Collecting and processing patient information can delay visit start times, reduce the amount of time physicians spend with patients and overload physicians and staff.
In an episode of the “AMA Moving Medicine” podcast, AMA Chief Experience Officer Todd Unger is joined by Christine Sinsky, MD, to answer questions about planning the current patient visit and preparing for the next. Dr. Sinsky is the AMA’s vice president of professional satisfaction.
Unger: What is previsit planning, and why is it so important?
Dr. Sinsky: So, there's a promise that we can make to our patients. And it's, “We will know who you are, and we will be ready for you.”
This is a promise that I first heard from a medical group in Michigan. And, I think it really captures the purpose of previsit planning. We will know who you are, and we will be ready for you.
I think it's very disconcerting to patients to be brought into a room and have the physicians say, "Oh, what are you here for today?" It's much better when the rooming staff, and the physician, know the reason that the person is there, and have prepared for that visit, and can make the most out of that visit for the patient. That's what previsit planning is about. So we know who you are and we'll be ready for you.
So, how do we do that? Well, one of the things we do is pre-planning the next visit at the conclusion of this visit. That is, adopt that other mantra, “The next appointment starts today.”
So, previsit lab, which we talked about in a different podcast, is an integral component of previsit planning. But, it's much more than previsit labs.
Using a visit planner, which is a checklist, the rooming staff can review ahead of time each of the patients on the next day’s schedule. When they do, they can see what the patient may be due for. For example, the patient may be due for a pulmonary function test. ... They may be due for an EKG. The physician will have left a note at the end of the last visit about what tests they want done during the rooming process at the next appointment.
In addition, in reviewing the patient’s chart the day before, the nursing staff can identify which patients are due for which immunizations. So they can be updated on their pneumococcal vaccinations, on their tetanus vaccinations, on any other vaccinations for which they are due.
Another component of previsit planning happens at the time of the visit. When the patient checks in, the patient can be given a pre-appointment questionnaire that they can fill out in the waiting room. Or, in some practices, this is given to the patient ahead of time, electronically, through the patient portal. In that, the patient can identify what their primary objective for the visit is. They can identify any additional concerns that have happened. The patient can identify any care that they've gotten elsewhere between visits, so that the staff can be updated about any ER visits or hospitalizations that may have happened between visits.
And, it's also a time when the patient can identify any additional concerns. The patient can be given a complete review of systems to go through. And, they can do all that before they're brought back into the room.
This kind of previsit planning allows the team to be prepared for the patient and not be caught off guard by an unexpected agenda item that the patient had. And the patient can identify that agenda item up front so the team knows what's on their patient’s mind for that day.
Unger: What steps can you take in the days before a patient comes in?
Dr. Sinsky: Much of previsit planning happens at the previous visit. One of the things we do is we ask patients how would they like to be reminded about their next appointment. Would they like a reminder letter? A reminder phone call? A reminder text? And, in my own practice, we have a way to automate that so that they're automatically texted with their reminder.
For some patients who will have more complexity, a rooming staff will call the patient the day or two before to both ensure that they're planning to keep their appointment, but also to identify if there are any specific new worries that they have. That gives the practice a chance to prepare even further for the patient.
In addition, for patients who are on multiple medications, having a previsit phone call by one of the rooming staff—or, in some institutions, a pharmacy or pharmacy tech staff will make this call—they can do medication reconciliation on the phone, while the patient’s at home, with their medications. And they're more likely to remember the medications that they're taking because they can go and refer to their medication bottles at the time.
Unger: What other steps can you take the day that the patient does come in?
Dr. Sinsky: Many physicians feel that they work in a chaotic work environment. And a chaotic workplace is one of those drivers of physician burnout. But we can avoid chaos in the workplace by planning relentlessly.
Part of that planning happens with the previsit lab. Part of it happens with a pre-clinic huddle, where, for five minutes in the morning, before clinic starts, all of the providers and the staff get together for the day and look at the schedule: Who's in? Who's out today? What are the special needs? And if there are any exceptional needs that might present in the patients who are on the schedule.
Another way of planning relentlessly is through what we call the mini-huddle. When the nurse or medical assistant comes out of the room after having roomed the patient, they can then have a mini-huddle with their physician to hand off to them some of the information that they've learned.
I ask my nurses to give me something medical and something social that they've learned about the patient. So they'll tell me the patient is here for their annual exam, that we changed their blood pressure medicine last time, and that they've noticed that their blood pressures have improved.
They'll also tell me something social. For example, that they have a new granddaughter and they brought some pictures of the granddaughter. All of those things help me enter the room with a better notion of how to best use the time with that patient—how I can best establish a bond with the patient, a relationship, and trust with the patient, and how I can best cover all the agenda items that the patient may have brought for that visit.
Unger: Do you have any final thoughts or tips about previsit planning implementation?
Dr. Sinsky: Again, the overall goal of previsit planning is to have an organized visit, where you can cover multiple agenda items from the patient, where you can close care gaps, where you can be sure that you have done all the medically necessary care that the patient provides without feeling chaotic. And having all the needed information ahead of the appointment minimizes the hunt for information from the patient. It minimizes the cognitive disruption that happens when you're distracted. And it can reduce the stress level for everyone—for the patient, for the staff and for the physician.