While electronic medical records are now the standard for maintaining a patient's information, the forms that patients fill out in advance of an appointment are still predominantly paper in format. In this study we share the results of a moderately-sized survey that explores the shift towards digital intake forms, and broadly compare the findings to related research.

Introduction

The commercialization of Electronic Medical Records (EMRs) during the 1990's and 2000's has led to digitization in clinical settings, driven by both resulting efficiency gains and policies enacted to move their adoption along quickly. By 2009, the benefits of these electronic systems were so clear that the Health Information Technology for Economic and Clinical Health (HITECH) Act was created to invest $25.9 billion dollars into the technology, and to apply increasing penalties to any practice choosing not to use such a system beyond 2015 [1].

The United States federal government has further doubled down on such programs by also implementing the Blue Button program for data transmission in 2015, and the 21st Century Cures Act in 2016 to create high penalties for electronic record information blocking [2][3]. These changes have mostly been institutional in nature, with the long-term goal of being catalysts to the direct improvement of the patient healthcare experience through digitization.

Far more immediate and noticeable have been the patient-facing technological gains that are a bi-product of the COVID-19 epidemic. Significant examples of these include widespread adoption and federal acceptance of telehealth, contactless check-in of patients entering a medical facility, contact tracing, and increased use of smart devices for patient self-monitoring [4][5][6][7].

One of these recent changes, though to a lesser extent, is the digitization of patient intake forms. These are the forms that are completed before an appointment for both legal and informational purposes that document the patient's health history, family history, medications, patient consent for treatment, and privacy policy just to name a few. Despite high adoption rates of electronic medical record systems, patients are still frequently prompted to complete this paperwork in advance of appointments either by printing out a PDF at home or filling out a clipboard in the doctor's waiting room.

For a patient that is referred to multiple specialists, this means filling out all of these forms for each specialist.

The authors of this study were not able to find any literature describing how much time is spent by patients completing forms in advance of appointments, but it is a known friction point. Conversely, most studies in this area focus on the amount of time practitioners have to spend on paperwork instead of the patient. In response to this, our team surveyed the public to evaluate preferences for digital form systems.

Method

Participants were contacted through Amazon's Mechanical Turk software, an online marketplace that permits individuals to complete tasks for a financial reward, which in this case was approximately $1.00 once the questionnaire was completed. Questions asked included age, sex, and 10 required multiple choice survey questions. All respondents were self-identified as being from the United States.

Open-ended screening questions were asked to verify the participants were not automated bots. The survey was made available from August 31st, 2021 to September 9th, 2021. The distribution of patient ages shown in Table 1 showed a skew towards younger relative to the actual healthcare community age group, likely due to the demographic cross-section typically using the Mechanical Turk platform.

Data

Tables 2 - 12 show the compiled results of the 10 mandatory multiple choice questions. We grouped the questions based on information they tell us about the present and expected state of intake forms (questions 6, 7, & 9), and patient preferences (questions 1, 2, 3, 4, 5, 8, & 10).

Present and Expected State of Intake Forms

According to Question 6, 23% of respondents noted that none of their practitioners have online forms and 11% noted that all of their practitioners do. Assuming that all participants have had healthcare encounters, this suggests that the number of practitioners using digital intake forms today falls between 11% to 77%. This contrasts heavily with the answers supplied in Question 9, where 95% of respondents expect all practitioners to eventually have online forms in the future.

More troubling however, is the ability for patients to complete forms without an online system. In Question 7, only 75% stated that they own a printer. That means that when confronted with practitioners who do not offer digital options, 25% of patients either have to visit a printing service center, or show up to appointment waiting rooms without their forms completed.

Patient Preferences

While our organization has previously reviewed existing literature surrounding patient preferences of clinics, our research did not uncover any research related to digital online forms effects of clinic preferences. In this study, Question 2 and Question 10 specifically made it clear that almost half of all patients would choose one clinic over another clinic if it offered digital online forms, assuming all else equal.

Regarding the device used, computers have a clear preference with phones and clipboards a distant second and third. Those who preferred phones were the youngest on average with a mean of 35 years old. Participants who preferred computers had a slightly higher age with a mean of 38 years old. Clipboard (mean of 41 years) and tablet users (mean of 44 years) came in as being preferred by the oldest users in the survey.

The security question fell in line with previous literature on patient preferences - a high tilt towards desire for security, and no one outright saying they do not care about health data security [8].

Discussion

As a whole, this survey made it very clear that more than three-fourths of patients have a strong preference for digital intake forms, and almost no patients had an aversion to doing so. We also drew the following conclusions:

Patients have a strong preference for secure digital forms: This survey was the first of its kind to show a preference by patients for digitally filling out their information. A fraction of respondents preferred using a clipboard in the waiting room - these participants skewed 2 years older on average. This might imply that to make the most patients happy, a paper solution should still be available if requested.

Laptops and Phones make up the majority of preferred entry tools: At a combined 78% of the votes, it is clear that patients, not just hospitals, benefit from electronic data entry and retrieval.

Pre-filled forms are an attractive concept: Patients showed an interest in, and almost no aversion to, the ability for forms to be pre-filled based on known information about a patient. Presently there are very few systems (primarily large-scale and expensive EMR systems) that offer this capability for patient intake. The concept of pre-filling forms for user confirmation exists elsewhere in job application software, credit card information in internet browsers, and income tax filing in predominantly nordic countries, all of which have been met with high praise [9][10]. There is no clear evidence to suggest that such systems offer a lower quality of care.

Digital forms influence which medical facilities a patient chooses: It has been well established that second only to the expertise of the physicians, the amount of wait time required for a visit is the second most influential factor when rating the quality of a hospital or clinic [11][12]. Digital forms offer the advantage of significantly reducing wait time by having the information completed in advance. Based on our experience, mental health forms typically are the longest in length as they must explore physiological and psychological histories - sometimes taking upwards of an hour to complete. Preventing this time from cutting into the planned appointment time is a key feature that digital forms offer.

Knowing that a system has a high level of data security is important to patients: As previously mentioned, data security is maintained as extremely important to the majority of patients. The study previously referenced [8] describes how practitioners are the only entity that patients are nearly 100% okay with having access to their personal health information. Public-facing security features like opt-in 2-factor authentication, public logs of independent security logs with other HIPAA compliance verification may assist in this.

References

[1]
Health Information Technology ("HITECH") Provisions of American Recovery and Reinvestment Act of 2009, Title XIII, Subtitle D, Pub. L. No. 111-5, 123 Stat. 115, codified in relevant part at 42 U.S.C. § 17937 and 17953

[2]
"Blue Button | The White House". whitehouse.gov. Archived from the original on 2017-01-21. Retrieved 2012-04-19 – via National Archives.

[3]
114th Congress's H.R.34 - 21st Century Cures Act, which became public law on 13 December 2016

[4]
Wosik, Jedrek, et al. "Telehealth transformation: COVID-19 and the rise of virtual care." Journal of the American Medical Informatics Association 27.6 (2020): 957-962. 5 Rahimizhian, Sima, and Foad Irani. "Contactless hospitality in a post-Covid-19 world." International Hospitality Review (2020).

[5]
Kretzschmar, Mirjam E., et al. "Impact of delays on effectiveness of contact tracingstrategies for COVID-19: a modelling study." The Lancet Public Health 5.8 (2020): e452-e459.

[6]
Stella, Alex Buoite, et al. "Smart technology for physical activity and health assessment during COVID-19 lockdown." The Journal of sports medicine and physical fitness 61.3 (2021): 452-460.

[7]
Dhopeshwarkar, Rina V., et al. "Health care consumers’ preferences around health information exchange." The Annals of Family Medicine 10.5 (2012): 428-434.

[8]
Evans, Chris, and Binh Tran-Nam. "Pre-Filled Personal Income Tax Returns: Evidence from Australia." National Tax Association Proceedings. 2010.

[9]
Wang, Shaohua, et al. "An intelligent framework for auto-filling web forms from different web applications." 2013 IEEE Ninth World Congress on Services. IEEE, 2013.

[10]
9th Annual Vitals Wait Time Report Released. Business Wire, 22Mar2018

[11]
De Groot, I. B., et al. "Choosing between hospitals: the influence of the experiences of other patients." Medical decision making 32.6 (2012): 764-778.

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