Slowdowns Can Become Quicksand Over Time
Keeping your workflow efficient is important for good patient care, as well as your practice's profitability and your staff's peace of mind. Patients won't have to wait, you won't feel like you're on an unending treadmill, and your claims will get paid more quickly.
Practices often run smoothly at first, but bottlenecks can emerge over the years, as more operations and processes are added and team members fall into outdated routines. New technology, extra reporting requirements, and different kinds of patients can change the dynamics.
Bottlenecks often occur in the schedule—as a part of your electronic health record (EHR) data entry process, the front desk patient reception area, and your phone system. To resolve them, you need to take a good, hard look at your operations and make some decisive changes.
These changes involve anticipating problems, possibly reassigning staff, and taking advantage of new technology. If you spend some time fixing your bottlenecks, you may be rewarded with a more efficient practice.
1. Uneven Appointment Schedule
The bottleneck: You can't keep up with your patient schedule because you have too many same-day appointments, no-shows, and patients with long lists of complaints that would take much longer than the allotted patient visit slot.
Use tactics to reduce no-shows. When practices expect many patients to fail to show up, they tend to double-book and overbook appointments, which then cause bottlenecks. In a 2017 Medscape survey, 24% of practices said no-shows made up 11%-20% of all patients.
To reduce no-shows, Linda Girgis, MD, a family physician in South River, New Jersey, recommends calling all patients the day before the appointment to remind them. Other physicians use texting or emailing, if they have gathered the patients' online addresses.
Late arrivals can also be a problem, Girgis says. In her practice, if patients arrive late three times, they are told they must reschedule the appointment.
Manage same-day appointments more strategically. Many patients ask for same-day appointments, which can force the practice to double-book appointments. "This can mean staying late to accommodate all of the patients who show up," Girgis says.
Girgis limits same-day appointments to patients who are really sick or in need of being seen. "Staying late is usually not an option, because many of us have kids to pick up after work," she says. "But we are open late on some evenings."
This may entail more careful screening when a patient phones for a same-day appointment. If you don't feel that the patient is critically ill, you can suggest an appointment the following day.
However, if the doctor is not going to screen calls for same-day appointments, the work should be done by registered nurses (RNs) or staff with even more clinical training, such as nurse practitioners, the American College of Physicians (ACP) advises. This work "cannot be delegated to unlicensed personnel such as office receptionists," the ACP states. Furthermore, "physicians should be accessible" to RNs doing the screening, and the RNs should use prepared texts to respond to callers' requests, the ACP advises. Physicians "should review nurses' scripts and protocols to determine whether they comply with acceptable standards and the physician's own medical philosophy," it adds.
In addition to the ACP's advice, it's also a good idea that screeners have enough people skills to deal with patients whose requests for same-day appointments are denied. They need to reassure them that they will be able to wait without having any ill effects on their health. Some callers who insist on immediate care may be directed to an urgent care facility or an emergency department, if you are unable to see them that day.
Plan ahead. At the end of the day, physicians and staff should look at the schedule for the next day. Determine whether all necessary information is available in the patient's chart the day before. If you don't have all the information, try to get it before the appointment. This is a courtesy to the patient, who may have to take time off from work to come in for the appointment, and it's helpful to your schedule.
Determine patients' complaints before they meet with the physician. The goal is to know the patient's full list of complaints in advance. You can then determine which complaints need to be addressed in the current visit, and which can be addressed in a future visit.
If you don't know the full list, the patient may bring up a pressing complaint at the end of the visit, causing the visit to last longer than planned, says Marie Brown, MD, an internist and geriatrician at Rush University Medical Center and a physician lead for the American Medical Association's STEPS Forward program.
"Before patients are roomed, give them an opportunity to write down or share what they want to accomplish during that visit," Brown says. "Have them write down their three priorities for that visit." Some physicians give patients a piece of paper in the waiting room, on which to write their medical issues.
Dealing With EHR Data Entry Requirements
2. EHR Work Slows Down Your Day
The bottleneck: Physicians are forced to spend too much time documenting patient information into their EHR and, as a result, are constantly falling behind with their work and their schedule.
"This situation is not sustainable," Brown says. "Doctors are taking their documentation home—and on weekends and even vacation. It's called 'work after work.'"
Make changes in the way you manage your inbox. For example, EHRs often direct all messages to the doctor's office directly to the physician's inbox as the default destination, Brown says.
The STEPS Forward in-basket module shows practices how they can customize their EHR inbox so that specified messages are rerouted to a pool of people on staff. This may require using IT personnel to alter the defaults.
Messages that don't need to go to the physician include daily progress notes for hospitalized patients; nurse visit notes for preventive care; routine physical therapy progress notes; test results ordered by consultants; previsit labs; and refill requests, according to the module.
Use non-physician clinicians to enter information into the EHR. Physicians get bogged down with EHR work because they think they need to enter all of the information personally.
Brown says much of the work can be done by staff. "We wouldn't expect a lawyer who is trying a case to document what is happening in the courtroom," she says. "There's a court stenographer to do that."
Medical assistants and other staff will be able to enter information accurately and efficiently by using customized EHR templates written by the doctor. (Installing templates may require working with the vendor.)
"My templates each focus on a chief complaint, providing questions in dropdowns with space to fill in answers," wrote R. Scott Eden, MD, a family physician in Maryland, in an article in Family Practice Management.
Consider hiring scribes. Hiring staff specifically to input information in the exam room is especially useful for physicians who are poor typists or want to deal more individually with the patient in the visit, says Laurie Morgan, a senior consultant at Capko and Co. in San Francisco, California.
Front Desk Staff Gets Overwhelmed With Tasks
3. Patients Backed Up at the Front Desk
The bottleneck: Receptionists are too busy with other chores to greet patients when they arrive and get their registration started.
Don't make receptionists answer the phones. When receptionists are assigned to answering the phone, they continually have to decide between the phone and the arriving patient standing before them.
Morgan says that one person can do both jobs in a solo practice, but not in practices of any larger size. "Staff are expected to multitask, but it usually means they don't do any of their tasks well," she says. "Incoming calls divert staff from signing in patients."
"Assign a different person for each job, and then cross-train them so that they can help each other out in high-volume periods," Morgan says.
Simplify patient questionnaires. Brown says patients are often required to fill out the same information again and again. This can lengthen the form-filling process as well as annoy your patients. Review your forms to see whether you've captured key information in a different form.
Use a patient portal. Having a portal on your website where patients can fill out forms also helps. "The benefit of having this information in electronic form is that you can add it directly to the chart," Brown says.
Have patients provide information in advance. Patients can download the registration questionnaire from the practice's website and fill it out before they come in for an appointment. However, Morgan says patients usually have to be reminded to do this.
Early check-in is especially useful for insurance information, Girgis says. "If staff can call the patient and get the insurance information, it can be verified by the time they come in," she says.
Provide a tablet for patients to register while in your waiting room. Having patients use an electronic tablet to fill out their information eliminates the problem of poor handwriting, Morgan says. The tablet may also speed up the process.
Morgan says patients can use the tablet to make their co-payment and even set up payment plans, and it ensures more privacy than having to talk about payment issues with the receptionist.
Help patients fill out paperwork. Patients who are impaired, have low literacy, or don't speak English well may need help filling out their forms.
"In my practice, we have a lot of immigrants," Girgis says. "The staff sits down with them and helps them to fill out the forms that our office uses."
This may mean pulling staff from other duties—or, in a larger practice, assigning staff to do this work. These staffers may be bilingual or trained to deal with specific paperwork, such as Medicaid or workers' compensation forms.
Some physicians wait to enter the data after work, but it's hard to clearly remember what transpired hours earlier, Morgan says.
Scribes can speed you up. A 2013 study reported that use of scribes increased the number of patients physicians saw by 60% per hour.
Include the patient in the EHR entry process. Brown says having the patient watch as she enters EHR notes can reduce errors as well as enhance patients' involvement in their care.
When she types in notes in the exam room, Brown asks the patient to sit next to her so that they can both look at the computer screen. "This way, the patient can make sure I captured the information correctly," she says. This eliminates having to make corrections later on.
The Phone Calls Never Stop!
4. Overwhelming Volume of Incoming Phone Calls
The bottleneck: Staff answering the phone are overwhelmed by calls asking to talk to a physician or waiting for medication refills.
Remove phones from the receptionist's responsibility. As already stated, having one person greet patients and answer the phones is an invitation for bottlenecks to happen. It's more efficient to have one person answering the phones and another person greeting patients.
When one person does both jobs, callers are put on hold for many minutes while arriving patients are greeted. Then the receptionist has to deal with the caller backup, and makes incoming patients wait for check-in.
Determine why people are calling. Patients' calls to the practice often involve some aspect of their care process that they are confused about, Brown says. In many cases, patients wouldn't have needed to call if someone had explained the matter and made sure that the patient heard, understood, and remembered what was said.
"In our practice, we view each call as opportunity to improve efficiency," she says. "Was there something we could have done differently so that person didn't have to make the call?"
This approach involves a little bit of research, which can be time-consuming, but it can save time in the long run, Brown maintains. Other callers may have had the same problem. Keep a record of the types of calls and requests you're getting, and figure out ways to forestall that problem. Some practices have found that printing out a visit review and instruction guide at the end of each visit helps patients to remember what they're supposed to do, and how the therapeutic regimen works.
Find a better way to handle refills. In many practices, requests for refills are a major reason for patients to call, and this can significantly tie up the phones.
"Patients who use medications for chronic diseases, such as high blood pressure or diabetes, are usually on them for life," Brown says. So it makes sense to put these patients on year-long prescriptions. "In my practice, we give the patient a prescription for 3 months with four refills for the rest of the year," she says.
She points to a STEPS Forward module that shows practices how to arrange for refills to be renewed just once a year, when patients come in for their annual comprehensive care visit. In most states, the maximum duration of a prescription is 12-15 months, according to the module.
"You write one prescription for the whole year and build in the refills," Brown says. "If you do 12 months' worth of refills, within 6 months the practice is saving 1-2 hours each day per doctor."
Provide a patient portal. Brown says having a portal has reduced the number of calls her practice receives. A portal can handle many issues, such as requesting appointments, paying bills, and reporting lab results.
However, there is evidence that portals can actually increase the number of calls in some practices. That was the conclusion of a 2016 study in the Journal of the American Board of Family Medicine. The authors did not speculate as to why this was happening.
Use phone trees. Some callers may resent directives to press various numbers for different services, but speaking to live person is not necessarily a good alternative, Morgan maintains. "It's a myth that people prefer to talk to a person," she says. "The live person is often still going to have to transfer them around."
Morgan advises customizing your phone tree so that it meets the needs of your patients. "Ask yourself, what are your patients most commonly calling for?" she says. "If they want school physical forms, that would go on the phone tree."
Girgis, on the other hand, does not believe in phone trees. "We don't have a place for voice mail messages," she says. "Patients who call in always reach a live person. Even if we can't help them, we still want to guide them."