It has become widely accepted that electronic health record systems have the capacity to improve quality in the healthcare industry by reducing or eliminating errors. For this to be successful requires clinicians and staff become proficient and effective users of the EHR. Converting from paper charts to an EHR necessitates a paradigm shift in learning, work effort, and workflow changes associated with any transition to a electronic database system – more so with a mission critical system that has the potential to impact the health of a patient.
In the rush to meet government mandates or receive CMS incentives, many hospitals and providers have adopted EHRs utilizing the same clinical workflows established in their pre-EHR setting. In other words, they have simply automated an inefficient process overlooking strategies to improve decision support, workflow efficiency, effectual user training, communication, and financial performance. That said, there is still ample opportunity to for process improvements in a post EHR implementation environment.
Following completion of the EHR implementation, the office can still develop a strategy to move beyond simply using the features and functions of the EHR and begin focusing on the data in the system to maximize the benefits that a functional EHR system can provide. An ideal start is to take advantage of the reporting features of the EHR to assess and measure the effects of the EHR to date. Analysis of reports will assist in determining what areas of the EHR are most effective and what can be improved upon in order to advance actual practice transformation.
Primarily, evaluate interfaces to other providers and healthcare systems with which the practice communicates (i.e., clinics, labs, hospitals, etc.). A EHR implementation can be compromised and data rendered ineffective if the interfaces are not operating effectively. Presuming all interfaces are working as designed, the office manager can begin the course of action of measuring operational specifics such as percentage of clinic visits, the amount of lab values entered, the number of e-prescriptions sent over a set timeframe, etc. Additionally, some practices measure the effect the EHR has on reimbursements and if the practice is realizing higher revenue related to the introduction of an EHR.
Once the effectiveness of the EHR has been properly evaluated, the office manager can begin to identify areas of opportunity to further optimize the operations of the practice. While there are a myriad of ways to increase EHR utilization, the following points represent examples as to how to achieve this:
Refresher training post EHR implementation
Electronic Health Records are similar to any other technology we use in that we are unsure if we are taking full advantage of all available features. There are many reasons why this may occur. First, during the first few weeks of use and training, users are typically focused on grasping the functionality of the system as opposed applying it in a meaningful manner. Secondly, once the user becomes accustomed to using the system in a way that appears adequate, it becomes difficult to change embedded routines. In order to mitigate these issues, it is beneficial to have the users go through refresher training courses in order to fully comprehend what EHR functions may have been overlooked or are not being utilized to their maximum degree. Refresher training is also beneficial for users who only use the system periodically or who are less knowledgeable of the system.
Establishing a “super user” who is proficient in using the EHR is a recommended industry practice. The super user is someone who has become proficient in the system and takes on the role of resident EHR expert assisting others in the practice come up to speed in a rapid manner. The super user is also the go-to person for system related questions as well as issues related to functionality and works as a mentor to new users entering the practice.
Enhanced Workflows post
It is essential to evaluate both clinical and operational workflows after EHR implementation. Used properly and aligning staff roles with the new technology, the practice has the opportunity to maximize value and eliminate waste and redundancy.
All too often, staff will remain in their pre-EHR roles after EHR implementation. Redeploying staff to perform tasks to augment the use of an EHR should be explored. Even in a post-go live environment, the staff can enhance their ability to evaluate internal operations such as care management and streamlined processes .
An EHR driven staff realignment methodology can have a positive effect on productivity as well as cost and patient care. To leave the workflow in a paper-based state is to not take full advantage of all the performance improvement opportunities the EHR can offer.
Determining whether the practice has realized the benefits of an EHR optimized environment are visible by way of the following examples; some are more tangible than others:
- Increase in staff productivity (i.e., less time spent looking for patients and other staff).
- A noticeable improvement in the perception of the value of an EHR.
- Reduced time spent reviewing patient charts after hours
- Ability to see more patients without extending hours.
Although the impact of these examples may vary from specialty to specialty, the practice will invariably experience a notable and positive change to both its clinical and non-clinical workflows.
Physician Practice Patient No-Shows:
- How many can you expect?
- How can you prevent them?
- How can you reduce their frequency?
The average no-show rate for physician practices can range from as low as none to as high as 60 percent of all appointments. Most practices experience an average of 5 to 7 percent. (Woodcock 2007, 178)
Practices in which physicians rotate between different sites tend to have a higher rate of no-shows. Patients may get confused as to which site to visit. The less loyalty patients have to a physician, the more likely they will be no-shows. (Woodcock 2007, 179)
Practices that schedule appointments too far in advance may find that patients make alternate plans for the scheduled time-frame. Patients given appointments well into the future may decide to locate other physicians who can see them sooner, start to feel better, or simply forget.
Some MGMA scenarios and best practices (Woodcock 2007, 179-180):
No shows aren’t just an administrative problem. Their causes may be deeply rooted in emotions and attitudes about your practice. Consider these comments and what’s really behind the emotion expressed:
- “You’re so busy, you won’t miss me.” Warn practice staff not to express relief at a no-show or cancellation, even on their busiest day. Patients will get the message that their absence is actually welcomed.
- “I hope I can remember this appointment.” Patients tend to lose those little appointment cards. If your patients are forgetting about their appointments, don’t schedule them more than three months in advance. Instead, call the patients six weeks ahead of time to schedule.
- “I feel wonderful; is there any reason for me to come in to be seen?” Remind patients, especially those with chronic illnesses, that routine preventive visits are important to their care, even when there are no symptoms to report.
- “I’ll just hear bad news.” Handle the emotional side of medical care by addressing patients’ fears head on. For patients you’re concerned about or for the services most patients find fearful, ask a nurse to make contact two or three days before the appointment to give last-minute support.
- I tried to cancel, but I couldn’t get through.” Set up a 24-hour/seven day-a-week cancellation voice mail and email address so patients can cancel or ask for scheduled changes at any time. Make sure someone is held accountable to monitor all such messages and to contact patients to reschedule within one working day of their communication.
- “You’re the one who moved my appointment.” Avoid cancelling clinics without ample notice, and offer alternative access to patients whose appointments have been moved.
Being knowledgeable about the emotional side of no-shows will help prevent at least some of them – and improve the care delivered to your patients.
Managing the Frequency of No-Shows
Here are ideas from MGMA resources and the healthcare industry to reduce patient no-shows (Baginski 2010):
- Track the reasons each patient gives for a no-show. Trends in excuses can help point to solutions. For example, are they covered by a certain insurance carrier, seen by the same physician or on a certain day of the week?
- Call your patients to reschedule their missed appointments. In this economy, you can’t afford to wait for patients to call you back.
- Set automated reminder phone calls the day before an appointment.
- Or, even better, have staff make routine reminder calls the day before an appointment. Research from the American Journal of Medicine shows this is more effective than automated phone systems – but certainly more time consuming.
- Send postcards/mailers a few weeks in advance to remind patients of their appointments.
- Develop a call list of patients who are able to come in for short-notice appointments. When a no-show happens, these patients may be able to fill the empty spot.
- Allow patients to prepay for their next appointment, giving them an incentive to return.
- Send “Sorry we missed you!” appointment letters (with or without fees) to patients.
- Place a nominal charge on your patient’s bill that will clear when the patient shows up for the appointment. If they do not show, the patient will pay the charge.
- Reward patients who show up on time with discounts on their bill.
- Limit appointments per patient to one per week.
- Explore ways to text appointment reminders to interested patients. Kaiser Permanente recently implemented SMS and its pilot program showed a .73 percent improvement in no-shows, saving $150 per appointment.
- Provide the option to send your patients an e-mail appointment reminder.
- Update/confirm contact information when a patient makes an appointment. This will help you track down patients who don’t show.
- Print future appointments on a business card to give to the patient before they leave your office. “I couldn’t read the handwriting” excuses won’t fly with this method.
- Have patients repeat the date and time of their next appointments, whether they’re in your office or on the phone.
- Discharge patients who accumulate a set amount (your choice) of no-shows in a year.
- Charge for same-day cancellations (which can be just as bad as no-shows), unless it’s an emergency.
- For patients who use public transportation, remind them to schedule their appointment according to the transportation schedule.
- Schedule repeat offenders during a time that has less of an effect to the overall schedule.
- Consider overbooking when appropriate. Overbooking doesn’t have to mean double booking. It could be shortening time between visits or adding more visits to a certain time of day. But beware – longer wait times and lack of understanding about scheduling can leave patients feeling disrespected, according to an Annals of Family Medicine research article.
- Always thank patients who cancel and reschedule well in advance of your no-show policy. A little goodwill can go a long way.
- Schedule accurately so patients don’t have long wait times, which may lead them to believe that the practice doesn’t value their time, convincing them to not value yours.
- Compare the number of patients handled by each of your doctors and their clinical staff. Consider reassigning the load so patients are evenly distributed and seen by the provider they visit with the most.
- Evaluate your practice management system to see if it can supplement or automate any tracking or patient reminder tools you’re currently using.
- Hold a gift card drawing for all patients who show up on time in a given month.
- Clearly explain, and have new patients sign, a written no-show policy.
- Elizabeth Woodcock, MBA, FACMPE, CPC, in the book Mastering Patient Flow, offers the following suggestions to reduce the number of no-shows:
- Develop strong relationships with patients to increase their commitment to your practice. Suggestions include sending birthday or holiday cards and assigning nurses to specific patients to work and follow up with.
- Schedule appointments within a reasonable time of the patient’s call. The longer the lapse, the greater the chance of a no-show.
- Switch to open or advanced access scheduling to provide appointments the same day a patient is looking for an appointment.
Overbooking Appointments as a Possible Solution
The challenge of balancing the interests of patients with those of the physician is increased when patients fail to show up for scheduled appointments. Overbooking appointments mitigates the lost productivity caused by no-shows but increases patient wait time and physician overtime. Basically, when patients fail to show up for their scheduled appointments, physician productivity and efficient clinic capacity are reduced (Cayirili 2003). To mitigate this loss, healthcare clinicians have experimented with a number alternative appointment scheduling policies. Some clinics overbook appointments by double-booking patients into common appointment times and relying on no-shows to allow the schedule to catch up (Chung 2002). Others have experimented with “wave scheduling” policies that build extra appointments into a schedule to boost better productivity and leave the other appointment slots empty (Silver 1975). This combination allows a schedule to catch up after backlogging occurs, thus reducing patient wait time and reducing the need for clinic overtime. Practitioners have reported success in managing appointment schedules with these and other similar approaches, but their accounts have been anecdotal and do not analyze or describe how scheduling performance relates to no-shows or other system characteristics (Chesanow 1996) (Chung 2002) (Baum 2001).
In 2007, two University of Colorado researchers (Linda R. LaGanga and corresponding author Stephen R. Laurence) won a 2007 Best Paper Award from Decision Sciences for proposing overbooking as a solution for the loss of productivity for physician clinics when patients fail to show up (LaGanga and Lawrence 2007). In their paper, the authors propose to build upon and extend the double-booking, block scheduling, and wave-scheduling devised by practicing clinicians to develop and measure the performance of a number of scheduling rules based on these policies. The authors suggest that physician practices adjust traditional appointment scheduling performance measures to capture the dynamics of overbooked appointment scheduling systems, determine their effectiveness when overbooking is used to compensate for the lost productivity of no-shows, and provide recommendations for improving performance in overbooked appointment scheduling systems. LaGanga’s and Laurence’s analysis is potentially useful for schedulers and providers to identify and evaluate operational policy changes that will boost clinic productivity and improve patient services.
Dr. LaGanga, who is also director of quality systems and operational excellence at the Mental Health Center of Denver, a state-contracted facility, said the model allows users to place a value on wait time and productivity.
For small private practices where the percentage of no-shows is low, the value placed on limiting wait times likely will be greater than for a busy practice that serves mostly managed care members or a specialty practice where the competition is minimal. So, in general, the practices for which benefits of overbooking outweigh the risks likely will be large, busy practices that have a high percentage of no-shows.
A misconception of overbooking is that it means double-booking. But overbooking could be as simple as shortening the time between visits or increasing the number of visits for a particular time of day. For example, if the average no-show rate is 30%, and the average time allotted per visit is 15 minutes, a practice could reduce that 15 minutes by 30% and allow only 10.5 minutes per appointment, resulting in more appointment slots (LaGanga and Lawrence 2007).
Effects of Overbooking
LaGranda and Laurence created computer simulations to see how overbooking might affect patient wait times and physician overtime. This illustration uses a 50% no-show rate because, the researchers said, although unusually high, it’s easy to illustrate how overbooking relative to the no-show rate would impact the daily schedule. In this case, the clinic would book 10 appointments in five appointment slots, assuming only half would show up (LaGanga and Lawrence 2007):
Patient Arrival Pattern
|Spaced throughout the day||No effect on physician. No patients waiting.|
|Bunched early in the day||Physician runs behind early in the day but catches up, preventing overtime. Patient wait times extend throughout the day but are eliminated toward the end of the day.|
|Last appointment of the day is late||Physician stays on schedule until the late arrival, which creates idle time that turns into overtime by the end of the day. No patients waiting.|
|Bunched late||Physician experiences idle time midday and experiences overtime. Patients experience waits late in the day.|
|More patients arrive than predicted||Physician runs behind schedule and stays behind for the entire day. Patients experience waits throughout the day.|
Risks of Overbooking
The researchers further developed simulation models to determine the impact overbooking would have on clinics, depending on clinic size. Size is measured by the number of appointments per day. This model shows the impact overbooking would have on patient wait times, assuming all patients show up, instead of no-shows continuing at their usual rate. This model assumes appointments are 15 minutes long, but it can be adjusted for any appointment length (LaGanga and Lawrence 2007):
Patient wait time
Appointments per day
|10%||5 min.||6 min.||7 min.||8 min.||16 min.|
|20%||11 min.||12 min.||17 min.||18 min.||22 min.|
|30%||11 min.||16 min.||18 min.||20 min.||25 min.|
|40%||14 min.||16 min.||20 min.||25 min.||30 min.|
|50%||14 min.||19 min.||20 min.||30 min.||35 min.|
Appointments per day
|10%||8 min.||12 min.||15 min.||16 min.||29 min.|
|20%||16 min.||18 min.||30 min.||30 min.||38 min.|
|30%||15 min.||29 min.||33 min.||35 min.||41 min.|
|40%||18 min.||29 min.||39 min.||45 min.||46 min.|
|50%||18 min.||33 min.||43 min.||49 min.||55 min.|
Dr. Lawrence stated that “the real cost is if you do overbooking, there will be patient waits and overtime to be sure.” But he argues that overbooking could still be beneficial for some practices. The dilemma is determining when it might work or when the stakes are too high (LaGanga and Lawrence 2007).
Baginski, Caren. MGMA In Practice blog . July 9, 2010. http://blog.mgma.com/blog/bid/34426/30-ways-to-reduce-patient-no-shows (accessed November 25, 2011).
Baum, Neil H. “Control your scheduling to ensure patient satisfaction.” Urology Times 29, no. 3 (2001): 38-43.
Cayirili, Tugba. “Outpatient scheduling in health care: a review of literature.” Production and Operations Management 12, no. 4 (2003): 519-549.
Chesanow, Neil. “Can’t stay on schedule? Here’s a solution.” Medical Economics 73, no. 21 (1996): 174-180.
Chung, M. K. “Tuning up your patient schedule.” Family Practice Management (41-48) 9, no. 1 (2002).
LaGanga, Linda R., and Stephen R. Lawrence. “Clinit Overbooking to Improve Patient Access and Increase Provider Productivity.” Decision Sciences 38, no. 2 (May 2007): 251-276.
Silver, M. “Scheduling: Least developed art.” Family Practice News 5, no. 32 (1975): 34.
Woodcock, Elizabeth W. Mastering Patient Flow: Using Lean Thinking to Improve Your Practice Operations. Engelwood: MGMA, 2007.
Staff members of physician practices have varying responses to organizational and process change. Some will adjust quickly, others will assume a wait and see attitude, and some may passively (or even actively) resist the move to an EHR. This is why communicating an EHR implementation plan is crucial. To this point, the staff must also be dynamically involved in the integration so that they feel that they have direct input and will eventually come to actively support it. Therefore, by explaining the new processes and identifying the benefits of these changes, each staff member will gain a sense of ownership in their part of the EHR implementation process.
An EHR adoption, like any other IT integration project, will change the job scope and responsibilities of all staff in the practice. This may result in some employees becoming territorial or retreating into a mode of pre-EHR activities; ultimately handing off accountability to someone else. In anticipation of this, EHR implementers need to communicate and receive feedback from every impacted staff member, so they understand and take personal possession of any changes in their job scope and responsibilities.
Processes to Facilitate Change
Both clinical and non-clinical staff may become sensitive to change when they do not perceive any personal or professional advantage to making a change. Physician practices should have an over-arching plan of action to facilitate all aspects of organizational change around EHR adoption:
- Create process teams
Create process teams within the staff to define the new workflow processes. These teams will get the rest of the staff involved and help to educate them as the practice prepares to adopt an EHR. These teams should meet at well-defined intervals on a regular and consistent basis.
- Communicate the logic for EHR adoption
Explain all the benefits of EHR adoption, how each member of the staff will benefit, and how the patients will ultimately benefit by improved quality of care. Be careful to avoid the, “because we said so” or “it’s a government mandate” statements. While this may be true in some instances, it does dot capture the true spirit of EHR adoption.
- Define measurable success factors
Clearly state what the critical success factors are surrounding the new EHR workflows and processes and follow this with a reporting system to evaluate success and improve the processes once the EHR has been fully deployed.
- Clearly communicate results
Establish a communication plan to communicate the definition of success. These communications should happen frequently at pre-defined intervals on a regular basis. Be certain to include all successes (as well as areas for opportunity) in these communications. Nothing aligns people faster than gaining success, even if they are initially small accomplishments.
Communicate, communicate, communicate…
Always communicate extensively with the staff about which phase of the adoption path the EHR implementation is in. Also, as the practice gets to actual implementation, the practice should begin thinking about how it plans to communicate this change to the patients. Within the practice, a well-defined communication plan should be in place that provides a framework for informing, involving, and obtaining buy-in from all participants throughout the duration of the project. Again, Process Teams or Staff Meetings should occur at clearly defined intervals on a regular basis. When training needs have been assessed, a Training Plan that meets the staff’s needs should be clearly communicated to all members of the practice.
Even after establishing and supporting the various avenues of communication, the practice must continue to reevaluate its current needs. Add maturity to the communication processes by creating robust training procedures that are standard and repeatable. This material can then be tailored to meet the specific needs and specialties of the practice as it evolves.
Finally, physician practices should have clinical leaders or “champions.” The concept of a physician as champion is important in effectively adopting an EHR. Having EHR champion(s) who will lead the communication strategy is essential and displays that they believe in the benefits of EHR adoption.
What does it mean to be a physician champion?
- Lead by example by doing the work and demonstrating to others it can be done
- Help others move through the cultural change process
- Share what they learn to professional colleagues
- Exhibit enthusiasm, patience, and professionalism
- Communicate a consistent message to all staff; both clinical and non-clinical
- Speak with an passionate voice about the EHR implementation and what it holds for everyone involved
- Show commitment: If the physicians are not on-board then the rest of the staff will be hesitant to support it as well
Making a commitment to incorporate teamwork and communication as part of the EHR implementation project is critical to the success of the project; and collaboration, as an integral part of culture change, is an essential part of the EHR implementation plan. While nothing can guarantee success, lack of teamwork, collaboration and communication will certainly advance failure.
Implementing an EHR is more complex than just replacing the paper chart with an electronic version of it. EHR implementation requires transformational change in the physician practice. Most people can relate to the fact that change can be difficult; so, as part of the EHR project management planning phase, attention must be given to the culture change necessary for a successful and less stressful EHR transformation and deployment. Managing the cultural change process is critical to the success of implementing an EHR. In fact, implementing an EHR is not all about the system; it is about embracing the change necessary to incorporate the EHR into how the physician practices medicine.
How Do We Manage Change?
Although change is critical, it is also important to manage and prioritize the changes being asked of a clinical practice. The first step is to define the vision of the project. This should be completed at the time the Project Manager establishes a Project Charter for the EHR implementation.
Communicating vision and goals to involved parties is an important element in managing change. People tend to feel better about change once they gain an understanding of it and have an opportunity to provide input into the change process. A good time to get input from staff is during the operational redesign process.
For cultural change to be effective, practices should be sensitive to what else is going on in the office and, for that matter, in people’s lives. Knowing as much as one can about physician practices and their staff will assist in mapping out and communicating the best approach for implementation. The introduction of an EHR into a physician practice also creates opportunities for freeing up certain staff resources to do other, more value added tasks.
Knowing the computer skill readiness of the staff and physicians (basic computer skills, understanding of EHR terminology, etc.) is important in planning the implementation. The communication process should include a clear framework for how staff will become proficient with the EHR.
Communication is Important
It is vital that all participants involved with the EHR project sense the support and guidance of their practice leaders. Both physicians and Practice Administrators need to speak in a unified, enthusiastic tone about the project and how it will impact everyone involved. They need to speak and listen directly to all levels of the practice (clinical and administrative). A confident and convinced team focused on a vision and guided by clearly defined, strategic, measurable goals will drive the successful adoption of the EHR project.
Full encouragement and communication from Practice Administrators/Office Managers is important for both effective implementation as well as sustainable improvement. There should be a plan in place to communicate the specific benefits of the changes to all staff. People need to feel as if they have a personal stake in the success of the EHR project.
Finally, to ensure the acceptance and confidence of all staff involved in bringing changes to reality, it will be important to communicate the way in which the solutions were initially created and planned. If the perception in the practice is that support staff had no input into creating changes that will affect workflow, resistance is more likely to occur. If it is understood, however, that all participants were consulted, acceptance is better guaranteed.
Making a commitment to incorporate cultural change methodologies and practices as part of the EHR implementation project is essential to the overall realization of the project. Culture change must be an integral part of the EHR implementation project plan; it should not be taken on informally, nor should the need for it be put off or ignored.