Revamping the Patient Intake Process To Add Value (And Remove the Clipboard)
In waiting rooms across the country, the clipboard is infamous. It’s become part of the ritual of seeking care, yet its value is routinely questioned. People seeking care are asked to complete several forms in the waiting room ahead of the appointment or to complete a mailed set of forms at home. While the purpose may have started pure (to help the patient and clinician gather key thoughts to help the care process), the information that patients provide through many forms in the waiting room is:
- often duplicative with information we already know about people in the electronic health record
- inefficiently transferred into electronic form (often by clinicians)
- not rich enough to help track longitudinal care outcomes that patients and clinicians care about
- more helpful to check certain boxes for billing rather than providing true value to the patient
- confusing, because of multiple forms and processes (mailed forms, other EHR functionality), and/or
- not reviewed (some brave people even told us in some focus groups we did for other work that they made up answers to see if they would be noticed😳)
Providing and gathering important clinical information well is in the best interests of all involved. But this is also an important point of dissatisfaction for the above reasons.
What if we re-imagined the patient intake process to really focus on delivering the most value to patients and clinicians? What if we placed a priority on being efficient and respectful of time?
This is work that we are currently undertaking. And to not jump to conclusions, we are participating with broader customer journey mapping and design thinking to evaluate the problem and ensure that any potential solution fits the needs that we identify.
Our priorities for this work are three-fold:
- Improve the consumer/patient experience of providing Information
- Improve the clinician’s experience with documentation (avoid transcription paper → digital)
- Develop an enterprise-wide ePRO Platform/System
Digital by Default
One of the philosophies that we are trying to promote is one of “digital by default,” meaning that we first encourage our patient/clinicians to make the most of digital tools to promote efficiency, and then rely on secondary processes when people are unable or do not wish to engage with us digitally.
In this patient intake work, we would encourage all those who engage with us for clinical care to help us make sure that we have the most accurate information about them in our electronic health record. This would mean that we have an up-to-date history and patient profile (including family history social history, and social determinants, and allergies), an up-to-date medication list, an up-to-date problem list, and an awareness of any other symptoms that may be germane to their care (review of systems). We would encourage our patients to complete this ahead of time, ideally through our upcoming mobile application/patient portal.
It requires active energy on the part of patients to proactively work with clinicians/teams to make sure that the medication list in the record reflects what is in their pillboxes or cupboards.
By starting with what we already know about the person (rather than a blank sheet of paper), we can enable people to provide updates and help us curate the problem list in the medication list, making this truly shared work between patient and clinician.
One of the common refrains that I will hear from people is “it’s on the list in the record, it all should be up-to-date.” Emphasis on the should, as we all know that this requires active energy on the part of patients to proactively work with clinicians to make sure that the medication list in the record reflects what is in their pillboxes or cupboards.
Rarely are things ever taken off of the problem list. But patients are in a great position to help us understand what is germane, and what is no longer relevant.
The same is true for medical problems that we keep track of collectively. When used well, the problem list summarizes major health conditions that require active management by the clinician and the patient. Rarely are things ever taken off of the problem list. But patients are in a great position to help us understand what is germane, and what is no longer relevant. A recent example from my clinical practice comes to mind from just last week. I was meeting with a new patient who used the current pre-check-in process in our portal functionality. The patient flagged several problems for removal. In all but one of these cases, I agreed and very easily this helped us update the problem list. In one case, I felt that we should keep the issue at the top of mine, explained that we should leave it on, and dismissed the patient’s flag/request for removal after explanation. This worked really well, and it saved me clicks through the process.
Change and Trust
I’m often asked if people are in the best position to update their history. What if a wrong diagnosis is added in the family history? If our goal is to get the most specific condition accurately captured in the problem list, can we really expect patients to give us the most complete ICD-10 coded problem? Will this be wasted time in rework or unnecessary discussions?
I think the questions are fair, but I really think that we need additional experience to show us that we can trust patient engagement in this process. To be clear, I think that this is collaboration. This is teamwork between patients and clinicians, not patients taking sole responsibility or clinicians taking sole responsibility. Research that I’ve been involved with has informed my view that patients value being able to complete portions of the record or history intake at home, outside of the time-pressured clinical visit (or waiting room clipboard), and where they can also verify history with family members if needed. So in some ways, history can be more accurate. Certainly reviewing the medication list would be more accurate if done at home with pill bottles rather than reviewing a printed sheet of paper containing what we think are the currently prescribed medications.
We also have to trust that this will be a timesaver, or at least help us get to have better conversations with patients. Of course, physician is synonymous with teacher, and opportunities to clear out misconceptions are valuable patient engagement and awareness opportunity, even if we feel that it is not value-added time. But that distracts from the greater point that engaging patients in completing in this information and taking ownership of it will help us, in the long run, develop a better and more accurate record to assist with care.
Workflow and Reconciliation
We are currently evaluating the tools that we can use in tandem with our workflow for patient intake. Regardless of the exact tools or the process used, there will be work to be done in the reconciliation of what patients can provide. But we must remember that we are already doing this work now, just incredibly inefficiently.
One of my goals for our program would be to reduce the time that clinicians take in documentation, by using reconciliation rather than typing or keeping in entries in various parts of the history, electronically capturing review of systems in a way that can easily and quickly be imported into notes, and in a way that over time can track relevant data for particular clinical departments services or clinics to enable better outcomes tracking.
Patient Reported Outcomes
We must also incorporate an enterprise-wide solution for capturing patient reported outcomes electronically. This will help us measure our impact on patients’ lives, and it will help us identify opportunities to help intervene where people may be struggling. We are looking closely at how electronic PROs (or e-PROs) can be part of our digital intake process, and how we can enable our clinics to use validated instruments to track progress.
Final Thoughts
We are still very much in a learning phase. The diagram below outlines our current concepts, starting with the journey mapping, collecting voice of the customer (including patients, staff, and physicians) developing a process for some of the main pain points, reviewing all of the in-use forms, and prioritizing them. We will use prototyping and lean startup in our approach.
Throughout this work, we must insist that everything we ask patients to complete or that we ask doctors to look at provides value.
