Medical Practice Efficiency Killers

At Marysville Primary Care, the physicians have a good idea of what awaits them each day before seeing their first patients.

The four doctors at the Ohio-based practice take a look at their schedule at least one day ahead of time, communicating any concerns with two nurse practitioners and other staff members - all in the name of increased efficiency.

"You need to be realistic about what you can do in 15- to 30-minute time slots," says internist and pediatrician Mary S. Applegate, one of the practice's physicians. "To do that, our staff works together and troubleshoots things a day ahead of time."

Part of that troubleshooting also involves realistic appointment scheduling based on the patient. For example, someone who has not seen a physician in more than a year does not get a 15-minute visit, nor do patients with psychiatric issues, she says, because it is unrealistic to think a full visit can be completed in that time frame. Nurse input is also crucial, Applegate adds, because they know certain patients, like seniors, take at least 15 minutes to get ready for their exams, hence they require a longer visit.

"We agree, as a group, what we think is reasonable for visits and there is not much variation from physician to physician," she says. "We need to be realistic so every patient doesn't put you behind 10 minutes because 10 patients later, you are 100 minutes behind and that is a very inefficient thing to do."

Practices can be full of efficiency killers, those parts of your day-to-day operations that eat up time, create redundancies and extra work for staff, and can cause office confusion.

Barbara Stahura, senior consultant with Gates, Moore & Company in Atlanta, says she sees several reoccurring themes when advising practices on how to streamline operations.

Poor preparation is one of the bigger efficiency killers, Stahura says, including missing lab results or lack of proper pre-visit patient instructions. This can be solved in part by having staff and physicians know what lies ahead by holding meetings first thing in the morning or even at the end of the prior work day.

"A lot of times, there are communication issues between the front and back office to know what's needed and things that go hand-in-hand with the patient visit. So if possible, have a group meeting," Stahura says. "At least have both parts of the office say, 'Here is what the day looks like, here's what's missing, and here are the key problems.'"

Efficiency killer 1: poor communication

Staff meetings are a big key to efficiency at Hodges Family Practice, with offices in Asheboro and Ramseur, N.C. Monthly meetings allow everyone to provide input on practice-related issues and suggest changes to day-to-day operations where inefficiency may be present.

"Everyone's role in the practice is unique and important," says family physician Beth Hodges, one of the three doctors at the practice. "The front office and the back office need to work together."

The monthly meetings spurred one rule of thumb at the practice to aid efficiency: All follow-up visits from the local hospital must be accompanied with records. Now, records await physicians at the entrance of the exam room so knowledge of prior X-rays, prescriptions, and other information is readily available.

Hodges says the practice also empowers its two nurse practitioners to be the "eyes and ears" of physicians so when a doctor enters the room, she can be as efficient as possible, provided with information from the patient and subsequent action by the nursing staff.

Another obstacle to efficiency is failing to anticipate patient questions or concerns, from the nurse practitioner informing a patient about clinical procedures to a billing clerk reviewing financial policies, Stahura adds.

Anticipating patient questions -before and after the visit - can free up physicians to see other patients while a nurse or physician assistant answers questions on medication side effects or other issues. This resolves another time waster: patients calling the practice after their visit with questions.

To help avoid some of the post-visit calls, practices need to be realistic with the timeframe for patient test results and clear on a patient's responsibility when it comes to insurance coverage, Stahura says.

"We don't want to stop the clinical interaction, but we want to give a clear understanding of what patients can expect, she says.

Efficiency killer 2: work flow snags

A good way to reduce efficiency killers in your practice is to look at office flow - the complete set of steps a patient goes through from picking up the phone to making an appointment to the final payment of the bill for that visit.

For Applegate, this means breaking down the exact responsibilities of everyone involved in a patient visit. If a nurse's tasks take three minutes and a physician's tasks take 20, that results in 17 minutes the nurse is sitting and waiting for the doctor to finish, a big time waster that can set appointments back all day long.

She advises looking at office flow and dividing up the work in as equal as possible pieces to get patients seen more efficiently.

Stahura borrows a line from comedians Abbott and Costello, calling it the "Who's on First?" issue for each practice. Like Applegate, she advises clear lines of responsibility among staff, with the physician doing tasks requiring a medical degree - rather than answering phones, for example - and everyone else at the practice taking care of duties specific to their background and training.

"If we don't identify who is doing what, prior to a patient visit, then again, you run into a productivity issue, but also the potential for redundancies, and potential for confusion," Stahura says. "I see that as a big issue."

To help better define lines of responsibility, make sure job responsibilities are both written and current and then chart out, step-by-step, the patient visit either on paper or using a computer program.

"If you flow that whole visit, you see what it takes for each step and who does each piece of that visit," she says. "That goes hand-in-hand with the development of job descriptions … and is enlightening for a practice. It shows you where you may have redundancies, but also shows you that you have to think through who is going to take care of that piece of the visit."

Efficiency killer 3: misused tech

Technology, especially EHRs, is billed as a practice time-saver, but opinions vary as to whether these tools create more efficiency or new problems instead.

Applegate is in the latter camp. Although she finds value in easily located data, quick access to patient contact information, and fast doctor-to-doctor communication, she also finding faults with their EHR, including its interference with the doctor-patient relationship.

"If I only have 15 to 20 minutes with a patient and a bunch of EHR stuff to do, the patient does not get my undivided attention; it takes away from the exam and from my relationship with the patient as I'm looking at the EHR, not the patient," says Applegate, who also teaches medical and pediatric residents at local hospitals. "Residents are so focused on the EHR and not the patient, and that is distressing to me as a long-time physician."

Applegate says she makes the best of her practice's EHR by clearly communicating with staff her issues with the system and ways they can help. She also communicates difficulties to the IT staff so they can possibly customize the system as much as possible to "have a malleable tool that actually can be configured according to the needs of the patients."

In the other camp, Hodges loves her EHR. She concedes that it takes some time to train and get staff acclimated, but in the long term, the system can reduce inefficiencies. Like any tool to help your practice, however, she advises using it to its full advantage.

That means no handwriting notes and scanning them into the system when you can type them directly into a patient's record and having easy access to a laptop or computer terminal in the exam room to avoid interruptions during a patient visit.

The system is "critical" when it comes to her practice's satellite office as well, Hodges says. It allows her to see other partners' patients at that location without having patient information faxed back and forth among offices, avoiding a potential HIPAA violation by misdialing on a fax transmission and having records sent to the wrong number.

"For us, it eliminates extra work and lets us access information securely from any location, whether it is from the satellite office, the hospital, or even my home," says Hodges. "I can get information out immediately without going to our main office for a paper chart. That is a tremendous help for our practice."

Keith L. Martin is associate editor at Physicians Practice. He can be reached at keith.martin@ubm.com.

This article originally appeared in the January 2011 issue of Physicians Practice.