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November 13, 2006
Advocates of e-signature technology emphasize its ability to improve workflow and save time. Many healthcare facilities have or are on their way to installing electronic medical records (EMRs), so it makes sense for them to utilize electronic signature (e-signature) technology to better integrate these processes and eliminate the paper trail. Patient registration processes and paperwork requiring physician signatures are generally time-consuming. By electronically capturing patient signatures as well as physician signatures, markings, and initials, HIM staff can reduce manual scanning of signed documents and instantly import these digital files into a patient’s EMR. Other advantages to implementing e-signature technology include the following: • Document image quality is also improved by capturing digital signatures rather than scanning signed documents. • Data security is enhanced by creating secure, uneditable PDF files that meet HIPAA security requirements. • Signed electronic document images can be integrated directly with EMR systems. • E-signature technology can streamline revenue-producing HIM areas by keeping files in digital format, thus enabling timely access to coding, billing, and other patient information. “The entire process of signing and authorizing documentation from home or office is the greatest advantage of e-signature technology,” explains Don French, senior vice president of research and development at Optio Healthcare in Alpharetta, Ga. E-signature technology, which features a “real,” nonreproducible signature, normally requires physicians/users to enter a password and a personal identification number (PIN). Some e-signature software requires a second PIN to authorize the signature, according to French. E-signature systems are usually accessible through a hospital intranet’s physician portal and integrated with transcription, deficiency management, and billing systems. Software will affix the signature in the proper place on a document and, once the signature is affixed, no one can change the document. HIM’s Involvement “From our perspective, it’s usually a health system representative who encourages the physicians. Often, HIM’s role is to explain benefits, lay out the costs, and teach physicians how to use e-signature technology, and how to maximize benefits from it. We see only about 10% of physicians using e-signature technology to the max,” explains Robert Hill, CHE, principal of Health Strategies & Solutions, Inc., a Philadelphia-based strategic business planning and consulting firm. “Doctors are set in their ways. E-signature technology can represent better patient care and time savings for them.” The HIM department’s responsibility is often to choose one solution or e-signature software that will integrate with the EMR system already in place. Many hospitals support three or four different software platforms for various aspects of their EMR system, but it is more efficient to utilize the same vendor for different HIM applications. Cost, integration, and software capabilities are all important considerations when choosing e-signature technology, according to Hill. He notes that the federal government, in its push to promote widespread adoption of EMR solutions, is more willing to accept deals in which hospitals and physicians purchase EMR systems together. This arrangement allows both parties to implement a complete package solution that integrates e-signature technology with billing and other software, which will save money in the long run. Although an EMR system is not required for e-signatures, many HIT experts say it makes sense to at least have the basics of such a system installed to realize the technology’s greatest benefits. “The reality is that electronic signature and applications like that really make you look at your workflow and analyze it. It makes for more efficient management of your workflow. The technology is wonderful, but only if it’s applied properly. It establishes a cause and effect; people need to understand that it will facilitate changes,” says Mike McGuire, senior vice president and general manager of healthcare sales and service at Optio Healthcare. E-signature is most valuable if the work environment is largely paperless; in which case it is embedded and flows right in with the patient EMR, explains Joseph M. DeLuca, MA, FACHE, managing practice director at IT Optimizers in Oakland, Calif. However, in organizations that do not have an EMR, there is the option of scanning and indexing documents and then physicians go online to sign them using e-signature software. DeLuca says this is the lowest level of e-signature technology efficiency. “From an efficiency standpoint, if we tell physicians that e-signature will save them about 10 minutes a day or an hour a week, which gives them time to see another patient, they see the time savings and benefits for them,” says John Donohue, health system director of information services at The Children’s Hospital of Philadelphia (CHOP). E-signature technology is part of an optimized workflow and may be installed in steps, according to French. EMR is often the first step of optimizing HIM workflow, followed by e-signature. E-signatures improve patient care because they move patients through the healthcare system more quickly, which benefits the physician as well as the patient. An e-signature represents the end point of care episode. “The purpose of e-signature is to complete the patient process more efficiently,” says French. “Pen and paper is fine, but if you can sign documents remotely, it’s a trade-off and doctors can see immediate benefits from it.” E-signature technology, like all aspects of an EMR, must be compliant with state laws and standards. “An HIM department has to determine if documents need to be printed after e-signature and maintained in a paper file or maintained in an EMR. Today, more hospitals are eliminating the need to file paper records and are going to EMRs,” explains Eli Nahmias, president and CEO at Meta Health Technology. Software automatically loads documents on the Web site/portal, where physicians can access materials that await their electronic “John Hancocks.” Patients Benefit, Too “Physicians buy into things that make their practice more efficient, give them more time to enhance the patient-physician experience. If something hinders them in any way, they will fight it,” explains McGuire. Physicians hate paperwork, says Nahmias, so nearly all of them are excited by the advent of e-signature technology, which saves them a lot of driving time if they work for a healthcare organization with multiple locations. Donohue says CHOP talked about installing e-signature technology for the past four or five years before finally making the conversion. It chose to take that route primarily to increase security through authorized procedures associated with e-signature technology. The hospital was also interested in the ability to audit and track signatures. CHOP now uses e-signature in the registration area. When a patient arrives at admissions, the documents he or she needs to sign are affixed to a digital tablet. As the patient signs each document, the tablet captures and embeds the same signature on a digital version of the document. The patient keeps the original signed consent form while the electronic files are instantly stored in his or her EMR. Another feature enables parents to sign permission forms electronically. According to Meta Health Technology, even in hospitals that have implemented e-signature, between 30% and 50% of documents—such as physician orders, face sheets, progress reports, and handwritten histories and physicals—still need to be manually signed by physicians. Some companies such as Meta Health have developed an add-on to their e-signature solution that enables all types of documents to be electronically signed and automatically routed. Deficiencies are anticipated, assigned, and completed automatically through integration with their deficiency system. University Hospitals of Cleveland (UHC), a 947-bed tertiary medical center and a member of the University Hospitals Health System, which has more than 150 locations in northern Ohio, notes that its number of incomplete records dropped to its lowest level in two years upon implementation of e-signature. Physician visits to the medical records department have decreased by 15% and are expected to drop further. Today, the medical records department is leading the hospital in physician satisfaction. Now, UHC’s 800 physicians don’t have to chase paperwork that requires their signature. “I don’t think I have one client who does not use e-signature,” says DeLuca. “There are different levels of usage. Some use it in a paperless environment, on all records, as a standard of practice. On another level, certain components of laboratory or diagnostic radiology use e-signature, or a specialty hospital or clinic such as a cancer center uses e-signature. Physician offices are early on the adoption curve. Even in multispecialty private practices, many do not have e-signature technology, due to lack of EMR use. I think this is an issue that recent legislation is trying to mitigate.” Is E-signature Safe? An electronic document that has been signed with an e-signature and time-stamped cannot be easily manipulated, according to DeLuca. If an organization uses a U.S. Postal Service Courts e-signature time stamp (electronic postmark), third parties and the legal system accept the time stamp as a standard more readily than they accept an e-mail time stamp, which can be manipulated. The Future The number of e-signature technology users is growing, notes Nahmias. Approximately 20% to 25% of all hospitals are using it and this number is growing rapidly. “Most medium- to large-size hospitals have adopted e-signature technology in some form or other,” says Donohue. As more hospitals and physician practices integrate EMR technology, the adoption of e-signature technology is likely to follow. It is generally regarded as a safe and reliable timesaver that benefits physicians, patients, and the HIM department. — Laura Gater’s medical and business trade articles have been published in Medical Imaging, 24x7, Podiatry Management, Veterinary Forum, Corrections Forum, and other national and online publications. |
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