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Spotlight: Career

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Physicians Practice® spoke with Fernando Mendoza, MD, FAAP, FACEP, the founder and CEO of Scrivas, LLC, about the rising rates of reported burnout among physicians and how medical scribes might be able to alleviate some pressures from physicians.

Reducing burnout with medical scribes

Physicians Practice® spoke with Dr. Nada Elbuluk, practicing dermatologist and director of clinical impact at VisualDx, about how cognitive biases present themselves in care strategies and how the industry can begin to work to overcome these biases.

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Physicians Practice® spoke with Michael Morgan, at the time the CEO of Updox and a contributor to Physicians Practice, to discuss the new technologies that you should consider implementing in your practice and why implementing a virtual care strategy will be so important post COVID. 

The Paperless Practice: Virtual care strategies

 Today we are featuring my conversation with with Rich Miller, chief strategy officer of Qgenda, after his recent presentation at the Medical Group Management Association's virtual Medical Practice Excellence conference.

Here's a brief excerpt from the program summary: As we move through the Recovery stages of the pandemic healthcare organizations and practices are overhauling technology and processes to accommodate COVID-19 safety protocols and return to more typical operating levels. They're having to make quick adjustments. So just balancing a new combination of telemedicine visits and in person visits, or transitioning to touch free workflows. These critical guidelines and policy changes are impacting patient flow without the right technology and visibility. And these changes can negatively impact patient access and throughput.

Prior to his appearance at the conference, Rich also contributed an article to Physicians Practice about how providers and practices as a whole can 

Our conversation centered around clinical capacity which, Rich explains, is very broad in concept but fundamentally refers to brining providers and patients together in the most efficient way possible.

 One of the ways that I think about clinic clinical capacity is sort of like two funnels coming down towards each other. So, the health system, and the patient system is very much like a funnel of in-taking new patients and doing initial diagnosis and triage, etc, etc, and trying to get them to those points and care.

And that sort of happens over and over again as we move people through that system of diagnosis and treatment, as well. The same is true of providers. So whether it's as far out as making sure that providers are onboard and properly in their credential to work in various locations, and all that kind of thing, the kinds of things that big health systems think about, all the way down to just saying, “Well, how many people do we have in this Urgent Care Clinic today, to see patients who, you know, show up for a walk in or, you know, scheduled patients?” So really clinical capacity, in its simplest form, is the marriage of those two things.

At the small scale, it's really very similar between, you know, a large health system and a small private practice with a with an office practice because those large health systems are made up of lots of small units that work just like that. So an orthopedic unit for a major health system, versus orthopedic unit, for a private practice group, really what they're trying to do is they're just trying to make sure that they can take as many patients as possible, while providing a very high degree of care and not burning out those providers while they're doing it.

 Like a lot of other areas of healthcare, the pandemic had a cascading effect on capacity management, according to Rich Miller.

 So, you know, the Coronavirus, the effect was really dramatic, and really just cascaded all throughout the health system.

You know, on the macro level, the effect of COVID-19 had a huge effect on the concentration of patients. So, we went from, you know, ORs being booked up and patients coming in for elective procedures and people coming into ambulatory clinics to, you know, see a specialist about a shoulder that's aching, that's my shoulder aches here sometimes. So, I naturally the point to that. And those things all got just canceled and shut down and all of those resources were then shifted over into our intensivist areas, the ICU, places like that. And suddenly you have, you know, these massive spikes, especially in places early on, like in April, during the surge in New York City and surrounding areas, Massachusetts, you had an incredible surge in these ICS where they were literally, you know, repurposing any possible room that they could in order to take care of these very, very sick patients.

Also, at the macro level, because there was this huge interruption to the kind of regular business of health care, there was a massive, massive interruption to revenue. So typically, in health systems, surgery is about 50% of your revenue. And even if you're an independent private practice provider, and you're a surgeon, surgeons are incredibly important for your revenue. Certainly, ambulatory revenue is still a real part of that. But both ambulatory and surgical revenue were cut way back way back. So there's a huge shortfall in revenues for 2020 that these hospitals are facing at the same time, that they had to spend more on facilities and PBE and all that kind of stuff. So Big macro effects.

On the micro level, the areas where we are providing care really changed dramatically. And a lot of it had to do with making sure for example, that we had the right level of isolation when people were in waiting rooms and things like that, I had an experience. And I'm going to talk about this a little bit at the practice excellence conference of going to my primary care provider for a regular physical. I drive up and there's like a sandwich board sitting in the in the parking lot that says, “Please call this number before you walk in, and I call it at some of the front desk.” So literally triage and people in their cars, like they want you to stay in your car and make a phone call. So people got very creative about how we were going to distance those patients. And immediately they asked, you know, did you take your temperatures, we asked you last night, were you good? Have you had any contact with anyone in the last, you know, blah, blah, blah, etc, etc, and went through and evaluated whether or not I would be safe to enter that space. And to their credit, that process worked incredibly smoothly. And, you know, boom, boom, boom, I was in the exam room and working with my physician. So that was terrific.

Things like the amount of cleaning and turnover that we have to do, every exam room now has to be cleaned after every patient has really added huge pressure on a system that already was pretty pressurized. The last thing I want to say about it is that it changed. It elevated, I should say the importance of different people you see all the time in healthcare, like for instance, the people who do the laundry, and the people who sanitize and turnover rooms and housekeeping and people who transport patients. Now, people who worked in those roles were suddenly critical critical providers of care, and where in the past, you would only schedule maybe you schedule your physicians, and we'll schedule our you know, advanced practice providers or our nurse practitioners and stuff. Now, we saw how systems that went from, you know, 3000, people under that kind of very precise scheduling to 30,000 people, literally housekeeping people, and need to be able to communicate with those people immediately. So suddenly, a lot more people were involved with carrying out the project. And it really is amazing what health systems have done in the way that they adapt. And it's just, it's been incredible seeing clients and friends and what they've done and been through.

 Managing clinical capacity often requires tools that are already at your practice, but new innovations are always on the horizon.

 Typically, what you would find in a small setting is, you know, a paper or Excel spreadsheet, or emails kind of flying around. You know, in some of the best cases, you have a really, really good administrative system, front desk person and scheduler who is just incredibly vigilant about making sure that those schedules really tie off. So, in general, what we see for tools are pretty rudimentary; certainly, there's going to be small EMR and things like that for booking this patient encounters. But oftentimes, there's very little by way of hard information about how things like exam rooms and provider time are being managed.

One of the things that's exciting for me is the way that we're using provider scheduling, to get right down into the nitty gritty of managing the day to day.

So I've actually worked in provider scheduling since 1998, a very long time. I'm dating myself here a little bit. And, you know, originally it was like, you know, who's on call and, and just trying to understand who the kind of go-to person is for care. But over time, there has been a steady march, closer and closer to now that's kind of the way that I like to say. Where in the past, we may have gotten to saying, “Well, this person is working today”, and then gotten to the place of saying, “Well, their first patient is eight and then I expect them to close at their clinic by 4pm today. Now we're even getting into place where we're saying, this physician is working in three these three exam rooms. This is a medical assistant, that's working with us. And those patients are being roomed and set up and ready for an encounter with their provider. So the provider walks in at this stage of set, and they can have a very productive conversation and get right down to take care of their. So, scheduling has really started to evolve to get more real time. And rooms management is certainly a big part of that.

 Ultimately, your ability to effectively manage your clinical capacity can have ripple effects in patient outcomes, provider satisfaction, and even practice revenue.

 I think that, you know, my wife is a provider and so I know a lot about how, you know, she feels about her day when she has crazy clinics that are piled up sky high, and then other days where maybe she's, you know, seeing 60% of patients that she should be able to see, all the time knowing that there's this incredible backlog of people who are waiting to see her.

So, I think that the real central theme of this is: how do we rationalize this process? How can we make sure that we have a really nice steady flow of patients so that providers aren't overwhelmed, they have time to work on their note and make sure that the wrapping of those cases appropriately that they can spend adequate time with each patient and provide the care that they need to, while at the same time identifying where they're underutilized resources.

That's something that is absolutely incredibly common, where providers have, you know, canceled appointments or scheduled as schedules that aren't managed very vigilantly? Maybe the person doing the scheduling that day wasn't doing a particularly good job, but one of the areas that is really, really poorly managed is facilities and rooms. And if you ask a typical provider, you know, do you have enough rooms in your ambulatory clinic, or in your office? They almost universally say, “No, we do not have enough rooms, because I don't have rooms when I want them.” So my perception is that provider is there just aren't enough rooms available in this facility.

Now, we've done lots of studies and actually looked at how those facilities really run. And the fact of the matter is, that rooms are really incredibly underutilized, that lots of rooms sit empty. And the reason that people perceive that rooms aren't available, isn't that rooms aren’t actually available—that there isn't actually physical space—but the spaces are so mismanaged that when they need a room, they can't identify, can I take this room and someone else gonna come and take this room? So there's a tremendous amount of wasted space there.

In the big application, whether you are, you know, a huge Health System, or you are an independent private practice, is you, if you start thinking, well, I guess we need to go out and get more rooms, now you're building facilities or leasing new facilities, that is incredibly expensive. So now we're seeing this change, where health systems and practices are saying, let's really look at how we're using this, let's implement a system that gives us some strong idea of what our utilization looks like, and maybe we can put off, you know, building that new $7 million facility.

 Up next, Rich discusses how some of his clients streamlined their clinical capacity management.

 It's interesting, we had a client who contacted us and said, you know, we have a huge problem with the way that we're managing rooms. This is University of Alabama, actually. And one of the things that they were struggling with is that they really didn't understand how many rooms are being used and whether or not rooms were booked whether patients were booked to those rooms. And so, our service team being a bunch of maniacs decided, hey, you know, let's just take our product as it exists today, and see if we can put something together to help these guys out. And so they kind of configured the product and sort of a weird way to accomplish what they were trying to do. And this happens all the time in software, people like come up with unexpected uses for your software, and you kind of use it in sort of a strange way to try to make that outcome happen. And what was startling is even using what was very rudimentary, we were able to increase the number of patient visits by 7.4%, increase in the clinical session volume by 4.7%. So, these are things that they were really able to, to measure as outcomes from implementing the system.

That was incredibly inspiring for us, it actually kind of set off sort of cascading series of events within the company where people said, this is they're not alone in this, there are lots of clients who are looking for this. And one of the things that's difficult about making rooms work right is that it's not just a room, it's a room with providers, and it's a room with the support staff to run those rooms. And because, you know, we have strong domain in the provider scheduling and management area, we realized, “Oh, this, this is something that we can very easily address.” So, we started developing some terrific new tools really based on those learnings and interviews of other clients and things. And it just really made us realize that the facility, the rooms that you're working in, what kinds of equipment are in those rooms, and the providers who are going to run those rooms, there's so much untapped opportunity to help people stay busy see clients see patients, and move folks along that, that we didn't realize we had to play a role to play and now that's become a big part of our business.

 If you're looking to improve your clinical capacity management, Rich has some tips on your search for programs and processes.

 I think the one of the things that is so important about doing this right, is that you're not just looking for a system to operationalize that—it is absolutely important to be able to say, you know, this person is, is, you know, in these rooms, and these patients are roomed in these spots, and to have that kind of command and control, but the most important thing that you can do is implement an operational system that produces data after the fact that lets you go through and do really terrific analysis to understand how are we actually using this.

For instance, if you were doing this and Excel, for example, spreadsheets can be quite structured. But when you're doing things like managing rooms and appointments in Excel, there's no real structure to the data, your ability to take that data across multiple days, or years or across multiple facilities and bring it together and say, let's do an analysis of our utilization. Or let's do an analysis to figure out “Should we open up a multi-specialty clinic with different specialties, all in the same building, all using rooms that are appropriate, and can work for those different specialties and sharing those, so we're really maximizing that space and gaining those efficiencies.”

Well, you're never gonna be able to do that without a system that can operationalize it and without analysis and tools that look at that data and produce real answers to the questions of how using the space and how efficient you are.

 Finally, Rich offers some advice for practices looking to streamline their clinical capacity management.

 I think that I think that we spent a long time really focus on things like EMR and meaningful use, and really making sure that we understood the patient side of the business. I think we made huge progress. I mean, if you go to a hospital now, and with having a, you know, coronary event or something like that, pretty darn quickly, they're going to be able to pull up your medical records. You know, wherever you are, especially, you know, if there using the same EMR, you know, obviously, there's a lot of ability to instantly transfer records. But even across the similar systems, we've gotten very good at sharing data. And I think we've got a lot better at kind of moving the flow of patients.

But I really think that 2021 is kind of the beginning of the of the year of the provider, I think we really actually need to look at our providers and say, this is a real scarce resource that we have here, we have a dramatic physician shortage, I have lots of Doctor friends who are retiring early, because they're like, this is horrible. My pay has been cut this year, I'm not accruing any vacation. You know, like, I just you know, and I'm working like an animal in order to take care of people and I've totally burned out. And I think that for us to be sustainable, we really need to focus our attention on how we can maximize the productivity of providers, minimize the amount of administrative garbage that they have to get involved with so that they can just really focus on patient care. And really try to make sure that the work that we put before providers is being managed as even and equitably as possible.

I don't know a single provider who doesn't want to come in and who doesn't want to come in on a given day and take care of patients and help people but when you run the person to the red line that's very frustrating or when that person is sitting around for an hour and a half because there were no patients booked or because of cancellations and things. That's a problem too. So I think that I'm hoping that the next revolution that we'll see in healthcare is really a focus on providers, how to support them, how to make them as efficient as possible, so that we can maximize access for patients and really provide the care that we need to provide.

Physicians Practice® spoke with Rich Miller, chief strategy officer of Qgenda, about practices' clinical capacity management during the pandemic and what you can do to optimize your capacity management strategies.

Managing your practice's clinical capacity

 This month at Physicians Practice, some of our contributors are focusing on the topic of burnout among physicians and staff.

Self care is of critical importance for physician and during the pandemic, self-care took on a whole new level of importance for providers, especially those on the frontlines.

Today, you will hear my conversation with Dr. Wayne Jonas, executive director of Samueli Integrative Health Programs, as we discuss the rise of burnout among physicians and staff both during and just prior to the pandemic, and strategies for reducing burnout in these populations.

We began by addressing why burnout remains such an important topic.

 We were already having trouble with burnout before the the bomb was dropped on the world with the COVID pandemic. You know, many of the frontline people, intensivists, emergency room, physicians, primary care physicians, and others were approaching 40% to 50% criteria for burnout. So, we already had a challenge in the system in dealing with burnout. And I think now with the rapid change that's going on—with sort of the implosion of the economy with the decline in, in both revenues and the capability of doing even basic clinical care—that has just exacerbated the change on top of this. So it is extremely important that we up our game in burnout prevention and management. And so you know, your questions are very appropriate for these areas.

I mean, the reasons for avoiding burnout have been very well delineated. The National Academy of Medicine did a major study on it published last year, American Academy of Family Physicians made it their theme over the last year on physician well being. And so the reasons for those are well known.

You know, with burnout, we have reduced empathy and the ability to actually provide care and a part of healthcare. We have less responsiveness to the needs of patients, and we pick up less on what's going on and therefore we're less accurate in our diagnostic and treatment decisions and capabilities. Trust gets eroded, there's an increased chance of error and mistakes and therefore harm in these areas. And now, if you pile on top top of that, the economic stresses that are occurring both for those in practice as well as for our patients, you know, we've got we've got a problem.

 One of the first steps in reducing burnout is to address that there is in fact a problem. However, bringing up these topics might be erroneously perceived to be admitting a weakness—there is a stigma attached to addressing or admitting burnout and fatigue.

Physicians Practice® spoke with Dr. Wayne Jonas about the rise in reported burnout among physicians, especially during the pandemic, and how the industry can work to overcome stigmas and begin to address these issues. 

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