American College of Physicians: Internal Medicine — Doctors for Adults ®

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How one project is helping doctors improve patient scheduling, more

From the April 2001 ACP-ASIM Observer, copyright © 2001 by the American College of Physicians-American Society of Internal Medicine.

By William Hoffman

In July 1998, the Institute for Healthcare Improvement (IHI) set out on an ambitious mission: to improve access to medical care and reduce delays in appointment scheduling at primary care and specialty practices. To accomplish its goal, the Boston-based group has been helping practices adopt cutting-edge management techniques.

The Idealized Design of Clinical Office Practices (IDCOP) project is now in its third and final year, and the early returns are promising. While the IHI won’t have precise data on the project until later this year, several participants say they have reduced their costs and improved outcomes in a relatively short period.

Veterans of the program say that they have reduced backlogs through innovative scheduling techniques, including the use of same-day visits and seeing patients in large groups. Some participants have also tackled thorny issues like exchanging e-mail with patients.

Here are the experiences of some practices that have participated in the IHI program and the lessons they have learned trying to build a better practice.

Same-day scheduling

The IHI program targeted four areas: access (how patients get into doctors’ offices); interaction (what the staff does and how patients are treated once they’re in the office); reliability (putting the practice’s knowledge to work to improve performance); and vitality (securing the practice’s finances and boosting morale).

The concept that has received the most attention is open access, where practices open their doors to same-day appointments. The goal is to reduce physicians’ crushing backlog so patients can schedule appointments—and see their physicians—more quickly.

Not surprisingly, many physicians are wary when they first hear about open access. Scott Decker, quality manager for ThedaCare, an integrated health care system with physician practices and hospitals in Appleton, Wisc., said that many doctors at his system worried that same-day scheduling would flood their practices and create chaos.

At Dean Medical Center in Madison, Wisc., “People thought of backlog as job security,” explained John J. Otterson, RN, a practice management consultant who works with the organization. Physicians worried that open access would lead to dry spells with no appointments.

IHI calmed those fears by giving physicians plenty of data. IHI statistics, for example, indicate that about 0.7% of a physician’s patient panel will call for an appointment on any given day.

Physicians participating in the project went a step farther and collected their own data to project exactly how same-day scheduling would affect their practices. John C. Notaro, ACP–ASIM Member, an internist and partner at Buffalo Medical Group PC in Buffalo, N.Y., analyzed his practice’s patient demand before abandoning his old scheduling system. Here are the steps he followed:

  • Analysis. Dr. Notaro first broke down office visits into three types: regular returns (typically doctor-initiated check-ups for blood pressure and chronic conditions); same-day visits (usually initiated by patients for nonemergency situations); and deflections (pa­tients who can’t be seen on the same day or need to be referred to another physician).

    Dr. Notaro’s staff then tallied patient calls from his panel of 3,200 patients. He estimated that most practices can create an accurate portrait of their patient demand by logging calls for two weeks.

    “I now know I have to be prepared to see 28 to 32 patients on Monday, 26 to 30 on Tuesday, 24 to 28 on Wednesday, 18 to 22 on Thursday and 24 to 28 on Friday,” he explained. Like other physicians interviewed for this story, he said he confirmed the IHI’s 0.7% call average.

  • Appointment types. Next, Dr. Notaro’s practice divided the day into 15-minute increments. He and other participants said that 15-minute increments best accommodate routine appointments as well as longer appointments.

    Dr. Notaro’s practice also reduced the number of appointment types it uses in its schedule. He explained that many offices put appointments into categories like annual physicals, new patients, same-day visits, etc. Instead of scheduling these appointments as soon as the office has an opening, schedulers often try to slot particular appointment categories during certain times of the day or month. Missed appointments or unexpectedly longer patient visits create backlogs in the waiting room.

    Dr. Notaro’s staff generally found that routine returns were best scheduled for early morning before same-day patients request appointments. His practice also tends to leave open slots for same-day visits in the late morning and afternoon. (The system works because most same-day patients can wait until then to see a physician.)

    Dr. Notaro also said that to accommodate same-day visits, physicians should fill no more than half of their schedule with discretionary appointments for pre-scheduled visits. Schedulers should try to avoid timing these visits after vacation weeks, business travel and other times when the physician will likely face a backlog of same-day patients.

  • Backlog. Dr. Notaro and other practices that participated in the IHI project agreed that moving to a same-day schedule is the hardest aspect of open access. The IHI encourages physicians to eliminate their backlog of appointments before opening up their schedules to same-day visits. IHI organizers and participants agreed that clearing out backlogs first allows staff and physicians to concentrate their full attention on the new system, rather than implementing open access piecemeal.

    As they try to plow through previously scheduled appointments, most physicians and their staff work long hours. How much longer depends on the size of the practice, the patient panel and the backlog. IHI officials said that most practices finished in a few weeks to a couple of months.

    Once the backlog is cleared away, however, most physicians say they have been happy with the results of moving to same-day scheduling. Dr. Notaro, for example, said he hasn’t had a day that his schedule wasn’t full.

At Dean Medical Center in Madison, Wisc., Mr. Otterson said that the nine physicians and three physician assistants at the group’s IHI prototype site reduced their routine office visit wait time from 22 days to 10 days in 18 months. The practice also virtually eliminated double-booking of urgent and symptomatic appointments.

And at Strong Medical Group-Fairport in Fairport, N.Y., general internist Wallace E. Johnson, ACP–ASIM Member, said that his practice reduced the average waiting time for physicals from 16 days to five. Dr. Johnson noted that initially, at least, many physicians worried that patient requests for appointments would be too unpredictable.

Beyond scheduling

Several participants said that once they tackled open access, it was much easier to change other aspects of their practice.

Dr. Notaro, for example, said his experience phasing in same-day scheduling showed him the value of organizing his practice’s schedule around “pods” of at least three or four physicians, nurses and physician assistants who work collaboratively to reduce workloads.

Dr. Notaro also created a “virtual lipid clinic” in his practice. Studying his patient panel’s insurance data and medical records, he discovered that less than half his high-risk cardiovascular patients were taking their medications, and that many were not being monitored regularly. The practice used software to help nurse coordinators identify and contact patients regularly to arrange routine monitoring and adjust medications and treatments.

Several practices have also tackled the controversial topic of sending e-mail to patients. Mr. Otterson from Dean Medical Center said that 35% of the patients polled at the organization’s prototype site told the group that they would use e-mail to communicate with their physicians. Patients now get follow-up calls from nurses, physician assistants or physicians within 48 hours on e-mail requests for medication refills, advice and scheduling.

Mr. Decker from ThedaCare and other participants reported that they feared that exchanging e-mail with patients would result in a blizzard of frivolous e-mail messages. But the anticipated blizzards never arrived. Patients signed agreements outlining their obligation to use e-mail responsibly, and most have limited messages to important medical matters.

Physicians also quickly realized that answering e-mail can often be assigned to a physician assistant, Mr. Decker added, or deferred until the end of the day. To address privacy concerns, some practices signed agreements stating that they would not e-mail private medical information to patients.

Group visits

Another concept that has received attention is group visits. Patients with similar health problems are brought together as a group with physicians who treat them. Physicians can treat similar patients simultaneously rather than seeing each individually for similar treatment.

Participants say that so far, patients seem to like the idea. Chronically ill patients appreciate the support of others suffering from similar conditions, and group visits can offer more education and interaction with multiple caregivers in a shorter time than individual appointments. Patients can schedule one-on-one visits before or after group meetings if they need more personal attention.

Mr. Decker said that ThedaCare recently organized group visits for 25 diabetics whose disease is not well controlled. During a group visit, assistants do blood work-ups while an eye doctor may lecture or give examinations. Most importantly, Mr. Decker said, physicians don’t have to repeat virtually the same instructions and advice 25 times.

While patients and physicians seem to like group visits, reimbursement remains a sticky issue. Mr. Decker, for example, noted that most payers won’t reimburse for group visits.

He said that many cite concerns about the potential for fraud, and many worry offices may bill for patients who don’t show up or for incomplete work. Others say they are concerned about “max-packing,” in which physicians discover and treat ailments unrelated to the original purpose of a patient’s visit, such as removing a mole from a patient being treated for a sprained shoulder.

Some payers, however, are interested in the innovations produced by the IHI project. Independent Health Association Inc. in Buffalo, N.Y., for example, is monitoring the IHI efforts for its impact on payers, and it has liked some of what it has seen. Though data are incomplete, Thomas Foels, MD, director of practice management at the health plan, said some of his preliminary observations bode well for the program.

He said he suspects that “max-packing,” for example, increases physicians’ clinical efficiency, and its preventive nature may actually result in fewer referrals. He also said that open access likely reduces emergency room use and medical complications by addressing problems before they become serious and expensive.

Dr. Foels also explained that the IHI project has sometimes produced surprising results. While payers initially worried that “right-sizing” patients’ medicationsm—as Dr. Notaro did in his virtual lipid clinic—would boost pharmacy costs, overall pharmacy costs actually went down as patients received corrected doses and more appropriate medications.

Mr. Decker from ThedaCare said participants have approached payers about modifying reimbursement policies, but these discussions are still preliminary. Recent IHI meetings have focused on the need for payer models more closely aligned with the comprehensive office redesign.

Charles M. Kilo, ACP–ASIM Member, president at GreenField Health System in Portland, Ore., said that physicians need to take the lead in encouraging payers to develop new business models. “American health care costs a heck of a lot of money,” noted Dr. Kilo, who is also a fellow at IHI. “Physicians drive many of those costs.”

Payers want proof that idealized design can improve quality of service and outcomes and save money, he said, yet physicians are often reluctant to provide the proof that payers want to justify a new business model. “‘Help me demonstrate how good I can get’ is a very unusual thing for a physician to say, because we often make assumptions about the quality of our care with no data to substantiate it,” Dr. Kilo said.

Nevertheless, Dr. Kilo said he is in early discussions with Blue Cross-Blue Shield of Oregon about reconciling office redesign and payer models. He said optimistically that insurers are waiting for physicians to join them at the negotiating table.

Others share that optimism. “I have not seen another program that works as well to improve quality as quickly,” said Dr. Foels. “The big question is ... can we spread the program to the broader community? That’s what we’re about to find out.”

William Hoffman is a freelance writer in Fairfax, Va.

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