QR codes in the medical practice

• 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.

WHAT'S A QR CODE?

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.

TECH-SAVVY 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.

BETTER ENGAGING PATIENTS

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, http://www.caduceusdigital.com/.

FRONT OFFICE USES EVOLVING

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.

MAKE QR PART OF YOUR ROUTINE

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."

QR CODE USES

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.

THE ABCS OF QR CODES

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:

STEP 1: Select the text, address, contact information, or Web site address in the EHR system or word processing application or a Web page.

STEP 2: Right-click the mouse or type in a pre-set key combination (hot key).

STEP 3: Select "Generate QR code" from the pop-up menu.

STEP 4: 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 http://www.caduceusdigital.com/.

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