Fixing the Flow of Care

News

As we work to build a better system, a better way to take care patients, we need to make sure we find a way to take care of them in a comprehensive and equitable manner. And we need to build a system that inspires the next generation of providers to enter primary care, to see the incredible satisfaction that can come from the honor of being involved in patients’ lives.

To do this, we need to get rid of the chaos, remove all the stuff that doesn’t have to do with doctoring, to build a better patient and provider experience.

We need to rethink, improve, streamline, and redesign everything from the first patient contact all the way through their arrival in our practice, to every touch throughout their visit, to the needs that arise during the immediate follow-up and the interim time between visits.

Especially for our incredible internal medicine residents who practice alongside us, the experience of training in our outpatient setting has long been a vexing one, filled with unknowns and pitfalls that make it challenging not only to take care of patients, but to see the joy in outpatient medicine and to become inspired to choose a life in primary care.

As we rethink the patient experience, and begin to use more of the functionality of the electronic medical record, there are multiple opportunities to make things better for both patients and providers.

My hope is that we can dramatically improve the pre-visit experience, making sure our patients understand our agenda and the tasks they’re due for based on our records.

Sure, the system has ways of prompting patients that they are overdue for their mammogram or colon cancer screening or shingles vaccine, but these prompts — which go both ways to the patient and provider — still don’t seem to lead to the task getting accomplished.

As I’ve said before, it would be great if the system actively engaged patients and gave them useful information for decision-making — and then make it as effortless as possible to actually make these things happen.

Send them all the health screening questionnaires we have and help them understand why they are being asked to fill these out.

If our system says they are overdue for breast cancer screening, we should ask them before the visit if they want to get this set up for today, and then queue it up so it’s ready even before the patient arrives.

Did they need referrals, forms completed, refills, specific tests ordered by another provider?

Are they here today for a preoperative evaluation, and do they already know which tests the surgeon wants them to have done by their primary care doctor?

We have all experienced this so many times, at the end of the visit after we’ve wrapped everything up, that we hear, “Oh wait, one more thing,” or, “I forgot, the surgeon told me to give you this form so I can have surgery tomorrow.”

In our practice setting, there is very little of the support often seen in private practices — not enough nurses, not enough medical technicians, not enough nurse practitioners, and certainly no physician’s assistants or others specifically assigned to help take care of our patients.

So much of this ends up falling on the doctor that we are often overwhelmed and things end up falling by the wayside.

Patients arrive late, doctors are running late, the electronic medical record isn’t working, printers are down, room assignments are scrambled — so much can go wrong with so many moving parts.

Finding a way to make this easier will improve the experience for everyone.

Going back to the time of scheduling an appointment, we need to make sure we have updated contact information and insurance, remind them to arrive 20 minutes early, and ask about transportation needs. We can remind them that something as simple as arriving 5 minutes late for a 20-minute appointment will lead to things being shortchanged. And if they’re not going to come, make sure it’s easy to cancel and reschedule.

Once they arrive in the practice, while they are waiting at check-in, we can offer more ways to make the appointment better.

If they haven’t completed all the necessary paperwork, give them an iPad or other device to finish important pre-visit work.

Ensure that everyone is enrolled in and has access to the patient portal, and if they’re not, connect them to resources to ensure this happens in their community, to promote equitable access to care before, during, and after their visit.

To make sure we can help each patient as much as possible today, something as simple as a paper notepad can help. Ask patients for their main reason for coming today, what problems they want to address, and whether they need a form filled out, referrals, or refills, alongside a list of missing health maintenance items they’re due for.

Just recently, we’ve discovered that something that improved the patient experience and the flow of patients for the attendings at our practice, has made things more challenging for the residents.

During the pandemic, we switched to having patients do labs, ECGs, and vaccines right in the same exam room where they were being seen, to avoid having people move to multiple other stations throughout the practice.

The attendings, when they finish with one patient and put in orders, the nurses and medical techs can come in and do phlebotomy and ECGs and vaccines, while the attending moves on to the second patient room assigned to them.

Due to space constraints, our residents are usually only assigned one room, so even after the patient arrives, they do their history and physical, and they present to their supervising attending to develop a plan and place orders, there is now a significant wait before the resident can move on to their next patient, creating more delays and frustrations.

Thinking about how we can find a place for them to see the next patient, or else get the patient out of the room and back to the lab or vaccine station, or even to a different room for an ECG, will help eliminate some of the bottlenecks leading to frustration for everyone.

We have been trying to improve the primary care experience for years, and it seems like we are constantly reinventing, rearranging, and tweaking things to try and make the system better.

It’s time for a global rethinking of how these processes function and the barriers that prevent us and our patients from getting fully into the flow.

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