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Additional: Quotes about the app timing out or other perceived glitches. In: "Technological Issues/Limitations" Code.

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Additional: Quotes about the icons for checking NPHQ status. In: "Technological Understanding" Code.

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"And it was just interesting how difficult it was to kind of follow what was going on. She even described it as kind of a "hodgepodge" where they're pulling patient information from different sources. [...] I think that for these MA's who are checking for completeness in the patient's chart, they're pulling from all sorts of different sources and checking for completeness for all sorts of different sources, and don't really conceptualize that this piece of the standardized questionnaire is something separate." GI R Debrief

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"We’d love iPads to give to patients to fill out in the waiting room.

(Cati: Rebecca Carey thinks iPads aren’t the way, moreso doing it on the phone)" Menlo Medical Notes

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"Sometimes call ahead for completion. But sometimes phone is connected to caregiver, not patient." Menlo Medical Notes

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"If it doesn’t get done, MA’s will do it if they have time, or let the doctor know it wasn’t done, and they may say “I’ll take care of it.” Menlo Medical Notes

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"Doctor will go over it anyway if it wasn’t filled out.

“99% of the time” she fills it out herself with the patient if they didn’t complete it before the visit, sometimes its done by the doctor." Menlo Medical Notes

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"Chelly: Much of Cindy’s population is not English-speaking, they are not likely to answer it even if they get one in their language. The number who enrolls in MyHealth is very small and even those who enroll are not active on there.

Cati: What is the workflow for patients that need a translator?

Cindy: We use a language line if we don’t speak it ourselves and will translate for the patient.

Cati: How is that going?

Cindy: Usually they say “I don’t want to fill that out.”

(FG Cardiology)

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"If a patient doesn’t have MyHealth or complete it, we don’t have paper to hand to them. The MA finishes it in the room with them." FG with UMP Cardiology

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"But I guess physicians, if it's not done, physicians sometimes tell staff that they'll go over it in the appointment. So there is that workaround, but it takes a lot of time." UMP PC 3

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"It sounds like if a patient shows up and hasn't done it, that they really do that; getting them on My Health if necessary, doing it with them in the waiting room if at all possible." San Jose 1

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"She also advised against using iPads for the questionnaire. I guess she had purchased two with the idea of using them for the new patient history questionnaire, but she actually found it probably just increases staff burden. It's the same process as a phone and most people do have a smartphone. It's just easier overall to alleviate staff burden if patients do it on their own device or, as needs be, doing it verbally during rooming to get the pertinent cardio questions done." San Jose 1

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"So it turns out yesterday for some reason, two patients had a language barrier that required them to go do the questionnaire in person. [...] So Nu had asked her to come in early, about 20 minutes early at least, so that she could do it in person with Genevieve. What ended up happening is the patient came in right on time, so not early, and then there was an interpreter there, but there continued to be miscommunication and eventually the patient just tried to talk in English to Genevieve but wasn't an English speaker. So it took a lot of time to do that and it also didn't result in the information that she needed. So just highlighting what should be the workflows for non-English speaking patients? San Jose 2

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"She reiterated again that the big thing is time, that there's not enough time. She suggested that when patients are being scheduled, the new patient coordinator should schedule them earlier so that there's enough time to complete the NPHQ before the visit, especially if patients don't already have MyHealth already." San Jose 2

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"And then there's not time in the visit to go over the NPHQ. She said that yesterday when that patient came in and they couldn't get the NPHQ done, she went to Karla and she asked, "Should I still ask the questions?" And Karla said, "Yeah, you should do the important ones." But Genevieve was like, "I don't know which ones are important." So she wasn't sure what to do there. So she would like more clarity there." San Jose 2

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"What was really interesting was I asked, "what happens if it's blank?" He [physician] fills it out. I was really like, "What? Oh, my god. That seems like a lot of extra work." And he was like, "Yeah, but I do it. It's fine, but also it's not fine."

[...] I think it was just that the physicians, they're in service of their patients, so they do it without complaining, but objectively it is extra work." PV 2

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Perception that MyHealth leaves people behind

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Perception that MyHealth leaves people behind

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"And then just chatted about how elderly tend to complain. Some find it overwhelming where they'll do one page and then click next, and then it's a whole other page. And then it can take a long time to get people on My Health." San Jose 1

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"And she shared a story about a non-English patient where she was on the phone for a while helping a patient through an interpreter to try to download the app and it was just very difficult because the patient was saying, "I downloaded it but I don't see it." And they ended up not being able to help the patient because they were like, "What else can you do when the app isn't showing up?" I just was thinking about the amount of dedication of trying to get someone on My Health, calling an interpreter over the phone and getting them to download the app." San Jose 1

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"And I did ask, "Are you proactive about getting people on My Health?" And they said, because Vanessa had walked back in at that point, "Yes, very proactive." And what I really loved was saying that they bribe them with saying, "You get to message your doctors. You can check your tests." And I really have never thought about using the 'getting to message your doctors' as a bribe. I know patients love to do that." San Jose 1

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"And when I asked about purpose, she said, "To get people to use MyHealth, makes it easier." San Jose 2

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"She hasn't had to go through that NPHQ with patients in the room. It sounds like she doesn't have time for it. She will ask them to finish it on MyHealth while waiting for the doctor. And if they don't have MyHealth, she tries to get them on MyHealth with what time she has so that they can do it online. So it sounds like she doesn't go through the questions verbally, she'll just try to get it on MyHealth." San Jose 2

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"And then the same PCC who mentioned that some of her physicians prefer paper said that physicians would be upset." Neuro 3 (Coded to MyHealth)

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"I asked what would happen if there was no paper and they said there were some accessibility concerns. "Older patients don't use MyHealth. What about them?" Neuro 3

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"For her, it was useful to know that she could send a reminder about My Health." PV 2

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"And then they said that they do have copies of paper, the old-new patient packets, it's supposed to only be sent if they aren't on My Health." Neuro 1

Context note: Paper is given a lot at this site despite this intention.

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"Older patients don't always have My Health." Neuro 1

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"Rachel: And which issues did she [front desk] have?

Cassie: That it times out and that older patients don't really use MyHealth in the first place." PV Debrief 1

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"An over the shoulder look at dashboards seemed to show that there was still a decent number of patients who are receiving NPHQ on MyHealth and not completing it.

On the ground, it did not sound like anyone was re-sending the MyHealth link to encourage completion before the visit or completing it with the patient during the visit." Email to Rebecca

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"It's not being managed through the front desk at all. It's all back MA's and it's moved from the physician to the back MA. Although there's some physicians who say, "if you haven't gotten it done, don't don't worry about it, I'll just do it." Which I think is also kind of crazy." Menlo Medical Debrief

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"Yeah, we did hear the same thing that especially for practices that didn't have very many new patients, that an alert would be great because they lose track of when it's, you know, if it's just happening once a week or once a month, they don't notice." Menlo Medical Debrief

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"It’s “extra work, never had to do it before.” [...] Only doctors did it before. “We didn’t do anything.” Menlo Medical Notes

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"Because I don't work with this much, I have to find it every time." It's not something that's really part of her workflow. So she has to look around for it and it's not intuitive where it is. [...] She would love for there to be a banner or an alert popup to be like, "Hey, they haven't completed this, check it" or something to remind her. I asked her more about that. She said, because it's not something that she deals with much, it's not part of the routine yet. She says, "I never remember to go check that when I'm checking patient's information. I never remember that, if there was an alert, that would be helpful." SFM & SIM 2

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"There was this clear pattern of, the newer people weren't getting the emphasis of "online first over paper." UMP PC 2

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"So neurosurgery PCCs don't really know what the new patient history questionnaire is, but importantly, she mentioned that they also room for neurology once in a while so there's a chance that they wouldn't know to look for it. [...] Nobody else knows how to do it. And she again just reiterated that "we should be informed about these things in huddles. We should know what's going on."

Rachel:

Yeah, the quote that I have is, "We're still a team and we need to be informed of what happens on either side." [...] It was interesting to hear that their staff sometimes fills in for others and they would not know how to check for it." Neuro 2

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"And then he actually showed me how to pull in the notes. [...] 'Here's where the new patient history is, and then here's the notes window where I look during the visit, and then it gets pulled over to my notes, so I see it in notes. And then I asked, "Do you pull that over yourself?" And he said, "Oh, I have a template that automatically puts it over." So once you fill it out in Epic on the patient history side, it just automatically pulls into notes." PV 2

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"He also pulled up the email that he got from Rebecca and their numbers dipped in July. I wonder if that could overlap with vacations and staff shorting. His opinion was like, "well if it's out of sight, it's out of mind." And then he said, "We stopped monitoring." Neuro 3

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"The key staff person who does touch the NPHQ by doing all of the pre-visit reconciliation also didn’t seem to know what the NPHQ really was. While NPHQ reconciliation was very embedded in their workflow, through talking to them, it felt that they did not know what the work was apart from just checking for icons and clicking buttons." Email to Rebecca

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"And there was something new about the paper actually, what was that? ... Oh yes, that she found a copy online for her pod.

... So that was interesting that there might be one floating around online somewhere." Menlo Medical Debrief

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“It would be a nice option to have it on paper. Often they have a long wait in waiting room to do it.” Menlo Medical Notes

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"They have a paper backup (only one pod, who found it online)." Menlo Medical Notes

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"Marjorie brought in the paper that her pod uses. Dom: “That would be so much easier.” Menlo Medical Notes

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"Not a ton of paper—puts more work on MA’s. Current system is helping reduce work." Menlo Medical Notes

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"Okay, so I've been asking, "what would it look like to get rid of the questionnaire?" She said it would probably still be okay. Specifically about the paper questionnaire." GI 2

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"Tatiana: Oh I don't want any paper. We have a GI surgery clinic here that's all paper, and it drives me insane." FG GI

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"And she noted also that Medicare people, who tend to be older, really don't like the online version or doing things on their phones, so it kind of ends up being something that's done on paper." SFM & SIM R

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"She's been there over 20 years and she was able to talk a little bit about paper. She recalled, "I remember the days where we had to... I would be preparing packets. And it took a lot of time and it cost money." SFM & SIM 2

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"So she said they prefer the paper versions when rooming the patient or, imputing the data I guess, "Because it's simple yes/no. We already got it. If we have to fill that out with them in person, they don't answer with simple yes/no. They give long, slow answers and it takes forever." SFM & SIM 2

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"Raquel, the newer person, if they [patients] show up and they haven't done it, she will typically just hand out paper." UMP PC 2

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"There was this clear pattern of, the newer people weren't getting the emphasis of "online first over paper."

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"So Charmaine is also new, and seems to rely on, if they show up and haven't done it, she just hands out the paper." UMP PC 2

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"Joyce, the front desk staff who has been there a while, she will do online first. And when asked [about purpose], it was like, "we were told that it needs to be done online. And we'll give out paper, but it's very rare." UMP PC

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"Also saving paper, "We love to save paper, " UMP PC 3

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"And I love the strong emphasis on no paper. And when they got this message about the switch, I have your quote, "We're shredding it all, get rid of it all." But also I wrote down, "Electronic or nothing," was something she said that I liked." San Jose 1

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"And I know that she did reinforce 'yes, there's this online version,' but I think what people are recognizing the most is these paper versions." Neuro 2

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"So I see it as there's two paths that could lead to good reconciliation rates or completion. One is maybe understanding purpose, so you know why you're doing it. But then the other is, I think just having a strong directive from up top of, "We are going paperless, we're shredding this and you can't fall back on anything else." San Jose 2

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"Morgan at some point confirmed that if they are filling out this online version, the actual NPHQ, they are not supposed to get the paper versions. I asked what percentage was done online versus paper and she thinks it's 70/30 online versus paper, which is the opposite of what Joyce said at the front desk." Neuro 2

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"If they say that they haven't completed it at all and they haven't seen anyone, then they will give them paper." Neuro 2

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"So Bang said that each of the clinics tell the front desk on the first floor what papers patients need to have completed. " Neuro 2

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A facilitator

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First theme

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"Yeah, I think the biggest takeaways were, it sounds like most patients would probably look at it and be like, "Yeah, I didn't do that." Because it's so different, and matches with what people have said where they hear complaints that "I had to do this twice." So I think that there's a strong chance that there's duplicate work being done."

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"They said some providers really specifically want paper. One of them said she works for about 10 in her team and two or three of them are very specific. They want paper." Neuro 3

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"One of the PCCs said even if they filled it out online, some physicians will ask them to fill it out on paper as well. The PCC is taking that request via or on behalf of the physician." Neuro 3

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"And when I asked about the existing paper, he said, "That's been this way for years." Neuro 3

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"And then they said that they do have copies of paper, the old-new patient packets, it's supposed to only be sent if they aren't on My Health." Neuro 1

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“Cassie: I Googled because I was curious what was out there. If I Googled [clinic], I would be able to print an old version of the questionnaire. It's attached on the website.” (Portola Group Debrief 2)

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“They're really happy not to use paper and they're trying hard to get rid of paper all the time." PV1

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"Her preference is paper for people who don't have phones.” Neuro 1

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“So she [front desk staff] said of the old paper questionnaires that the quote was, "some of them, it just pisses them off." She said "pisses them off" multiple times.” PV

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Codes pulled:

Paper questionnaires, MyHealth, Workarounds, NPHQ Integration