Introduction
The healthcare sector is the largest employer in the United States, with annual spending reaching $3.8 trillion in 2019 (CMS, 2020). In most developed countries, 10% of the GDP goes toward healthcare, but in the US it is closer to 18%. Unfortunately, deficiencies in the delivery system result in billions wasted every year (Health Care Industry, 2021). Inefficiency is defined as “using more resources than is necessary to produce a unit of beneficial patient care or service” (James, 2015). The problem with inefficiencies in family practice is not only wasted time and effort; but medical errors, reduced productivity, and frustrated patients, staff, and physicians (Young, 2010). There are three components to consider when looking at your office efficiency: behaviors that occur pre-visit, during the patient visit, and post-visit (James, 2015).
Pre-Visit Strategies
Addressing Scheduling Concerns
Things that "front desk" staff can do to impact the pre-visit planning include verifying insurance, identifying transportation barriers, and making reminder calls to increase compliance with scheduled visits. "No shows" (appointments where the patient does not present and has not called to cancel in advance) impact the flow of care as well as the overall productivity of the office. In a study of 13 practices in Colorado, it was determined that the most effective tool for reducing no shows (30%) was providing a reminder call. Other strategies included counseling patients on behavior, restricting access, or expulsion from the clinic (James, 2015). Inappropriate scheduling can also be a downfall to clinic workflow. Physicians frequently find themselves spending more time than scheduled for a patient visit, leading to delays in patient care. Offices should train receptionists to ask the right questions to more accurately determine the length of time needed for each visit. Physicians can also hold themselves accountable to time limits or ask their medical assistant (MA) to help. A “nudge” is when a medical assistant knocks on the door to let the doctor know there are 5 minutes left in the visit and it’s time to wrap up. Agenda setting at the onset of the visit provides clear expectations to patients about time limits.
Prep Your Charts and Huddle with Your Medical Assistant
Chart prepping is a great tool that can be done that morning or the night before. A physician can start pulling in templates and plan for what orders and refills will be addressed. Similar benefits can be found by reviewing new notes or consults that have come in since the previous visit and updating the chart accordingly. It provides opportunity for "chart hygiene" as well, like cleaning up the problem list or medication list. Delegate some prep to an MA, such as assessing for gaps in care. Prep can include identifying incomplete testing patients will need to be reminded about, health maintenance items that can be captured that day, or point of care testing the MA can do during the rooming process. One can pre-complete forms that will be utilized during the visit and gather missing hospital records or consult notes. Prepping saves time overall because the physician is capturing as many things in the visit as possible and in the most efficient manner possible by having a plan.
Huddling can also improve the flow of your day. Huddles work best when there is a scheduled time to meet, helping to reinforce the routine nature of the process. Have one person lead and have an opportunity to take notes or pre-order testing when appropriate. Keep it brief, covering only the most important needs of the day (Stewart, 2007). Consider meeting the night before if the team aren’t "morning people." In a practice that has lots of add-on visits, consider huddling in the morning and again before afternoon patients. The huddle might include anticipating special needs of the patient, such as requiring an interpreter (Stewart, 2007). Team huddles can review all the items identified in the chart prep process. Decide how to delegate each need to specific team members to increase efficiency in the overall visit. Huddling allows one to review the overall flow of the day, anticipate roadblocks, and plan for how to work through them.
Inefficiencies During the Visit
There are several ways to speed up efficiency during patient care. Studies have found that the most important part is solid communication between team members. Utilizing technology and your electronic health record (EHR) to its fullest capacity is also critical to speeding up your day.
Enhance Communication through Care Teams
A lack of good communication has been identified as a barrier to workflow (James, 2015). Creating care teams can help. They are composed of physicians, MAs, and other non-clinical staff who work as a cohort to care for a specific panel of patients. Within the team you still need to clarify roles and responsibilities. Practices that adopt this strategy found that it strengthened team member relationships as well as relationships with patients (James, 2015). Before implementation it is important to have buy in from the team. Teaming can provide an opportunity for staff members to have more autonomy and engagement in patient care.
Staff call ins are a challenge for any office and disrupt the flow of care. Making sure that the office has good communication about when a staff member calls in sick and who is responsible to cover which duties can lead to more efficiency and less frustration. This is another place where teaming can have built in cross training.
Take the Time to Build Templates
Patient note templates are great for visits that operate like checklists. For example, Annual Wellness Exams for Medicare. Having detailed templates for health maintenance exams might save time and help to ensure completion of required measures for billing purposes. Similarly, well child exams work well as templates. Consider making one for each age group with options to specialize for different genders when necessary.
For "bread-and-butter" family medicine topics like diabetes, hypertension, and hypothyroidism it may also be beneficial to have templated "History of Present Illness" (HPIs) and ‘Plan’ sections. But don't be tempted to create a template for every single diagnosis that might walk into the office.
Some straightforward things like a joint complaint don't take that long to dictate and may be so individualized that the end result is a vastly different template. Similarly, when a template is too detailed it may actually result in inefficiency. For example, one may only need two or three different options for a physical exam (PE) template. This should reflect what one would typically perform when seeing the average patient for a straightforward exam versus a more complex exam like an annual physical. Consider keeping a specialized musculoskeletal exam or genitourinary exams as part of a separate template. These can be added to other PE templates when needed rather than creating numerous full PE templates.
Use Dictation or a Scribe
Although many of us, especially younger graduates, are more proficient at typing on a computer than ever, don't underestimate the added efficiency of using a dictation device or a scribe for daily note writing. I've used all three throughout my career and each can be beneficial for different aspects of maintaining charts and day-to-day tasks. Even though a scribe can help write notes, reviewing them, along with addressing messages, results, and documents, is the responsibility of the physician. This is where dictation and fast typing can help to maintain efficiency.
Post-Visit Strategies
Post-visit time is usually spent addressing outstanding messages, results, and paperwork. To improve documentation time, again, the use of templates, scribes, or dictation can help. Delegating tasks to specific team members like refills, test tracking, and prior authorizations may help staff be more efficient in their aftercare time as well.
Provide Protected Time for Team Members to Work Uninterrupted
Staff need dedicated time without interruptions, just like physicians, to be most efficient. Having time at the beginning or end of the shift where the phones are off may help. Also, MA team members can cover one another while they take 30-60 minutes dedicated to completing their clinical duties. One can stagger these blocks to reduce interruptions in the rooming process. With less interruptions MAs can accomplish more while feeling less overwhelmed. Physicians should also protect time at the beginning, middle, or end of their day to answer messages, review results, prep, or complete charting.
Streamlining the Medication Refill Process
Med refills tend to be a time-consuming task for all. Decide as an office who will respond to faxed pharmacy requests to refills vs only honoring patient requests. Train staff to identify patients that will need a visit before a refill will be honored by the doctor and redirect these requests to scheduling staff instead. Physicians can also play a role in reducing the number of refill requests by providing a safe number of refills that will align with the need for follow up visits. If a patient needs to be seen again in 6 months, provide 6 months of refills. Always have patients schedule follow ups before leaving the office, and ideally 2 weeks prior to them running out of medications. This requires discipline from the provider but will ultimately train patients to follow up routinely. This also ensures payment for the medical decision making that goes into providing refills. Physicians can also pre-order labs that to be done ahead of the visit so that results can be reviewed at the time of the follow up. This reduces yet another patient phone call and staff task.
Use the Portal to Provide Results
We all recognize how much time it can inadvertently take to call a patient with results. Not to mention, it's difficult to get paid for these phone calls. Take advantage of your EHR patient portal to provide results. Push all normal results to the portal as the standard for patients to be informed. This incentivizes your patients to sign up for portal access. This frees up time for other tasks. Abnormal results can still be submitted via the portal with a more personalized note.
Pre-made templates can be utilized to explain common results to patients. For example, “your bone density testing revealed osteopenia which is a thinning of the bones. This can increase your risk of fractures. Your risk of developing osteoporosis can be improved through weight bearing exercise and vitamin D and calcium supplementations. It is important to take fall precautions as discussed at your recent visit. We will repeat your testing in two years." Given all the time one spends typing or dictating the same things over and over, the time spent building a few templates like this is well worth it.
Downsides to the portal could include all patient messages coming to the physician directly without being filtered. Reviewing them can take up a lot of time, and often many of these messages can be handled by the office support team. Make sure the EHR is set to have all of the messages go to a staff person first. Then, they can redirect messages to a receptionist to schedule an appointment, a medical assistant to follow up on a refill request or lab result question, or the physician directly when appropriate. Sometimes, messaging back and forth with a patient can be more efficient than a phone call. It also provides the legal documentation necessary to demonstrate medical decision making. But when there is important information to provide and one can anticipate the patient having a lot of questions, picking up the phone may still be the bigger time saver.
Barriers to Implementation
The most common issue that practices address when implementing office changes are buy in from staff, physicians, and leadership. Make sure that the manager and medical directors have a shared vision and approach to implementation. Provide training and a time for physicians and staff to ask questions. Also, reevaluate after implementing a new process to identify barriers to applying a new workflow and modifications that could make it stronger. If things aren’t working, don’t hesitate to change it again. Include staff in process improvement initiatives. This will naturally create more buy in from their peers and help address barriers specific to certain roles before implementing a new workflow.
Conclusion
The healthcare system has become more redundant and complex over time. For every hour of patient care, providers typically spend an additional 2 hours or more in clinical work (Stewart, 2007). In order to save time and sanity, it is critical that an office look at potential workflow inefficiencies on a regular basis. It’s also crucial that physicians lean in to trying new things. We’ve covered many ways family physicians are finding better efficiency in their practices. But ultimately a physician needs to create processes that make sense for his or her specific practice. Schedule a regular time, or create a committee, to look at these issues and make recommendations. Evolving office policies to reflect the changes in health care will lead to improved wellness for physicians, staff, and patients.
References
- (2020). CMS National Health Expenditure Data. Centers for Medicare and Medicaid Services. https://cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends- and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical
- (2021). Healthcare Industry. Wikipedia. https://en.wikipedia.org/wiki/Healthcare_industry
- James, A., Ross, S. E., Vance, B., Nath, R., Harrison, M. I., West, D. R. (2015). Inefficiency in primary care: Common causes and potential solutions. Family Practice Management, 22(2), 18-22.
- Stewart, E., Johnson, B., Huddles, C. (2007). Improve office efficiency in mere minutes. Family Practice Management, 14(6), 27-29.
- Young, (2010). Addressing common inefficiencies in office practice. Family Practice Management, 17(6), 28-32.
