Thought Leadership-The Patient Perspective

Pete Riversby Pete Rivera,  HIMSS Ambulatory IS Committee, and Consulting Manager, Hayes Management

 As we straddle the fence between manual processes and the use of technology, the process of walking into a typical doctor’s office today is the same as it was 20 years ago. We just inserted electronic data touch points to capture information where we once manually filled out forms.

The typical clinician has been trained to see patients with a certain methodology in a predictable workflow, aka, “That’s how we have always done it!” We need to change the process to leverage the technology. This does not mean that technology is the driving force; it means that we now have an opportunity to look at things differently.  The barriers that were once reasons for not implementing a technology (e.g., security, hardware costs, user adoption) are no longer valid. There are now low-cost solutions that address each of these concerns. New healthcare construction recognizes the need to direct the patient flow differently, but we don’t need to tear buildings down to start over. We need to think creatively.

For years, I advocated that health IT does not drive business.  I still do. Rethinking your processes to leverage technology is just smart business. You may be thinking, “Great, let’s get a committee together of doctors, nurses and technology people and figure this out.” That would be a start, but it would miss the crucial element: the patient.

You could create a use case, or even, do time and motion studies. Personally, I like to draw from my own experiences by thinking about how I would minimize interaction with support staff, while maximizing the information delivered to my provider and what I am able to get back clinically. Patients go to see their doctor – not support staff.  Anyone else is just in the way. My scenario would cover 80% of patient workflows. As your process matures, the more patient flow scenarios it would cover.

I visit my primary care provider twice a year, so here is my vision of a near-perfect flow of events:

I enter the lobby and take a seat. There is a tablet (attached to a theft-deterrent wire) next to my chair. I pick up the tablet, and I see a list of patients (by first name and initial of last name) in the queue. I click my name, and it asks me for my home phone and date of birth. When I log in I am checked in, it takes me to a co-pay screen. I can pay by credit card, or I can write a check and then take a photo of both sides to deposit it for payment. If my medical history forms are out of date, it takes me to that screen, and I fill out an updated medical history. It also helps with medication reconciliation by asking me upfront to update my medications. Finally, I fill out the HIPAA authorization form (if needed).

When I am finished, it posts these forms to my EHR; the doctor’s nurse gets a flag onhis/her  personal device that I am almost ready. Another flag alerts a medical assistant that I am ready for vitals. They take me to a kiosk in a separate area of the waiting room. An electronic scale, blood pressure cuff, pulse oximeter and thermometer are all connected to the kiosk. The assistant taps my name on the screen to authenticate, and measures weight, temp, pulse and blood pressure. This information flows to the EHR.

The nurse gets a flag that my vitals are done. He takes me to the exam room. Vitals are already done, so all he has to do is pull me up on the EhR, check and make sure all lab results or other visit related metrics are available for the provider. I sit down on the exam chair (that’s right – a chair like the ones you find in your highend dentist office). There is another tablet attached to the chair that I use to review my medical records.

The provider is flagged that I’m ready and comes in to see me. After a conversation and the “history of present illness” discussion, the provider talks about updated treatments plans, shows me a chart/graph on the tablet of how well I’m doing. He reviews the medications I listed in the waiting room and compares it to what is documented in the EHR. This is an opportunity to review any other test or information I should upload into the physician portal to keep my treatment on track.

He then recommends a revisit or consult. While he is closing out the note, he schedules, on my tablet, my next appointment with him or the specialist I’m being referred to. The primary care provider appointment is now scheduled, and your referring physician is notified to contact me. The provider asks me if I want a copy of my records emailed to me. I say yes and it gets sent to a drop box on the physician portal that I can retrieve later. I walk out of the office a satisfied patient.

All of this technology is available today. Unfortunately, some clinicians argue that patients are not ready to embrace these changes. However, all you have to do is point these clinicians to the nearest bank. Bank tellers have been minimized, online banking is in full swing, and in-person services are limited to new accounts and special needs. ATMs do much more now than just hand out cash, and you can use any machine anywhere to access your account.


While some offices are looking at increasing their front desk staff, we should be looking at what banks have done. Limit services to those focusing on new patients and special needs. The days of having your name called out in a crowded doctor’s waiting room should be over – that is, unless you really like being asked at the front desk what you are there for (while a long line of patients eagerly await your answer). It’s time to reinvent your practice’s workflow, and it begins by being creative and tapping into your patient’s experience.

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7 Responses to Thought Leadership-The Patient Perspective

  1. It is all about workflow isn’t it? I have argued all along that efficiency and workflow drives technology rather than the other way around. Workflow becomes a problem when it neither works nor flows. (

    You’ve focused exclusively on a patient perspective that is interesting. It continues to be a perception block when providers say ‘my patients are not ready’ – without even trying.

    • Pete Rivera says:

      Chandresh, you are right-we have to turn everything upside down in order to look at it from the patient perspective. Otherwise we will continue in the same paradigm.

  2. David says:

    Pete, I like the scenario you’ve outlined. I’d like to have the option to do the process on my smartphone, versus the office’s tablets, thinking about what germs the user before me deposited on that tablet!

    • Pete Rivera says:

      David we often struggled with the idea of what germs would be left behind at a Pediatrics Patient Portal which was installed in a patient waiting room. I had to deny the request by Information Technology for a CDC level protective suit before they worked on the computer…I think they were kidding.

  3. David, Pete outlines a process. The specifics can change. What smartphones and tablets can be replaced by newer technologies in future – wearables? But the concept is important.

  4. Yes, I agree the scenario you described would be wonderful! Reduced wait times would be great, but we still have a lot of heavy lifting on the EHR side of the equation. Have you seen the March 2014 US Department of Commerce Report that used human factors analysis and process flow mapping to describe the “established patient office visit” workflow. Many physicians’ notes aren’t written at the time of the encounter. See the June 9, 2014 Going Beyond Diagnosis blog post at for a link to the Department of Commerce Report. It’s an eye-opener.

    • Pete Rivera says:

      Harry, old habits are hard to break, and for the Providers that would take paper charts home with them they still think of the EHR as an extension of their previous workflow. If they are not using decent templates and speech recognition, then they are getting bogged down with the typing. In essence working harder not smarter.

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