When you walk in to see your next patient, is all of the necessary information assembled, organized, and ready? Or do you spend the first five to 10 minutes of each appointment determining who the patient is, why he or she is here, which performance measures are due, and what care the patient may have received from another provider, the emergency department, or an urgent care center since his or her last visit?
In our own practice, if the first time we think about a patient is when he or she checks in, we are already behind.1–3 There is a lot to be done at each appointment. Consider that the average family medicine patient age 65 or older presents with four problems per visit and, in our experience, one or more care gaps needing to be addressed.4 This is more work than a physician can typically handle alone yet is too important to leave to chance.
Pre-visit planning can help make your patient visits run more smoothly, giving you time to focus on what matters most to the patient and even a little time to spare to simply visit with the patient. Furthermore, you may be able to head home an hour earlier, feeling satisfied with the day and a job well-done, knowing that your patients and staff feel the same.
IN THE AUTHORS' OWN WORDS
Dr. Thomas Sinsky and Debra Althaus, RN, discuss some of the benefits that pre-visit planning provides for their practice.
The objective of pre-visit planning is to help the patient and physician conduct the face-to-face visit more effectively by gathering and organizing information ahead of time so they can devote more attention during the visit to interpreting, discussing, and responding to that information.
Pre-visit planning takes place in several steps:
1. Plan forward, or “The next appointment starts today.”5 The most efficient form of pre-visit planning begins near the end of the previous visit. As the visit draws to a close, the physician and patient decide on next steps, such as planning any lab tests that might be needed before the follow-up appointment. The physician is already familiar with the patient's conditions and medications, so it should take very little time to identify the appropriate tests for the next visit. The patient then may schedule these appointments immediately instead of having to remember to call back in several months to set them up.
In our practice, we use a checklist to help us plan for the next visit. The checklist is part of a form that also includes the date of the patient's last annual exam as well as any upcoming appointments and labs that are already scheduled. This format allows the physician to put today's care and the next visit's care within the context of the patient's ongoing care. The checklist features lab and other test options in three sections: those to be done before the patient leaves today; those due before the next follow-up visit; and those due before the next annual visit. The patient is then given the option at check-out of receiving an automated reminder phone call, text message, or letter closer to the time of the appointment. (The "Post-appointment order sheet" is available in the FPM Toolbox).
In an effort to be more patient-centered, we've also found that asking the patient when he or she would like to return is an effective way to share decision-making and give patients an active role in their own care. We also believe this approach, combined with the reminder system and pre-visit labs, have helped lower our no-show rate, which is less than 4 percent.
2. Look back. Some practices do not begin pre-visit planning at the end of the current visit. Instead, it starts a week or so before the next visit when a nurse or other staff member looks back over a patient's record and orders any tests indicated by protocol based on the patient's conditions or medications, as well as any instructions the physician left in his or her documentation from the previous visit. Practices that rely on physicians to enter future orders into the electronic health record (EHR) on the day of the visit will sometimes also employ this “look back” process by the clinical staff. Physicians may feel they cannot spare extra minutes at the end of the visit inputting orders when other patients are waiting, so the look-back process ensures the work has been done.
Reviewing the patient's record outside of the office visit requires more time than planning forward, but it is still more efficient than not doing any pre-visit planning.
3. Pre-visit lab testing. Pre-visit lab testing saves time, improves patient engagement in health management, and reduces the amount of work needed to report and respond to results. Some practices arrange for patients to come in several days before the appointment for lab testing. Others arrange for patients to have their blood drawn 15 minutes to an hour before their scheduled appointment and then use point-of-care testing or rapid turnaround of standard lab testing. In both cases, the goal is to time the tests so that the results are available to the patient and physician at the face-to-face visit.
By having the results available during the appointment, patients can be part of the ensuing decision-making and are more likely to adhere to the treatment recommendations than if they received those recommendations later by phone or letter. In addition, the physician and patient can avoid playing phone tag or engaging in several rounds of email after the visit to resolve unanswered questions. One practice found that pre-visit labs saved $25 in overhead per patient visit.6
Pre-visit labs can also aid safety. Because patients are able to review their test results together with their physician at the appointment, it is less likely that an important result will be overlooked or lost in the system.
4. Pre-visit phone call. Calling the patient ahead of his or her visit can help the clinical team prepare more thoroughly by clarifying the patient's agenda, anticipating any special needs, and completing many of the tasks usually performed during rooming, such as reviewing medications or screening for depression or falling. Some practices reserve pre-visit phone calls for complex patients. A pharmacist or pharmacy technician may also call these patients for in-depth medication reconciliation. In some cases, this process is aided by access to an all-payer claims database, which staff can use to see what medications the patient has actually filled. You can identify and address nonadherence to medication in a non-judgmental way with this approach.
5. Visit preparation. On the day of or the day before a visit, the medical assistant or nurse can do a quick review of the patient's record to see what needs the patient may have during the appointment. For example, they can identify if the patient needs an immunization, a cancer screening, or other prevention measures and close these “care gaps” during the rooming process. Conducting visit prep can be an effective tool in panel management and can positively affect the health of the entire patient population.
6. Pre-visit questionnaire. A pre-visit questionnaire is a list of questions the patient completes either on paper in the waiting room or through an online patient portal from home. See the questionnaire our practice uses.
Questions explore the reason for the visit (“What are you hoping to accomplish today?” and “Is there anything else you'd like to work on to improve your health?”), which prevents the situation in which a patient's main goal is revealed just as the physician is about to leave the exam room. Standardized questions applicable to the particular practice, such as screening questions for falls, depression, or domestic abuse, can also be asked. The questionnaire can also be used to update the patient's past, family, and social histories, as well as to conduct a complete review of systems. All of these uses can save the staff, physician, and patient time during the actual visit.
In our own practice, we have a separate pre-visit questionnaire for the Medicare Annual Wellness Visit that mirrors the template in our EHR, which makes it easier for the nurses to upload the information. Some EHRs are designed so that the patients' answers to the pre-visit questionnaire can be imported into the visit note, reducing the amount of data entry required of physicians and clinical staff.
7. Mini-huddle. The nurse or medical assistant often learns important medical and social information during his or her interaction with the patient during rooming. We have found that a brief “mini-huddle” with the physician before the physician meets with the patient can be helpful. The nurse can alert the physician to the patient's concerns (“She is afraid she will lose all strength in her arm”), a change in social situation (“His wife was recently diagnosed with breast cancer, and he is worried”), or a teachable moment (“Her sister just developed diabetes, so she is willing to work more on diet and exercise to prevent this from happening to her”).
Although we have not found many studies measuring the overall financial savings of pre-visit planning, our personal experience is that pre-visit planning definitely reduces the time spent on a patient's care during or after the visit. A rough estimate is that pre-visit planning takes about an hour of nursing time per day and saves about an hour of physician time and up to two hours of nursing time. It also increases the quality of care by identifying agenda items and care needed at the appointment, such as immunizations or cancer screening.
We have received mostly supportive feedback from our patients regarding pre-visit planning. When they leave an appointment, we reserve a time for their next appointment, which they can plan around. We plan ahead to make that next visit meaningful to them. They don't have to wait after the appointment for lab results or instructions based on those results, and they can speak with their physician about those management decisions.
Finding the right strategy for you
Pre-visit planning can take many forms, and practices can choose the ones that make sense for them. Each component adds efficiency and supports a rapid understanding of why the patient is visiting and what his or her comprehensive needs are. An organized system to manage this complexity and volume will allow physicians to relax and truly listen to patients, knowing that the standardized, predictable work of the practice happens correctly by default and resting assured that they have minimized the chance of overlooking an important piece of data.
You can read more about pre-visit planning, pre-visit labs, huddles, pre-appointment questionnaires, and building a culture of team-work at the American Medical Association's practice transformation website.