Just about every physician has seen a patient like Mrs. Hughes.
She’s a 68-year-old retired teacher with obesity who has hypertension, diabetes, hypothyroidism and osteoarthritis. The patient is on multiple medications and supplements and suffers from fatigue, insomnia, back and knee pain, and dizziness.
You, the physician, are about to go see Mrs. Hughes as your next patient. You are running 45 minutes behind schedule, and your inbox has 100 messages. Your quality measures aren’t at goal. Mrs. Hughes’ medication reconciliation has not been done, she needs a mammogram referral, and you wonder if she needs a Medicare wellness visit. During vitals, you notice her blood pressure is up and so is her weight.
She asks lots of questions after the visit. The next day, her lab results come back, showing high thyroid stimulating hormone (TSH). You reach back out to her, increase her levothyroxine and order repeat TSH in six weeks. You also note that her hemoglobin A1c is 8.5. Mrs. Hughes calls back multiple times about her medications and now wants an X-ray of her back. She feels like nothing is being addressed in an efficient manner.
You, the physician, feel burned out and the patient is dissatisfied with her care.
How can doctors and practice managers make this better? The solution: optimizing three high-yield workflows—annual prescription renewals, pre-visit lab testing and pre-visit planning.
“What drives burnout and that loss of excitement about caring for patients in this wonderful calling is doing things that don't require an MD or a DO or an advanced degree,” Marie Brown, MD, an internist and AMA director of practice redesign, said during an AMA STEPS Forward® webinar that offered tips on saving thousands of hours every year through these workflows.
Ask physicians or practice managers what fundamental workflows create a well-run practice, they’ll likely mention the efficiency component, reliability, trust, teamwork, support for individual physician well-being, a manageable workload or patient panel, low administrative burden, and usability of technology.
“All of these things when optimized, allow physicians to spend more time with their patients and create more connections with their patients,” said Jill Jin, MD, MPH, an internist and senior physician adviser for professional satisfaction and practice sustainability at the AMA
As the leader in physician well-being, the AMA is reducing physician burnout by removing administrative burdens and providing real-world solutions to help doctors rediscover the Joy in Medicine®.
Reduce annual prescription renewals
The first high-yield workflow, annual prescription renewals, is fairly straightforward.
“We sometimes call it ’90 times four: Call me no more,’” said Dr. Jin. The idea is prescriptions for long-term medications for chronic medical conditions are renewed for one year at a time, or the maximum duration allowed by state law, which is typically 12 to 15 months.
Some states even allow up to 24 months, but the default would be 90 times four: a 90-day supply with four refills.
“Ideally, you're renewing all of these prescriptions during one annual visit,” such as the annual wellness visit, said Dr. Jin.
This method also applies if a physician wants to change a dose.
“All you do is you cancel the prior prescription when you're putting in the new prescription,” which the EHR usually takes care of automatically, said Dr. Jin. Use smart phrases such as “dose change/cancel prior prescription” and incorporate this process into your team’s pre-visit planning tasks.
Through this process, “you're not adding any staff, you're not adding any overhead, you're just getting time back,” she said.
As simple as it sounds, there are some barriers. What if physicians want to see their patients more than once a year? In this case, the doctor would continue with that clinical schedule. But for prescriptions, “you write them for a year no matter what,” Dr. Jin advised. The concern is that patients won’t show up for scheduled visits, since refills are an incentive for coming into the office. But in Dr. Jin’s experience, practices that have implemented annual prescription renewals have not seen an increase in no-shows, and there's been no change in terms of the adherence to the visits.
In ordering a prescription, “you know that you get two faxes or even more and several phone calls and a patient portal message and an inbox message from the pharmacy. All of that is halved at least,” with annual prescription renewals, said Dr. Brown.
Planning for next patient visit today
Another vital part of optimizing the patient visit workflow is previsit planning. Components of pre-visit planning and labs include:
- Scheduling the next visit at the end of the current visit.
- Ensuring health maintenance or other routine "checklist" items are up to date.
- Confirming pre-visit labs are ordered and completed.
- Gathering necessary information for the upcoming visit.
Scheduling the next visit at the end of the current visit makes a huge difference in terms of patient adherence to the treatment plan as well as decreasing no-show rates and preventing running out of medications, said Dr. Jin. Some patients may need to reschedule, but that’s a small percentage.
“It’s better than everybody trying to call in two weeks before they're due for their annual and get on the schedule, which is typically impossible and going to result in delays,” she said.
Ordering labs for the next visit during the current visit also makes sense because the patient is already in front of you, noted Dr. Jin. “You're thinking about what's going on. You know exactly what you're trying to accomplish between today and the next visit. You can put in the labs and the chart's already open and everything is already there.”
To save time, care teams can prep the lab orders for the physician to sign or enter them at the end of the current visit. Each individual practice can explore their own hybrid options, said Dr. Jin.
Dr. Brown, who implemented this workflow in her own practice, said pre-visit labs have reduced phone calls by almost 90% and letters by more than 80%.
More time to care for patients
Implementing these practices would save about an hour or two each day. If you see this patient twice a year, that's two hours per year per patient. For a panel of 1,000 patients, that would save 2,000 hours a year, roughly 250 eight-hour days, which is one full-time employee.
With that time saved, “You could hire an additional nurse or staff member or medical assistant to do all these things for you,” said Dr. Jin.
Practices shouldn’t implement these workflows all at once. To prevent care teams from feeling overwhelmed, start small—and be flexible, the speakers advised.
AMA STEPS Forward open-access resources offer innovative strategies that allow physicians and their staff to thrive in the new health care environment. These resources can help you prevent burnout, create the organizational foundation for joy in medicine and improve practice efficiency.
