Finally: A Digital Fix to Filling Out Forms

Top Takeaways Test text message language with a small group prior to the pilot. Make sure the messages are easy to understand and clearly identified as coming from the health center. Using focus groups, incorporate patient input into the testing phase and after the roll-out. Coordinate messaging to patients across teams so as not to bombard patients with multiple texts. Having patients handle administrative forms online reduces the burden on care teams, but only if staff do not have to manually enter the data from the forms. Converting files into TIFFs proved problematic because color images needs to be supported for photos and conditions such as skin issues. Switching to PDFs is advisable. Expect to need to tweak the script several times—including changing file locations and naming conventions—as staff workflows are created. Developing a successful solution depends on eliminating the need for end users to directly access the vendor’s website. Information flowing directly into the medical record  is preferable.

 

 

 

 

 

 

 

 

 

 

Even before the pandemic, safety net health clinics wanted a secure, HIPAA-compliant digital solution to their paper form-filling woes. Once the COVID-19 crisis emerged, the need to move paperwork to patients’ phone, tablet, or computer became still more pressing. Enter mobile-friendly online intake forms to collect patient information that patients can complete from any device from anywhere. And a bonus: Some automated programs were easily integrated into existing electronic health records.

During the swift ramp-up to telehealth required by the pandemic, health clinics like Petaluma Health Center and West County Health Centers embraced online form solutions  to help serve their patients remotely to deliver quality, compassionate virtual care accessible to all as part of CCI’s Connected Care Accelerator.

Petaluma Health Center: An urgent need to streamline workflows

“I just consented. It was easy.”
–PHC Patient

In the fall of 2020—six months into telehealth services—it became urgent for the Petaluma Health Center to streamline its workflows. Providers, medical assistants, and telehealth support staff were feeling overwhelmed by the amount of administrative work associated with each visit. One of the most burdensome parts of telehealth: Seeking verbal consent for virtual visits.

So the health center decided to investigate whether it was possible to leverage technology to move the consent process to a  text sent to patients – a process that would ease the workload for care teams.

That’s where the online form solution FormDr came to the aid of Petaluma Health Center, a federally qualified health organization that serves 35,000 rural and suburban residents annually in several clinics across Sonoma and Marin counties in Northern California.

The center started testing on a very small scale. The innovation team configured its standard consent (in English and Spanish) in FormDr and sent it out to one shift’s worth of clinic patients. They didn’t receive many responses and realized the text message wasn’t very clear. After adjusting it accordingly, they tried again and received a good response.

Next, the organization wanted to establish a workflow for sending and handling consent responses. Staff designed and tested that workflow in the informatics department prior to transitioning the workflow to the medical records department. Then they rolled out the tool to its largest site, Petaluma Health Center, before following up at two other clinics: Rohnert Park Health Center and Coastal Health Alliance.

Care teams were pleased with the results, which left less than a handful of patients each shift that require a verbal consent. Those patients are identified by a care-gap huddle. Taking this responsibility away from care teams allows them to focus on clinical care. The innovation was later rolled out to all the center’s sites.

One unexpected benefit: The pilot drew attention to the volume of texts the health center sends its patients for each appointment – a number so high that patients found it confusing. Given that, Petaluma has worked to improve appointment messaging to better serve patients.

And as it turned out, the software tool was used for much more than consent forms. Since the pilot, the health center has used FormDr for gauging interest in COVID vaccinations, to collect patient occupation data for vaccine scheduling, to enable patients to send photos of blood pressure results and skin rashes, to collect ID and insurance card details, and to ask patients if they have or are interested in having home blood pressure monitors.

West County Health Centers: Saving money and time with online forms

“I like that I can tell the patient to click on a link and fill out the form and I get the form back. I don’t have to mail anything, it saves costs, and patients respond well to it.”

–WCHC employee

Like Petaluma, West County Health Centers serves a largely rural population. A federally qualified health center, it includes three primary care sites, a dental clinic, a teen clinic, a wellness center, and mental health services in Western Sonoma County in Northern California. Twenty percent of its patients are monolingual Spanish language speakers. Its service area covers hundreds of miles, and many of its patients have limited or no access to broadband. (The health clinics solve the connectivity conundrum by providing access points at libraries and schools for Wi-Fi coverage.)

Also like Petaluma, West County Health Centers knew it wanted to find an alternative to the traditional paper-dependent way of collecting patient information. In addition, it knew it wanted to use software that integrated with the health clinic’s electronic health record, eClinicalWorks, and is convenient for patients to access and use.

The health center’s IT team did its due diligence and reviewed several software systems. Several synched with West County’s electronic health record, but they didn’t allow for all the patient information the clinic collects, such as income details. Or, the software was embedded into other modules, such as an appointment self-check- in module that didn’t align with West County’s current system.

So after weeding out those systems, the team decided to trial FormDr. They built on learnings and best practices from Petaluma. Among other things, they conducted an initial functionality testing pilot in partnership with its Teen Clinic office manager to help design patient registration and intake forms using the FormDr software, while also figuring out staff and patient workflow.

What they found out: FormDr allows a clinic to send a customizable link to a patient via SMS/text or email through the software platform’s portal. The patient receives the link, fills out the form, and then staff has access to the FormDr site to export the information—in the form of a PDF, which can then be uploaded to the patient’s medical record, where a staffer manually inputs the data. While this proved doable for a small number of forms generated through the Teen Clinic pilot, this was not a sustainable solution to spread across West County’s entire system.

Here’s where the IT gurus were called upon to work their magic. The IT department tasked its data analyst with the job of creating a web scraper—a software technique used to extract content and data from websites—using several applications in the JavaScript Puppeteer library to access the FormDr program every five minutes and bulk download the PDFs, saving them to a secure file location. (For the less tech-centric: JavaScript is the most popular computer programming language. Puppeteer is what’s known as a node library or framework that only works with JavaScript.)

The script was also programmed to take a combined PDF, separate the pages and name them using a custom naming algorithm and then delete the form from FormDr.

But wait, more high-tech tools were needed to complete the task. West County’s medical records vendor, ScanSTAT (previously known as DataFile), then went into the file location, uploaded the forms to the correct patient record, and assigned them in the EHR to staff for data entry with a 24-hour turnaround time.

About that data entry bit: It’s not optimal from the staff perspective. “I like that I can tell the patients to click on a link and fill out the form and I get the form back,” says Erin Elo, gender, sexuality, and youth programs manager at West County Teen Clinic. “I don’t have to mail anything, it saves costs, and patients respond well to it.” That’s the good news. The not-so good news: “I don’t love how we have to export the data from that system, and it can’t go right into eCW. But patient facing, it works super well.”

The project had an unexpected bonus: It provided the opportunity for the center to review its front office chart prep protocol and tighten up reviewing patient information updates, including annual registration, medical history, and missing insurance cards. The health center also expanded its initial pilot to include the behavioral health team and one primary care clinic site.

However, the IT team realized that the web scraper was not a long-term solution, as it would not be able to handle the volume of documents once the service was spread across the agency. Bottom line: For such a seemingly simple ask, there was a lot of backend slogging to make the process seamless from the patient and provider perspective. In addition, the health center had some problems with the bot they created for the service, which made the process cumbersome. They are now in the process of transitioning from FormDr to a tool called Luma’s Health eForm, since they were already planning on contracting with Luma for online appointment booking, according to Summer Penn, West County’s director of information technology.

Implementation Findings:

• Note that the links from FormDr to the fillable forms look like spam. Using the URL shortener ly’s paid subscription, West County was able to condense and customize the links to create the look and feel that they originate directly from the health center system, so patients are more likely to open them.
• Safety first: West County did not include behavioral health screenings as a digital questionnaire in case a patient screened positive for an emergency such as suicidality and there was a danger in a lag in staff seeing and responding to the disclosure. Obviously, immediate attention to a positive screen in this case is an important clinical and legal consideration.
• Constant monitoring and maintenance of the web scraper was necessary because FormDr randomly updates the site.
• Adding templates to the EHR that are sent out as text massages to patients with direct links to the FormDr forms helps to streamline the system for support staff.

Image credits: Shutterstock

The COVID-19 pandemic upended the way California delivers health care. Health care systems completely restructured their services to keep both their patients and employees safe. Federal policymakers acted quickly to expand coverage and payment for virtual care. The California Department of Health Care Services also dismantled previous barriers to telehealth and began requiring Medi-Cal managed care plans to pay providers for telephone and video visits at the same rate as in-person visits. As a result, many California health care providers rapidly pivoted from in-person visits to virtual patient visits. For these organizations, this shift has been transformational, as they’ve adopted new technology, overhauled workflows, and redefined team member roles. The Connected Care Accelerator — a partnership between CCI and the California Health Care Foundation, with additional funding from the Blueshield of California Foundation — selected 40 safety net healthcare centers in California to participate in a 12-month program that provided funding, methods, tools and hands-on technical assistance to enhance virtual care initiatives. In a series of case studies, CCI showcases the most sustainable and impactful solutions and shares advice for fellow safety net clinics who want to integrate similar virtual care strategies.