The most popular element of the check-in process for patients is the opportunity to take a selfie, which goes into the patient’s EHR.
CHRISTUS Health System began introducing digital check-in at all its U.S. clinic locations in 2016, seeking to reduce administrative paperwork, improve the accuracy of data capture, and improve the patient experience. It got an unexpected bonus: a 5.9 percent increase in payments per patient.
CHRISTUS Health, one of the nation’s largest Catholic health systems, operates more than 60 hospitals and long-term care facilities and 175 clinics and outpatient centers in the United States, Mexico, Chile, and Colombia. Its U.S. service area includes several markets in Texas, Louisiana, and Arkansas.
Bob Karl, CFO of CHRISTUS Physician Group, said the move away from paper is easier for patients and staff alike.
“This saves us time and reduces mistakes and allows people at the front desk to focus more on the patient, rather than worrying about whether everything got signed,” he says. “This improves the processes all the way along.”
When patients arrive at CHRISTUS Health clinics, front-desk staff greet them, collect identification and insurance cards, update insurance information if necessary, and provide computer tablets for check-in.
Using tablets, patients take selfie pictures; review and/or update demographic data, health history, medication lists, and other clinical information; and sign privacy and consent forms electronically. Patients also review insurance information for accuracy and are notified of copayments and outstanding balances due.
The process includes several patient-friendly features:
- Questions are available in Spanish and English.
- Questionnaires start by asking if tablet users are checking in for themselves or someone else, such as elderly parents or children.
- Questionnaires include certain clinical screenings (e.g., risk assessments for falls and depression screening) that are needed for CHRISTUS Health’s accountable care organization contracts.
Completing the questions typically takes between five and 15 minutes, depending on the number of clinical questions appropriate for particular patients, Karl says. Patients’ information is immediately incorporated into their electronic health records (EHRs) and available for physician review by the time patients are roomed.
The biggest benefit of digital check-in, Karl says, is that more data is captured with greater accuracy.
“We are eliminating a lot of errors that come from taking paper and having someone at the front desk enter the information,” he says.
CHRISTUS Health phased in digital check-in across its markets over several weeks. Within six months of completing the launch systemwide, per-patient revenues increased by 5.9 percent, which more than covered the expense of the digital check-in technology. Karl cites two reasons for the revenue increase.
Increased point-of-service payments. As patients click through questions on the tablet, they are notified of their copayment responsibility for that day’s visit and any outstanding balances for previous services. Patients can drill down to see more details, including the dates and services associated with outstanding balances. The automated questionnaires ask patients how they wish to pay.
Karl finds patients are more likely to pay copayments and outstanding balances on the spot when the information is communicated via tablets than when front-desk staff make requests. Indeed, CHRISTUS Health has seen a 44.6 percent improvement in outstanding patient balances since introducing digital check-in.
“This flows as part of the natural check-in process, and you don’t have someone at the front desk having an awkward conversation,” he says. “Just by prompting the patient, this has improved patient payments.”
More accurate coding. The digital check-in process asks patients to provide some clinical information, such as health history, list of medications, and review of systems, which flows into the EHR. Clinicians then review patient information during visits. In some cases, those information reviews allow for higher-paying CPT codes than physicians had been using in the past.
“It is helping us to more accurately code what’s actually going on by prompting that conversation with the clinician,” Karl says.
Digital check-in has proven popular with patients. Indeed, 94 percent of patients report they are satisfied or very satisfied with the experience.
“We serve a very diverse population from pediatrics to geriatrics,” Karl says. “If, across the spectrum, we get 94 percent of the folks happy with their digital check-in experience, that is huge.”
Other positive results include the following.
E-mail captures increased dramatically. The health system has been asking patients to provide e-mail addresses for years but, when check-in was a paper-based process, many patients skipped the e-mail address requests. That is harder to do in digital check-in because patients are asked to enter their e-mail addresses and reconfirm those addresses for accuracy before moving to the next screen.
EHR portal adoption has increased 178 percent. Because more patients provide e-mail addresses, CHRISTUS Health can send e-mail invitations to enroll in the portal, a step many patients had heretofore not taken. Once enrolled in the portal, patients can see lab results, schedule appointments, and exchange secure messages with clinicians online, which reduces calls to offices.
Advice From the Frontlines
Training front-desk staff only took one hour, and digital check-in did not reduce the number of staff needed for registration, but it did change what front-desk staff do, Karl says.
Instead of shuffling papers and entering data into computers, front-desk staff support patients if they have questions about digital registration and have more time for other aspects of their work, such as answering phone calls and scheduling appointments.
Other lessons learned from CHRISTUS Health’s experience.
Reliable Wi-Fi is the top success factor. The extra bandwidth needed to accommodate several patients using Wi-Fi enabled tablets cannot be underestimated. Connectivity problems for clinicians, front-desk staff, or patients wreaks workflow havoc. “That is the No. 1 lesson we have learned: Make sure you have assessed your Wi-Fi access in all of your clinics before you do this,” Karl says.
Patients like using the tablets. For patients who have used smartphones or computer tablets, the digital check-in process is intuitive, Karl says. Front-desk staff are not required to do a lot of coaching. “There is the occasional 85-year-old that needs a little more help, but for most people, this is self-explanatory,” Karl says.
The most popular element of the check-in is the opportunity to take a selfie, which goes into the patient’s EHR. “That is not what we expected, but that is the No. 1 most commented-on thing,” he says.
All facilities should follow the same standards. Some CHRISTUS Health clinics opted to only collect demographic information via the digital check-in because clinic leaders think it is easier to have medical assistants input patient health history and other clinical information. That approach limits the success of the initiative, Karl says. “It’s in the offices where we are using both the demographic and clinical questions that we have seen the biggest improvement in our patient payments,” he says.
His advice: Make sure your EHR governance committee agrees on systemwide standards before implementation begins. “Trying to be flexible and accommodate individual clinics can cause problems,” he says. “The more you can standardize up front and get clinician buy in and agreement with what you’re doing, the better the roll-out process is going to be.”
Use a phased approach to implementation. CHRISTUS Health launched its digital check-in process one market at a time, with vendor support onsite for a full week. After implementation was complete in all markets, the trainers returned to optimize processes, troubleshoot, and share lessons learned from the launch in other clinics.
The initial version of the check-in technology requires a patient to go to the front desk to pay copayments and outstanding balances. Future versions will allow patients to swipe credit cards on the computer tablets. Patients will also be able to leave their credit card information on file for future visits.
Lola Butcher is a freelance writer and editor based in Missouri.
Interviewed for this article:
Bob Karl is CFO, CHRISTUS Physician Group, Irving, Texas, and is a member of HFMA’s Lone Star Chapter.