Many processes that are automated in various industries remain manual or paper-based in healthcare. Because every patient goes through the registration process during their encounters with the healthcare system, making the transition from paper to digital at registration could have a significant impact on clinic workflows, time management, and patient satisfaction. Increased patient familiarity with technology, the growing ubiquity of tablet computers, and the ease of translation from paper forms to tablets provide a strong technological basis for making the transition to completely paperless registration processes.
The outpatient registration process can be cumbersome and create bottlenecks in workflow because it often involves multiple interactions with clinic receptionists and paper forms that must be filled out and scanned into an electronic health record (EHR). Additionally, delays related to patient arrival times or the process itself have been shown to have significant effects on overall patient wait times and resource utilization (Almeida, Paterson, Craig, & Hookey, 2016). Because scanned documents are generally not machine readable, patients may need to complete the same forms multiple times.
Many studies on the outpatient experience focus on ways to improve patient flow and reduce wait times (Dhar, Michel, & Kanna, 2011 ; Harnett, Correll, Hurwitz, Bader, & Hepner, 2010). Researchers looking specifically at the registration process have examined patient characteristics (e.g., language barriers, problems with copays) or workflow issues (e.g., phone calls that interrupt the front desk staff), but they still focused on the paper-based process (Chand, Moskowitz, Norris, Shade, & Willis, 2009). Though the literature contains few studies evaluating transitions to a paperless registration process, one study showed that use of an electronic self-registration system led to a significant reduction in wait time and overall processing time (Knight, Guy, Handan, Lu, & McNulty, 2014). In investigations of electronic consenting systems for patient recruitment into clinical trials, however, groups have had success in moving from a paper-based to a tablet-based system (Chalil Madathil et al., 2013; Obeid et al., 2013; Sanderson et al., 2013).
Though NYU Langone Health (NYULH) in New York City already uses an integrated EHR system across inpatient and outpatient settings, the move toward a paperless registration process was a major strategic change because it concentrated on patient-facing technologies. The project planning process involved several factors known to influence the success of strategic initiatives: strong leadership at the highest levels of hospital administration, detailed analysis of new business processes and their potential effects on workflows, and working with market forces and external demands to develop a “consumer-grade” registration experience (Kash, Spaulding, Johnson, & Gamm, 2014). The strong business case for implementing the new process, the engagement of registration staff and administration in the planning and testing phases of the project, and the technical support provided during the transition from paper-based to paperless registration also set the groundwork for the project's success (Packard & Shih, 2014 ; Wutzke, Benton, & Verma, 2016).
After receiving a generous gift from a donor, NYULH embarked on a pilot project to move from a paper-based registration system (in which patients received forms on clipboards and returned the completed forms to registrars) to a tablet-based, paperless system. The paperless pilot project took place at the Joan H. Tisch Center for Women's Health (CWH), a multispecialty site located on the Upper East Side of Manhattan, New York City. The center not only has physicians from several specialties (e.g., gynecology, cardiology, internal medicine), but also provides on-site medical services such as imaging, gastrointestinal procedures, and noninvasive cardiac procedures.
This project took place in two phases at the CWH. (The patient surveys are provided as Appendix A to this article at http://links.lww.com/JHM/A22. The staff surveys are provided as Appendix B at http://links.lww.com/JHM/A23.) To obtain baseline values before implementation of the paperless process, the authors distributed anonymous paper surveys to new patients in waiting areas throughout the center during a 3-week period in January-February 2015. The center has two types of waiting areas: (1) those where patients wait for procedures, and (2) those where they wait for a typical medical appointment. According to the inclusion criteria, the authors surveyed only new patients in the medical waiting areas, and all patients in the procedural waiting areas, because in the latter situation, patients had to complete considerable paperwork regardless of prior registration at CWH. Returning medical patients only had to verify their data.
Baseline measures included patient satisfaction surveys, staff satisfaction surveys, and measures of the time it took patients to complete the paper forms for the registration process. The patient satisfaction survey (Appendix A) consisted of demographics, patient's overall confidence in completing medical forms, and five questions related to software usability, based on the IBM Computer Usability Satisfaction Questionnaire (Lewis, 1995). The questionnaire has been psychometrically validated and is widely used in healthcare (Dillon & Ratcliffe, 2004 ; Johnson, Johnson, & Zhang, 2005 ; Yen & Bakken, 2012). As part of the registration process, all patients were asked to complete the paper-based satisfaction surveys, which took less than 10 minutes to complete. Staff satisfaction surveys were administered to all CWH registration staff (Appendix B). The authors used an online survey created with Qualtrics software (Qualtrics, LLC, Provo, Utah). The staff survey was anonymous, included 12 measures related to usability (also based on the IBM questionnaire), but did not include demographics (to retain anonymity). The authors used the longer survey with staff with the aim of obtaining more detailed information. Research staff, including medical center information technology staff, observed patients in the waiting areas to measure the time taken to complete the registration process.
The follow-up phase of the project took place after implementation of the paperless, tablet-based registration system. To assess patient satisfaction with the new process, a link to an online Qualtrics-based survey was added to the last page of the registration process form. The online survey contained two questions related to the new user interface, but otherwise the measures were the same as those on the paper survey. The postimplementation staff survey also contained 12 usability-related questions, with one question from the preimplementation survey modified to reflect the change from “forms” to “screens.” The new registration system automatically captured the time it took to complete the process. Because the system required patients to voluntarily participate, rather than be handed a paper survey, this phase of the project lasted approximately 2 months (from April to June 2015), during which 1,741 patients used the tablet registration system. Again, the registration system automatically captured the time taken to complete the process, but it did not distinguish between new and returning patients. Of note, the budget for this pilot of the paperless registration project was relatively modest—approximately $250,000—and mainly for software and development costs.
The authors used χ2 statistics to evaluate the demographic differences between the preimplementation and postimplementation groups. Two-sided t tests were used to evaluate the differences between preimplementation and postimplementation survey results for both staff and patients. The institutional review board at NYU School of Medicine reviewed this study, and because the surveys were anonymous, considered it to be nonhuman subjects research.
To establish baseline values, the authors distributed 164 surveys during the preimplementation phase and received 139 completed surveys, though not all patients answered every question. During the postimplementation phase, patients were offered the opportunity to fill out the satisfaction survey after the registration process was complete. Though the same number of completed surveys was (coincidentally) received in both phases, the response rate in the second phase was much lower because, as noted earlier, 1,741 patients used the tablet registration system. Table 1 presents demographic data and other patient characteristics. Of note, because the survey was administered at the Center for Women's Health, all participants were female. Patient satisfaction results from both phases are shown in Table 2 and Figure 1. While the baseline satisfaction levels were relatively high, responses to four of the six questions, including the question related to overall satisfaction with the system, showed statistically significant improvement in the postimplementation survey.
Table 3 and Figure 2 present staff satisfaction results for both phases of the project. Because of the small sample size, and because none of the between-group differences were statistically significant, the authors only report the mean values for each question. Staff satisfaction levels were generally lower than patient satisfaction levels during the preimplementation phase, and they remained lower in the postimplementation phase. Satisfaction levels dropped on questions related to the simplicity of the system and the organization of the screens of the new system, but neither result was statistically significant. In the paper system, overall time to complete the registration process averaged 10 minutes for new patients and 6 minutes for returning patients, whereas in the paperless system, overall time averaged 4 minutes for all patients. Because of difficulties with accurate measurement during the preimplementation phase, the authors were not able to obtain comparable data sets in both phases, so only mean times for completeness are reported.
The move from paper to electronic registration is inevitable, as both patients and providers are used to doing many tasks online. In this project, patient satisfaction with the paper-based process was relatively high, so the authors were gratified to find that patient satisfaction levels increased significantly with the tablet-based process. The high level of patient satisfaction with the paper registration process may have been due to low expectations regarding technology in medicine and the registration process in particular. On the other hand, staff satisfaction with the paper registration process was lower, and did not change significantly with the paperless process. Many factors probably contributed to these results, such as the fact that staff members still have to complete some manual processes under the electronic registration system. Notably, staff members were surveyed relatively early in the process, so the growing pains of early adoption were still evident.
Early adoption pains have been well documented in the literature, and these pains were observed in this study as well. Overall, the change to a paperless registration process may have a greater positive impact on patients and the institution than on the staff. For patients, paperless registration decreases the time spent filling out forms; for the institution, paperless registration enhances overall efficiency and the ability to search for forms completed by patients. As evidenced by the findings, the registration process saves time and perhaps helps with overall time management in the organization, which may lead to increased office throughput and potentially more work for registration staff.
This study had several limitations. For practical reasons, research took place with a relatively homogeneous, female population in a relatively affluent area, so it may not be representative of a more general patient population. However, because tablets and smartphones are nearly ubiquitous, one would expect similar outcomes in other populations. While the paper-based survey had a relatively high response rate, the online survey's response rate was only 10%. This finding is most likely due to the fact that study staff handed the paper surveys to patients, whereas the online survey was offered only at the end of the registration process, with no staff intervention. In addition, though the overall patient demographics in the two groups were similar, and both groups are representative of the general population at the CWH, online respondents were more likely to report that they had smartphones and were “extremely confident” in filling out their medical forms. Even with these differences, however, the tablet technology likely was not a barrier for most patients, mainly because the online medical registration process is on par with other aspects of their lives. Patients who use online banking or online travel booking, for example, are accustomed to not having to fill out paper forms.
Few staff members responded to the surveys, so the results may not be representative of medical staff in general. However, the patient satisfaction findings provide concrete data regarding the impact of changing to a paperless registration process. In addition, although the authors collected time data, those data are reported mainly for anecdotal benefit because making comparisons between groups was difficult for several reasons. First, manual observation was used during the paper-based registration process, while the paperless process involved the use of automated time stamps. Observation by research staff was meant to be as nonintrusive as possible, so it mainly captured the overall registration process (i.e., the time between obtaining the clipboard and returning it to the registration desk), rather than the actual time to complete the forms. Requiring observation also led to fewer patients in the preimplementation phase because there was not enough study staff to watch everyone in the waiting room who may have been using the tablet. Finally, the authors could not control for the number of registration forms filled out in each group because the preimplementation phase distinguished between new patients and previously registered patients in the medical waiting area, whereas the postimplementation phase included all patients.
The authors also would have preferred to collect actual time measurements for staff. As part of the paper registration process, staff members scan the forms into the EHR. This is a time-consuming process that often is completed during down time or at the end of the day. Because of workflow issues, such data could not be collected. First, the authors did not want to interfere with the interaction between patient and staff, and, second, the registration process for staff does not occur in one block of time. Finally, as noted earlier, the paperless registration project was a pilot study, so it may have been affected by complications involved with any new technology project.
This pilot project was part of a larger strategic initiative funded by a donor's gift. Hardware (tablets) in this phase represented only a small part of the overall cost of the project. Paperless registration was a major strategic initiative for NYULH so the investment focused on integrating the electronic registration process with the EHR system, as well as designing user interfaces and developing and training staff on new workflows. Though paperless registration may become standard in healthcare, other organizations may not have the resources available to make this level of investment.
In this study, the authors measured patient and staff satisfaction with the transition from a paper-based registration process to a tablet-based process. Though patient satisfaction levels were relatively high under the paper-based approach, they increased significantly with the paperless process. However, staff satisfaction did not increase significantly, most likely because of workflow integration issues. Tablets and similar technologies are nearly ubiquitous, making patients amenable to technological progress in many aspects of the medical system. Since this study, NYULH has widened its implementation of the paperless process, and, eventually, the tablet registration process will become the standard, eliminating paper registration forms. The paper-based registration process is an easy target for change at most medical organizations, and the results of this study attest to the positive impact of this change. Technology can play a significant role in improving efficiency and patient satisfaction with the registration experience. In conjunction with proper support for staff transitioning to new workflows, technology should be used in the patient registration process.
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