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We've built this guide to help you better approach and navigate your patient eSignature project. You'll find decades worth of experience and strategies gleaned from the hundreds of hospitals who've implemented patient eSignature before you. All of this knowledge has been curated just for you, and we hope you find it to be most helpful.
The following information is intended to be read from start to finish. However, we've written this strategy guide so you can quickly navigate to any section that interests you most.
A patient electronic signature or eConsent solution is technology that helps hospitals eliminate persistent paper gaps across their enterprise. You’ve likely already made a meaningful investment in an electronic health record (EHR). This meets many of your needs, but it’s primarily designed for clinicians, rather than for patients or guiding interactions with them.
Whenever you have some sort of a form process that a clinician deals with exclusively, this can often be converted into an electronic process inside your EHR. However, if you have a process that requires the patient to sign off on something, this generally exists as a paper-based process as it’s outside of the “sweet spot” of EHRs. We refer to these types of processes as “paper gaps” and often they manifest as consent forms, questionnaires, POLST/MOLST forms, etc.
That’s why many hospitals like yours still rely on paper for such processes. However, while your staff might be comfortable with manual, paper-centric processes, they’re typically slow, inefficient and subjected to the limitations of hard copies. These include documents being lost, misplaced, and misfiled, workflow delays that in turn impact procedures and patient care, and the cost of maintaining a paper forms library.
After a while, many hospitals recognize that they need to eliminate these various paper gaps. They want a fully electronic solution to present to patients for the purposes of efficiency, cost savings, and delivering a seamless experience. In everyday life, patients have many technologies at their fingertips that make things easier, whether it’s ordering a ride with Uber or Lyft, outsourcing chores via TaskRabbit, or getting groceries delivered with Instacart. You can even buy vegetables from a rural farmers market, and use a Square reader to pay and electronically sign for your purchase. Because of this pervasive exposure to applying their electronic signatures, the patients who walk through your door will expect the same level of speed and convenience from your hospital. If a rural farmer can offer their customers a seamless and fully electronic signature, what will that same patient think when your hospital presents them with paper for signature capture? Your hospital should demonstrate to patients and the community its commitment to advancement and technology. Paperwork will never meet such expectations.
If we can agree that eConsents are a better way forward for providing a modern patient experience, the next question you might have is, “Where do I begin?” Then other considerations probably pop into your head like, “What makes up a good eSignature technology?” Or, “What benefits can it deliver to patients, staff, and the organization as a whole?” And, “How should I approach rolling it out to my hospital?”
It’s these questions and more that we’ll answer in this Strategy Guide and Playbook. Because while eConsents technology can deliver immediate and lasting advantages, there’s no doubt that it's a big endeavor that’s not to be undertaken lightly. Patients interact with various documents in the different departments in your hospital. In Registration and at the bedside, they have clinical consents that vary by specialty -- radiology, obstetrics, surgical services, etc. -- and procedure. So where do you begin the process of converting paper-based consents into electronic versions?
In the following pages, we’ll give you a blueprint that’s proven to be effective across many hospitals like yours. The goal is to prepare you to embark on this journey with the maximum chance of reaching your paperless destination successfully, while avoiding common pitfalls along the way. By the time you’re finished reading, we want you to feel fully equipped to proceed toward a paperless eConsent process. One that’s fluid, seamless, and efficient for clinicians, saves your hospital time and money, and delivers a smooth patient experience that boosts satisfaction and is commensurate with the level of care that you deliver.
This playbook isn’t really for the end user – i.e. someone who would use eConsents technology to capture patient signatures on a daily basis and is likely doing so now with paper forms. This guide is for decision makers in IT/IS who commonly evaluate technologies for the entire hospital. Departmental decision makers such as HIM, Patient Access and Admissions Directors will also benefit, as will C-level executives who are eager to eliminate paper forms enterprise-wide but don’t know where to start. The following sections are intended to help you better evaluate the challenges that managing paper consents present to your organization, and to offer insight on how to solve these challenges based on best practices used by hundreds of hospitals like yours.
This is the all-important question that must first be answered. If you can’t come up with a resounding “yes” for your hospital, then turn your focus to one of your 10,000 other pressing demands. Perhaps the better question is: Why should you invest time and money on a patient eSignature project?
In a word, yes. But beyond this, we need to look at the most powerful factor that drives change. We need to establish the all-powerful “why”. In our experience the “why” is always multi-faceted and multi-dimensional. We try to help hospitals evaluating eSignature solutions bring clarity to their problems. This starts with categorizing their challenges into two simple categories: tangible and intangible problems.
Tangible problems: Substantial in nature, they can generally be summed up as how the problem costs your hospital time and money.
Intangible problems: Generally derived from how the problem makes someone feel. More often than not, we see that intangible problems are what spark hospitals to make changes. Essentially, someone or a group of people get so frustrated with an issue that they decide to make a change. If you step back, you’ll see that this is nothing more than human nature in action
Now that we’ve established our two types of problems and defined them, let’s look at some of the problems associated with paper-based consents across the enterprise.
Continued | Should you spend time and money on patient eSignature?
As you can see with the intangible problem the common theme is frustration. There is another type of problem that deserves being mentioned as well and that’s the philosophical problem. These issues can be summed up as why you think the situation is just not right. Something about it is at its core wrong, and should be changed to a more elevated circumstance or situation.
Let’s look at the example of lost paper-based Informed Consents to see the combination of tangible, intangible and philosophical problems all in action.
Tangible problems: 14 percent of all scheduled surgeries are delayed as a result of missing paper informed consents. The average delay is 22 minutes. The average cost per minute for that delay is $60 per minute. That amounts to an average cost of $1,320 per delayed procedure. And that assumes the delay is only experienced with that surgery and doesn’t impact subsequent procedures. Unfortunately, this is often not the case. This is especially vexing if a delay is experienced with the first case of the day because all subsequent surgeries leveraging that OR are now at-risk of being delayed.
14% of operative procedures are delayed due to missing paper consents
22 minutes is the average delay experienced in the OR
$60 is the low-end cost of a lost minute in the OR
Such a domino effect quickly adds up to a big impact on your hospital’s bottom-line. This is where we get into the costly territory of cancelled surgeries and nursing overtime. It’s also worth mentioning that the research clearly shows that as a surgeon’s day drags on, the more prone they will be to make a fatigue-related mistake, which puts the patient and hospital at greater risk.
Intangible problems: The surgical team is frustrated, and inter-team discord can create a toxic workspace that may trigger negative ripple effects. This can even carry on into home life as the surgeon told their spouse they’d be home for dinner at 5:30 PM, but now they’re not getting back until 7:30 or 8:00. And the nurse whose son had a soccer game? Bad luck, kid. They have to work. These are all issues that affect people’s emotional and mental state. And, what about the patient in all of this? They’re likely anxious about having surgery, and now they have the extra stress of a delay.
Philosophical problems: This is simple. A hospital should represent the epitome of technology advancement and efficiency. Having the business of patient care interrupted because of something as mundane as a paper form being lost is fundamentally wrong.
Then there are multi-faceted problems associated with paper forms that fall into all three categories. For example, physicians waste time filling in instructions on various Informed Consents for different procedures. Even the most talented doctor is still a human being, and mistakes are made. That exposes the hospital to the risk of litigation if a patient claims they weren’t properly or fully informed about the risks of their procedure. This is not only an external problem from a compliance perspective, but also an internal one because physicians have the reality of a malpractice suits hanging over their heads. It’s also a philosophical problem, because in the Hippocratic Oath, every physician vows to do no harm.
These are just a few examples of the problems paper-based Consents present to your hospital – issues that will likely go away with the transition to eConsents.
OK, now it’s time to take a closer look at the numbers surrounding paper-based consents and eConsents. In 2018, we surveyed 535 U.S. hospitals about their use of paper vs electronic signature for Consents. Here are some of the highlights from our survey sample:
47% of hospitals claimed to only use paper-based Consents across the enterprise
38% of hospitals said they use an eSignature solution for eConsents in Registration
6% of respondents said they were using a bedside patient eSignature solution for Informed Consents and other clinical consents
4% of hospitals claimed to be completely paperless across their entire hospitals enterprise when it came to Consents.
5% of hospitals said they weren’t sure of their current situation with paper or eConsents
According to prospect theory, it’s common to worry that you have more to lose from something than you have to gain from it. This can make people hesitant to start down the eConsents path, because frankly change is hard, and the phrase, “Because we’ve always done it that way,” is heard too often in hospitals.
However, we’ve seen too many hospitals achieve operational cost savings, process improvements, patient experience improvements and improved HCHAPS scores by going paperless.
That said, there are right ways and wrong ways to tackle this initiative. We’ve seen hospitals achieve significant and rapid success across the board, but we’ve also had a few hospitals stumble when rolling out their eConsent initiative. Our goal is to help you avoid these pitfalls, and rapidly achieve success with eConsents.
The most common scenario we experience involves the various forms a patient signs during the Registration process. We ask the customer why and when the form is used. Nearly every time, a few forms seem to exist because “It’s always been that way.” Take the time to ask why a form exists and when it’s used. Don’t let the way it’s always been done go unchecked.
“When we looked to apply patient eSignature technology to our Oncology Consents it was discovered that we had been using the Chemotherapy Consent for every Oncology procedure. The staff would just cross out “chemotherapy” and hand write the actual Oncology procedure they were applying. Deploying eSignature helped us find a number of bad processes such as this and fix them.”
Anonymous Epic hospital eSignature customer
Now that you have a firm grip on what not to do, lets turn our attention on what you should do. First and foremost, decide what department, and which paper form processes, you want to address first.
While the mechanics of introducing patient electronic signatures in Registration and clinical departments are very similar (at its essence, applying eSignatures to eConsents), the advantages and payoffs are very different.
In this section, we’ll compare the benefits of applying eSignature and eConsents in Registration vs. the clinical setting, and we’ll break out the benefits aligned with tangible and intangible problems. From there, you can make a strategic decision on where starting a patient eSignature project for your hospital or health system makes the most sense.
In Registration, it really comes down to a numbers game. Nearly every patient who visits your hospital experiences the Registration process before being transferred to other departments. Most hospitals have each patient sign five or more forms, and when you multiply that by every patient who walks through your doors every year, that’s a lot of paper, sticky labels, money and time that could be saved.
So let’s draw this out and provide a simple cost savings example of applying eSignature in Registration.
Let’s say a hospital sees 100,000 patients each year. Each patient signs five paper documents that require sticky labels. Also, let’s say that the hospital’s HIM department handles 3.5 million pieces of paper each year. Here’s how the math breaks out:
Annual Paper Savings = 500,000
HIM Paper Reduction = 14%
Registration eSignature Cost Savings
Our eSignature customers report an average reduction of 85% of their paper expenses because the only paper that’s printed in Registration is the wristband and potentially a few labels.
There a few other tangible benefits that are worth mentioning:
There is a singular intangible benefit that’s no less significant than the tangible benefits when it comes to paperless Registration from an eSignature solution: The patient experience is better.
Patients appreciate the streamlined experience of paperless compared to a paper-based registration process. This can actually lead to tangible benefits for the hospital with improved HCHAPS scores. We wrote a piece about the correlation between patient eSignature and reimbursement that you can read more on HERE.
So what about the benefits eConsents provide in clinical settings? For starters, it’s not about reducing a massive volume of paper in an area like Surgical Services. Rather, it should be measured in the efficiencies created. This is especially true when it comes to Surgical Services and keeping the OR on time. The OR is the largest revenue maker for most hospitals, but it’s also the most costly department. Because of this, any efficiencies gained here are almost always significant.
Let’s revisit some of the statistics we mentioned earlier from JAMA:
If your hospital performs 10,000 procedures a year and 14% are delayed due to missing or incomplete Consents, that’s 1,400 surgeries adversely affected. That means the total cost of paper consent-related delays is nearly $1.85 million a year – a staggering amount.
Another way to look at it: that’s the ROI your hospital can achieve simply by moving away from paper consents and transitioning to eConsents.
In summary the benefits of electronic informed consents are not around paper savings, but rather it’s around improving the on-time efficiency in the OR. That’s a story you can sell internally. If you tell your hospital CFO that you have a way to eliminate 10,000 pieces of paper a year, they likely won’t be too interested. But if you say you have a way to improve the on-time efficiency of the OR by 14 percent, you’ll likely get their attention.
When it comes to the intangible benefits associated with eConsents there are three main advantages:
In short, the main benefit of implementing patient eSignature in Registration is the paper savings, which translates to cost savings. Whereas in clinical settings, eConsents eliminate lost forms and delayed procedures.
When looking at the high-level strategy for deploying patient eSignature at your hospital, one of the first things to consider is that not all department Consent processes are created equal. Some are straightforward while others are complex, require data entry and multiple signatures from multiple parties who are in different locations across the hospital.
Experience has proven that you don’t want to start your eConsent project by tackling the most difficult and complex consent processes.
Continued | Start in Registration - here's why
In our experience, the hospitals that follow this simple strategy and achieve long-term success consistently start in Registration. The forms in this department are simple, the gains are big and they can be realized relatively quickly. Most Registration forms contain some text and then areas for patient signatures. This applies to the consent of admission or consent to treat, the financial agreement, HIPAA acknowledgement, Medicare documentation and the secondary payer form.
Converting your Registration process to one with an eSignature solution is an easy win, on which you can strategically build.
Registration is a high-visibility department, which means the success you see here will likely spark more success and greater buy-in from stakeholders, department heads and other department end-users.
One more way to win big with eConsents in Registration is fiscally. On average our customers report an 85 percent reduction in paper costs in their Registration department. There’s also the knock-on effect of reducing the paper throughput to medical records/HIM by around 35 percent, which creates further time and cost savings. This makes it easier to secure the backing of your hospital leadership to prioritize and quickly expand into other clinical areas.
Another factor is that Registration clerks come and go. It’s a high-turnover position. With paper-based forms, the burden is on clerks to remember every form they need to pull for a patient. This slows the training process and increases the stress on employees. And, when a clerk moves on to another position in the hospital, as often happens, the training starts again with their replacement.
With an eConsent system, most of the work is done behind-the-scenes and automatically creates a packet of every patient form. This makes training easier and empowers clerks to focus on creating a good first impression with patients, instead of pushing paperwork. This is just one more reason that starting in Registration is the way to get your eConsent project off the ground.
Once you’ve successfully rolled out eSignature to Registration, it’s time to expand into clinical areas. But with so many possibilities, where should you start and why?
Let’s look back at the justification made for beginning with Registration: start simple. In general, processes and forms are more complicated on the clinical end, but there’s a broad spectrum. Search for a department where simplicity trumps complexity. The simpler the forms, the less complicated the process, and the less moving parts you’ll have to turn a paper-based workflow into an electronic one.
Remember, it’s partly about practicality, and partly about optics. Don’t spend months mired in the most complicated forms and processes on the clinical side, when there’s likely lower hanging fruit.
While some small setbacks are inevitable, it’s crucial that your eConsents process doesn’t grind to a halt now, or it will take a lot of effort to regain momentum. Find a department that has primarily simple forms and score success here. You’ll keep making progress and keep the excitement level high among staff members.
Once end-users in other areas see eConsents thriving in different departments, they’ll be more likely to want it in theirs, too. The sooner you can create a track record of success, the easier it will be to continue growing the solution across the enterprise.
For example, Anesthesiology is a common denominator across most surgical specialties. If you take the paper-based consents from this department and convert them to EHR-integrated and tablet-enabled processes that solve their problems, other surgical specialties will be exposed to this and likely want these same improvements in their own departments.
While certain departments may seem like great places to expand eSignature technology, it’s critical that they’re ready. Simply put, if they don’t want the solution then you’re going to have a hard time getting them to adopt it no matter how strong the potential outcomes.
Before moving forward, passing any Department you’re considering for a Patient eSignature solution through the Access Readiness Checklist:
Is the department head enthusiastic about using eConsents? (this is huge – move on to another department if not)
Are there other key stakeholders in favor of the solution?
How complex are the Consents and other forms?
What is the paper forms volume and throughput in this department compared to others?
Which forms have the greatest potential to cut costs?
Which forms will save time for clinicians?
How big of a threat are these forms to patient experience?
Are the department’s forms-driven processes simple or complicated?
Is there a functional process in place that can easily be replicated electronically, or are changes needed, which could involve the forms committee, compliance, legal and others?
Does documentation stay in the department or does it go to other individuals and departments?
Is there hardware in place, such as eSignature pads and tablets, or will these need to be purchased?
What accessories – charging stations, outlets, etc. – are available, and how well do these match the device needs for the eConsent solution?
Don’t roll out eSignature in any department where you can’t readily supply answers to these questions.
Using and interacting with eSignature technology requires LCD devices, and/or tablets. An essential component of an eConsent strategy is choosing the right devices and accessories. It’s not enough to select the best software or partner with the right vendor if the hardware isn’t up to the task. If you use the wrong tools for the job, it can lead to a lot of headaches for users and the IT/IS team alike.
Simple LCD pads often work well at Registration because they may be placed on a stable surface and they’re easy to use when standing. However, LCDs don’t cut it at the bedside because they aren’t easy for patients to handle while in bed.
Patients can’t see the eForm they’re signing. Generally, this is handled in Registration with laminated copies of Consents, but due to several factors, including that clinical forms vary greatly, presenting laminated copies of Informed Consents just won’t work. This is why iPads and other tablets are usually more effective in a clinical or bed-side eSignature application. They’re more mobile, easier to grip, and patients can see the entire electronic form that they’re signing You can find more information on this topic in our Tablet Best Practices Guide and Playbook coming soon!
This playbook is designed to show the benefits of implementing eConsents, to provide a blueprint for doing so successfully, and to help your hospital avoid common pitfalls. To recap, here are some of the steps that will put your hospital in a position to excel with patient eSignatures:
Consider the tangible and intangible problems you want to solve, and how eConsents can help
Make a strong case for eConsents by creating a common sense business case; try this resource
Choose an eSignature vendor that seamlessly integrates with your EHR
Choose a vendor that not only has the best technology, but will also be a responsive and proactive partner who’s all in to play the long game
Start your eSignature project in Registration to secure a likely early win; avoid reaching too far with an enterprise-wide rollout
Extend to clinical areas with simpler forms and workflows
Roll out eConsents to clinical departments with high visibility to other areas – such as Anesthesiology – to expose other departments to an aspirational paperless goal and build buy-in
Choose hardware -- LCDs, tablets, styli, cases, etc. -- that’s appropriate for the location such as Registration workstations or the bedside, and that meets the needs of end-users
Identify key stakeholders, get their input, and make them your champions for the whole enterprise
By following these guidelines, your hospital can likely boost patient experience, cut costs, reduce risks, improve efficiency, increase productivity and close paper gaps.
Want more info on this topic? Contact Us and we’ll be more than happy to chat about your specific paper problems and help you progress towards the paperless state your users and patients deserve.
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