Technology Covered in This Chapter:
A great deal of discussion about health care is taking place in the media and in the halls of government. As the debate continues, some people have already taken action to improve services and reduce costs. In this chapter, you will meet a doctor and the IT staff of a regional hospital and learn how they replaced piles of paperwork with their new paperless systems.
Dr. Gresham Bayne’s paperless system has enabled him to provide in-home care that was unachievable with a traditional paper-based system. And the hospital staff was able to reduce the costs and time it took to admit people for treatment. In both cases, Adobe LiveCycle ES was used to present and process e-forms, and to gather data for further process automation.
“Using LiveCycle ES products, our solution is making it easier to create, process, and manage the paperwork required to care for patients at home.”
—Dr. Gresham Bayne
“We have the tools now to reduce our paper use while also streamlining the patient registration process at our hospitals.”
—Steve Anderson, IT Director, St. Vincent’s Health System
Dr. Gresham Bayne on his way to a patient’s home (left), administering bedside care (center), and sending the information back to the servers from his car (right).
Making House Calls Possible
Doctor house calls were common in the nineteenth and early twentieth centuries. However, for the past 60 years they have been almost nonexistent. This is partly due to the tremendous amount of paper documentation that doctors need to complete to provide patient care. Some of this documentation is for the doctor’s records, but the majority of the documentation is for insurance companies, government entities like Medicare, pharmacies, and other service providers. A typical doctor’s visit with a new patient usually requires more than 25 pages of paperwork.
The paperwork requirements also increase the amount of administrative support staff the doctor needs. Dr. Gresham Bayne estimates that a full-time clinician requires four support people for administration tasks. As a house-call clinician, it was impractical for Dr. Bayne to drive around with four people in the car handling the various paperwork submissions. Additionally, a mobile doctor must carry his patient records on the road, and these paper folders could be large and cumbersome (Figure 10.1).
Figure 10.1 One of the closets that previously housed Dr. Bayne’s paper-based patient folders. A long-time patient’s folder often had 200 pages or more of documentation.
Prior to working with Acrobat and LiveCycle ES, Dr. Bayne thought that medical technology was not suitable for house-call physicians. “Virtually all of American health care infrastructure is designed from the perspective of office-based consultants. This leads to certification of all modern EMRs (Electronic Medical Records) under a standard which precludes the typical business processes we need in mobile medical care,” according to Dr. Bayne.
Providing care as a guest in a patient’s home is different than providing care in an office. It is usually a less structured experience with the doctor receiving information at various points from the patient and from other people in the home. Dr. Bayne has found the interactive flow of a PDF file to be more suitable for a house call than the highly structured nature of most EMRs. He has been using PDF forms in his practice for over five years, and they have enabled him to handle eight to ten house calls a day.
Making Paperless House Calls with the Janus OS
The PDF forms that Dr. Bayne uses are provided by the company Janus Health and a system called the Janus OS (operating system). Based in San Diego, California, Janus Health was founded by medical professionals (including Dr. Bayne) to enable doctors to bring comprehensive medical care to a patient’s home rather than the patient to the medical office.
The Janus OS is integrated with Adobe LiveCycle Forms ES, LiveCycle Process Management ES, and LiveCycle Reader Extensions to provide a complete paperless solution for a primary care physician. The only software doctors need on their laptops is Reader because the forms are Reader extended on the server. Because it is PDF-based, the Janus OS system offers the following functional benefits to mobile doctors in the field:
- Work offline: They can work with the PDFs without an online connection.
- Work with up-to-date forms: They are assured that the forms are current because the Janus team can easily update the master XDP templates in LiveCycle Designer. This is important in light of rapidly changing Medicare and patient privacy regulations.
- Access vital information: They can obtain more comprehensive patient information because a Janus PDF is more visual than a typical EMR and can include X-ray imagery (Figure 10.2), tables, and interactive controls.
- Use dynamic forms: They can easily navigate the forms because the Janus XFA PDFs are dynamic like the forms you saw in Chapter 6. Various subforms will hide or show based on what the doctor requires at any given time.
- Perform pre-admissions: They can pre-admit a critically ill patient to the hospital by filling out a simple XFA PDF form. This form is sent to the Janus servers when the doctor reconnects, and the various paperwork for the hospital is automatically filled in and faxed by the Janus fax server.
Figure 10.2 Janus PDF forms contain low-resolution JPEG versions of X-rays. The high-resolution versions are stored as Dicom images on the Janus servers.
Combining Acrobat and LiveCycle ES for a Real-world Health Care Solution
The Janus OS leverages the Acrobat and LiveCycle technologies you have been learning about in this book to deliver a real-world paperless solution for doctors every day. A typical doctor will make about eight house calls a day, and the Janus OS provides assistance before, during, and after each appointment.
The pre-visit activity
When an appointment is scheduled, the system kicks into gear by prefilling standard XFA PDFs with relevant patient information. The most important is the facesheet, which is prefilled with a list of the patient’s current medications and the details of the patient’s last appointment (Figure 10.3). These details include the patient’s vital signs and an hpi (history of present illness) that the doctor previously gathered with the interactive facesheet during the last appointment.
Figure 10.3 All the relevant information for a house call is prefilled into the PDF.
This PDF facesheet and a medical chart are sent to the doctor as attachments to a Microsoft Outlook calendar appointment. After the calendar items have been downloaded to the doctor’s Outlook system, the doctor can work online or offline with the facesheet in either Acrobat or Reader.
While in the patient’s home, Dr. Bayne uses a tablet or laptop PC with Adobe Reader to fill in the facesheet as he examines the patient. He also adds any new prescription drug information and other aspects of the patient’s current state.
As he concentrates on patient care, the XFA PDF guides him through the form-filling process with progressive disclosure and form validation. The doctor only needs to complete the facesheet because the data contained within a completed facesheet will be used by the Janus OS to complete all other documentation.
After the doctor finishes filling in the facesheet, he clicks Submit at the bottom of the form. If he is offline, the form will be encrypted and saved to his local hard drive. The next time Dr. Bayne reconnects to the server, the form and the data are automatically transferred to the Janus servers.
The post-visit activity
The Janus OS on the Janus servers takes various actions depending on the data in the PDF facesheet. The system starts by storing the form’s XML data in a database, but it also sends notifications and documentation to various entities if certain requests were selected on the facesheet. These notifications can be in the form of email, PDF documents, or faxes (Figure 10.4).
Figure 10.4 Notifications and documentation are sent to pharmacies, labs, insurance companies, and Medicare based on data in the PDF facesheet.
The Janus system is flexible and capable of transferring prescription and insurance information in any required format. Most pharmacies still request faxes, but more and more are accepting emailed prescriptions.
In addition to time and cost savings, the Janus system makes it easier for seniors and disabled individuals who live at home to receive quality health care. After a 60-year decline, house calls are making a comeback thanks to new point of care technologies and paperless systems like the one provided by Janus Health.