Good Business, Quality Care

Efficient Practices Provide Better Medicine

By Mary Medland
Mary Medland is a writer for Physicians Practice

Physicians, like all professionals, are understandably concerned about increasing office efficiency — but not at the cost of sacrificing care. That said, productivity and quality care do not have to be mutually exclusive. In many ways, efficiency is not only about running a better business, it is also about practicing better medicine.

Before the office visit
With planning, significant efficiencies can be achieved before the patient even sets foot in your office. Get as much information as possible when the patient calls for an appointment. During the visit, the patient can just verify the information. "Don't ask patients to once again fill out the same form," said Michael Coppola, managing associate with Chicago-based Health Directions LLC.

Avoid time-consuming insurance issues with a little planning, too. "Get the insurer information from the patient on the phone and then call the company to verify that the patient has coverage for that visit," said Coppola.

Scheduling and organization
It may be standard operating procedure to schedule patients for a mammogram months in advance, but it does not necessarily improve efficiency. "Don't schedule patients four or five months out," said Charles Kilo, M.D., an internist with a small group practice in Portland, Ore. "You know their schedule will change, and there will be plenty of phone calls back and forth. The more things that can be dealt with in real time, the less time-consuming everything will be in the long run."

Kilo and others reported that same-day scheduling increases efficiency by reducing no-shows. There are other benefits, too. "It's a big patient pleaser," said Kilo. "You can still book people in the future, just not months in advance."

The visit
Although each patient is different, you should still standardize as many details of the visit as possible. For Kilo, standardization means that every exam room is organized in precisely the same manner. Supplies are arranged on a cart and are always in the same place, so no time is lost looking for an item.

Kilo also removed shelves from his exam rooms: "They're just places to gather files and junk," he said.

While many physicians leave paperwork until the end of the day, Kilo completes this work immediately after seeing a patient. "People think it is efficient to do charting at the end of the day, but there is a big problem with the quality of those notes. Plus, you waste a lot of time trying to recall details about people that you saw hours ago," he said.

Learn to delegate
Many physicians have reported increased efficiency through delegation. Doctors need to accept that they can't do everything themselves, said Charlie Burger, M.D., of Norumbega Medical in Bangor, Maine. "Give responsibility to well-trained people."

Invest the time and money to train staff to perform at their highest level of responsibility and cross-train individuals to perform multiple tasks.

"I always tell people that good management means delegating, but you must supervise your staff — you cannot abdicate responsibility," said Martin Blume, a senior consultant with Eagle Medical Management in Scottsdale, Ariz. Delegating responsibility, he noted, can also encourage staff enthusiasm and decrease staff turnover. "Bear in mind," he said, "that to replace a person and get a new one up to speed will cost you about two years' wages."

Other physicians emphasize the importance of having a morning "huddle," during which the day's tasks can be discussed and delegated. Kilo begins each day by sitting down with his staff and running through the list of patients he will see that day. "We look at what we need to do to be prepared…Is there an X-ray we need to have ready? What procedures might be needed?" he explained.

Various technology helps
Even something as relatively primitive as an answering machine can save time. Blume installed a voice mail system that was strictly for pharmacists calling in prescription renewals. "I realized about 25 percent of my calls were from people requesting renewals," he said. "With the answering machine, my back office staff could check every few hours and fill those orders."

He also accepts faxed renewals from pharmacies. Some pharmacies even renew prescriptions electronically.

Of course, confidentiality is a concern for patients, as well as health care providers. For example, patients may prefer to be reminded by a quick e-mail that it is time for their Pap test, rather than by a phone message or postcard.

But e-mail is not limited to office appointments. Kevin Kearney, CEO of Denver's Point of View Survey Systems, a company that focuses on automated interviews, noted that many clinics are using e-mail to gather patient information.

"Our software certainly does not replace an interview with a patient, but an e-interview can provide doctors with more information about how their patients are faring," he said.

For example, Kearney cites a cancer patient undergoing chemotherapy. "In an interview, physicians often do not ask a patient about his level of fatigue or pain, or whether he might be depressed and potentially suicidal," he continued. "And from a cancer patient's point of view, well, he feels he is supposed to be brave and stoic. For this very reason, we've learned that cancer patients are more forthcoming and direct with their oncologists when they are communicating via e-mail, rather than face to face."

The e-interview also makes it possible to gather more information in less time. In addition, a patient who might be fairly quiet throughout a 15-minute office visit may be more forthcoming and able to provide physicians more concise and detailed information by e-mail.

Patients are also becoming more comfortable with a doctor sitting in an exam room with an electronic personal digital assistant (PDA) or tablet. "Here in South Carolina, patients are concerned about West Nile Virus," said Charles Bounds, M.D., a family medicine physician in a small private practice. "They like to look over my shoulder while I get on the CDC [Centers for Disease Control and Prevention] Web site and check on West Nile."

Bounds added that, not surprisingly, children love this computer-savvy approach. Adult patients like the quick, easy access to information at the point of care and are impressed that he is so technologically advanced.

However, sometimes low-tech is still best when it comes to efficiency. While virtually all physicians and staff point to excessive paperwork as a big efficiency killer, many are reluctant to hand patients a laptop computer to enter their information, preferring instead to rely on handwritten forms — and for good reason.

"I thought about putting a computer in the waiting room," said Blume. "But if a patient typed in a wrong number, we would have a mess that would take a lot of time to straighten out. We decided that we’d rather take the information on the phone when the patient calls to make the appointment and then verify it when he comes in."

Of course, while efficiency is one of the goals of technology, time can be lost to the technology learning curve. Physicians must be prepared to train, adapt and change. "The biggest mistake that I see," said Coppola, "is that physicians are reluctant to refine their way of doing business to make the best use of new technology…which they have just spent tons of money on."

Quality care still most important
In the end, efficiency is always going to involve change. But first, doctors have to recognize where the problems lie. "Then experiment and change things to see what works best," Blume said.

His view was echoed by Kilo, who consults on practice design and efficiency with national organizations, such as the Institute for Healthcare Improvement and the American Academy of Family Physicians. "We are working to change the way practices function and to many doctors, this is a very frightening thought," he said.

Making these changes doesn't have to be frightening if physicians realize that the foundation of an efficient practice is excellent care. "You must provide good customer service and excellent quality of care," said Blume. "If that is not there, nothing else matters."

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