North Carolina physicians promote open scheduling

Practice Management. By Mike Norbut, amednews staff. June 30, 2003.

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To many physicians, backlog equals business. But to some university-affiliated practices in North Carolina, a backlog equals inefficiency. They believe physicians can improve their performance and increase their revenue by going to an open-access scheduling system. They've set up a grant-funded collaborative to teach their theory to physicians across the state.

Primary care practices affiliated with Duke University and the University of North Carolina health systems have successfully employed open-access scheduling, a system that seeks to match supply with demand, work down the patient backlog, and increase the intensity of each patient encounter. It has not been an easy transition for many practices, but the results have been positive enough to convince health system officials to spread the word.

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The collaborative's message: open-access or advanced-access scheduling can increase work relative value units, increase office efficiency, and improve patient and employee satisfaction.

"What happens is if you can get practices to work toward getting patients with their usual physician, increased RVUs are generated and you don't have to see them as often," said John Anderson, MD, a family physician and medical director of Duke University Affiliated Physicians. "The acuity level is higher because you end up doing more, and you can bill for that. The intent is it's going to build your practice."

However, the decision to switch to an open-access system does not simply mean creating more open patient slots. It means breaking down some rules and notions and focusing on continuity, Dr. Anderson said.

For example, one Duke practice had a 132-day wait for patients to get a physical, but only because the doctor limited physicals to three per day. Once the physician removed that requirement, the wait time dropped to less than a week, officials said.

The practices use as their blueprint work by Mark Murray, MD, and Donald M. Berwick, MD, who have published several studies and articles on the topic.

Dr. Murray, a family physician, formerly ran the Sacramento (Calif.) Medical Center's family practice department for Kaiser Permanente and now runs a business that helps practices institute advanced-access scheduling. Dr. Berwick, who specializes in public health and preventive medicine, is president and CEO of the Boston-based Institute for Healthcare Improvement.

In a Feb. 26 JAMA article, Drs. Murray and Berwick describe methods to make an open-access system work, including reducing the number of appointment types, attempting to match the patient up with his or her actual physician whenever possible, and being prepared for scheduling aberrations, like school physicals, flu vaccinations and appointments on days after holidays.

Open-access scheduling tries to accommodate a patient's needs and looks at the ebb and flow of a weekly schedule to create more flexibility on busier days. Practices in the Duke University system have switched to one-on-one physician-nurse relationships rather than have nurses working with several doctors, and care teams meet on a daily basis to assess each day's schedule. Schedules generally are half-full at the start of the day but fill up before the day is over,

The advantage to reviewing a schedule ahead of time is that you can see if the patient needs any preventive screenings and you make more out of each visit, thus increasing the RVU, said Susan Blackford, MD, an internist with Durham Medical Center, a Duke practice. Also, by seeing your own patients, you can use higher codes and you don't need to send the patient back to the original physician for a follow-up visit.

The result, physicians said, is happier patients and happier staff, leading to less turnover.

And as patients get used to the new system, you have fewer cancellations and ultimately, less reliance on that backlog, they said.

Practice Management is written by members of our Business staff.