Patients and providers are frustrated with seemingly endless data entry and with interfacing more with computer screens than with each other during face-to-face visits. A Northwestern University study demonstrated that physicians who utilized electronic health records (EHRs) in their exam room spent 1/3 of their time looking at the computer screen. Recent studies have shown that data entry can consume up to 49.2% of a physician’s workday.
With the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and the government mandate that required Medicare payments to be cut by 1% for providers who had not adopted an EHR system by January 1, 2015 (with this percentage rising to 3% in subsequent years), providers will have to continue to find positive ways to adapt to these changes.
The Importance of Patient Engagement in Documenting Health Information
Accurate and complete documentation of health information must happen; however, consensus is lacking with regard to how this information is best incorporated into the patient’s health record. Some studies have shown that the use of documentation support or scribes could help to decrease data-entry time for physicians. However, this solution is expensive.
Another solution might be to capitalize on patients’ vested interest in their own health care by actively engaging them in the entry of their own medical history information into the EHR. This active participation by patients can help to deliver much needed health information directly to providers. Advanced knowledge of patient health information ahead of a clinic visit can assist providers in planning and in directing patients to the appropriate patient care pathways within their institution; indeed, in 2015, the Office of the National Coordinator for Health Information Technology identified the use of patient-generated health data as an important issue for advancing patient engagement, care delivery, and research.
In 2016, the leadership team of the Perioperative Anesthesia Assessment Center (PAAC) at the University of Texas MD Anderson Cancer Center proposed a study to evaluate the effects of engaging the active participation of patients in documenting their own health information into a new EHR. We hypothesized that this active participation would have multiple positive effects on health care delivery as it would decrease data-entry time for providers and would help to guide individual patient-centered care.
Envisioning the Ideal EHR
Developing an Electronic Patient Questionnaire
Prior to the implementation of the new EHR in March 2016, the PAAC team worked with our information technology (IT) analysts to develop an electronic version of a patient questionnaire that had been designed and vetted by a group of subspecialty experts, including anesthesiologists, surgeons, internists, cardiologists, endocrinologists, and pulmonologists.
The questionnaire contained 40 medical and perioperative questions designed to elicit information requested by our institutional outpatient surgical clinics and anesthesia providers. Prior to the introduction of this electronic questionnaire, each clinic had been asking patients these same questions at each visit, with some patients answering the same questions multiple times in the same day.
Engaging Clinicians in EHR Development
The step of engaging clinicians to work with IT analysts was key to ensuring that the process improved with the implementation of this new technology and did not simply lead to the creation of an electronic version of our existing current process, which may not have reflected the ideal future state. It was also important for clinicians who had knowledge of the capabilities and limitations of the new EHR to be engaged in this process.
To that end, our physicians took courses provided by the selected EHR vendor to help them better understand these capabilities. This step made it possible for physicians to collaborate with the IT specialists rather than having traditionally nonclinical personnel dictate the clinical workflow.
Facilitating the Flow of Information
Another key component of provider engagement was the use of common structured documentation and note templates agreed on by larger groups of users performing similar tasks. In this case, all providers agreed on the data needed from patients and how that information should be displayed on the page or note.
The use of structured notes facilitated the flow of data and information from various sources, including patient-entered questionnaire data, so that it could be reflected in many areas of the EHR (such as the patient’s problem list and medical and surgical history) and also could be used for research and analysis.
Incorporating Patient Preferences
The goal during the development and pre-implementation phases of converting to the new EHR system was to imagine our best and ideal future state by thinking outside the box and keeping the patient at the center of that focus.
Although patients were not consulted on the specific questions to be asked, they were consulted about their desire for less redundancy and repetitiveness when answering questionnaires and their preference for having a typical in-person clinical visit (which can last for more than an hour) or a “fast-tracked” visit of 20 minutes. Patients overwhelmingly preferred answering fewer redundant questions and having the option of a fast-track visit.
Assessing the Impact of the New System
To assess the effects of our new EHR system and the new process flow for patients seen by our PAAC team, we utilized time-driven activity-based costing (TDABC) methods. Time estimates were calculated using time stamps, captured in the EHR, correlating with each time a provider accessed the patient record while performing clinical tasks.
Measuring the Effects: Patient Participation, Cost Savings, Provider Satisfaction
Since the implementation of the new EHR and the questionnaire in March 2016, 34% of our patients have answered our questionnaire at least one day prior to their arrival in our center, giving us much-needed information regarding their personal health history.
We were disappointed that this percentage was not higher, but we are currently developing educational materials for our patients and providers to broadcast this message of patient time savings to encourage greater participation. We intend to have these materials available for patients both online and in ambulatory clinics throughout the institution by the end of 2018.
Additional efforts are also being made to ensure that patients know how to use the online patient portal and that needed questionnaires regarding health information are linked directly to patient visits and appointments within that portal. We also plan to continue monitoring patient participation in the hope that, as a result of our efforts, the numbers will continue to rise.
One year after the implementation of the new system, TDABC analysis using data from the Bureau of Labor Statistics demonstrated cost savings of 19.09% and a 10-minute decrease in provider data-entry time.
Time savings was used as a surrogate for provider satisfaction. Throughout this study, the average number of patients assessed per day by the PAAC remained constant; however, the overall number of full-time employees decreased by 21%.
Moving Forward with Increased Patient Participation
As is common in other industries today, health care delivery needs to be more interactive, with patients having greater ability to exchange their information into and out of the system. Time is a commodity that both patients and providers can appreciate. Engaging patients to actively participate in helping to enter their medical information is one way for both groups to realize this benefit.
With this in mind, several take-home points can be highlighted:
- The process of developing a new EHR system requires active participation by all team players, discussion of what is needed to improve the current procedures for obtaining and entering patient information, and consideration of patient needs and motivating factors likely to increase patient involvement.
- Health care teams that have been able to cultivate detailed knowledge of their process of care and have identified specific data-entry points may be the most likely to benefit from patient input into the EHR.
- Any EHR system that allows the patient to input data is useful in that it can save patients and providers time and frustration, can allow for advanced care planning, and can help to ensure transparency of patient information throughout the institution.
- Patients want to answer questions once, and providers want to transmit the information to their colleagues both inside and outside of their own institutions. Health information exchange and interoperability across different EHR platforms would go a long way to help alleviate the patient burden of filling out endless and repetitive questionnaires.
- Patients would be motivated and more incentivized to answer questions ahead of visits to health care organizations if steps are taken to show them the benefits of their efforts.
This research is supported in part by the National Institutes of Health through MD Anderson’s Cancer Center Support Grant (CA016672).