Knowledge, Image, and Consent Management - Filling the Holes in EHR Implementations, E

Filling the E-Signature Gap in Your Epic Implementation

JUNE 2014

Midwest Informatics, LLC

Connecting the Docs SM Introduction

This paper examines the e-signature gaps in your Epic implementation; reviews leading vendors who could help close this gap; and offers a n objective recommendation on the best-fit vendor. Epic implementations are the primary focus of this paper due to Epic's continuing expansion and likely dominance of the EHR market. But as impressive as Epic is, Epic just doesn't do everything, or do everything well. Capturing patient signatures and consents is one of the most glaring gaps.

Capturing consents in the current Epic world is still a multi-step, manual process that requires the physical signing of paper forms and routing the signed forms to HIM/Medical Records for scanning into the patient's electronic record. Obviously, that's a problem for the doctor waiting for that signature to appear in the patient's record before they can proceed with treatment. At an organizational level, if you want to achieve HIMSS Stage 7, i.e., become a "Paperless Hospital", this manual consent process may be a major problem. How big of a problem is it?

In a telephone survey of hospital HIM Directors 76.5% of organizations at current Epic customer sites, 76.5% of the surveyed still sign paper organizations surveyed are still using paper forms and scan them consent forms, having the patients or their into their EHR later. family sign them, and then sending the signed paper to HIM for scanning and adding to the patient's electronic record. Only 18.8% signed an electronic document and the remaining 5.9% use a combination of home-grown solutions and manual labor.

Electronic signatures require an electronic form (e-form) that the patient reads and consents to, plus the ability to "burn" the signature onto the form, after it is signed. Not surprisingly, e-signature vendors come from the ranks of forms/e-forms vendors.

Gathering signatures in a timely fashion are critical workflow steps in the healthcare world. Epic doesn't handle consent forms well natively. The first limitation is that Epic only allows one signature per document, due to its method of storing signatures as annotations on their.

Limitation #1: Epic doesn't allow more than one signature per document. Signatures/annotations are stored separately on Epic's " “BLOB" server, a repository for random, large image files. Epic’s This method of capturing and storing consents has has3 major limitations:

1. The method of storing the signature separate from the document the patient signed, increases risk. One Epic customer expressed the situation and need this way:

"Epic's signature solution isn’t acceptable to 76.5% of organizations us. They treat it as an annotation. It’s surveyed still sign stored in a place that is not where we want paper forms and scan to keep patient specific information. There’s them into their EHR always that risk that the signature doesn’t later.Epic Limitations get attached correctly...we want it to... be signatures / documents burned onto the document and saved in our separate document management system." only 1 signature per document no free-form2. Consent comments types that require multiple signatures, such as treatment of minors requires that both the minor's and one of the parents consent signatures must be captured, which requires that you develop a manual workaround or duplicate the forms with different signatures. Rochester General Hospital described the situation simply:

"[Epic] doesn’t allow them to annotate anything else on the document..."

3. Epic's method of storing and linking annotations/signatures to documents do not support making comments or changes to the form. Some patients may be uncomfortable with certain language on the form and refuse to sign it, as is. In a conversation with an Epic customer about this problem, the customer described what they would like to be able to say to the patient:

"“Sir, that’s fine. I can still get you to sign the form. Just please circle what disturbs you. And just say, 'I don’t fully agree.' At least we can get you taken care of.’”

Epic's BLOB server technology itself has another major limitation - it can only store 14 million documents. That sounds like a lot, until you consider the number of documents in a patient's chart and the number of patients seen at hospitals in a year. Epic’s BLOB server limitations is are the main reason that organizations don't use Epic's internal document management capabilities. Here is how an Epic customer describes this situation:

"[Epic] stores it on ... their blob server, and it doesn’t manage high Epicvolumes can't of store documents more well which is why any large hospital doesn’t use it for than[storing] 14 million documents. They all go out to a third party document managementdocuments system – but instead because, as soon as you exceed 14 million documents,hospitals need [Epic] more can’t handle it anymore." than that... e-Signature Vendors

Due to Epic's documents/forms limitations, 94.4% of Epic customers surveyed have implemented a document management system alongside Epic. However, only 23.5% have an automated e-signature solution using their document management or internally developed system. The other 76.5% are capturing signatures on paper and scanning them Epic later. Clearly, the majority of Epic’s customers, at least, do not know that there are not aware of are automated methodsbetter ways to close the e-signature gap.

HIMSS Analytics do not collect vendor data on e-Signature vendors or Consent Capture/Management markets, which they likely consider to be part of the electronic forms market. None of the Epic customers interviewed for this study were aware of specific e-Signature or eForms vendors. This industry gap niche was been filled by e-Forms vendors who have extended their forms delivery systems, e.g. consent forms, to capturing signatures as well.

HIMSS Analytics does have data for e-Forms vendors:

Of the vendors in the pie chart above, all are EHR vendors, with the exception of FormFast and Standard Register. FormFast is the dominate vendor in this space and specializes in both e-Forms and e-Signature products. After extensive research into this company and their nearest competitors, FormFast is the leader due to:

 FormFast eForms interface with Epic use patient information received from Epic to pre-populate forms with patient information, so only the signature is needed.  With over 20 years of experience, FormFast has developed thousands of forms, and can make use which can be used out of the box and which allow of customer logos, bar-codes and other customizations to the forms.  Consents and other signature needs can be captured via their eSignature product, which can also trigger the subsequent events in the hospital workflow and reduce delays in treatment.  Forms can be printed to support the physical signing of the consent form.  eSignatures can be entered on signature pads connected to the Registrar’s PC, or on tablets or laptops at the bedside, or in the OR, ER, or ambulance bay.

RECOMMENDATION: When considering vendors in an unfamiliar space, it is always wise to consider the market leader and how they achieved that status. FormFast has led the e-forms marketplace for most of their 20 year history. Though their e-signature products are best known to their hundreds of Meditech customers, Rochester General Hospital, for example,many hospitals are beginning to use FormFast along with Epic i. s using FormFast along with Epic to close the e-forms and e-signature gaps in their Epic implementations. Bottom Line:In summary, FormFast e-signature products are the best solution for consent capture / e-signature needs and are recommended for organizations using Epic. About Us

About Midwest Informatics (MI) MI combines state-of-the-art informatics technologies and Lean methods to deliver solutions healthcare providers can use and advice you can trust. MI specializes in healthcare project and program management, research, EHR/Epic implementations, strategic planning, organizational development / organizational change consulting, health information exchange, and making healthcare and your organization more Agile and innovative.

About FormFast FormFast is the leading provider of process automation Solutions for hospitals. Our comprehensive set of technologies, including eForms, eSignature, workflow, and ECM, integrate with existing systems to add functionality and streamline slow, outdated practices enterprise-wide. More than 1000 hospitals around the world rely on FormFast to help them make the transition from manual tasks to fully automated processes.

Midwest Informatics, LLC tel : 636.484.0470

FormFast tel : 800.218.3512