Morgan Lewis Jr.

A QR code is a two-dimensional barcode, holding the same information in a   smaller space. 

To create a QR code, you can use a free service such as Goo.gl or use a paid   service such as FASText to integrate with your electronic health record system. 

QR codes can be used to track inventory in your office, provide personal   health records to patients, or link to online resources.

By now, you've noticed those funny little   boxes in the corners of magazine ads or posters. The symbols look like a cross   between a crossword puzzle and a barcode. 

Similar to barcodes, those little printed boxes,   called quick response (QR) codes, contain multitudes of information only   readable by special digital scanners or your smartphone. After you scan a QR   code, your smartphone can present the information or perform a function, such as   access a Web site.

Although originally developed for an automaker, advertisers now use QR codes to interest consumers in their products or services. That's not the only possible use. The codes also can engage your patients and help you run your practice more efficiently.

Skyline Family Practice in Front Royal, Virginia, a   three-doctor practice 70 miles west of Washington, D.C., has incorporated QR   codes into its front office and exam rooms for nearly 2 years. Using a software   program designed by two of the doctors, nonclinical and clinical staff alike can   create QR codes to help patients manage their conditions and keep appointments.

"We embarked upon this, and as it turned out,   we've developed this one particular program that allows us to do some pretty   amazing stuff from a medical care perspective," says practice founder Floyd   "Tripp" Bradd, MD, FAAFP. 

In this article, we'll show you why and how   Skyline uses QR codes in its practice, the benefits the practice has   experienced, and how you can incorporate the technology at your practice. 

Released in 1994, QR codes were developed by   Toyota subsidiary Denso Wave. Unlike a barcode, which contains data only   horizontally, QR codes hold data vertically, too. The two-dimensional capability   allows QR codes to hold more information in a smaller space. 

The automaker used the codes to track the   manufacturing process, inventory, and shipping. Other Japanese technology   companies and European manufacturers followed Toyota's example. Recently, in the   United States, the codes have been used predominately to drive consumers to Web   sites or to watch commercials or videos on their smartphones. 

"Yes, those are good uses for it," says   Skyline partner Bernard Pegis, MD, FAAFP, who co-developed the software used at   the practice. "But that's like taking a really nice laptop and using it as a   paperweight." 

Bradd says his fascination with QR codes   started when he acquired an iPhone and noticed how many retailers were   integrating the codes in promotional materials. He also noticed how many of his   patients, nurses, and front-office staff members owned smartphones. 

Bradd and Pegis, who are long-time technology   enthusiasts, thought QR codes could be an effective tool to track medical and   office supply inventory. For example, if a nurse uses the practice's last pair   of gloves, he or she can scan the QR code on the box with a smartphone, and the   quantity would be automatically updated in a database program the doctors   developed. 

"One of the problems for most offices,   particularly smaller ones, is that they hemorrhage inventory," Bradd says. "It   can be gloves, dressings, or any number of small items that the staff members   use but don't keep track of. No one has a clue as to where it went because no   one tracks it." 

Although the inventory management program was   sidetracked because of other time-consuming projects, that didn't stop the   doctors from implementing QR codes in other areas of the practice.

Emerging technologies are a natural fit at   Skyline Family Practice. Bradd has used an electronic health record (EHR) system   since 1993, and Pegis has created computer programs since he was 10. The doctors   and nurses use touchscreen laptop computers in the exam room, and their patients   complete paperwork on Kindle Fire tablets. 

"When I saw the QR codes, I immediately saw   all sorts of ideas for what you could do to improve the care in the office,   getting the information to the patient, and engaging them," Pegis says. 

Pegis created a one-dimensional barcoding software   while working in his college's bookstore as an undergraduate. He then designed a   two-dimensional barcode design, similar to a QR code, after becoming frustrated   with ordinary barcode limitations, he says.

"I never did anything with it," he says.   "Then, when Denso Wave started publicly using the QR codes, I thought, 'Ah,   that's much better than what I was working on.' " 

At Skyline, Pegis designed the computer   program to produce QR codes. Several QR code-generation applications have sprung   up on the market, such as Google's Goo.gl program, but Skyline's is the first   specifically created for EHR integration, according to the doctors. The   application, called FASText, works as an add-on to the practice's EHR system,   McKesson Practice Partner, although it is compatible with any Microsoft   Windows-based application, he says. 

The main benefit of generating QR codes is   engaging the patients' attention and emotions through their smartphones, Bradd   says, which are growing in adoption. Nearly half (49.7%) of all mobile phones in   the United States are smartphones as of February 2012, according to Nielsen   Mobile Insights, a market research firm, up from 36% the previous year. Patients   lose paper handouts, care instructions, and appointment cards, but they rarely   misplace their smartphones. 

"The younger ones love it because they love   the ability to use their phone for something," Bradd says. "We've actually   increased patient engagement in that demographic." 

Pegis recalls how he used the program during   a recent encounter with a teenaged patient who wounded her knee. Rather than   printing wound-care instructions on paper, which could be lost or ignored, Pegis   selected the instructions on his EHR screen, clicked a few keys, and generated a   QR code. The patient eagerly scanned the code into her phone. 

"She looked at it and she said, 'Wow, that's   so cool!' " Pegis says. "Now she's got a handout, she's excited about it, and   she's not going to lose it." 

Although more elderly patients are adopting   smartphones, adult children who assist with their parents' care likely already   own a device, Bradd says. 

During such a visit, he will select an   elderly patient's medication list in the EHR and create a QR code. The patient's   child will scan the code into his or her phone from the screen. Bradd also will   create codes for treatment and nutrition plans and links to Web-based patient   handouts and resources. 

"A point of contact most elderly patients   have with their children is that doctor's visit," he says. "After that, the   adult child will have a portable document they can go home with, and if they   happen to drop by their mom and dad's house, they can compare the meds." 

Any text from a Web page, e-mail, or other   document can be selected and copied into a QR code. Skyline's program, which it   sells for $50 through its spin-off software company, Caduceus Digital Systems,   is available at its Web site, 

Front office employees at Skyline use QR code   generation for appointment reminders and referral contact information. At check   out, the office employee will select the date and time of the next appointment,   create a QR code, and then print out the code using a small label printer at the   front desk. 

An appointment scanned into the patient's   phone eliminates date and time confusion and creates an automated reminder if   the patient uses his or her smartphone's calendar application, Pegis says. 

"Adult children of elderly parents love that," Bradd   says. "They live out of their phone. I won't say teenagers are more compliant   [with appointments] because it's on their schedule, but they have it in there."

For referrals, the physician or front-desk   employee selects the referring physician's contact information and creates a QR   code that is scanned into the patient's phone. With the contact information   already inside the phone, the patient doesn't need to search for a number to   make an appointment. The office staff also offers patients a code for Skyline's   contact information. 

Front-desk employees were eager to   incorporate the QR codes into their workflow, Pegis says. 

"Once I showed it to them, they said: 'Wait a   minute, you mean I don't have to write these things out again? I'm sold,' " he   says. "It took them all of about two and a half seconds before they were on   board with it." 

Skyline physicians also added their own QR   code to an influenza vaccine awareness poster that the U.S. Centers for Disease   Control and Prevention (CDC) distributed. When the patient scans the code on the   poster, it jumps to the CDC influenza vaccine information statement. 

Time spent on the Centers for Medicare and   Medicaid Services' stage 1 meaningful use requirements delayed some QR code   ideas for Skyline, including the inventory management implementation. 

The physicians also have not yet recorded and   measured how the QR codes have benefited care, other than their patients'   enthusiastic reaction. 

"We get a whole lot more of an emotive   response after they've acquired the information than if we just handed them a   piece of paper," Bradd says. "Emotion is associated with memory, so the sticky   factor increases because of that." 

In the meantime, the doctors intend to expand   QR code use with patients, and they hope to begin sharing them with physicians   outside the practice as electronic data exchange becomes more common. 

"It's been a wild ride," Bradd says. "But   it's been fun in the sense that it's amazing what you can do with the   [technology]. Our patients have become so accustomed to it that they're sitting   there looking over shoulders at HbA1c curves. That's been very   helpful for them, and now with the QR codes, it's done that much more." 

Some of the information that can be   embedded in a quick response (QR) code includes:


 • chronic illness   treatment regimens; 
 • wound or injury management plans; 
 • medication   lists; 
 • nutrition plans; 
 • appointment dates and times; 
 • practice   address, phone number, or other contact information; and 
 • referral   information. 

Quick response (QR) codes can store thousands   of text characters in a thumbnail-sized black-and-white matrix. The code also   can instruct a smartphone's Web browser to open a page or dial a number. 

Generating these codes is simple, say Floyd   "Tripp" Bradd, MD, FAAFP, and Bernard Pegis, MD, FAAFP, family physicians at   Skyline Family Practice in Front Royal, Virginia. They created an application   called FASText that can work with your electronic health record (EHR) system, or   any word processor, such as Microsoft Word. Here's how FASText works: 

 Select the text, address,   contact information, or Web site address in the EHR system or word processing   application or a Web page. 

Right-click the mouse or type   in a pre-set key combination (hot key). 

Select "Generate QR code" from   the pop-up menu. 

Have a patient scan the QR   code with his or her smartphone with any of the many QR code readers available   from the Apple App Store or Android Market. 

"It's just too easy to drop in a blob of   information so I don't have to retype it all over again," Bradd says. "Since it   works across all text editors, it has worked very well for me." The FASText   application is available for free as trialware at 

Articles

By now you've noticed those funny little boxes in the corner of magazine ads and posters. Although originally developed for the auto industry, these quick response codes can also find a home in the physician practice.

QR codes in the medical practice

Healthcare jobs are expected to be the fastest-growing category through most of the new decade, according to a report released by the Bureau of Labor Statistics. 

The occupation projected to add the most jobs through 2018 is registered nurse (582,000), followed by home health aides (461,000). Seventeen of the 30 fastest-growing occupations are related to healthcare or medical research. Employment of physicians and surgeons is projected to grow 22 percent by 2018.  

"The growing and aging population will drive overall growth in the demand for physician services, as consumers continue to demand high levels of care using the latest technologies, diagnostic tests, and therapies," according to the bureau, which adds that physician assistants and nurse practitioners increasingly may be used instead of some other practitioners, because they are less costly. 

Heatlhcare jobs are expected to be the fastest-growing category through most of the new decade.

Healthcare tops job growth estimates

Ten business days is the most time California private health plan members will have to wait for a non-urgent appointment with a primary care physician, according to a regulation that took effect in January. 

California's "Timely Access" regulations require appointments for the state's 21 million health plan members to be scheduled within certain time frames. 

The burden of compliance, however, falls on the health plan, not the doctor, according to a statement from the state's Department of Managed Health Care.  

A 2009 study by physician placement firm Merritt Hawkins found that in Los Angeles, new PPO and HMO patients wait an average of 59 days to see a family practice physician.

Ten business days is the most time California private health plan members will have to wait for a non-urgent appointment with a primary care physician.

California limits appointment wait times

Physicians' moods affect the number of prescriptions, referrals, and lab tests ordered, as well as the amount of time they spend talking with their patients, according to a study by Ben-Gurion University of the Negev in Israel. 

The study surveyed 188 primary care physicians in Israel. On days the doctors reported positive moods, they spoke more to patients, wrote fewer prescriptions, ordered fewer tests, and issued fewer referrals. When doctors were in a bad mood, they did the opposite. Additionally, if the physicians' burnout level was higher, then their moods more strongly affected their behaviors.  

Physicians' moods affect number of prescriptions, referrals and lab tests ordered, as well as amount of time spent talking with patients, a new study shows.

Author | Morgan Lewis Jr.

Articles

QR codes in the medical practice

Healthcare tops job growth estimates

California limits appointment wait times

Study: Physician's mood affects care