Electronic forms system replaces blue-card method

New system streamlines patient admissions

The old blue-card system for patient registration is fast becoming obsolete at Winthrop-University Hospital in Mineola, NY, where the three-year implementation of an electronic forms process is coming to fruition.

The 591-bed teaching facility now prints patient admission packets and other patient documents using the Patient Linkup Enterprise system from Standard Register in Dayton, OH, says Amy B. Wolin, MPSHSA, Winthrop’s director of patient access services and president of the Hospital Admitting Officers Association of New York. The necessary forms automatically print based on the type of admission being entered by the registrar, she adds.

Rather than keep large inventories of preprinted forms that may become obsolete, the hospital now can print only the forms needed, Wolin says, and in most cases can eliminate the messy multi-ply forms in which the third and fourth pages often are barely legible.

"Through network printing, we’ve eliminated the number of printers needed at each location," Wolin points out. "We used to have separate printers for each type of preprinted form, including message sheets, multi-ply forms, labels, and registration documents. Now all documents are created from the laser printer, so the clerk is no longer required to retrieve forms from various bins."

After selecting the company’s Patient Linkup Net system, Wolin notes, the hospital upgraded to Enterprise primarily for the following reasons:

- Enterprise runs on an NT server, as opposed to an NT workstation, and places no limit on the number of documents that can be printed. The Net software was limited to a maximum number.

- If Enterprise goes down, it can be brought back up without doing a check of every printer on the network, as is necessary with Link Up Net.

- Because Enterprise works off a network server, it doesn’t require as many backup systems.

- With Enterprise, form changes can be made by a telephone call to the vendor. No one has to come on-site.

Winthrop started its implementation of the electronic forms system in the emergency department (ED), with registration and the ED clinical record, then expanded it to include all registration documents, Wolin says. "Now we’ve moved to putting all nursing clinical documents [on-line], which will complete the implementation hospitalwide."

Conquering the fear of change

The next phase, she adds, will be to look at the enhancements that are possible with Enterprise, such as electronically faxing documents to physicians’ offices and insurance companies.

Before implementing its electronic forms system, Winthrop established a multidisciplinary task force to oversee the process, Wolin says. "There’s fear of change and of changing documents, so we involved every department that touches a document." There were three key decisions that had to be made, she notes:

1. Define which documents will be brought on-line.

2. Determine in what packets, or outputs, those documents will print.

3. Decide where you want the documents to print, and on what "triggers."

For example, Wolin explains, there are medical packets, preadmission testing packets, and same-day surgery packets, each of which includes the forms needed by those particular patients. In the case of the same-day surgery patients, half the forms print in the registration area, and half in the same-day surgery area where the patient reports, she adds.

It’s crucial, Wolin says, to determine a "downtime system" for when the electronic forms system is not in operation for any reason. "It’s important to have the ability to do off-line documents, so you can go to the terminal and print documents without the patient’s name, as if they came from your forms vendor." That could mean either generating blank forms and adding labels to them, or simply keeping a single form on hand that can be taken to the copy machine, she says.

"The next piece is how you decide whether a new form is going to go on-line," Wolin says. "What we’ve defined is that when there is a need for a new form, [the request] goes through a documentation committee, then to the medical records committee, and then to the forms committee, which determines whether to put the form on-line, to send it to the print shop, or to get it from the forms vendor."

The criteria used are the quantity needed, who uses the form, and the benefit of having it on-line as opposed to in hard copy, she notes. "It may be a form used only by case managers for tracking or one used only by the telemetry unit. It may not meet normal size dimensions, such as a full four-page foldout."

Then, Wolin adds, the appropriate question may be, "Is there a reason it needs to be a foldout?" One side benefit of installing the electronic forms system, she points out, is that it offers an opportunity to revisit the design of forms that have been around for awhile.

"Our physician orders are on multi-ply forms, and they take the second page and fax it to the pharmacy," she says. "If you fax it, why do you need two copies? Why don’t you just fax the first page and put the original back in the chart? Those are the things you go through."

A nurse pointed out that she fills out the front of a form and then flips it over to answer a single question on the back, Wolin says. "We moved that question to the front of the page. It was just that when that form was originally designed, they ran out of room and had to go to the back. Normally, we’re all so busy, no one will sit down and say, I wonder why this is like this,’ and check it out."

Verdict still out on savings

Because Winthrop is in the middle of a major transition, it’s not yet clear how much money the new system is saving, she notes. "We’re destroying old forms, creating new ones, and stocking up on downtime forms. The [patient] floors have to order paper. Logically, there should be a cost saving, because plain paper is less costly than preprinted documents. Other hospitals have seen cost savings once [the system is] fully implemented."

Still, Wolin points out, the hospital also goes through many more printer cartridges, and more printers may be needed. However, legibility is dramatically improved because each copy of the form is a high-quality laser-printed original, she adds.

"It’s hard to get your hands around what the cost saving is until you’ve tweaked the system," she says. "After the initial install, you look at the forms and say, Do you really need these forms? I thought I needed that fourth copy, but do I?’"

It’s already clear that the new system is saving time and effort from a training perspective, Wolin says. Because forms print out in packets, depending on the type of patient being registered, it is far easier to make sure new registrars are in compliance, she adds. "Before, we had to say, For inpatients, pull these forms; for outpatients, pull these.’ Now it’s automatic."

However, employees have had to learn to change their registration routine, Wolin says, a process that becomes ingrained over time. "In the past, [registrars] would hand the patient a blank form. Now they have to wait for the form to print and give it to the patient.

"Before, when staff completed the registration, they would see the plate maker go off, and hear a dot-dot-dot’ noise," she adds. "They were so conditioned to hearing that noise and then getting up to retrieve the form that at first people were reprinting forms. Now they have to get up even though it’s silent.