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

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Three doctors share innovative strategies for tackling common practice challenges

From the May ACP Observer, copyright 2003 by the American College of Physicians.

By Bonnie Darves

SAN DIEGO—Fed up with complaints from irate patients who couldn't get through on the phone to make appointments, Jeffrey P. Friedman, FACP, decided to fix the problem himself.

The New York City internist took on the ambitious task of building a Web-based scheduling system to let patients book appointments over the Internet without ever picking up a phone—or being put on hold. Today, just under half of all the 34-physician group's patients make their appointments online, which has slashed the practice's no-show rate.

Like most innovators, Dr. Friedman encountered some obstacles on his road to building a better mousetrap. Not all of his colleagues, for example, were thrilled that patients would be able to see when their physician was on vacation or had a day off. Physicians also worried that some patients would abuse a scheduling system that they, rather than the practice, controlled.

But those fears did not pan out, and now Dr. Friedman and his partners are reaping the rewards.

During a half-day Annual Session workshop organized and led by the College's Practice Management Center on practice innovations, Dr. Friedman was one of several panelists who described how he overcame colleagues' concerns and implemented a novel practice system. (A fourth panelist, Charles M. Kilo, ACP Member, made practice changes that are featured in an April ACP Observer article, "How one group gives new meaning to 'virtual' access.")

Here's a look at the innovations that helped three physicians make their practices stronger.

Web-based scheduling

Sometimes the best way to deal with a persistent problem is to attack it at the source. That's what led Dr. Friedman to begin building a new scheduling system for Murray Hill Medical Group, the Manhattan practice where he is a managing partner.

The group's patient satisfaction scores were suffering, in large part because of its overtaxed phone system. Dr. Friedman, who is also assistant professor of medicine at the New York University School of Medicine, thought that letting patients book their own appointments might cut down on no-shows and cancellations—and reduce the practice's steep front-office staff costs.

Over several years, he built a system he called Scheduware that allows patients to go to the Web and make an appointment directly into the group's medical record system. Now, patients book nearly 40% of Murray Hill's appointments online, and 95% of the Internet-schedule users—who number more than 10,000—have not switched back to the phone system. No-show rates for appointments booked online are less than 1%, while hard-to-fill slots such as early morning appointments are now quickly snapped up over the weekends.

Cost savings are just as impressive: Since launching the scheduling system in late 2001, the practice has trimmed its support staff from 20 to 15, and it now saves an estimated $170,000 a year. "After only four months," Dr. Friedman said, "the return on investment was 450%."

While he was sure the system would be more convenient for patients and save the practice money, Dr. Friedman said his idea wasn't a quick hit with his colleagues.

"It was a hard sell because the doctors didn't want patients looking at their appointment books," he recalled. Some physicians worried that patients who saw they had open slots might think the physicians weren't busy or popular with patients. Others were afraid that patients might abuse the system by booking multiple appointments, showing up for only one while canceling others at the last minute—or not canceling at all.

Neither scenario, however, came to pass. Patients have been pleased by the hassle-free booking method that takes them less than a minute. They also like being able to choose appointments times that are convenient for them, rather than the "next available" slot that happens to pop up on a scheduler's computer screen.

Here's how the system works: Only established patients can use it, and patients have to first register online. That ensures that they understand the group's policies and procedures before they can make an appointment. (The practice also wants to verify patients' insurance coverage before they show up for a visit.)

Once they have registered, patients go to the doctor's calendar—which is structured like online airline-schedule calendars—and choose an appointment slot. Patients do not see the amount of time allocated for appointments.

After patients have booked an appointment, they receive immediate e-mail confirmation, as well as additional confirmation messages three days and one day before their appointment. (The messages contain instructions for advance preparation, such as fasting.) The system encrypts all communication to and from the practice, as well as patients' personal data, to protect patient confidentiality.

Murray Hill now has a much better idea of when patients need appointments: 50% of patients who make online appointments, for example, want to be seen within 24 hours. And Dr. Friedman's solution to an overworked phone system is paying big entrepreneurial dividends. He is now making the system available, on either a licensing or subscription basis, to several large clinics around the country.

(For more information, contact Dr. Friedman at friedj03@popmail.med.nyu.edu.)

Group visits

For geriatrician John C. Scott, FACP, his "aha!" moment came 12 years ago while working at Kaiser Permanente in Denver.

"I saw that every patient on my schedule was over 80, had multiple conditions and was taking multiple medications," he recalled. "Every time I closed the exam-room door at the end of the visit, I knew there were more issues to deal with, but I didn't have time." His conviction that "there has to be a better way to do this" led to the concept of group visits.

The group-visit model that Dr. Scott helped pioneer at Kaiser has since grown to encompass special patient groups—such as geriatric patients, or those facing orthopedic surgery—and those with chronic diseases.

The concept has been a boon for Kaiser, which found that group visits saved the HMO approximately $50 per member per month, while cutting hospital admissions by 12% and emergency room visits by 18%. But the model makes equal sense in fee-for-service settings, Dr. Scott claimed, because many practices simply don't have enough doctors to meet patient demand.

"The demands on physicians are the same, regardless of the reimbursement system," said Dr. Scott, who spent 25 years with Kaiser before recently taking a position at the University of Colorado. "We're overwhelmed."

The group visit concept is based on two premises. First, certain patients' needs can be more efficiently addressed in a group setting. Second, the patient-to-patient interactions, learning and camaraderie that occur in groups can actually improve outcomes.

"We have a huge untapped pool of human resources we could use in health care delivery: the patients," Dr. Scott said. In group settings, he explained, patients who have been coping with chronic disease for years can help others who are either newly diagnosed or struggling with a new infirmity.

In Kaiser's model, 15 to 20 geriatric patients meet for two and a half hours once a month with a physician, a nurse and possibly another health care professional. Other staff can include a psychologist, pharmacist or physical therapist, depending on the visit's agenda.

The first 90 minutes of the visit are divided into social time to build and maintain the group's cohesiveness, education time, one-on-one time within the group setting, a question-and-answer segment and brief planning for the next session. Over the next hour, physicians and nurses meet with patients who require traditional one-on-one attention with the usual documentation.

Almost all of those brief visits will be level 3 or 4 on the evaluation and management scale, Dr. Scott said. He added that he knew of no situations where payers had challenged claims for patients first seen in group visits and subsequently examined, or provided treatment or medical advice.

The key, he continued, is making sure the group visit involves actual patient care and isn't structured like a lecture. "This is care delivery, not a class," he explained. "If you turn it into a class, insurers won't pay."

Many physicians shy away from the model, afraid that all the patients in a group will want individual attention or that a few patients will dominate the session. But in Kaiser's experience, those problems haven't materialized, Dr. Scott said.

Data show that only six or seven patients out of the group will actually want to be seen individually, he said, and half of those requests will be because of a disease flare-up or new symptoms. In addition, Kaiser found that once patients' social needs and questions had been addressed in the group setting, physicians spent considerably less hands-on time doing physicals. For male patients, a complete physical took an average of five minutes, and for females, only seven minutes.

While patients understand that they must keep group discussions confidential, Dr. Scott noted that confidentiality is another big obstacle for some physicians—more so than for patients. "We care about this," he said, "but patients aren't worried about it." He pointed out that physicians concerned about liability issues can have patients sign confidentiality agreements.

Kaiser officials have been surprised at patients' interest in groups. (Group visits are voluntary; physicians or nurses ask patients if they are interested in joining.) Dr. Scott said that on average, 40% of patients who are asked want to join, while 40% decline. The remaining 20% often try a group and stay.

Since Kaiser implemented its group visit model, it has seen improvements in several areas besides costs. A two-year trial found that group-visit patients improved their overall quality of life and needed significantly less help with everyday activities.

Patients' satisfaction ratings for their primary care physician also jumped. Patients expressed far greater satisfaction with their primary care physician's unhurried approach and with the amount of health education they received.

But the biggest benefit, Dr. Scott said, has been the support patients provide one another. Group sessions often take on a life of their own, with members setting lunch dates and developing friendships outside the group. And it's not uncommon, he added, for patients to rally together and support a group member who is going through a difficult time.

Digital transcription

Steven D. Atwood, FACP, faced a more mundane problem in his practice: how to make the most of the money he was spending on transcription.

Dr. Atwood, a solo general internist in Springfield, Mo., was tired of waiting for his transcriptionist to pick up tapes. He was also looking for a way to get transcriptions back faster.

So he dumped his microcassette recorder and bought a new digital recorder. Instead of using tiny cassette tapes, his new machine stores notes digitally. The recorder is about half the size of his old device and tucks easily into his shirt pocket, holding five to eight hours of dictation.

Dr. Atwood


Dr. Atwood explains how the shift to digital transcription technology saved his practice time and money.


While digital recordings tend to offer better quality than old-fashioned tape, that's not the system's biggest advantage. Dr. Atwood can send and receive digital files from his computer—a major convenience. Now he can send dictation to a transcriptionist any time of day and saves about six hundred dollars per month for the service. By going digital, he said, the quality went up and the cost went down.

"I no longer have to wait for a transcriptionist to come by the office a few times a week to pick up tapes," he said. And because Dr. Atwood now e-mails files to his transcriptionist, he is no longer bound by geography when looking for transcription services. His current transcription vendor is based in Tennessee, while the transcriptionist lives in Montana.

Another big plus: He gets his transcribed notes back much faster. "Sending files electronically allows the transcriptionist to provide much quicker turnaround," said Dr. Atwood. In most cases, Dr. Atwood said, he receives the completed transcription work in less than 24 hours, a big improvement over the three-day turnaround his local transcriptionist provided. The vendor often can return simple letters in less than an hour if he asks.

As transcription vendors and independent transcriptionists move toward the new technology, the number of experienced professionals is growing. A recent search for transcription services on www.yahoo.com, he said, produced a full three pages of results. In addition, because transcriptionists working in the digital environment tend to be technology savvy, they can often provide additional services such as database management or formatting files for electronic medical record systems.

What do you need to get started with digital transcription? Digital recorders sell from about $150 to $200, depending on the model and the features you get. (Some also play MP3 music files.) Dr. Atwood gave high marks to the Olympus 330 and the Panasonic 9300. (For digital-dictation equipment purchases, Dr. Atwood recommended Web sites like www.TranscriptionGear.com and www.DICTRAN.com.)

To transfer files between his office and the transcriptionist, Dr. Atwood uses a simple dial-up connection to the Internet. The average file size for a day's worth of transcription is 3 megabytes, which takes about 30 minutes to transfer using his simple system. For a larger practice with several physicians sending transcriptions, he recommended using a high-speed Internet connection to cut transfer time.

He also recommended asking transcriptionists to use file types that can be compressed. (Both the dictation sound file and the returning transcription can be compressed.) Because compressed files are far smaller than typical word-processing files, you can send and receive them much more quickly.

Finally, because he e-mails files with confidential patient information, Dr. Atwood uses encryption software and a password system to keep files from being accessed or modified without his knowledge. The software is readily available, he said, from digital transcription vendors and Web sites that sell computer hardware and software.

Bonnie Darves is a freelance writer in Lake Oswego, Ore.

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