In this episode of AMA Thriving in Private Practice, Marie Brown, MD, discusses how to get into an efficiency mentality and make changes at your practice to improve workflow challenges and decreasing unnecessary work “because you’re the boss.”
- Marie Brown, MD, professor, internal medicine, Rush Medical College; director of practice redesign, American Medical Association
- Carol Vargo, director, physician practice sustainability, American Medical Association
Vargo: Hello and welcome to AMA Thriving in Private Practice, a 10-episode series exploring the unique needs of physicians in private practice settings. In our show, we’ll talk about efficiency solutions and how to transition into the world of private practice. We also will focus on other tips and tools to help free up time so you can focus on your patients. I’m your host, Carol Vargo, director of physician practice sustainability at the American Medical Association. Today I’m joined by Dr. Marie Brown, an internist, professor at Rush Medical College and director of practice redesign here at the AMA. Thanks for being with us today, Marie.
Dr. Brown: Great to be talking with you, Carol.
Vargo: Great. Why don't we start by sharing with our listeners more about your background in practice and the work you are now doing at the AMA.
Dr. Brown: Great. I'm happy to and thanks for the opportunity. I practiced internal medicine in Chicago for over 30 years in three different settings. Initially at a federal qualified health center. And when that closed, my colleague and I moved down the bus line, to continue to care for the patients on the west side of Chicago. And we opened a two-person, very small private practice where we saw patients for about 20 years. And most recently I joined Rush University, a large integrated health system. So, I was able to see patients, cared for the same patients, many of whom I cared for, for over 25 years and their families in an FQHC and then mostly in a two-person practice and then in a large integrated health system.
And now at the AMA, I am taking what I've learned primarily from private practice and applying that so that we can help our colleagues, our teams become more efficient and get rid of things that are not necessary so that we can get back to doing what we were called to this wonderful profession to do. And that is to care for our patients.
Vargo: So, given all that private practice experience, I think you referenced 20 years. How do you think that's really informed the approach to the work that we're going to be discussing today?
Dr. Brown: That's a great question. I think the main impact that being in private practice and implementing many of the things that we're going to talk about, the lesson that I learned was that you can do it with a small team. You don't need a quality improvement department. You don't need a lot of experts. It's actually easier to do some of the simple workflow changes or opportunities to decrease unnecessary work because you're the boss. You can decide that you're going to change something, bring your team along, which we'll talk about, make sure that the team agrees and implements it. And you answer the question, what's in it for me, for every member of the team. And you don't have to go through a lot of committees. You don't have to wait for the compliance department or the practice manager. I found that changing workflow and improving quality of care was much more under my control, that autonomy that I had in private practice made it much easier, more exciting.
Vargo: Yes. We've heard that quite a bit from many of the private practice physicians that we've done our interviews and research with as well as the private practice physician community members that we interact with on a daily basis here at the AMA. But there's often some challenges obviously facing private practice. And what do you think based on your experience when you were in private practice, what were some of those big challenges that were impeding some of your abilities to impact workflow?
Dr. Brown: That's another great question. I think it's very similar to when you're in any setting and that is this mindset that we as physicians often have, that we are in charge, that we have to do everything that we are the captain of the ship. And if I don't do it, it's not going to be done to my standard. So I think the challenge is really learning that the world has changed, that taking care of patients is so complicated and so complex. And that's in a good way because we have so many therapies to offer our patients and our patients are living longer. So, they have many more co-morbidities, they're on many more medications. So, the challenge is really letting go a little bit of that mindset that I have to do everything myself or it won't be done to my satisfaction. And that takes time to build trust amongst your team.
And as I mentioned, you really have to answer the what's in it for me? I abbreviate that as the WIIFM, for the receptionist, why should we do it this way, for the medical assistant, for the nurse, for your practice manager. That is often challenging because we like to be in charge or we wouldn't be in practice. We like to have control over our schedule but we will have more control over our schedule if we begin to trust the team and delegate some of those tasks that do not require an MD or a DO.
Vargo: Let's dive a little bit deeper into the points you've made about the challenges in terms of what have you found at the AMA are the types of solutions that you and your team are developing to address those challenges?
Dr. Brown: Well, I think the basic solution, the underlying solution is to really start to think like an efficiency expert, step back a little bit, embrace the fact that we were trained to think differently, that we were trained as physicians to think of the exception. So that every headache that walks into your office, you assume it's a brain tumor or meningitis or a subarachnoid hemorrhage until you take a history, do a physical, maybe order a test and prove otherwise. And that's how we're trained. Always to think of the exception, the worst case. And that's how we save lives. And when we're trained like that for 15 or 20 years, to ask us, physicians, to think more like an efficiency expert is really asking for a big change.
So when you are talking to your colleagues and you want to think about changing workflow or looking at this more like an efficiency expert, honor, that they've been trained this way, honor that you've been trained way but to do this work, to save two or three hours a day in your practice, we have to stop thinking like a doctor and think about what would work in general. So, if you're thinking about a change in workflow that would save two hours a day, it's natural to think of why it wouldn't work. Well, if it doesn't for 50% of your patients, that's okay. Instead of saving two hours a day, you're only going to save an hour a day and it's useless really to worry about the one patient it won't work for. Fine, don't do it for that one patient but we always want to think of what works well for the team and the majority of patients.
Vargo: Yeah. I think that stepping back and viewing it from a holistic management approach is a great framing for the work that you're doing at the AMA. And trying to get physicians to adapt, I think is very challenging but I think that's the crux of what the work and the solutions and the tools that we've developed are really, I think, hopefully going to be easy for them to pick up and use. When we talk about practice efficiency, what are some of the core tenants or principles around practice efficiency and why is it important especially for private practice physicians?
Dr. Brown: I think recognizing that the knowledge explosion that is out there is important to help physicians recognize that we can't do it alone. So, there are 1,600 guidelines out there. Now, these just can't be applied to every patient in the short time that we have. So, the knowledge explosion is one. The implementation of the electronic health record has had its advantages but we do know, and the AMA research, as you're aware of Carol, has demonstrated that for every one hour of face-to-face time, say three 20-minute visits results in two hours of documentation time. And that's just not sustainable. People are taking work home because you can't take the patient home, so you take the documentation work home. And that leaves us away from our families, our partners, taking care of ourselves, as well as having the time to read and stay up to date on the ever-changing knowledge base that's continuing on a daily basis.
So, it's very important to recognize how things have changed and that because the world around us has changed, we really need to change as well. And now with COVID and the Great Resignation, the staffing crisis is huge. And in private practice, often we can't compete with the salaries that are offered at large organizations or at hospitals. So, we really have to maximize the work of our staff and making sure that they're being efficient because there just aren't people out there to hire, or because of the pandemic, many of our staff have had to stay home to care for their own families.
Vargo: So, if a physician wanted to assess their practice efficiency at that high level, where should they start?
Dr. Brown: That's a great question. And even though we think we can fix everything because that's our job and that's what we're good at. And sometimes it's a broken bone and sometimes it's a heart attack but to fix this, we really need to ask our team. So, your team knows better probably than you do where there's waste in your system. When they are doing things that seem completely unnecessary or are duplicative and could easily be changed to save what we think with many of the things that we've proposed and done research on, could save three to four hours a day for the entire team. And that will increase access, that will increase your patient satisfaction, decrease errors, allow for value-based care to reach out to your panel as we move in that direction and get your team home on time and you home on time. When you turn the lights out, the work is done and everybody feels wonderful, that everybody was taken care of, you delivered great quality care for all of your patients and your team's health and your family's health and your health is intact.
Vargo: So a physician in a small practice should take some time out of the day, get the team together. And then what? And I think this is where the AMA and the work that you and your team has done around the STEPS Forward platform is the next step. The what do I do next? So talk a little bit about STEPS Forward and how that can help physicians on this journey of creating more efficiency in their practice.
Dr. Brown: Great. I'd love to. So we have developed over 70 toolkits. These are brief, actionable, practical ways to make these changes in your practice. The one that I would encourage people to turn to is called “GROSS, Getting Rid Of Stupid Stuff.” And this was written by Melinda Ashton, a physician in Hawaii. And she wrote about this in the New England Journal of Medicine, and then was kind enough as our subject matter expert to write the toolkit. And it's as simple as asking your teams and writing things down on a post-it, what they're doing that they see could be done differently. For instance, one organization found that everyone was doing six vital signs in an ambulatory setting for patients who had no acute problems. Well, no one says you have to do six vital signs every single time a patient comes in for a blood pressure check. Knowing that you can do the minimum number of vital signs is critical. And then you stop doing many of the unnecessary ones. And that frees up time so that you, as a physician, have more time to be with the patient and find out what is their agenda?
Vargo: I think as I listen to you speak and I think of myself if I'm in a small, busy practice, 70 toolkits, that's a lot. How can I possibly absorb all that? But I think what's innovative about the STEPS Forward platform is how this kind of content is delivered and who can use it. Can you talk a little bit about that?
Dr. Brown: Yes. And we have taken the best of the saving time toolkits and put them into a playbook called the “Saving Time Playbook.” And that is also a brief sort of primer and that's broken down into three parts. Part one is style up doing unnecessary work. Part two is incorporate practice fundamentals. And part three is make the business case for it. So in part one, when we talk about getting rid of unnecessary tasks, we focus on going upstream in the inbox since the electronic health record is a source of great frustration and time for most physicians. Instead of thinking about how you can empty it and hire staff or spend time triaging, look upstream and talk to your IT folks about what should not even enter a physician's inbox. So that's number one.
And then another simple one, we have a toolkit that you'd be led to in the playbook on annual prescription renewal. When I was in private practice and I read about this, thinking of my patients with hypertension and diabetes or asthma, who are on chronic medications for years and years and years, probably for the rest of their life. And I was refilling them 90 days with one refill and read about Dr. Sinsky and other doctors changing that to 90 times four. We say 90 times four, call me no more. When you refill it for a whole year, you continued to see the patient as often as needed every month or every three months but you only refill the medicines once a year. And the next step to that is synchronizing them so they all come due on the same day each year. And we go into detail about how to do that and how to communicate that change to your patient and your local pharmacy because that's sometimes where you'll get some pushback.
When I did that, I found that in six months, because you start today, you're not going to see the benefit for six months, my inbox went down 50%, as far as requests for refills. Faxes didn't come over from the pharmacy, patients weren't having the pharmacy call while they're waiting there, interrupting your regular flow. So to your point that these are very actionable, very practical opportunities to improve the way we deliver care and the time it takes to deliver care so that we can get back to saving time and spending that time with our patients, spending that time with our teams to look for other opportunities and finish work at work so that we go home, we give our undivided attention to our partner and our families.
Vargo: That's so important. And what I love about STEPS Forward is it's open to anyone. These are all free resources. Practice managers utilize them, probably just as much as physicians I would guess.
Dr. Brown: I agree. Yep.
Vargo: Yeah. And also, there's videos, vignettes. I mean, it's not just like a dry piece of step one, do this. I think it's pretty interactive and I think it's been great. And as we well know, I think what's the latest stat? Over a million downloads of these kinds of tools and resources on the STEPS Forward platform have occurred, which I think is really excellent. So kudos to you and your team. So you mentioned this a little bit about it takes six months maybe to implement one of these changes. You're going to do something today and you're not going to see the results but this is in a way a long-term gain, particularly given the complexities of our health care system, advancing solutions on a lot of these issues are long-term. So, looking ahead, what can private practice physicians look forward to seeing from your team in the future, in terms of some of these additional new innovations?
Dr. Brown: That's a great question but I think I'd like to step back, Carol. There are things you can do today that won't take six months. So there's another tool kit on pre-visit labs that help the physician change the workflow so that labs are pended by someone else. So we see our patients with diabetes every three months and they need an A1C every three months. Well, that can be ordered today. And then it's done a week before their next visit. So you have everything you need at the time.
Another thing you can do right today is look at your electronic health record. And if there's things in your inbox that shouldn't be there, I found that using a very popular, EHR at the large institution, I was able to turn off unnecessary notifications that were coming to my inbox that were results of tests that another doctor ordered. I didn't realize but I had control over that. So I could go into that patient's chart and turn off those notifications. I trusted my cardiologist, I trusted my consultants. I did not need to look over their shoulder at what they were ordering. And it's a patient safety issue as well. If he or she orders a set of electrolytes and it comes into my inbox and their inbox, who's taking care of it? Does he or she think it's my responsibility to address a low potassium or am I assuming his team, his or her team is?
So, it's important to only have in your inbox, things that require your attention. And that, when I did that today, I saw the impact tomorrow because those notifications weren't coming in. So, the toolkits have many things that might take three to six months to see the benefit but many ideas that you can implement today that you'll see immediate benefit from such as how to implement team huddles, how to organize your office or design your office so you're co-locating with your medical assistant or your nurse. So, you're not spending time back and forth messages electronically. You just have a conversation day to day. So, there's lots of opportunities to make immediate changes.
And what we encourage you to do is look for something that you're going to be successful at, that is going to be easy, it's kind of low-hanging fruit, a little change that the team can see, “Wow, we all benefited from this. The doctor isn't interrupted. I know what to do. I can handle this.” The rest of the team and everybody's getting finished with work on time. The receptionists’ happy because everybody's being seen on time and the patients aren't frustrated and complaining to them. That's how you answer that what's in it for me.
To your question, what are we developing? We are publishing another playbook called “Taming The EHR.” In that, we will have a list of things that should never enter your inbox and another table, which will demonstrate what you have control over in your own office, rather than what the vendor has control over. So, we give you the power that you have to control your own destiny, what comes into the inbox. It may just be the triage and your IT person can flip something on or flip something off. And I'd like to highlight some of the other resources that you've helped developed, Carol.
In addition to STEPS Forward, the Debunking Regulatory Myths, where we help you find the source, whether it's CMS or another regulatory agency, where you see the actual regulation or rule because quite often we are over-interpreting it, which is costing us a lot of time. We've also developed the de-implementation checklist, which is a two-pager that lists things you can stop doing and things that you can do. So verbal orders are okay, paper checklists are time savers. They're okay. They're not against the law. We can use these. And sometimes with the electronic health record, we think that we have to do everything electronically but talking to each other and using checklists and verbal orders are tried and true time savers.
Vargo: So, you read my mind because you used the term, “power.” And I really want wanted to pull that out and say, I think a lot of what the AMA is providing and the work we're doing is about empowering the physician. And that can be a frightening prospect when you get to the issues around regulations and physicians interpreting regulations or being interpreted to them. And what I love about the work that the AMA is doing in terms of removing the obstacles to patient care, which is what our team does along with the AMA's advocacy unit, is that we really have the knowledge and the power about, yes, it's okay to do this. The regulations do not say you have to do this. So, it gives you that sense of confidence that you can move forward and take some of these steps. And that's why I think the work you're doing is so important. That's a great point you made there.
Dr. Brown: I think we have much more power than we think at times. Simply extending the automatic log-off. It may be set for five minutes. And then when you're talking to a patient, you have to remember to move the mouse or touch the keypad. Well, we'd have the power to change that with all the vendors to whatever we want it to be. In an ER, you, in a public space, you want it to be short but if you're in your own private practice and there's no risk of security or somebody else getting on that computer, it can be whatever time you want it to be. And many times, we think we don't have the power but, in fact, we do.
Vargo: Agreed. And I think the conversation we've had today has been really helpful, I think, in pulling that out, hopefully for our audience and really appreciate the viewpoints that you bring from running a private practice for 20 years, which I think is so critical to have that expertise to share with other private practice physicians. Are there any other final thoughts or comments that you'd like to share with our listeners?
Dr. Brown: Yes. And thanks for the opportunity. I enjoyed private practice immensely. There wasn't a day that I didn't look forward to going into work. I felt like I was spending the day visiting old friends, patients that I had the privilege of caring for, for many, many years. And what I loved about private practice is that I could implement these changes without going through committees. And I was able to affect these changes very, very quickly. And this is why I was so drawn to the work at the AMA because we want to spread these resources and empower our colleagues so that we have time to get back to doing what we were called to this profession to do, and that is spend time with our patients and have time to take care of ourselves and our family.
Vargo: That's so great Marie and we're so fortunate to have you here at the AMA to provide that perspective. Really interesting conversation. Thank you so much for sharing what physicians can do to really find joy and meaning in their practices through helping them become more efficient.
Dr. Brown: Thank you, Carol. It was great talking with you.
Vargo: You as well Marie. For AMA's Keeping Your Practice Open guide and other resources that Marie has mentioned and highlighted today, visit [the AMA website]. I'm Carol Vargo and until next time, this has been Thriving in Private Practice. Thank you for listening.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.