Before you sign that DocuSign Contract - Again - SMARTMD Before you sign that DocuSign Contract - Again - SMARTMD

During the pandemic, companies rapidly transitioned their paper processes to digital. Hospice was no exception. In fact, the inability to sign forms online became a showstopper for patients in facilities where physical access became limited or non-existent. At the time, the obvious choice was the market leader in electronic signatures – DocuSign (followed closely behind by Adobe Sign). And if your IT department had adopted DocuSign BEFORE the pandemic, they were geniuses!

Fast forward to 2023, and we see a different picture emerge. The limitations of DocuSign are much clearer now. If you are honest with yourself, you know it’s just not a good fit. It’s like those jeans that looked great at the store, even fit pretty well when you tried them on. A few washes later and in the mirror in the clear light of day, you know in your heart it doesn’t really work.

Great product, Bad fit

DocuSign is the undisputed leader in getting signatures on agreements. It was built for two attorneys who have pre-negotiated a contract and now need a signature – without resorting to faxing or mailing paper back and forth. Great idea – securely stamping signatures on PDFs. In fact, such a good idea that the company that invented PDFs (Adobe), built a competing product (Adobe Sign), but that’s the topic of a different article.

Unfortunately, the situation between two attorneys does not even remotely resemble the experience of a seriously ill patient admitting into care. And that’s the problem.

Static vs Dynamic

For attorneys, they have already agreed on the terms. If changes were necessary, they would have already taken the time to make them. Nothing changes at the point DocuSign enters the picture. Hence why the contents are locked the moment a signature is added.

That could not be further from the truth for our admission cycle. Anyone who has worked in admissions knows that nothing is static. Discharge dates change, who can sign the forms can change the second the patient becomes incapacitated, who you thought was the HCPOA turns out not to be when you finally get to the patient’s bedside and read that POA form, and the attending physician – don’t get me started on that. Everything can change between the time the referral is received and the patient is admitted.

The DocuSign model practically forces you to wait until the very last second to engage the patient. Start any sooner, and you run the risk of paying a second (or third time) for a DocuSign envelope. But then, if the electronic process begins so close to admission, what’s really the benefit? Engaging patients online does not buy you anything, you may as well wait until you are in front of them anyways.

To Save Nurse Time, You Have to Engage Early

DocuSign drives the organization away from gaining one of the most profound benefits of online engagement – time. Getting consent forms in front of patients as early as possible saves time for the admission nurse (the one resource everyone is short of). First, patients & families get to see the paperwork long before the admission nurse shows up. That means they can take 5 minutes or 5 hours to read over the material without holding up any of our staff. Second, patients have an opportunity to respond. They can ask questions – like what’s an attending physician – and we can answer (no, Uncle Bob can’t be your attending, but we’ll check anyways before the nurse comes out). There are few things more time-consuming than walking someone through a bunch of legal agreements they didn’t know even existed. If you’re hoping DocuSign saves your nurses time, it does, but not nearly as much as it could.


The DocuSign (and obviously Adobe Sign) model is rooted in passing a PDF around. PDFs are awesome because they are pixel perfect. Regardless of what device you open them on, they look exactly as the author intended. They even print exactly like they appear on the screen. This is why PDFs are the format of choice for any in marketing or advertising.

This built-in, wonderful quality of PDFs creates a nearly unsolvable problem on mobile phones. The text in that PDF gets proportionally smaller on a small screen. If you’ve ever tried to read a PDF on your phone, you know it’s pretty darn hard. You’ll have to resort to zooming and panning to read it. Getting through five pages will seem like an eternity.

Now, ask your 80-year-old mom to try and read it on her phone, and you realize it’s a non-starter. But here’s the problem – statistically, 50% or more of all patients and families will use their mobile device to review and sign consents.[1]

In retrospect, this makes sense. Everyone who has a grandparent knows a senior citizen that is completely comfortable texting and face timing us at all hours. Ask them to pop open your laptop, start a web app, and create a signature with their mouse – that’s practically mean. To put it bluntly, sending a PDF for signature ensures you are alienating half of your audience. If they do sign, they are basically trusting you without understanding what they’re getting into.

Asymmetric Information

This brings me to the most esoteric, yet most important argument against using DocuSign. There is a profound difference in our comprehension of our consent forms versus what patients/families comprehend of those agreements. We understand them in all their nitty-gritty detail, while patients are practically clueless. That makes sense – how many times in one’s life do you admit to hospice care, or for that matter, does a family member? Probably less than the number of times you refinance your home – and those forms make me uncomfortable and afraid I’m signing my life away without understanding what I’m agreeing to. Imagine what our patients are thinking.

This is a classic case of Asymmetric Information. Our patients are at a significant disadvantage. This issue is compounded by the fact that half of our patients can’t even read the forms because they open them on their mobile phones.

When we search outside of healthcare, we find solutions that overcome this problem. Take, for example, TurboTax. Instead of presenting an unimaginably complex tax form to the user, the app presents one small portion of the form at a time. Just long enough for the user to comprehend. They also augment legal language with common sense explanations and short videos. The outcome is that millions of citizens can get through their taxes with confidence, knowing they aren’t likely to regret their decision.

Conclusion – Consider Alternatives Before You Sign Away Another 3 Years

I’ll sum it up this way. Would you try to fill out your tax returns using DocuSign? I suppose you could, but boy, it’s not anywhere close to ideal. It would be time-consuming and complicated, and let’s hope you don’t do the math wrong between your income and write-offs. Fortunately for us, products like TurboTax exist. They take us through a series of guided steps to help us fill out our returns. In the end, it spits out a legal form with your signature. That’s a model worth copying in hospice. Paying for anything less is an act of desperation and a disservice to our patients and families. If you wouldn’t do it, why on earth would you make your customers?

Fortunately, we don’t need to search far for an alternative. Companies in sectors such as banking, mortgage origination, and human resource management (think new employees) have solved the vexing problems of customer onboarding. In these domains, the solution is a platform that combines process, education, document collection, AND signatures. But that’s for another article.

[1] Based on over 100,000 referred patients between 2019 and 2023.