The line at our front registration desk to check in every morning starts piling up about 30 minutes before we start seeing patients, and it never seems to really go away or even thin out much through the day.
Our poor patients are stacked up, often stretching out into the hallway, and it can be a challenge for many patients who find standing physically taxing. And in addition to the psychological stress of waiting in line, they all know that what lies at the end of the line isn’t going to be easy either.
When you check in, you’ve got to identify yourself by name and date of birth, provide your insurance card, lots of other personal and confidential information, and then the registrars at our desk need to go through multiple machinations before you’re finally ready to see your doctor. They are supposed to verify your insurance, update your contact information, hand out some forms, and ultimately print out a little wristband that has your name, date of birth, and medical record number on it, which you must wear throughout your visit with us.
The Information Blizzard
In the old days, patients would just arrive, and announce “I am Mrs. Jones; I’m here to see Dr. Pelzman; I have a 1:30 appointment.” The staff registrar would reach behind them, dig through the (hopefully) alphabetized stack of thick paper charts, locate Mrs. Jones’s (again, hopefully), and move it over to the “ready to be seen” bin. But in today’s modern world, we have to have one electronic system talk to another, have our scheduling system talk to our registration system, which talks to the insurance database that verifies that it’s all okay for them to be seen today.
If they are a new patient, there are a whole bunch of forms that need to be filled out, a dizzying snowstorm of paper including a new patient questionnaire, information about completing a healthcare proxy and living will, assignment of benefits forms, and lots of fun and interesting facts about our practice.
Our staff is supposed to verify that all of the contact information we have in the system for them is accurate, but more often than not, we hear them saying to patients “Has anything changed since you were here last?” More often than you would think, patient’s phone numbers have changed, they have moved, or someone they are no longer speaking to is listed as their emergency contact, but asking these questions in the wrong way does not give us the opportunity to set the record straight.
Just the other day, I happened to notice that two of the patients I saw in one session still had deceased family members listed as their emergency contacts, and one of them no longer lived at the address we had in the electronic record. Kind of makes it problematic when we get called at 2 in the morning by the central lab to notify us that the patient’s potassium is critical at 7.0, and we need to reach them to make sure they are still alive, or to keep them that way.
Automating the Screening
Many initiatives are being put in place to add additional items to ask our patients about; however, I wonder whether some of these questions should be asked outside of a private space. Either at the front desk, or in the waiting room, patients are being encouraged to tell us their race and ethnicity, their preferred pronouns, and to answer a wide array of mandated questions including whether they feel safe at home, may be suffering from food insecurity, or are feeling depressed.
There’s a move to put all of this stuff onto tablets, so that patients, while they are doing the inevitable waiting in the waiting room, can get a jump on things and fill out this information for the providers. This week we had a demonstration of an early version of this system, which is supposed to help us collect accurate data and take better care of our patients. To me, it looked like it added another 30 minutes to the patient visit, before they were even possibly ready to be seen by us. The experts giving the demonstration were repeatedly unable to get things to load, and they were only able to demonstrate what happened when patients answered “no” to every single screening question.
The providers who attended the demonstration quickly noticed many items that would undoubtedly lead to problems, slowdowns, and delays — something as simple as how date of birth was entered. Many of our patients were born overseas, where the standard date entry is day/month/year, whereas this system only accepts month/day/year. And it’s only available in English?
It also seems that many of the asked items were “hard stops” in which something had to be filled in, whether the patient wanted to or not. What if they don’t have a phone?
Many, many, (many) years ago, when I first joined this practice, I noted that I had started building a large population of Russian-speaking patients, referred to me by several of the medical technicians. One day, I had the bright idea of translating our initial visit questionnaire into Russian, since many of the patients would get that form at check-in and simply not fill it out since they had no idea what it said. We got it professionally translated, and printed up in Cyrillic, and I was very excited to put it into play. Then I got the first one back from a patient, and realized that the answers were also in Russian, which was Greek to me. So we were back to square one. End of experiment. Lesson learned.
Dealing with the Answers
Asking questions you cannot understand the answers to, or don’t have the resources to deal with right then, often means that it may not be worth asking those questions. Before asking all of our patients if they are depressed or suicidal, when we don’t have the internal or external resources to safely take care of them, we should think if we should be asking.
If we are asking patients if they have access to healthy foods, do we want to know the answers, even if we can’t help them in any way? If patients have housing or transportation issues, and we don’t have the resources to make those things better in their lives, is this something we should be asking every patient in the waiting room?
I’m not saying that those questions aren’t critically important for overall health; we need to explore and repair the social determinants of health and mental health issues that are vital parts of getting and keeping our patients healthy. But if every check-in process for a flu shot or a blood pressure check unlocks an endless stream of problems we need to address, we need to demand that we have the tools to take care of them — before we are made to ask, and not just because we have a really cool tablet in the waiting room that allows patients to enroll in the portal and update their medications and problem list.
We need to be able to give our patients the tools they need to live safely, to achieve a better state of mental health, to locate a safe place to exercise, to have access to safe drinking water and healthy foods, a good job, a place to live, a decent education, a life free from bias and discrimination, and all the rest of the things we know are missing from their lives.
Get in line; take a number.