Since the HITECH Act of 2009, hospitals have rapidly moved away from traditional paper-based processes towards paperless processesNever before has the healthcare industry seen such a period of technological advancements and adoption over a relatively short period of time. For all these paperless advancements, however, there are still consistent “paper-gaps” within hospitals. This  is very important because what this tells us is that hospitals generally are still struggling with the same paper-based processes. Electronic health record (EHR) systems (i.e., Epic, Cerner, MEDITECH) are wonderful at tackling clinical documentation, but they are less focused on digitizing the processes that can occur between the hospital and the patient. This results in paper-based consent forms, questionnaires, government forms, and so on. 

Given that many hospitals have paperless initiatives, it is becoming increasingly common for hospitals to evaluate and pursue patient electronic signature (eSignature) solutions in order to close these “paper-gaps. This is wonderful, but the healthcare industry (namely hospitals) is unique in many ways, which means electronic signature behemoths, like Docusign eSignature, who is industry agnostic, may not always be the best fit.  

So, what is a hospital left to do other than flounder as they pursue an eSignature project? Well, we are here to help; we have 20 years of eSignature experience focused on exactly what hospitals and their patients need. Below, we have outlined six common challenges we see hospitals struggle with when it comes to researching electronic signature solutions. We want to lay these  common patient eSignature challenges and solutions out for you and provide you with solutions that will ensure a smooth and successful eSignature project. Note that the following eSignature challenges transcend any one hospitalEHR situation, or eSignature solution provider (such as ourselves). Understanding and accounting for these eSignature challenges will help you no matter who you select as your electronic signature provider. Of course, we always hope it is us. 😊 

6 challenges

Top 6 eSignature Challenges & Solutions for Hospitals 

  1. Lack of EHR Integration 
  2. Single Department Solution Focused 
  3. Differences in Registration & Bed-Side Scenario 
  4. Bad Paper Form Makes for a Bad Digital Form 
  5. Not All Forms Are Created Equal 
  6. Capturing Patient eSignature Outside Your Hospital 

eSignature Software Challenge 1 | Lack of EHR Integration 

AEHRs have become the “home-base” for clinicians, their desire to stay within the inherent workflows and user interface of their EHR has sharply increased. In other words, if you ask the clinician to use any supplementary technology that forces them to leave their EHR, is likely to be met with an understandably high degree of pushback. According to NCBI in EHRs: The Challenge of Making Electronic Data Usable and Interoperable,
Among the capabilities that vendors need to improve or develop, the AMA says, are reducing cognitive workload, facilitating digital and mobile patient engagement, and expediting user input into product design and post-implementation feedback.

If you want a healthcare eSignature initiative to succeed, it is of paramount importance that the electronic signature solution can integrate with your EHR. However, this is a very limiting factor when it comes to evaluating the best eSignature providers for your hospital. The list of eSignature technology vendors for healthcare is whittled down pretty quick with this singular filter. However, if accessibility, usability, and adoption are of any importance to you, this will be the first qualifier you must have when it comes to considering your eSignature capture options. 

eSignature Challenge 2 | Single Department Solution Focused 

Once you get past Challenge 1, you will naturally consider where you should begin your eSignature project. More often than not, hospitals appropriately select the Patient Access area as the first place to utilize eSignature because the forms are simple, you are able to eliminate copious amounts of paper, and it significantly improves the patient experience. According to HFMA’s, How Ochsner Health System Uses E-Signatures and Self Check-In to Drive Patient Satisfaction,

As the health system deployed the EHR in each of its various hospitals and clinics, registrars in all patient access areas—including outpatient, inpatient, and the emergency department —also began to take advantage of the electronic signature pad for each of the newly consolidated forms. 

Be mindful, howeverthat other areas of your hospital need eSignature capture solutions too. Apply some forethought to your eSignature evaluation and analysis process and consider the unique eSignature challenges and needs of other areas of your hospital (see Challenge 3 below). In other words, while one patient eSignature solution may be great when applied to Patient Access, it may fall woefully short in meeting the needs of your other departments.  

eSignature Software Challenge 3 | Differences in Registration & Bed-Side Scenario 

Applying eSignature successfully in the Registration and Patient Access Departments are vastly different than applying eSignature solutions successfully in the clinical care setting. There are two main differences you should consider as you evaluate the application of eSignature at the bedside: 

  1. Logistical differences: In Patient Access, the patient is often sitting opposite a Registration Clerk at a desk. Many hospitals choose to use an LCD device to capture the patient’s eSignature. However, the situation in the clinical care setting is quite different. On the floors, the patient is often in a bed and leveraging an LCD device to capture the patient’s eSignature at the bedside is challenging, at best. Often the LCD device needs to be tethered to a workstation via USB cord, and holding and signing an LCD device in bed is not the easiest thing to do. If you really want eSignature at the bedside to be successfulthen leveraging tablets to account for the unique logistical challenges is your best bet. 
  2. Form differences: Forms in Patient Access are generally simple and straightforward, requiring minimal input from the patient and often only requiring a single signature. Forms in the clinical care setting, however, are often more robust and complex in nature. Informed Consents, for example, have a multitude of unique complications that should be accounted for (see Challenge 5 below). 

eSignature Software Challenge 4 | A Bad Paper-Form Makes for a Bad Digital Form 

One of the most common pitfalls we see hospitals struggle with in their eSignature project comes as a surprise. What is not surprising is that hospitals get really excited about their electronic signature project. Naturally, they tend to focus on all the paper and money they can save and how they can improve the patient’s experience. According to NCBI’s, An investigation of the efficacy of electronic consenting interfaces of research permissions management system in a hospital setting

patient workload attributed to paper-based forms was roughly 15% more than digital interfaces, and patient satisfaction with eSignature devices was 25% higher overall, compared to paper. 

However, as hospitals go from the “buying” phase to the “implementation” phase, they find that their existing paper-based forms are in need of a significant overhaul. This form-level overhaul can take time as these forms are often legal in nature and must be reviewed by legal, the department head, the forms committee, and othersOur best advice is to look at the paper forms you wish to digitize and evaluate if they need to be updated first. 

eSignature Software Challenge 5 | Not All Forms Are Created Equal 

Different forms bring about different challenges, and you need to be eyes wide open to this when considering an eSignature solution, as not all solutions can meet the demands of more complex form processes. Two prime examples are found in Informed Consents and with POLST/MOLST forms.  

Informed Consents | Informed Consents often require more than a patient’s signature. They require the Surgeon’s signature, but they also require information such as the name of the procedure, the description of the procedure, the risk(s) of the procedure, and so on. This information must be on the forms when the patient electronically signs the forms, which may be beyond the capabilities of some eSignature vendors. 

POLST/MOLST Forms | POLST and MOLST forms are state-level government forms and are oriented towards palliative care. In addition to basic signature capture from the patient and their care provider, there are many data fields that need to be filled in or checked off. Some of these fields are interconnected with other fields, too, and the risk for human error is thereLooking for eSignature solutions that can capture signatures as well as discrete data is important. It is extremely helpful, howeverto have an eSignature provider that can set up required and contingently required fields to help reduce the opportunity for human error. 

If your eSignature vendor can help you not only eliminate the paper, but also help you eliminate various issues (ex. Form completion errors) that the HIM department sees, then you are really onto something. 

eSignature Software Challenge 6 | Capturing Patient Electronic Signature Outside Your Hospital 

One of the more recent developments we have seen with eSignature in hospitals is associated with new business practices resulting from the COVID-19 pandemic. The long-term trend towards telemedicine and the overarching concept of treating patients remotely has increased the need to extend patient eSignature capabilities to the patient beyond the walls of the hospital. The primary driver for this is focus hospital have on: a) keeping an unnecessary amount of people out of the confined space of their waiting rooms, and b) reducing the time these patients spend in the waiting room. By allowing the patient to electronically sign all forms before they enter the hospital, a contactless check-in process and an expedited registration process are both possibleThis is how hospitals are leveraging eSignature solutions (see our Impression solution for a demo of this) to help reduce the spread of COVID-19 within their hospitals and help ease the concerns of the communities they serve. 


Applying an eSignature solution to convert your “paper-gaps” into fully paperless processes is a great idea for any hospital. However, hospitals are unique in so many ways that standard “off-the-shelf” patient eSignature solutions may not be appropriate. If you mind these six common challenges hospitals face with eSignature, then you will find yourself in a far better position to implement a successful process that will be good for your hospital, staff, and patients. 

Access eForms has over 20 years of hospital specific eSignature experience across Epic, Cerner, and MEDITECH systems. If we can be of any help as you pursue, plan for, or consider an eSignature solution, please do not hesitate to reach out. It is our pleasure to help hospitals achieve their goals and provide the superior care that their respective communities deserve. 

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Cody Strate

Written by Cody Strate

For more than 15 years, Cody has provided sales and marketing leadership with the goal of providing the smoothest, easiest, and most pleasurable customer experience imaginable. Cody is a Forbes Communication Council member and lives in Colorado with his wife, two kids, and two dogs.