Rethinking the Paper Trail

Armin Moradi

2020-05-26

Thank you

Dr. T. Peluola
Dr. N. Patel
Dr. K. Reddi
Christina Skibinsky

Before I begin, I want to thank Dr. Peluola for supervising this presentation, Dr. Patel for supervising the research project that led to this presentation, Dr. Reddi, for facilitating everything inbetween, and Christina Skibinsky for providing the fuel, otherwise known as form GMOs.

Old Paper Trail

Overview

January 2020
30 Form G
10 Form M
17 Form O

A stack of 30 Forms Gs, 10 Form Ms, and 17 Form Os were reviewed and analyzed for issues and a few repeating themes emerged which I'm going to discuss. These forms were most completed in January 2020 with less than a handful from earlier.

Issues

Unhelpful naming for cataloguing

The first thing that caught my eyes was the naming scheme of the scanned forms

It's not really a fault of the paper trail, but more of a cataloguing issue for the future. The dates are there, and the names are different, but some had the physician name in the filename, some didn't, some had the date formatted with comma, others with a dash.

Thinking about someone from the future trying to automatically catalogue and sift through 1000+ forms…well…the idea seems near impossible.

A computer could do a much better job of cataloguing if it just had a little bit more info!

Not really much of an issue that this project was targeting, but a warm-up to the issues we're going to talk about next.

Issues

Illegible handwriting

This was the main motivation for this project, but curiously, I didn't find many examples of illegible handwriting. Either I've become better at reading or I had exaggerated how bad handwritings really are.

So instead I have here one of the neatest handwritings in the stack of forms!

Sadly, it turns out my handwriting is one of the worst in the department! That's certainly something to work on!

Issues

Scanner failure

The next issue was a bit unexpected, but it's technology after all, and things can fail.

Here we have part of the paper that was to be scanned completely cut off, making the copy less than legible. In this one you can still make out the name, but similar failures may not be so tame.

Issues

Errors and scratches

Here you can see the word 'for' written, scratched, then written again. I'm not sure what I was thinking when I was writing this but certainly wasn't transferring my thoughts properly.

Things of this nature happen.

Issues

Missing fields

Some of the forms had dates or names missing from some of the fields, but not all, which leads us to the next issue with is repetition.

Issues

Repetition
date x7
name x5
location x3
patient residence x2

And lastly, but certainly equally as important, is the repetition of words and phrases over and over that introduces new points of failure and opportunities for unnecessary shortcuts.

Full names become first and last omitting middle, the hand becomes tired, the mind numb, and time is wasted. 1 Form may not be an issue, but 10 forms certainly do a number on the wrist.

Issues

Old forms are a hazard

This one comes of Ms. Skibinsky herself, and is quite important. It has been brought to my attention that at some point in time a few months ago, we've been using old forms with old details regarding the appeal personnel, and the wrong contact info was on the form for the lawyer responsible for the appeals.

This is not necessarily a problem that requires a shift to digital media, but it certainly helps to fix it right then and there, as opposed to having to go through whatever beaurocratic process to have it changed, updated, and print a whole stack.

Issues Summary

Workflow

Curiously, the core of most the above issues can summarized in one phrase: cumbersome workflow. Writing, saving, scanning, copying, all take effort, effort that does not involve decision making and is wasteful for humans, and frankly, is more suited for a machine. All these steps introduce opportunities for error.

Advantages

Well-known
Easy to deal with
If it ain't broke, don't fix it

It's not all lost, of course. Dealing with paper is easy in that the behaviour of a paper is expected. We can see it, feel it, know that it will do as expected. No behind the scenes "code" running magic, nothing that we can't see. It's there, or it isn't, those are the two possible states of paper.

And of course, it's the way things have been done and it has worked so far.

From OMG! to GMO.

But it IS broke!

So the question then is, how do we fix this? As I mentioned earlier, all these tasks fit a machine more than they do humans. So We've tried to enlist the help of the most common computation machinery we have access to, and that's the all-too-familiar personal computer.

I believe almost everyone here has had an opportunity to work with digital EMRs and knows how terrible they all are. Even the best ones I've heard of are clunky, unintuitive, and a hassle to use. That's mostly due to how they try to replace the paper trail, and not work with it.

For this pilot project, we've opted to instead work with the humans than against them. After all, I like to be efficient, I like my wrists when they're not in pain or fatigued, and I'm as far as I know at least 50% human. Excluding microbes.

Out with the old, In with the old

Accessible
Fast
Easy

The old is not going away, it's just pumped full of steroids!

So we set out to create a simple page – I won't call it a platform, I won't call it an app, and I certainly won't call it a lifestyle – just a simple page that replicates what we already have to the letter, but augments the functionalities a paper provides in an intuitive way.

The great thing about this page is that it integrates all three forms (G, M, and O), and only adds, but does not subtract what's already there. It's possible to simply print the page blank and you'll get a clean Form GMO stack of paper to fill it out as you've already done, or you can type away to your heart content and only print it for your signature. And everything inbetween, of course. The signature is required, so eventually there will be our beloved paper trail.

The page is accessible as in it can work with any reasonably modern free browser running on even old hardware. I tried it on a 400MHz computer with 256MB RAM and it functioned well. It's amenable to all the accessibility technologies that the paper can't provide such as screen readers, magnification, text to speech, and other assistive devices for our colleagues who may require those devices. It's fast, does not use extra scripts, does not track, and generally doesn't really do anything beyond what you see, and you'll see what it does shortly. And it's easy to use or not use: it gives you the choice to either use it or not, and if you decide to use it, it gets out of the way.

New Workflow

The paper trail is the king!
Long live the king!

The workflow is not much different than the old workflow. As you'll see shortly in a possibly-broken live demo, the form is the same, the fields, the look, even the logo is exactly where you'd find it on the paper forms.

At its most basic form, all one needs to do is to print the page. That's it. Double click, print, done. And things will be just as they have been before. Except, now some of the fields are already filled in, and that's the date field. The computer knows the date, says hey, I already know this, I'll fill it in for you, don't worry about it.

On the other side of the spectrum, the form becomes a little less-than-sentient and actually helps. The page recognizes the fields that should have the same content, such as patient name, address, next of kin information, and remembers the physician who was entered last and continues to fill that until a new person is entered.

So, the first time you enter a patient's name, or the date – although that's automatically entered, but you can still change it – all the other fields that are supposed to be the same get updated in real time. Or, again, you can fill them in yourself, but you don't have to. Instead of spending 15 minutes writing repetitive information, you can spend 20 seconds filling this form and spend the rest with the patient, which I believe would be a better use of time.

Another great thing about digitizing Form GMO is that the layout doesn't have to stay the way you see it on paper. So what I've done is add a small section with all the relevant information that's required at the very top, and that information is read and copied to relevant parts of the actual form. But when printed, the top section disappears, and the printed media looks exactly as the Ministry of Health intended.

Disadvantages

None

Obviously, there are no disadvantages

Disadvantages

I may be biased

I wrote it, so I may be a little bit biased

Live Demo

So, let's show and tell

Fill form in web
Show printed form

Future

Where do we go?

This was just a pilot project, but there is a lot of potential here. Beyond rescuing my wrists from the tyranny of the pen, I wanted to also generate a little discussion on how digital forms don't have to be PDF, they don't have follow the same rules that paper follows, and they don't have to be cumbersome to use, like SCM's form which, after 5 years I still don't know how to use, and I haven't seen anyone actually use them either.

Digital forms can help, they can increase efficiency and they can be opt-in as opposed to all-or-nothing. It doesn't have to be an all digital vs all paper fight, it can be the best of both worlds, we can have people choose how much keyboard and how much paper they're comfortable with and let them work the way they see fit.

This form is now available, but I'm working on having it approved for use in ER. As soon as it's approved, I'll let our fantastic nursing staff know and I expected that knowledge is going to be propagated to whoever is on call. I've already received positive feedback on the forms, I've used it a few times, although had to recycle the papers and it's quite pleasant.

Discussion, Feedback, QA

I'm open to feedback on an ongoing basis, and I'm hoping to continue to improve this and hopefully future instruments of documentation.

Are there any question or concerns that I can address?

Thank you

Rethinking the Paper TrailArmin Moradi2020-05-26