Many sexual health services are investigating ways to increase service efficiency in a climate of finite fiscal resources and increasing patient demand, while still maintaining good-quality health care provision.1 At Sydney Sexual Health Centre, this has involved the adoption of information technologies such as text messaging reminders2,3 for retesting and vaccinations and implementation of express sexually transmitted infection (STI)/HIV testing services.4
In December 2010, the center introduced an express STI/HIV screening service for asymptomatic people.4 The service involves a computer-assisted self-interview (CASI) for risk assessment, self-collected samples for STI testing, and staffing by an enrolled nurse (second-level nurse who provides nursing care under the direction and supervision of the registered nurse) who performs the blood tests and throat swabs. Evaluation of this new service showed that it significantly increased clinical service capacity and total patient visits.4 However, because registration at the center involves patients physically being managed by reception staff and the process is paper based, the increased patient numbers also increased reception staff workload and created “bottlenecks” with long times to complete the patient registration and arrival process. There was no extra funding available to use more reception staff, so we designed a new electronic patient self-registration and appointment self-arrival system we hoped would increase clinic efficiency and reduce reception processing time.
Setting and Preimplementation System
Sydney Sexual Health Centre is a large metropolitan public sexual health clinic with 34,000 visits in 2013 from 12,000 patients. The center offers both appointment-based and walk-in consultations. Each new patient approaches reception staff, who provide them with a registration form and instructs them to complete the form at the reception desk. Once complete, reception staff give general instructions regarding clinic process and send the patient to the waiting room. The registration information is then entered by reception staff into the clinic database. Reception staff then place the registration form into the paper medical record and deliver it to the clinician. Each time a patient reattends, their patient details are manually checked with them and updated by reception staff if required.
Electronic Self-Registration and Appointment Self-Arrival System
In early 2012, the center developed a novel self-registration and appointment self-arrival system that enables patients who can read and understand English (91.5% of patients in 2012) to electronically register their patient information before a consultation (self-registration) and let the clinician know they have arrived for their appointment (self-arrival).
The system uses a CASI that allows the patient to data enter and update their own demographic and contact details, directly into the clinic database. No sexual history is currently collected in this system. In the new system, this information is electronically available for the clinician and therefore not printed or placed in the paper medical record. The CASI has inbuilt information screens that explain confidentiality and privacy and the use of patient information. Prior to implementation of the new system, confidentiality and use of client information was only briefly covered on the paper form due to insufficient space and was only addressed further if a patient specifically asked reception staff. Full name, date of birth, postcode and 2 contact methods are compulsory, and the client cannot continue self-registration unless complete. It also contains inbuilt checks to help ensure data entered by the patient are valid such as (2) mandatory double entry of e-mail and telephone numbers and (2) automated check of mobile numbers against Australian rules regarding mobile numbers. Each time a patient reattends, their patient details are displayed so they can update them if required.
Patients with an appointment receive a randomly generated 3-digit reference number in their SMS appointment reminder. They enter this code into the CASI, and the system automatically registers them for their appointment. If the patient does not have an appointment, the system will create a triage visit for them. Once the client is registered, reception staff give the medical record to the clinician.
The reception desk was redesigned to fit 3 touch-screen computers for patients to use and a bar code scanner system so that medical record numbers could be scanned rather than manually entered.
We evaluated the impact of the new system on reception processing time and patient information data quality, among patients attending the sexual health clinic using a preimplementation and postimplementation study.
During the before period, an internal auditor manually collected data on the time from when the patient arrived at the reception desk to the time the medical record was ready for the clinician and the time taken at each stage of this process. The auditor aimed to collect data from 50 patients in a 1-week period. The auditor selected a variety of days and times to capture any variation in patient flow that may occur in a week. During the after period, similar data were extracted from the electronic system on all patients attending during the same times and days as the before period. The time to complete the CASI replaced the pen-and-paper registration and reception data entry in total.
Total number of calls, call wait time, and call abandonment rates for the reception telephone extension were also extracted from the electronic telephone system used at the center, for both time periods.
Total reception processing time was defined as the time from patient presentation to reception to the time the medical record was ready for the clinician.
Time for patient data to be provided was defined as the time from patient presentation to reception to the time the patient completed the registration form (includes updating form for returning clients).
Time for reception staff to process the patient was defined as the time from when the patient completed the registration form to the time reception staff sent the patient to the waiting room.
Time for reception staff to prepare medical record for clinicians was defined as the time reception staff sent the patient to the waiting room to the time the medical record was ready for the clinician.
We compared the median time taken in each stage of the registration process in the before period to the after period. The median time it took patients to complete each of the reception steps was described using summary statistics and formally tested using the rank sum test. Telephone call abandonment rates before and after the implementation were formally tested using the χ2 test. Only summary data by 5-minute periods was available for telephone wait times so statistical tests could not be conducted to assess if significantly different.
Ethics approval was granted by the South Eastern Sydney Illawarra Area Health Service (Northern Sector) Human Research Ethics Committee for use of retrospective patient data (08/223).
Preimplementation, the median total reception process time was 8.33 minutes (interquartile range [IQR], 6.82–15.43; n = 56). Postimplementation, the median total reception time was reduced to 5.83 minutes (IQR, 4.75–7.42; n = 153), producing a median time saving for the patient of 2.50 minutes. The greatest time saving was seen in the time for administration staff to prepare the medical record for the clinician, decreasing from a median 5.31 minutes (IQR, 4.02–8.29) to 0.57 minutes after the implementation of the new system (IQR, 0.38–1; Table 1). There was also a statistically significant increase in the time reception staff took to process the patient and the time taken by the patient to complete the CASI, from 0.28 to 0.68 minutes and 3.10 to 4.20 minutes, respectively, before and after the implementation of the system.
In the preimplementation year (2012), the clinic had a total of 31,978 patient visits by 10,606 patients, of whom 6190 were new. In the postimplementation year, this increased to 33,770 visits from 11,837 patients, of whom 6951 were new (data not shown).
In the preimplementation period, 20% of patients provided a postal address and 31% provided an e-mail address. Postimplementation, these proportions increased to 60% and 70%, respectively, (<0.001).
The average wait time for calls to be answered was 78.1 seconds predesign (n = 243) and 40.2 seconds postdesign (n = 197). The incoming call abandonment rate was 11.1% predesign and 7.1% postimplementation, but this was not significant (P = 0.151).
To our knowledge, this is the first evaluation of an electronic self-registration and appointment self-arrival system in a sexual health service that has demonstrated significant improvements in reception processing time for new patients.
The self-registration system resulted in a significant decrease in the total reception time to register new patients. These results differ from what Borelli et al.5 found as their patient journey through registration only improved the patient total journey by 1 minute. Their model, however, differs from ours because the registration component also includes patient triage by a clinician. We believe that the large savings in reception time shown are mainly due to removing the need for reception staff to manually transcribe data from the form completed by the patient. The new system allows patients to enter their data directly into the patient database, which immediately interfaces with the electronic medical record. The system has some inbuilt checks to ensure the data entered are valid but cannot ensure the data are correct for that patient.
The efficiencies overall in the registration process were achieved, although the reception time taken to process the patient and time for patient data entry increased significantly in the postimplementation period. We believe that the gains could be greater in future with the possibility that over time the time for patient data entry may improve as return patients become more familiar with the system.
Although we know the new system is not wholly responsible for the increase in patient visits seen in the postimplementation year, it has enabled the same amount of reception staff as the preimplementation period to process 1792 more patient visits and register a total of 761 more new patients. This is a considerable amount of extra work and may not have been achievable without the advances of the new system.
The new system has also freed administration staff to attend other duties, like answering telephone calls, and this resulted in a reduction in the rate of abandoned telephone calls, albeit not significant. The average wait time for a patient telephone call to be taken by reception staff was also reduced, but because the data were only summary data by 5-minute periods, statistical tests could not be conducted to assess if significantly different.
Having more complete patient details was an added benefit after the system was implemented. Borelli et al.5 also saw improvements in the proportion of patients providing an e-mail address when they trialed their purpose built self-registration system in their sexual health service. We believe that our change may be because the patient was made more fully aware of their confidentiality and how the information may be used and because some of the fields were mandatory with the client being unable to continue without completing.
There are a number of limitations to our study. Because of human resource limitations, we were only able to provide an internal auditor for parts of each day; therefore, the preimplementation period only has small numbers. Similarly, not all new patient presentations were audited in the preimplementation period, and we are unable to determine if these patients differed significantly from the ones audited. This study only looked at the reception process and was not designed to look at efficiencies in the rest of the patients’ journey or cost-effectiveness. Also, we did not assess patient or staff satisfaction of the new system, but this is currently being planned. Finally, patients who could not read and understand English enough to complete the CASI were excluded from using the system, and therefore, these results are not generalizable to the entire clinic population, but approximately 91% of clients at this service could use the system. In future modules of the system, we will consider trialing and evaluating a translated version of the CASI instructions/information in the main languages of our client population. We have previously published on patients’ lack of acceptance of an express model that included a CASI; therefore, it would be important to ensure the reception CASI was acceptable to this client group first.6
Overall, the evaluation shows the potential for electronic self-arrival and self-registration systems to be used by other outpatient services with large patient volumes as an integrated part of the electronic patient management system or as a standalone feature. Our center already offers Web-based STI testing that requires patients to register online. There are plans to make the electronic registration system available online for patients to complete before attending the service, as has been reported by Koekenbier et al,7 which may further improve reception efficiencies.