• May 2008 FEATURE ARTICLES •
Preventative Care
Checking In at Check-up Time
A healthcare system implements an automated patient outreach solution, increasing proactive appointment scheduling.
By Vicki Fehrenbach and Alex Grahovac
Today’s focus on quality of care has a
far-reaching impact on medical practices throughout the country.
Driven by a commitment to improving patient health and by
emerging payer incentives, physicians are exploring clinical and
operational strategies to increase the number of patient visits
for screenings and preventive care. Medical Associates Health
Center (MAHC) consists of 90 providers at 12 locations
throughout southeastern Wisconsin, and was among many practices
challenged with finding effective methods for prompting patients
to schedule recommended services.
Traditional education and communication
tactics achieved limited success; therefore, MAHC began to
explore alternative solutions. Ultimately, it adopted an
automated patient outreach system that integrates with practice
management (PM) and scheduling software with the ability to seek
out and generate calls to patients due for care.
The Issue
Our management team was acutely aware that
many patients were neglecting their routine and preventive care
— in fact, there was a persistent downward trend in the numbers
of patients scheduling these visits. Cancer screening rates in
particular were suffering. When asked, some patients said they
simply forgot to schedule appointments because of busy
professional and family lives. Many believed they did not need
this type of care because they felt "just fine." A certain
number cited lack of insurance coverage (particularly Medicare
beneficiaries), while others noted that copays and out-of-pocket
expenses were growing (specifically those who selected
high-deductible plans).
Our physicians recognize that as the average
age of the general population increases, preventive care becomes
increasingly important to overall health. Additionally, growing
pressure to report on quality measures served as an incentive to
increase patient compliance. Like most medical practices, we
dedicated time for staff to place reminder calls, totaling about
3,000 a day, to patients with upcoming appointments or who
needed follow-up care. But this labor-intensive process was less
than reliable. When we were extraordinarily busy, during flu
season, for example, or when staff members were absent, this
task was the first to fall off of the day’s to-do list. Nor was
it carried out consistently throughout the practice. Some
locations were better equipped to make the calls, while others
had fewer resources.
We investigated whether or not our electronic
medical record (EMR) system could help us remind patients and
physicians about needed care at the point of service. However,
we discovered that the necessary functionality had yet to be
developed and would not be available in the near future. Even if
the EMR approach were possible, it would be purely reactive in
nature, reaching only patients who were regularly coming into
the office.
For example, if a female patient was seen for
joint pain, the EMR might someday be able to notify the
physician if she was overdue for her mammogram and well-woman
check. But if she had not made the initial appointment, we would
have no idea she needed additional care, and would be unable to
remind her to make other necessary appointments.
The Solution
Internally, our physicians began to discuss
ways to become more proactive with patients, and we discovered a
solution almost by accident while attending a professional
conference. Our medical director and quality director happened
upon the Phytel display booth and learned that the vendor
offered an automated patient outreach solution that interfaces
with PM systems and scheduling software. The system identifies
patients overdue for preventive and chronic disease services,
and then automatically generates calls to these patients,
notifying them that they should telephone the office to schedule
an appointment.
After discovering such a system existed on
the market, we created a multidisciplinary committee to search
for similar products. The group was comprised of departmental
representatives from information systems, clinical operations
and scheduling, and led by the medical director and director of
quality. While the committee discovered a number of systems that
offered similar capabilities, the Phytel Proactive Patient
Outreach solution was best suited to our needs and we
implemented it in July 2007. The committee appreciated how this
system actively sought out patients who might otherwise slip
through the cracks and, in addition, provided comprehensive
reports on calls placed and subsequent responses.
Implementation
Our first step was to build interfaces
between the Web-based outreach solution and our PM system. IT
professionals typically allow from between 90 and 120 days for
this process, but we were able to complete the work in about one
month. The system was configured to provide HIPAA-compliant
access to select patient information. Data that was made
available included demographics such as age and phone numbers,
as well as what preventive and disease management services
individual patients required. The interfaces likewise allowed
access to our scheduling software to provide information about
which patients had already made appointments, and therefore
required no reminders.
While these technical requirements were
addressed, our medical staff reviewed the protocols that would
guide proactive calling. The vendor provided a set of protocols
based on national quality measures and evidence-based practice
standards. Our medical staff reviewed each, determined which we
would adopt and refined them to meet practice objectives.
Ultimately, we implemented seven preventive services protocols
(annual visits for adult females, annual visits for adult males,
bi-annual visits for younger patients, well-child check-ups,
colon cancer screening, breast cancer screening and osteoporosis
screening) and six disease management protocols (asthma,
diabetes, hypertension, cholesterol, thyroid and heart failure).
Like most medical practices, we dedicated time for staff to place reminder calls,
totaling about 3,000 a day, to patients with upcoming appointments or who needed
follow-up care. But this labor-intensive process was less than reliable.
We also established timing and frequency of
proactive calling. Patients receive an initial call at the time
they are due for a service and a reminder two weeks later if no
appointment is scheduled. A third call is made in another two
weeks, after which, notification is discontinued. If a patient
is due for more than one service (e.g., colon cancer screening
and a cholesterol check), the system makes only one call.
Schedulers later determine how best to book the patient for all
care needed.
Before go-live, we conducted training for
clinical leaders and scheduling staff. Five 90-minute sessions
were offered to ensure personnel had the chance to attend. Most
of the training focused on schedulers, since their workflow
would be most directly affected. For example, when reminder
calls are made, patients have the option of confirming their
appointments or indicating they want to cancel, or reschedule,
via their telephone keypad. When schedulers arrive each morning,
they immediately open the outreach report (through software
hosted on their desktop) to note the changes in the day’s
schedule.
They then contact patients and re-book
appointments as necessary. As proactive preventive or disease
management calls are made, schedulers need to be prepared to
handle incoming requests for appointments. Because of HIPAA
regulations, the automated outreach solution can indicate only
that the patient is due for a follow-up visit, but cannot
mention specific services or disease states. When the patient
calls for the appointment, the scheduler accesses the outbound
call log to determine what type of visit the patient needs.
The Results
We began to experience positive results
within weeks of adopting the proactive patient outreach
approach, as the numbers of patients scheduling follow-ups and
proactive care appointments increased. In fact, within six
months of implementation, we estimate that we scheduled
approximately 13,000 additional visits triggered by the outreach
program. In some cases, we reconnected with patients who had not
been seen in two years or longer. After using the system for
several weeks, however, we discovered areas that required
fine-tuning.
Although training had been provided, some of
our front desk personnel did not thoroughly understand how the
outreach program operated and found it challenging to respond to
the influx of patient calls. A second round of training with the
vendor several months after implementation improved the process.
In addition, some patients were understandably puzzled when they
began to receive automated reminders from the practice because
they had become accustomed to less-frequent, personal phone
calls from our office.
We believed adequate notice informing our
patients of the impending shift to the automated call system had
been provided through on-hold messages, notices inserted into
patient statements, announcements in our community newsletter,
and postings at check-in and check-out. Nevertheless, some
patients were cautious about embracing the new approach.
Eventually, though, most realized the change was prompted by our
genuine concern for their well-being.
We discovered that a number of the system
protocols also needed further refining, and our own database
needed cleaning up as well. For example, our colon cancer
screening protocol indicated patients would be contacted when
they turned 50 — but it placed no upper age limit on calls. One
95-year-old patient called our office in confusion because he
had previously, and correctly, been informed by his physician
that he no longer needed this screening. This triggered a
re-examination of these parameters, with adjustments being made
within a few weeks.
After making the first calls, we discovered
that many of the patients’ phone numbers had changed, that some
had moved out of the area and that others were deceased. Despite
these issues, we are tracking compliance on a number of
preventive care and disease management standards, comparing data
before and after initiating proactive outreach. Baseline cancer
screening statistics were recorded in May 2007 and will be
re-evaluated in May 2008. Similarly, diabetes management was
assessed in December 2007 and will be reviewed again at the end
of this year. Overall, we estimate earning 10 times the amount
of our initial investment within six months of implementation.
Overall, we are extremely satisfied with the
results we have experienced through the use of the automated
patient outreach. It has enabled us to increase the number of
patients we see for preventive care and disease management,
which will no doubt help us achieve our overarching goal of
improving the health and lives of individuals in our community.
Vicki Fehrenbach,BSN, is director of quality
and Alex Grahovac is director of information systems and telecommunications for
Medical Associates Health Center in Menomonee Falls, Wis. Contact them at
vicki.fehrenbach@ma-hc.com or
alex.grahovac@ma-hc.com.