My professional life changed forever in 1989. I left my solo fee-for-service practice and joined two colleagues in a group practice where the payment model was capitation. I joined a Health Service Organization (HSO).
At the time, there were very few physicians practicing in capitated models. There were only about 150 physicians in Ontario practicing in HSOs. We had the beginning of a primary care team. In our office we had RNs working to scope, mental health councillors and a visiting psychiatrist.
One of the things that naturally evolved in our office was an early form of Advance Access. With multiple team members, the ability to ‘see’ people in non-traditional ways and the luxury of seeing fewer people for longer appointments, I was able to see most people on the exact day they wanted to be seen.
My practice has evolved and I have freely stolen from the way other people practice. I went to a primary care conference in Texas several years ago and learned that primary care physicians at Kaiser were using e-mail, the phone and other providers to provide care in up to 50% of their patient encounters.
My goal is to see patients on the day they call, the next day or the day they want to be seen. I am almost always succesful.
The first question many of my colleagues will ask why is this important. They rightly point out that many requests for appointments are not urgent and could wait a few days or a few weeks. That is all true, but so what? The patient is not going away and they need to be seen sometime, so why not at their convenience? It costs me very little and is very important to them.
I also think that my office is much more efficient, my staff is happier and I have much less wasted time. My receptionist walks into work very morning knowing that we have a spot available for every one who wants to be seen. She doesn’t have to hunt for the next available appointment and negotiate with patients about availability. Patients are happy because they know that when they are sick or their parents or children are sick they will be seen. Not as add-ons or squeeze-ins, they get a regular appointment. Every day a patient says to me, “thanks for getting me in today”. I just smile, I am oblivious to what is happening in the front office and I don’t know that the appointment was just booked.
I get very few no-shows. Nobody calls at 10, gets an appointment for 2 and doesn’t show up. And when patients come they usually have one complaint. I do not have a one complaint per visit policy and I don’t need one. I rarely have a patient come in and tell me about the cold or back pain they had 3 weeks ago. It’s gone now but they didn’t want to cancel. That doesn’t happen.
The second question is how do I do it?
Because I’ve been doing this for years, I never have to catch up. It’s like having a clean garage. I have to spend a few minutes each week keeping it clean but never have to do the major clean up thing. OK, this part about the garage is not true, but the analogy holds.
I make use of the phone-a lot. As I review lab results and consultations, I delegate calling the patient with the results to the right person. Normal results are dealt with by a clerk, slightly abnormal results that need explanation or action are dealt with by a nurse and I call people for significant things. Might as well call the patient now because if they call first it’s 3 or 4 calls to sort things out.
I book phone appointments. People are given a specific time and date and I call them at their preferred number. Most people are waiting by the phone and if i call a few minutes early, they are already waiting. Even short office visits take about 15 minutes. If someone, leaves work, drives to my office, finds parking and then waits 15 minutes to see me, they want to get their money worth. My average call is 3-5 minutes and it is almost always terminated by the patient. “Gotta go Doc”. Talking to me on the phone for 300 seconds can be quite a chore.
One of my priorities in the next 12 months is to add e-mail as a tool for patient communication.
Most of my phone appointments are follow ups. I start someone on an anti-depressant and want to make sure there were no side effects, or I review an U/S before the someone is sent to see a surgeon for gall bladder surgery. There seems little point in bringing someone into my office to get a message that could be given over the phone. It is more efficient for the patient and more efficient for me.
My payment model makes all of this possible. I get a few dollars for a follow-up appointment if it’s done face to face and nothing for a call but the efficiencies are so obvious to me that I’m more than happy to make the call.
And of course I could not do any of this without a fantastic primary care nurse working with me to share the load. I rarely do immunizations, PAP smears or preventative care reviews. The nurse does that. We also share responsibility for well baby care, pre-natal care and all of those crazy forms that everyone wants filled out today or yesterday.
Another thing we stole from kaiser was dealing with unscheduled issues anytime they come up. A 35 year old woman shows up with a rash and someone notices that her last PAP was over 3 years ago. We don’t give her an appointment to come in for a PAP, we offer to do it on the spot. Some women want to defer, but most sigh and agree. That is a major saving of time for both us and the patient.
I used to do a presentation on behalf of the OMA about advance access. It met with mixed reactions. But I have had some fantastic feedback over the years and physicians and practices that try it have been successful and happy. A friend of mine from Etobicoke, who has been a skeptic about primary care reform tried it and told me that his practice has significantly improved. That conversation with Dr William Russell was very comforting to me.
I’ve only scratched the surface on the benefits and the challenges of improving primary care access for a practice. It helps patients plan their lives, frees up clerical staff time and relieves them of an onerous chore and improves the quality of life and likely the income of the physicians who move forward on this.
I’ve only talked about primary care offices. I see little reason that many of these same principles couldn’t be adapted to specialty care too. I won’t make the mistake of telling specialists how to practice. I tried that once with my wife and got an earful.
It probably helps the rest of the health care system as well and that is why the Ministry of Health and Health Quality Ontario should put some resources into helping practices improve access. Issuing a fiat that primary care access must improve won’t work, but working with the OMA to develop an action plan might.
Our current problems with government won’t last forever and we need to start planning for a return to a normal relationship.
Scott D Wooder, MD