Using Google Docs to manage patients more efficiently

During my sophomore year of college as a pre-med, I volunteered at the front desk of a free clinic, where it was typical to see patients waiting sometimes for more than two hours. At first I figured it was just because some patients took longer to examine than others. It wasn’t until I got certified as a nurse’s aide and started working in the medical department at the same clinic that I found out what was really going on.

It wasn’t that the doctors were taking longer to examine some patients; it was that the  medical staff didn’t always know that they had a patient waiting in the first place.

Our clinic has a pharmacy, dental, mental health and medical department, three of which are managed by the front desk staff. When a medical patient signs in, the receptionist puts the patient’s chart in a bin to let the medical staff know that a patient has arrived. There is no bell, no blinking light, so a nurse would only know when a patient  checks in by peeking down the hall every so often to see if a chart is in the bin. The bin was often blocked by hall traffic, closet doors and even carts filled with prescriptions, so the staff wouldn’t see the chart until long after the patient had arrived. And when the front desk couldn’t find the patient’s chart to begin with, the medical staff again wouldn’t know till much later – if at all – that a patient was in the waiting room.

So it was possible that our department wouldn’t realize  that someone was patiently waiting to be seen until we cleaned up at the end of the day, after all the doctors had left, and happened to find the lone patient still waiting in the lobby. I felt terrible whenever this happened. They had been waiting for hours, and all we could do was offer to reschedule their appointment.

Ideally, medical staff would peek down the hall at regular intervals, see the chart in the bin, room the patient and put a colored clip on the door of the room. Each doctor had a color, so he or she would know if the room held a patient that was waiting for them. But even after the patient was roomed, it was still possible for doctors to miss their patients.

Once, a physician asked me and another staff member if she had any other patients to see. Since the volunteer nurse who triaged her patients wasn’t present at the moment, we told her that if she didn’t see any rooms marked with a red clip, she was done for the day. However, there was a cabinet next to one of the examination rooms that made it impossible to see the clip from where we were standing. Naturally, we found another patient waiting in that examination room at the end of the day. Again, all the physicians had already left. These kinds of situations  occurred so often that I frequently found myself brainstorming ways to check in, room and see our patients more efficiently. I actively monitored the bin to make sure patients were triaged as soon as they came in. I even organized and labeled documents in separate folders to make it easier for the volunteers to triage patients, but this still didn’t fix the core problem.

Finally a light bulb went off at the annual AMSA convention when I heard Dr. Andrew Morris-Singer mention using Google Docs to manage patients more efficiently. This system would be perfect to use at our clinic, I thought. At my next shift, I spoke to a director at the clinic to discuss how we could use a Google Docs to track patients and facilitate easier communication between the front desk and the medical department. The front desk staff would note in the doc that they had checked a patient in, and then the medical staff would see the update to the doc on their own computers at their station. No longer would it be necessary to crane their necks down the hall and squint to see a chart in the bin.

Once I got the okay, I began creating a table that would provide enough information to sign patients in and give the medical staff the entire responsibility of  managing the medical charts at all times. After using the Google Docs for just a couple of days, the entire clinic was so impressed. The front desk had no more charts to deal with and the nurses were able to track and manage each patient from the time they walked in to the time they left.  The physicians and other staff members also started using the Google Docs as a reference to determine where each patient was instead of searching for colored clips on doors.

After just one week, staff members were telling me how much the new system had improved patient management. And for the first time, patients were telling me “Wow, that was fast!” as I took them to their rooms. I’m relieved that I don’t have to apologize for long waits anymore. And I still can’t believe that as a volunteer, and an undergrad at that, I actually implemented a system that radically changed how our clinic runs, streamlined clinician work flow and improved patient experience.  Even though I may not be a physician yet, I can still take part in making a direct improvement in our health care system.

Avanthi Jayaweera is a pre-medical student who blogs at Primary Care Progress.

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  • Matthew Mintz

    Avanthi, great job coming up with a fantastic solution to patients in need. Glad you are pre-medical as the profession needs forward thinking individuals to become physicians. One slight catch though. Google Docs is not HIPAA compliant. Identifiable patient data on Google Docs is not secure and therefore a violation of HIPAA. However, I believe there are commercial products available out there that can solve this.

    • VKA

      Matthew, you should read up on what HIPAA regulations actually require. It is easy to yell “HIPAA!” and shut down a great idea. As long as personally identifiable data is not stored (deleting the document at the end of the day works), then google docs is the effective equivalent of writing down a list of patients.

      For that matter, only demographic information that “relates to the provision of care” is protected. In other words, as long as no patient data entered into google docs- such as what they’re there for, who they’re seeing, etc., there’s no relationship between the demographics and patient care- and no need to protect it. In effect, using google docs is the same as yelling a patient’s name into a waiting room.

      • Matthew Mintz

        “The front desk had no more charts to deal with and the nurses were able to track and manage each patient from the time they walked in to the time they left.”

        Not trying to shut down a good idea, but based on the above quote, it appears the HIPAA compliant way you describe is not what is being done. Also, my last sentence states “I believe there are commercial products available out there that can solve this.” Essentially, what I believe these products do is create some sort of Firewall around Google docs to secure it similar to other online EMR’s.

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          It’s not really doable. As a covered entity, the clinic must have a business associate agreement with Google in order to use its software product for managing PHI, and the fact that a medical visit occurred is considered PHI. Google doesn’t do BAAs.

          The only way they can get around this is to not identify the patients at all (as Observer suggested). It’s OK to identify the doctors.
          Another option for this clinic would be to move some of those cabinets around and clear people’s field of vision… :-) but that’s too low tech, I guess.

        • VKA

          No one but google can build a firewall around google docs- for anyone else to do it would be a violation of patent law, not to mention google’s terms of use. (Think of it this way- would a doctor be okay with someone sitting outside his or her door, and charging people $10 per visit to unlock the door for them?)

          See my reply above. Above all else, I trust in this clinic’s sense of self-preservation to make sure that this system complies with HIPAA. Do you really think they’d let an undergrad just do this without vetting it and making sure it’s compliant? I’m pretty sure that a system with just a patient’s name which is deleted at the end of the day does not contain HIPAA information, but I could be mistaken. Maybe they’re using initials to be extra safe, who knows.

      • EE Smith

        “As long as personally identifiable data is not stored (deleting the document at the end of the day works), then google docs is the effective equivalent of writing down a list of patients.”

        No, that doesn’t work. Google Docs data is not stored locally; you don’t really have control of the data. You don’t control the server(s) where it’s stored or who has access to it, and just hitting “delete” on your local computer doesn’t necessarily delete all copies of it from all servers.

        • VKA

          That’s the point. THERE IS NO “DATA”.

          If someone online sees a list of names on a document with no title, no nothing (or better yet, a list of initials) with no relationship to what’s going on- there is no relationship to the provision of care. HIPAA comes into play when you have a relationship between demographic data and clinical data- such as Patient “XYZ” here for “condition W”. If you instead have “XYZ” on a document with no clinical information associated with it, it isn’t protected data, from my (and several others’) interpretation of HIPAA rules. For all anyone knows, it could be a list of people invited to your dinner party where you announce your campaign for office on the platform of burning every book that has a copy of HIPAA in existence.

          Regardless- this girl appears to work in a clinic with multiple physicians, nurses, and support staff- do you really think they didn’t run through all of this themselves? That they’d endanger themselves by violating HIPAA in this manner? If nothing else, I trust the doctors’ sense of self preservation that this system is HIPAA compliant- maybe they decided to be extra sure and use initials only, or whatever.

  • DocFellow

    Another solution that is cheap and effective but will not be used due to the availabity of proprietary and expensive EMR systems with a check in feature with encryption to hide a patient name to make it HIPAA compliant. Of course the nurse subsequently goes to the waiting room to yell “Mr. Jones?” for everyone to hear, but let us keep wasting our money…

    • EE Smith

      There’s a difference between a handful of people in a waiting room hearing the name “Mrs Jones” called and seeing some random lady walk back, and all of Mrs Janet Anderson Jones’ appointments being available online for the world and its dog to hack into.

      • DocFellow

        As we have seen with some recent security leaks, anyone can access data for their own purposes if properly motivated. The point is that cheap solutions are turned asunder when laws ostensibly to protect patients are another tool to protect corporations touting compliance in inferior products for outrageous sums. Personal gain will always trump logic and reason unless we as a profession initiate common sense solutions.

  • Observer

    Folks, don’t jump so quickly to create legal barriers that don’t exist. It’s true that Google docs isn’t appropriate for health information, but it is a great idea and completely legal for ‘there is a patient for the green doctor in examining room 3′!

    • EE Smith

      Just so long as there’s no personal information entered. Because for personal information, entrusting it to Google anything (gmail, gchat, gdocs, google glass) is really not much better than sticking it up on Facebook.

      Google techs have full permission to see everything and don’t always have the purest of motives (in one recent case a google employee was stalking a 15-year-old girl via her gmail and gchat data).

  • http://www.HealthcarePioneers.com/ Simon Sikorski MD

    Be careful with HIPAA! This can really blow up if misused.

    There are a lot of companies that have secure platforms that you can check out at the Healthcare Pioneers meetings all over the country. Best ones I’ve seen are in New York. (Although I have not met any yet on West Coast) :)

  • edpullenmd

    Really, this seems like creating a whole new layer of work and hassle to solve a problem that for most offices happens almost never. Just get the reception staff to pay attention and empower patients to advocate for themselves, i.e. don’t passively wait for hours. If waiting hours is the norm, you’re failure is scheduling and workload, not a lack of google document use.

  • darbsnave

    From the generally negative comments regarding Avanthi’s idea, I have to ask if there is any level of innovation anyone would be willing to risk if they thought it might run afoul of Federal laws. My impression is that no matter how good or bad a proposed innovation is, forget it if it might be a problems with HIPAA or other governmental laws.

    So, then is it a general rule that government laws carry a hidden cost in that they discourage innovation?

  • darbsnave

    Avanthi,

    I don’t see the Google Docs-HIPAA thing necessarily as an insurmountable hurdle for your idea. I can see ways you might get around the problem.

    I wouldn’t noise it about that if you put patient names on Google Docs. That sounds like a potential problem. It’s probably hard to innovate if you’re in jail.

    You need data. You can’t go by patient and staff comments.

    You need advice and support from sympathetic people. Perhaps join an entrepreneur group of some sort.

    There are bigwigs who are interested in healthcare innovations. They know innovations usually come from the ground up, not from the top down, and that small solutions can mean a lot. The big academic name in this area is Clayton Christensen. Perhaps Regina Herzlinger. Check Google Scholar. Also Donald Berwick, Ezekial Emanuel, even the CMS Innovation website. Even if you think these people are 20 times smarter than you, you have the big advantage in that you were there.

    If you think this is worthwhile, I’d pursue it further. Even if it fails, you’ll learn a lot. Good luck.

  • USFlorida med student

    Use PracticeFusion! We set it up for our student run free clinic and it works like a charm.

  • Avanthi

    Thank you everyone for all your feedback. The Google Docs are used just to communicate in real time. No confidential information is ever used on the spreadsheet. The spreadsheet bascially lists what time each patient checks in so we can keep track of how long they have been in the office. Even physicians’ names are abbreviated to make the information more general. For instance, Dr. Longwood would be inserted as Long or something similar.