Pre-Visit Planning
by Dr. Jon Hart
A good proportion of healthcare delivery in the US happens on the fly. Even when an office visit is scheduled in advance, many practices don’t start any work on a patient until they see the whites of their eyes. Mrs. Jones shows up, and we look through the chart to see what needs to be done in the moment. This approach opens the door for inefficiency, ineffectiveness, missed opportunities, poor experience, and low-quality outcomes.
A notable exception to this in healthcare is elective surgery. A person doesn’t just show up one morning and say, “I’m here for a surgery!” What type of surgery? Was there any pre-op testing needed or done to ensure an optimal outcome? What type of equipment is needed in the OR? What are the surgeon’s preferences for equipment and setup? All these questions (and more) are answered ahead of time so that OR flow is smooth and efficient (in theory).
Primary Care Practices could take a lesson from the surgery teams on this one. Pre-Visit Planning is an essential tool in the PCP’s toolbox, especially if value-based care is a priority. Some practices know this and diligently participate in pre-visit planning, but most don’t.
This article will address the following questions: What is Pre-visit Planning (PVP)? Why is it done? Why is it NOT done? What are the essential components? And, what are the expected outcomes?
What is PVP?
PVP involves an advanced look at who is scheduled weeks, days, and hours prior to that appointment to assess all the patient’s needs and potential needs, closing loops before the visit, if possible, and at the very least teeing them up for completion during the visit.
An optional but quite useful method of final preview of visits is a Morning Huddle. Having the office staff gather at the start of the day to assess (and initiate or close) workflow needs for scheduled patients can improve efficiency and effectiveness of the patient’s time in the office. Daily huddles are standard practice for much of corporate America, but medicine has lagged in adopting this. (More on that in the “Why NOT” section below.)
A preview of the patient’s visit can be a beneficial tool for a practice whether the office solely focuses on a fee-for-service (FFS) style of practice or value-based care VBC). Surgery departments and centers have learned that this type of planning can greatly improve throughput of patients, allowing for more volume. Same for the PCP practice.
From a VBC perspective, in addition to the efficiency of patient flow, a PVP allows one to assess screening and prevention opportunities and a need for an Annual Wellness Visit (AWV). Since VBC is outcomes-based, it’s also important to know if there is information needed to positively impact patient care and outcomes. This leads us to the Why.
Why is a PVP done?
As noted in the surgery example, a primary reason PVP is done in primary care is to improve efficiency of the visit. Pre-planning allows a practice to gather needed information for visit, like any labs or other tests done recently or records from a recent hospitalization or specialist visit. A preview also gives the opportunity to anticipate needs like referrals, followups, immunizations, or other diagnostic tests. Given the multilingual nature of many medical practices today, PVP can assess the need for an interpreter during the visit. Pre-visit screenings can be done through a well-designed PVP process, too, like screening for depression with a telephonic or electronic PHQ-9.
By efficiently gathering information prior to the visit, the effectiveness of the visit will be enhanced.
Were labs and tests identified as needed for this patient? If the PVP started days or weeks before the visit, there is time to order them and have the results ready for the visit.
Are there HEDIS measures that need to be done for this patient in terms of screening, prevention, or disease management? (Link to VBC Intro and to HEDIS article)
Is the type of visit scheduled the most appropriate for this patient at this time?
Can this visit be flipped to an AWV? Mr. Smith scheduled a visit for a blood pressure followup, but he hasn’t had a Medicare AWV yet. (Link to VBC Drivers AWV and to previous article on the importance of AWVs)
As a result of all this pre-visit work, what pertinent information and setup needs to be shared with the physician or provider at the time of the visit?
Answers to these questions provide a foundation for a more effective visit where the patient’s needs are met, and their time in the office is optimized to positively influence their health and well-being. Add to that, if the practice is in value-based care contract arrangements, the face-to-face time was best used to meet the needs of activity-based payments (like HEDIS) and positively influence medical expense (AWV, prevention, etc.).
Another important reason PVP is done is to improve processes and workflows. Appropriate planning ahead affords a practice the opportunity to focus on the important work to be done, both from a FFS and (especially) VBC perspective. What are the tasks and processes needed to create value in the visit? What can be automated?
This awareness can lead to a decrease in administrative burden. What proactive work can replace reactive, hair-on-fire work? Where do the workflows and processes cause frustration, appear mindless, or feel menial? Those elements need to be altered or completely de-implemented. A sound PVP process also limits physicians and office staff from working below their licensure. Less burdened employees who are working at the top of their license are more likely to have a positive work experience, decreasing the incidence of burnout.
So,
Why is it NOT done?
Given the above benefits, why are offices and organizations not doing this as a standard practice? I’ve observed several reasons, though I know the following list will not be all-inclusive.
First, many physicians and physician practices are not aware of this as a potential tool. Prep meetings and huddles are common in the corporate world, but not so in medicine (outside the operating room). We in medicine tend to lag the corporate world in workflow improvements or using technology for non-clinical reasons. (Ever been on a web-based meeting with a bunch of doctors? You’ll know what I mean.)
Physicians embrace technology in other areas of medical practice, though. I think the lack of process improvement, in particular PVP, reflects our churn-and-burn, treat’em and street’em approach to care delivery that FFS medicine has engendered in us over the last 100 years.
Even though PVP could help in FFS medicine, we hold on to the notion of just taking things as they come into the office, when they’re in the room. We finish one and move to the next room, prepping ourselves just before knocking on the door. This is how we were trained and how we’ve practiced. An alternative just hasn’t crossed our minds.
Let’s say a practice has heard of PVP and desires to do it. What holds them back?
When a practice is in an activities-based VBC contract, and they know they need to improve their HEDIS measure completion, they may not have the ability to track and sort their patients’ HEDIS needs. (The same can apply to AWVs.) Their EHR isn’t accurate, they get no information from the payers, so “Why bother” can become their mantra.
The converse issue of getting too much data from multiple disparate sources also jams the system. Trying to sort out the payer “Care Gap” reports that all come in different formats through different payer portals for each insurer and then reconcile them with what’s in your EHR can be frustrating and very time-consuming. Easy to access, actionable, insightful information is lacking.
In fact, that’s another reason some practices just throw their hands in the air. They don’t have enough time or hands to sort through all that information, aggregate it in a meaningful format, and then act on it. Larger organizations have addressed this issue by hiring numerous Quality Specialists to comb through this data and either act on it themselves or send it to the offices to be worked. This approach can be cost-prohibitive to smaller practices and may be an unnecessary expense for those who can afford it.
If an organization did have access to all the information it needed to adequately pre-plan a visit, there’s still the issue of multiple mouse clicks in multiple software platforms. The best way to have the clinical team lose interest in a task or process is to add a bunch more clicks to their work that add nothing but time.
A similar issue occurs when new processes and workflows are added to the mix without adjusting or even de-implementing existing processes that are not creating value. Without automating the repetitive, proactively moving work to the appropriate level of licensure, and stopping processes that the patients don’t value and are not monetizable or aligned with your priorities, a PVP planning workflow or Morning Huddle will become “just one more thing to do” in the minds of staff. As I’ve said in other articles, this is a perfect recipe for cynicism, poor performance, and burnout, in other words, failure.
A movement was created a few years back called GROSS – Getting Rid of Stupid Stuff. Its focus is on simplifying and streamlining EHRs to improve efficiency and decrease unnecessary time spent. The same principle holds for workflows and processes outside of the EHR. What “stupid stuff” are physicians, providers, and staff doing now that needs to be stopped to allow them to focus on the important work in front of them?
For starters, look for any clerical or administrative task that a licensed medical professional is doing that doesn’t require a license. Move these to the unlicensed staff. Next, look for tasks in the office that are repetitive and not patient-facing. Automate these. Look at your ordering workflows, your results reporting workflows, and your referral processes. Chances are, there are numerous opportunities to decrease touches of the same task or automate with process smoothers.
Components of PVP
In addition to workflow and process improvement in the office, there are at least four other components of a highly functional PVP:
Presentation of accurate, actionable data to Care Team
Order sets
Signature requirements, verbal orders, and simplified order process in place
Communications tool for Care Team
The operative words of the first bullet point are “accurate” and “actionable.” If the information on who needs what is not up to date, you actually create more work for the staff. This information must be available long before the visit as well as on the day of, at the point of care. To be most effective, team members with multiple job roles need access to the same data.
Standing orders, when used appropriately, are great streamliners of the medical office workflow, especially for prevention, screening, chronic disease management, and medication management. (This is said by a control freak who was very slow to adopt sliding scale insulin orders!) Someone coming in needs a flu shot or mammogram? Get the order in before the visit. Patients with diabetes or lipid disorders can have standing orders for Hgb A-1c or lipid panels. For patients coming in with chronic medical conditions, 90-day refills of their maintenance meds can be queued up and ready to sign during the visit.
Setup of these task-simplifying orders requires all the appropriate verbal orders, order sets, and signature requirements are set up in your system. Of course, this should be done in a way to ensure legal and compliant processes.
Lack of communication across the Care Team is the biggest detriment to providing care at the highest value in the office and across the healthcare continuum. PVP work is no exception. If multiple job roles work in the PVP process, or a team member is out of the office, the rest of the team needs a way to know where Mr. Smith is in the PVP process and what work has been done or is in process. Make sure you have an accessible, dynamic communication tool available to all necessary staff in the process.
Expected Outcomes
The potential outcomes of a good PVP process range from decreased personnel expense to improved throughput times to improved patient outcomes.
Streamlining and automating processes and workflows can allow for more work to be accomplished by fewer people. Technology can enhance your workforce’s ability to complete tasks.
Planning ahead for a visit and putting the work into the hands of the right and best qualified team members can improve office efficiency, so more patients can be effectively seen in the office space. Volume is important to a FFS practice, but is also a benefit to a VBC-focused practice. A more efficient patient flow allows you added time to see patients with fragile chronic conditions more often, which can avert exacerbations and decompensation of the conditions.
In the same vein, timely assessment of preventive and chronic care needs addressed while the patient is in the office will lead to improved outcomes. Knowing why a patient is coming in and what all their clinical needs are prior to the visit can decrease their likelihood of disease complication or need for admission.
An often under-appreciated factor in the Value Equation is experience. The better the experience, the higher the value. PVP improves the experience of the physician or provider by having all the necessary pieces in place for the visit to happen as needed. Plus, a well-designed and supported process takes the burden of finding much of the needed information out of their hands, presenting it to them when they need it.
Staff experience is enhanced through less work redundancy, more meaningful work at the top of their licensure / ability, and a smoother workday. This positive experience can translate into decreased turnover and less burnout – adding further benefit to personnel costs.
Patients aren’t left out of this Experience lovefest, either. People recognize and appreciate when someone anticipates their needs, especially when it can mean improved health and well-being. A good PVP process does just that. Important point: efficiency doesn’t mean feeling rushed. In fact, the improved efficiency found in a PVP process that works can allow for a few more minutes of individual conversation between staff and patient. When their needs are met and they don’t feel like herded cattle, patient experience can go through the roof.
Finally, in practices with VBC contracts, there is another financial reward to PVP besides improved throughput. HEDIS measures in pay-for-quality contracts are met. Improved outcomes augments pay-for-performance bonuses while aiding in medical cost control and reduction, creating savings to be shared or kept. Plus, attribution can be aided by the appropriate use of AWVs that might otherwise have been missed.
All these benefits make a strong case for a sound PVP process. Of course, Pre-visit Planning can help with your patients who have initiated contact through scheduling a visit. What about your patients NOT on the schedule? That’s a topic for another time ….
