By: Deborah Wells, MS, CPHIMS, Senior Strategy Consultant, The Children’s Hospital of Philadelphia, Co-chair HIMSS Connected Patient Community, and member of HIMSS Patient-Generated Health Data Task Force.
A year ago, I posted a blog titled “Electronic Pre-Visit Questionnaires Improve Workflow and Encourage Engagement”about a pilot which The Children’s Hospital of Philadelphia (CHOP)had just completed, using patient portal and kiosk technology to deliver developmental questionnaires in primary care. The project was extremely successful and the questionnaires have since been rolled out to all of CHOP’s 31 primary care practices. The project was so successful that there have been numerous requests for the development of additional types of questionnaires in both the primary care and specialty care areas.
Having completed one type of questionnaire, it could be tempting to say “CHOP now has electronic questionnaires!” In reality, it is not so simple, as the process of developing the second round of questionnaires has shown.
As the next phase of the project, a new-patient questionnaire has been developed and is being rolled out for our specialty care practices. What we found was that different types of data, different rules for when to give the questionnaire, and other factors have brought new challenges.
Characteristics of the Developmental Questionnaire:
- Standard form that does not differ across clinical practices so that very little customization was required as each new practice was added.
- All of the data is discrete allowing it to be mapped into specific fields in the EHR. There is no free text data that has to be stored as notes.
- There are relatively few questions and none that require typing so that a touch-screen tablet device can easily accommodate filling out the questionnaire in the office.
- Logic had to be built to appropriately assign questionnaires based on the age of the child. Registration staff received an alert to indicate that a patient needed to fill out the questionnaire for the visit.
Characteristics of the New Patient Questionnaire:
- Most of the specialty practices use a similar questionnaire for new visits. There are some differences, however, between practices. Thus, some adjustment to questions and data mapping are necessary for each implementation. This, of course, means that these questionnaires cannot be rolled out as quickly as a standard form.
- In addition to discrete data collected in check boxes, there is considerable typed (free text) information. Some of this information, such as name, can be mapped to discrete fields. Other free text data must be stored in notes. This free text data cannot be used to create logic-based workflows.
- The questionnaires are much longer than the developmental questionnaires. The length and subsequent significant amount of typing mean that different hardware is required in the office for family use. For these questionnaires, the practices must use laptops on carts, instead of touch-screen tablets. Incidentally, this created the need for a significant workflow change in the registration process. Instead of a registrar providing a touch-screen tablet across the desk, an MA is instead assigned to provide the cart when the patient is taken to the exam room. Thus, an additional staff member is involved.
- Privacy and security policy requires that patient portal accounts must be signed up for in person. Because these are new patients to the practice, they will not have had the opportunity to visit the office to acquire a portal account and password. This created a conundrum for the use of the portal as the preferred means of having patients fill out the forms before coming to the office. A new security class had to be developed that allows an account to be created at the time that an appointment is made that only allows the user to fill out the form. Once saved, the form cannot be reviewed or changed. When the user comes into the office for their appointment, the account is changed to normal security, due to in-person authentication.
Implementing technology is rarely as easy as it sounds. What we have discovered is that with each new form, and often in each specialty’s practice, significant differences in workflow, as well as design and build for electronic questionnaires will be necessary. This requires that IT resources be designated for these tasks and the work must be prioritized against other work requests.
The electronic questionnaires have been so popular with patients and providers that there is now a backlog of requests. The ultimate goal is to have as many questionnaires as possible available electronically.
Patient Portal Adoption
The preferred method for patients and families to fill out electronic questionnaires is through our patient portal. This is particularly true for longer questionnaires that can take some time to complete in the office. Having the patient’s information pre-populated in their record before or at the beginning of their visit allows the physician to spend more time reviewing the information with the patient or conducting the exam.
Unfortunately, so far the portal use rate for filling out the forms is low. Efforts to have families sign up for and use the portal, including marketing campaigns, encouragement during the registration process and other efforts, have not produced the desired results in most cases.
There are many reasons for this. Parents are focused on getting their children in and out of their exams as quickly as possible, so they don’t have time, or forget to sign up, at the time of their visits. A major barrier in pediatrics is the issue of teenagers having access to health information that their parents cannot see through the portal. Many parents are uncomfortable with this, so they forgo the portal altogether.
What we have found, consistently, is that the best way to improve portal usage is to have physicians themselves explain the benefits, and encourage families to use it. In practices where physicians routinely make this effort, adoption by patients is three to ten times what it is in practices where this does not occur.
As more physicians see the benefit of families contributing data to the record in advance of visits, it is hoped that usage will increase.