The road from a paper-based environment to a paperless one is neither straight nor without challenges—especially in a large integrated health system like Cleveland Clinic. Yet that health system is making definite strides in one important area—patient check-in—by streamlining the process, as well as feeding information to the back end for analytical purposes. Mobile computing is one component of its strategy, according to Rob Lipowski, Cleveland Clinic’s integrated enterprise applications director.
Lipowski describes what many would term a paperless environment as “paper lite”—information that starts out on paper culminates in an electronic rendition of the information that is entered into the electronic health record (EHR). While useful, the information captured with that process is not as useful as it could be. For one thing, data in certain formats, such as PDF, TIFF or JPEG, are not conducive to gathering data for analytical purposes. “Furthermore, we find ourselves creating paper only to eliminate the paper, so we found operational inefficiencies in that regard,” he adds.
Cleveland Clinic set out to address those inefficiencies while enabling a back-end analytical component. The goal is to make things more efficient operationally, while feeding an analytics engine for the purpose of better quality outcomes. “This is really a story about enriching EHR with data that was there, but it wasn’t discrete or accessible in the past,” Lipowski says. Two teams, one clinically focused and the other administratively focused—are collaborating to reach that goal.
The focus of the project is front-end registration, where Lipowski envisions that the patient could enter his or her information on a tablet computer, and the information would be automatically uploaded into the EHR. He views this as entirely possible for patients on a typical outpatient visit or who are in bed in the ED, as long as they are cognizant and able to do so. Cleveland Clinic has started down that road with this project, but is still in the early adoption phase, Lipowski says. “We have started a couple of pilots and we have learned a lot,” he says, adding that it is not yet at the point where it is collecting data in an electronic fashion.
Lipowski sees three significant challenges that still must be overcome:
- Workflow. Making sure that the process is smooth, simple and as transparent as possible, so the patient is not frustrated and there is no extra time and work for the patient service representative who may be registering the patient. “Driving that workflow change, in the way the documentation is going to be collected, is going to be extremely sensitive, because it does impact the patients’ overall impression of Cleveland Clinic as a whole,” he says.
- Integration. The data need to be obtained and contained within the EHR and exposed to an analytical engine at the back end. “There are going to be technical hurdles that need to be overcome to enable all of that going forward,” he says.
- The sheer number of form types. This is a significant hurdle at large health systems—Cleveland Clinic uses over 4,000 form types, Lipowski notes. He says there is a need to consolidate and standardize those form types. Those forms range from consent forms with static information with a patient’s signature, to questionnaires specific to patients at one of the facilities, which will help inform the patient’s conversation with the physician. “The [electronic] forms are going to enable us to gather that information discretely, pipe it into our EHR, and analyze it on the back end,” he says.
Lipowski says that it’s too early to tell how the workflow will change, but says it will depend on the level of integration. He says Cleveland Clinic is working with a vendor on a technology that will enable it to collect the information on the consent forms and the questionnaires in the way it wants. He says the technology it has been researching will enable the forms to be converted to electronic versions seamlessly. The larger component is to standardize the forms for the hospitals and clinics across the enterprise; that’s more of an operational change than a technology change, and is more complex, he says.
In the future, Lipowski says, there will be a need to for launch points from its EHR (supplied by Epic), which will drive workflow change. (Launch points, he explains, are the packets of information—for example, three consent forms and two questionnaires—that will be put in front of the patient, who will enter the information on a tablet.) The information must also be presented it in a way that is meaningful to the clinical staff.
He adds that, from an infrastructure perspective, the wireless network will need to be robust enough to maintain stable connections, so the patients’ experience will be a good one, not a source of frustration. Lipowski’s team ran the first pilot for the project in late 2012, and has tested various types of hardware components. The first generation was a “one-trick pony” signature device, not a true tablet. “Today we are talking about something much more robust, and the story and the goals have changed between 2012 and now,” he says.
“Today we are still putting our toes in the water and putting together pilots that will help us learn about the technology and about the workflow changes that will be necessary,” he says. He envisions rolling out the system across the health system by the end of this year or early 2015.