing staff has to acknowledge each of the forms that are filled out electronically. This “feature” is something that our HIM (medical records) folks love and our nursing staff find a minor annoyance. Essentially the nurse should make sure that their is a good signature before seeing the patient. This is a bit of a change in process for us since the front desk staff use to do this. However, checking for that signature is important. I expect we could offer someone a paper form and scan it in if they refuse to sign the signature pad, but we help them to realize that it will be electronic in one way or another since we’ll scan that form anyway.
Is it a perfect way to ensure that the forms get signed? No, but it’s at least as good as the signatures we get on the paper copy. Plus, we have one added layer of verification. In order to identify a patient and check them in, the computer asks for a set of personal information or a swipe of their ID card (I’m at a University). Even if they didn’t sign the form, I think them identifying themselves in this way, filling out personal information on themselves is a pretty compelling argument. Granted some of our verbage should probably changed to help with this argument.
Of course if they still refuse to sign, then we have the same recourse as if they refused to sign a paper copy.
I’m not sure what you mean with your advanced directive comment. It could be electronic also. I’m not sure how it would be different.
I think the concept of completely paperless is a bit of a myth. I think I blogged about this once. Anyway, if you define completely paperless as a patient’s entire medical record is electronic, then yes we are paperless. If you define it as everything is done electronically and we have no paper, then no we aren’t.
Think about how many pieces of paper you get into your office from other offices. This will prevent true paperless for a long time to come. We also give the patient a bunch of paper (patient education sheets, referrals, RXs, Doctor’s Excuse, physical forms, etc). We could combat this with secure emails to the patients or a patient portal or ePrescribing, but let’s just say that I don’t think our patients are quite there yet. My goal is to be as close to paperless as possible. It’s taken 2.5 years, but we’re almost there.
I should also mention that we sent all of our old charts to a scanning company so those will soon be paperless too. That’s one large office space that will now be freed up for other uses.
Now that was a longwinded comment.
No that is a good answer. You bring up a lot of very valid points.
Have you investigated digital signatures? Or patient account cards (i.e. smart cards with their information and digital signatures on it?) I don’t know how cost effective that would be considering most patients may or may not be regulars to your facility.
I’ve been mulling over a patient portal type of situation for a while. What would be neat about that is that if they had a scheduled appointment or procedure, they could log in and fill all that paperwork out in advance so all they would have to do is check in. That type of scenario could definitely improve workflow and patient care. It would definitely streamline the process if there was some sort of digital signature software that would allow them to digitally sign their forms, therefore eliminating the need for an actual hand-written signature. Digital signatures are as legally binding as well. Just some food for thought.
As far as the paperless thing goes, I understand completely. There will always be a need for printing in one form or fashion. I do however agree that patient records should be stored electronically. They are easier to find, maintain and manage versus having to go and pull a paper chart. Plus the doctor’s can work the charts from virtually anywhere, again streamlining workflow and patient care.
I hope that eventually we can have some sort of national repository for those kinds of things that all medical facilities can access. That would definitely make it easier for the patients. At that point all they would have to do is make sure their demographic information was up to date and their medical history would be right there for the doctor’s review. I think that would offer a more comprehensive point of care for the patient and give the Physician a better idea of the patient’s medical condition.
Better yet. If we had a national repository, we could use their driver’s license or state id or even social security card as a smart card with all of their digital information including digital signature.
The smart cards would definitely be cost prohibitive at this point. I work in college health and so it actually could be a possibility if they cost less since we do use their college ID to identify them and quickly access their account. However, the cost is way to high. Plus, there’s still the issue if that card gets lost.
We actually also have the ability for the patient portal where paperwork can be filled out online before coming to the office. It also supports scheduling appointments, messaging patients, requesting refills and I’m sure something I’m forgetting. Our problem is the account creation process. Once the university gets a single sign on solution, then it will be a no brainer ldap lookup and we’re done. However, I just feel bad giving our patients one more login and password to remember. It would be nice and is something that we’ll be seriously evaluating in the next year.
Don’t hold your breathe on the national repository. First is that a lot of people don’t want to use their social security number, driver’s licenses are done by states and I don’t think there’s a national repository of those numbers, and is there such a thing as a state id? The government has talked about having a national healthcare ID number which could resolve this, but of course we don’t want to have to have another number to manage. Basically we want our cake and want to eat it too.
If you search my blog for CCR you can see the potential of something like it working well with a national repository, but I think the RHIO model is probably more likely. Too bad the security, privacy and granting of permissions is such a bear that I don’t think we’ll ever really have a national repository of healthcare data. I hope some day I look back at this comment and declare I was wrong.
Bond Clinician has portals and a kiosk feature. The Kiosk feature allows patients to check in, to verify existing information, and to complete any new information. The kiosk handles everything from demographics to history to signing forms to verifying eligibility.
Amy,
That’s good to know about Bond Clinician. How do you handle the signing of forms? Do you have some sort of signature pad for them to sign?
To check out a completely integrated patient checkin system connected to the practices EMR check out this physician website http://www.lawrencegordonmd.com and register as a patient.
This is delivered through waitingroomsolutions.com.
Yes, the we interface with two different signature capture devices. Additionally, if desired, a practice can have a patient sign electronically using their indentifying information used to get onto the kiosk and their birthdate. Most practices have them sign on the pad, but Clinician does have the birthdate acknowledgement signature as well. The kiosk is a great feature. I was just a patient at a hospital here, and they lost a clipboard with the medical history, a driver’s license, and the insurance card. A kiosk would definitely help with these issues. Practices are always skeptical about how many patients will use it, but they are always suprised at the number of patients who are interested. Bond Clinician also has a patient portal, so the patient can complete the same information and home and then just check in when they arrive at the office.
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How educated are your patients. I live in a rural community where many of my patients can barely write their name. I would love for them to be able to put their information electronically, but don’t believe that to be a realistic goal. Additionally I would be concerned about theft. Are these kiosks bolted in to place and are they ever damaged by patients.
Melissa,
Yes, it’s not ideal for a lot of situations. Geriatric doctors likely wouldn’t be a good fit either.
Theft is a possibility, but we did have ours bolted down with a nice cable. Plus, no patient information was stored on the computers if it was stolen.