Jerome Carter, MD  October 10, 2016

Good patient communication practices are essential for high quality care and happy patients. While email and patient portals are increasingly popular, phone calls are a still the main way patients communicate with practices. Patients contact practices for a number of reasons with the most common being: making/changing/cancelling appointments, obtaining lab results, renewing medications, reporting new symptoms, and obtaining records.

Safely and effectively managing patient communications requires a few basic components:

  • A variety of channels to receive communications (e.g., phone, email, portal) to assure all attempts to contact the practice are successful
  • A method for capturing communications so that patient and staff interactions are preserved
  • A method for assuring that all communications receive proper follow-up in a timely manner
  • A method for tracking the status of all communications and their eventual disposition.
  • Policy/procedures that formalize whatever processes are put in place to address 1-4
  • Employee training that assures every employee knows his/her role in managing patient interactions

Process-centric thinking can be very helpful in solving common practice problems. Fortunately, it is not hard to learn how to analyze and improve patient communication processes, even in very small practices, which is the main goal of this tutorial.

Series objectives

  • Demonstrate how to identify patient communication tasks and steps
  • Demonstrate use of workflow analysis methods used to collect and analyze information about tasks, steps, information needs, and resource requirements
  • Demonstrate how to build process workflow models using BPMN 2.0
  • Discuss current business process management system (workflow technology) features
  • Demonstrate how to create workflow technology applications

In this series, I do not assume the presence of an EHR system, so practices with or without an EHR can benefit from this tutorial. Having an EHR system does not automatically assure good patient communication practices are in place because all EHR systems do not provide the same level of support for managing processes over time. To illustrate this point, let’s look at how an EHR might provide process support for managing patient communications. Here are four proposed levels of process support (my own creation) based on EHR functionality I have seen in various products and the features present in typical BPM systems.

  1. Level 1 (data-focused, no process support) – System allows user to record that a communication was received along with basic information (date, time, reason).

  2. Level 2 – In addition to capturing data about the communication, system allows the user to assign responsibility for follow-up to a specific person via a “to-do” list or similar feature. Once responsibility for follow-up has been assigned, all future management is left to that user and his/her interaction with the “to-do’ list. There is no explicit requirement to indicate the final disposition.

  3. Level 3 – In addition to Level 1 and Level 2 functionality, the EHR system offers extended safety management features for every communication:
    1. Requires a final disposition to be entered
    2. Requires a priority level and time limit
    3. Sends reminder alerts to the person assigned responsibility for follow-up

  4. Level IV (full process support) – Functionality of Levels 1, 2, 3, plus the following:
    1. Visual display (process workflow model) of the process used to manage communications. 
    2. Alternate paths — The ability to indicate within the model how specific exceptional situations are to be handled (alternate workflow path).
    3. Errors – Red flag warnings when the usual workflow is not followed or something unexpected is entered into the system.
    4. Dashboard that permits review of all active communications along with assigned staff, status, priority, and time limit
    5. Communication history – Log of all past communications
    6. Escalation – If a communication has not been addressed within the allotted time limit, it is bumped up to the next administrative level for disposition.

Tutorials are less boring when tied to a specific example, so, let’s look at a case study of a typical practice that consists of two clinicians plus support staff. I am using an EHR-less practice to illustrate that making use of workflow technology can occur in increments. Practices that do not wish to take the EHR plunge need not avoid automating key processes.

Scenario
Over the course of a day, Typical Primary, LLC receives numerous patient communications. Responding to inquiries takes up significant FTE time and results in after-hours work for clinicians. When the office is closed, calls are routed through an answering service that logs the calls and then passes them on to the on-call clinician.

On a typical day, most calls are related to med refills and appointment requests. Occasionally, appointment requests are for problems that turn out to be serious conditions (new blood in stool, breast lump) that require immediate attention and good follow-up. For example, a patient calls to request an appointment for a newly-discovered breast mass. She is given an appointment, but fear leads her to rationalize it as not being a serious issue and she fails to keep the appointment. A missed appointment, whether for an office visit, referral, or test can be a serious safety issue.

Communication is a two-way street. There are times when the practice wishes to contact the patient (abnormal result, change in appointment date/time, stop medication, etc.), so a reliable process is required to assure that practice-initiated interactions are monitored and tracked until final resolution. Lately, there has been a change-over in staff, and the new hire is not managing communications as well as the employee who left after being with the practice for seven years.

Noticing that communication problems are increasing, the practice manager calls a meeting to discuss how to improve things. She notes the following problems:

  • Attempts to contact patients for abnormal lab results often go to voicemail, resulting in follow-up delays.
  • Patients are complaining about time spent waiting on-hold.
  • Patients often call back multiple times regarding the same issue because no one in the practice has contacted them.
  • One clinician accidentally deleted her on-call notes and cannot recall the name of one of the patients who called about severe back pain and dysuria.
  • When a patient calls, the chart is pulled and a sticky note is placed on the chart. Three charts with notes pending follow-up were mistakenly refiled, but the clinician only remembers the names of two patients.
  • During flu season, the number of calls increases by 30%.

To solve these problems, the practice decides to look at how patient communications are currently handled and then determine what improvements are required.

Up next: Symptoms of bad processes.