Electronic Pre-Navigated Patient Intake in Complex Patients: A Zero Net Win-Win

The prevalence of pelvic floor disorders in the United States is high (Table 1). It is well recognized that pelvic floor disorders, such as incontinence, lower urinary tract symptoms, neurogenic bladder dysfunction, and pelvic pain often coexist and overlap in the same person. Nygaard et al.,(1) estimated that in community-dwelling women in the United States, 23.7% of women had one or more pelvic floor disorders. During the evaluation and management of pelvic disorders, specialty providers often focus on issues most relevant to their own discipline. The single-focus approach employed by specialty providers is further incentivized through funding mechanisms that favor brief visits prioritizing single foci of care. Comprehensive clinical evaluations with review of extensive records and thorough history-taking may lead to improved outcomes, but this approach is increasingly difficult—healthcare workers face burnout and an under-resourced healthcare system exacerbated by the effects of the COVID-19 pandemic. Nevertheless, multidisciplinary and integrated approaches to pelvic health have been shown to improve care coordination, diagnostic accuracy, shared decision-making, and the delivery of timely, appropriate, evidence-based treatment, concurrently reducing healthcare costs.(2,3) Despite the growing evidence that integrating care improves outcomes, little is known about the effects that integrating multidisciplinary care in pelvic health can have on patient and provider experience.

Burnout has been established to affect healthcare workers, including physicians, nurses, and healthcare staff, at greater rates than in other fields.(4) Per the Maslach Burnout Inventory, it is defined as a syndrome including emotional exhaustion, depersonalization or cynicism, and low personal accomplishment as it relates to one’s work.(5) Healthcare workers are most prone to burnout when administrative burden is high and when confidence is lacking in the quality of care provided.(6) The COVID-19 pandemic exacerbated an already critical situation; but although COVID-19 may serve as an additional challenge for staff mental health, it cannot solely explain the observed burnout levels.(7) Fortunately, the pandemic has brought further focus on the need to improve worker health. Strategies to improve efficiency of documentation and supporting clinical efficacy have shown some promise in reducing burnout.(8)

Integrated healthcare models are known to support clinical efficacy in urologic care.(2) In these models, healthcare providers and specialists are aligned with a high degree of collaboration, communication, and navigation. To address what we believe is an essential approach to pelvic health, which is fundamentally multidisciplinary, we created a responsive, personalized intake form that renders a concise yet thorough account of the patient’s multidisciplinary pelvic symptoms, medical history, previous testing, and treatments. To understand the effect of this navigated patient intake on healthcare provider, staff, and patient experience, we conducted a single-institution survey pre- and post-implementation. We hypothesized that navigated patient intake would decrease self-reported burnout and exhaustion levels while increasing satisfaction and time spent on self-defined “meaningful work.”

Methods

A single provider with an extensive background in urogynecology, neuro-urology, and collaboration across disciplines in clinical and academic settings programmed the HIPAA-compliant intake in Qualtrics. This intake uses skip logic so that complex patients are screened for the full complement of symptoms and given the opportunity to list all diagnoses and prior care. Simple patients see only a simple layer of the questionnaire. The data are collected as discrete data points for future research but also render as a text file in the EMR for the provider to manipulate for their encounter note. The launch was initiated in urology, but the intake content applies to all pelvic health providers at our institution. The collaborating departments are due for launch of the combined intake soon, which will spare the patient the redundancy of completing repeat intakes for each discipline of pelvic health provider seen.

Urology providers, nursing staff, and administrative staff were surveyed before and after launch of the intake tool. Other baseline characteristics of participants, such as years of experience, gender, and age, were not included because they were not relevant to the study premises.

Study Design

This was an observational, prospective, single-center cohort study. The study has three main phases (Figure 1):

• Phase 1. Participant registration, study agreements, and usual practice survey;

• Phase 2. Pre-survey; and

• Phase 3. Post-survey.

Figure 1. Summary of the three main phases of the survey.

Pre- and post-surveys were used as a timestamp to indicate the beginning and end of the intervention, respectively. The intervention was the introduction of the patient intake form and formal education to all providers.

• Ethical considerations: Local ethical and institutional approval or exemption was obtained prior to the study. Our institution deemed this study appropriate and in conjunction with health research authority guidelines. Individual participants will never be identified in study reports or performance feedback.

• Data collection, management and privacy: Data were entered into a secure password-protected database hosted by our institution that was accessible only to the study team. The data collected were anonymized for analysis. Healthcare workers completed paper surveys about their practice role, meaningful work, the Maslach Burnout Inventory, time spent documenting, and their attitudes toward navigated pre-documentation of patients. Patient data on multidisciplinary needs were collected pre-launch in a standard paper intake and post-launch in the systematic electronic navigated patient intake. Patients also were asked about satisfaction with the process (either paper or electronic) at the time of the initial visit, including seven questions from the Patient Satisfaction Questionnaire Short-Form PSQ-18.

• Statistical analysis: P values ≤ .05 were considered significant. All statistical analysis was performed using RStudio and Stata. Paired and unpaired Student t-tests, and χ2 tests were performed using these packages.

Results

A total of 118 urology providers, nursing staff, and administrative staff were surveyed. Of these, 49 (42%) met criteria for inclusion in this study: they completed pre- and post- questionnaires and maintained a stable position within the department during this time. Of those, 14 respondents (29%) routinely used the patient intake form during patient interactions, whereas 35 (71%) did not. Those who used the patient intake form included three physicians, one nurse practitioner, two licensed practical nurses, two medical assistants, one registered nurse, one nurse navigator, one surgical scheduler, one patient care coordinator (phone staff), four front desk staff, and one medical records associate.

Staff

Staff surveyed included providers, nurses, and administration. Comparing pre- and post-navigated patient intake survey results from all participants (n=49), there was a statistical significance in exhaustion levels. Post-survey exhaustion levels (mean 3.3; 95% CI 2.6-3.9) were less than pre-survey exhaustion levels (mean 2.65; 95% CI 1.7-2.9, p value .008) as per the Maslach Burnout Inventory criteria. Providers noted the electronic navigated patient intake form helped simplify their role in facilitating MDT-integrated care for pelvic health patients (χ2 7.59, p value = .05).

When comparing navigated patient intake users (n=14) and non–navigated patient intake users (n=35) at the time stamp of the post-survey, there was a statistically significant difference in the level of professional efficacy as per the Maslach Burnout Inventory. Post-survey navigated patient intake users reported a mean = 26.3, (95% CI 22.8-29.7) compared to pre-survey navigated patient intake users (mean = 4.06; 95% CI 3.2-4.8, p <.001). There was statistically significant improvement of physician provider satisfaction for intaking new patients (χ2 = 9.75, p = .04) as well.

When comparing navigated patient intake users (n=14) and non–navigated patient intake users (n=35) at the time stamp of the pre-survey, there was a statistically significant difference in satisfaction for intaking new patients (χ2 = 9.4, p value =0.05).

Comparing controls, navigated patient intake users measured versus themselves over time pre- and post-survey reported more time spent doing meaningful work (mean = 76%, 95% CI 60-92, p = .012) and fewer hours of administrative duty (p = .04). Comparing controls, the non–navigated patient intake users versus themselves pre- and post-survey, demonstrated a decrease in professional efficacy over time: pre-survey mean = 31, 95% CI 29-33 vs. post-survey mean = 24, 95% CI 19.6-29 (p = .0084).

Patients

We evaluated the first 49 patients who presented via the navigated patient intake versus 49 patients seen using a paper intake prior to launch. The 49 navigated patient intake users were threshold-positive for urinary and other symptoms, as follows:

• Urinary: Urogenital Distress Inventory (UDI-6)/American Urological Association Symptom Score (AUASS): N=58;

• Bowel: CRAD-8: N=34;

• Prolapse: Pelvic Organ Prolapse Distress Inventory (POPDI-6): N=27;

• Pain: Genitourinary Pain Index (GUPI) pain subscale: N=28; and

• Neurologic symptoms: N=45.

Both the paper and navigated patient intake groups demonstrated multidisciplinary pelvic symptomatology. Patients who completed the navigated patient intake tool were identified with multidisciplinary needs at higher rates than patients in the traditional processes (4.5 coexisting conditions versus 2.1, on average [p < .05]).

After launch of the navigated patient intake tool, patients were provided questionnaires regarding satisfaction with the intake process, including seven questions from the patient questionnaires for PSQ-18. Of 22 serial new patients asked to complete the satisfaction survey, 9 filled out the electronic questionnaire and 7 filled out the paper questionnaire. Those completing the electronic questionnaire took an average of 31 minutes, whereas the paper questionnaires took 87 minutes (of whom 3 of 7 completed the questionnaire in clinic). Confidence in the doctor’s office having everything to complete medical care was greater in the electronic group (strongly agree) than the paper intake group (agree). Intake questions were felt to be more relevant by the electronic group (strongly agree) than the paper intake group (agree).

Discussion

This single-institution pilot study indicates that there is a role for integrated multidisciplinary care tools in managing healthcare worker burnout, increasing meaningful work, and improving staff and patient satisfaction.

With the implementation of the navigated patient intake tool, exhaustion levels decreased across all employees. This finding reinforces previous studies that have examined the relationship between EHR-related work and burnout. Melnick et al.,(9) identified poor EHR usability as a key factor in driving professional burnout among physicians in the United States. In a patient with multifaceted pelvic health disorders who has undergone multiple prior treatments and has a complex medical history, the EHR may encumber physicians, providers, and staff as they spend time documenting, amending, and comprehensively editing their patients’ records, imaging, testing, and history. For example, we can consider the patient with chronic pelvic pain, defined as “cyclical or noncyclical lower abdominal pain of at least 6 months duration, which is unrelated to pregnancy and not exclusively due to dysmenorrhea or dyspareunia.” Chronic pelvic pain has been estimated to affect about 10% of the general population.(10) Associated conditions include lower urinary tract or sexual dysfunction, chronic fatigue syndrome, fibromyalgia, Sjogren syndrome, and psychological conditions, such as depression or anxiety, supporting the role of collaboration across disciplines, including neurology, rheumatology and psychology/psychiatry.(11) The pre-visit navigated patient intake tool allows the patient to congregate and explicate those components of their medical chart in an organized manner such that physicians, nurses, and administrative staff can readily process needed information. Furthermore, the responsive nature and scoring of validated surveys from multiple specialties allows healthcare workers to facilitate the multidisciplinary care often necessary in these patients.

Decreased exhaustion levels reported by all employee types are likely a result of many factors. This includes usability of our navigated patient intake tool, patient preparedness with records, and decreasing the need for tedious backtracking for medical history, imaging, testing, and treatments. By decreasing exhaustion levels, this tool addresses a key component contributing to burnout of all types of employees within our institution, not just providers.

Our results revealed that a navigated patient intake tool increases the amount of time participants feel they spend on meaningful work. Meaningful work plays a central role in a sense of personal accomplishment(5,12) and fulfillment among healthcare professionals. The demands of administrative tasks and documentation detract from the time physicians, administrators, and nursing staff have available for the work they deem as most meaningful. This is magnified in complex patients, whose extensive medical histories, testing, and imaging can be difficult to curate, and increases the burden on all members of their healthcare team. Self-reported examples of meaningful work include “hands-on” patient care (e.g., catheter changes, cystoscopies, and vasectomies), to engaging in shared decision-making and counseling patients (Table 2).

Our study suggests that tools such as the navigated patient intake tool hold promise for addressing burnout in healthcare. Providers reported more satisfaction interacting with new patients when they were predocumented using the navigated patient intake tool. Comments such as “I had more time with my patient” reinforce existing evidence that supports the relationship between productivity and physician burnout.(13) Provider satisfaction has been shown to correlate positively with the adoption and continued support of new tools and technologies that decrease administrative load.(14) The navigated patient intake tool is a novel instrument that allows patients to engage with their healthcare team in a more substantive way. Our navigated patient intake tool employed validated measures such as the following to quantify subjective patient complaints:

• American Urologic Association Symptom Score (AUASS);

• Pelvic Floor Disability Index (PFDI-20);

• Pelvic Organ Prolapse Distress Inventory;

• Colorectal-Anal Distress Inventory;

• Urogenital Distress Inventory;

• Genitourinary Pain Index (GUPI);

• Patient Health Questionnaire-4 (PHQ-4) for Anxiety and Depression;

• EQ-5D health thermometer score; and

• Neurologic review of systems (NROS).

These surveys were responsive to patients’ reported signs and symptoms. With this tool, providers entered an encounter better prepared with subjective and objective data, enabling them to focus patient encounters on counselling and treatments. Our findings suggest this novel approach to navigate patients through responsive intake tools may be implicated in provider satisfaction.

Limitations

As with any study, there are limitations to our research. These include its small size (n=49), incongruent baseline characteristics, and lack of randomization.

Conclusion

With the availability of powerful EMR systems and means by which to allow patients to enter information prior to the visit, a well-programmed electronic intake can pre-navigate care. The optimal program will allow the provider more time with the patient, a comprehensive understanding of the clinical picture, and lower administrative burden. Additional studies are needed to evaluate patient navigation tools and the effects of such interventions to promote well-being of patients and providers.

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