Support Staff Shortages in Healthcare: The Role of Smart Software and the Spoils of Pre-Visit Planning

It is no secret that healthcare has been in crisis — a staffing crisis. While the pandemic certainly exacerbated the situation, present workloads, emerging patterns contrary to traditional practice, and burnout are only the latest in a long line of factors straining the healthcare workforce.

Providers, labor experts, and public health entities alike have been decrying a looming and extended shortage of healthcare workers for over two decades1. Specifically, primary care providers and nurses have been the subject of many workforce studies, in an attempt to understand and mitigate the consequences of understaffing, but they do not represent the full impact of healthcare staffing shortages.

STAFFING SHORTAGES ABOUND

Generally speaking, no one questions the importance of primary care physicians, which makes their shortage disconcerting, at best. Many Americans spend most of their non-urgent health care time with their primary care physician and know them by name, so it is unsurprising that this is one of the larger areas of focus. But what about other health care staff?

Nurses, the backbone of the healthcare system, receive far less notoriety and support. With the present global nursing shortage dating back to the early 2000s1,2,3,4, it is alarming that little has changed after two decades5,6,7,8,9. Even more unsettling is the breadth and depth of roles filled by nurses that are under-filled, underutilized, and overworked.

Nurses are everywhere — from critical support staff roles to midwifery, advanced practice, and sometimes solo practice in remote or underserved areas. They make up the largest proponent of the healthcare workforce, represent the greatest number of registered healthcare professionals in the United States, and are projected to have the fastest employment growth rate of any occupation7.

And yet, there are not enough nurses to fill critical roles. Multifactorial reasons are attributed to the shortage; however, ways to mitigate the shortage are not the purpose of this article. Suffice to say that, with those roles unfilled, redistribution of fundamental nursing staff has had to occur. Enter: the medical assistant.

Historically, health care workflows have started with reception, progressed to nursing for triage and vitals, and then culminated with the physician. Due to advances in medical technology, staffing shortages, and the development of team-based care, these roles and responsibilities have shifted over time. Most recently, this has been represented by the usage of medical assistants (MA) for basic nursing tasks so that greater clinical decision-making and participation could be redistributed to nurses11,12,13.

However, this rebalancing of clinical and non-clinical tasks has not gone without repercussions: while all staff reported higher engagement from improved team-based care efforts, they also reported higher levels of stress and burnout10,14. This, in turn, has led to turnover and alternate career choices for many MAs, opting out of the combination of low pay and high stress.

In short, in addition to extended shortages of primary care providers, nursing and MA shortages have put significant strain on systems that rebalanced workload across the entire health care team. Worse, the rapidly changing pace of technology and increase in technology-based demands have further strained an already struggling system, impairing clinical efficiency and adding unneeded stress to all members of the clinical team. With this grim picture, what can be done?

CLINICAL WORKFLOWS AND TECHNOLOGY

Briefly mentioned above, clinical workflows play a significant role in not only clinical staff efficacy and satisfaction, but also patient and payor satisfaction. Properly designed and executed workflows can accommodate staff fluctuations, maximize technological impact, improve efficiency, and keep the entire team on-task and on-time. This is no secret. But optimizing clinical workflows…that may feel like a secret, especially to clinics and health care teams struggling to maintain a balance between efficiency and morale.

In truth, effective clinical workflows often come down to when, where, and how technology is used in practice. Much-maligned EHRs are strongly criticized for being billing tools as opposed to clinical tools, increasing non-clinical tasks for clinical staff, and obscuring or encumbering clinical tools with administrative hassles. Few EHRs are designed by clinical staff, making the adaptation of EHR workflows to clinical workflows difficult, if even possible.

Technology further diminishes clinician perceptions of self-efficacy by often claiming more attention than the patient during both in-person and telehealth visits. All too often, a patchwork of complex order sets, outdated templates, and repetitive user interfaces drive clinician workflow throughout the workday. Yet even these trials can be improved upon, if not outright eliminated.

PUTTING IT TOGETHER

Thus far, two critical health care issues have taken shape: looming workforce shortages, particularly among support staff, and suffering workflows from an over-reliance on technology, largely due to staffing gaps in redesigned and better-balanced team-based care. Seemingly a catch-22 situation, each feeds the other, creating an abhorrent negative feedback loop that further stretches the tenuous hold current staff have on meeting essential health care needs.

But what if there was a way to reduce staffing dependence and improve technology in one step? Surely a solution must exist; a cost-effective, easy-to-implement solution that fosters organization, efficiency, and improved clinical outcomes. Sounds a bit like a unicorn, right? Maybe not.

While it would admittedly not be a panacea for staffing and technology issues in clinical practice, such a solution may be able to act as a tourniquet for resource depletion: effective pre-visit planning.

PRE-VISIT PLANNING

Pre-visit planning comes in many forms and is an essential task in outcomes-based care. As regulatory and third party demands on performance, outcomes, measures, and prevention increase, it can be next-to-impossible to keep track of who needs what and when. Sadly, while many EHRs are designed to meet minimum government standards for outcomes-based reporting, they are often ill-equipped to help manage care-based expectations in a timely and workflow-friendly way.

Additionally, due to the technology- and patient-based demands on physicians, pre-visit planning tasks often fall to other clinical and non-clinical staff, like nurses and MAs, to ensure physicians are adequately prepared for patient interactions. With global staffing shortages of nurses and MAs, it is not difficult to see how pre-visit planning efforts may have fallen by the wayside and had a negative impact on overall patient care.

PRE-VISIT PLANNING USING TECHNOLOGY

Admittedly, technology, even with deep learning, artificial intelligence, and other forms of machine learning, should not always replace humans. It can be wildly beneficial when used appropriately, but horrifyingly inept when misapplied. Take clinical decision support (CDS) software, for example. Even programmed to understand rudimentary pathophysiology, pharmacology, and biochemistry, it is still only as good as the combination of its programming and utilization/user(s). Such is the plight of many types of health technology, lending reliance, comfort, and even preference for human interaction over technological intervention in many settings.

However, as time has shown, many tasks can be safely and efficiently delegated to technology, freeing up limited clinician time for truly essential tasks and decisions. One such example is the use of pre-visit planning software. Incorporating software solutions specifically designed to handle complex but iterative pre-visit planning tasks and organization not only ensures uniformity and consistency, but also frees up invaluable staff time to truly deliver quality care.

Imagine knowing exactly what procedures, services, and preventive care a patient needs based on their medical history, payor information, and demographics, all at a glance. It’s not a fantasy; effective pre-visit planning software can do all this and more. From comprehensive transitions of care management (TCM) and inclusion of advance care planning (ACP) discussions and documentation to state-mandated, age-based standards of care and third-party payor treatment protocols, pre-visit planning software is almost like a personal assistant designed specifically for medical practices.

Automated data entry, documentation, and billing based on existing, charted information, and specific clinical inputs are just a few of the additional benefits available in some of the more comprehensive software programs, like that offered by Affirm Health.

Their pre-visit planning application employs a unique analytics engine to examine patient history, individual determinants of care like clinical circumstances and insurance-based mandates, and organizational goals to generate organized, evidence-based treatment recommendations. Available to the clinician before the visit starts, the application not only assists in helping the entire care team feel prepared for every patient visit, but it cuts down on staff and staffing burdens by automatically organizing and even creating necessary documentation.

Sound too good to be true? The pre-visit planning application is just one tantalizing example of how to simplify workflows and decrease the impact of staffing shortages. Will it solve all of a clinic’s workflow problems? Probably not. But by setting the team up for success, pre-visit planning, especially from targeted software solutions, can absolutely have a profound and lasting effect on team performance, outcome improvement, and patient satisfaction.

FINAL THOUGHTS

Staffing shortages across the healthcare continuum will persist until adequately addressed. However, solutions are not likely to be effective in the short term, and so alternative solutions need to be sought out and embraced. Ideally, these solutions will be conducive to improved care both now and in the future, as teams are able to rebuild and grow, and the care landscape continues to evolve.

Regardless of the circumstances, effective pre-visit planning is vital to efficient clinical workflows, staff utilization, and billing and outcome management. Effortless, software-based pre-visit planning, then, is a boon; how can your practice start benefiting today?

REFERENCES

1. Fitzgerald DC. Nursing shortage: A crisis for the next decade. Contemporary Nurse. 2002/10/01 2002;13(2-3):109-112. doi:10.5172/conu.13.2-3.109

2. Finlayson B, Dixon J, Meadows S, Blair G. Mind the gap: the extent of the NHS nursing shortage. BMJ. 2002;325(7363):538-541. doi:10.1136/bmj.325.7363.538

3. Nevidjon B, Erickson JI. The nursing shortage: Solutions for the short and long term. Online Journal of Issues in Nursing. 2001;6(1):4.

4. Colosi ML. Rules of engagement for the nursing shortage: more registered nurses on staff leads to lower hospital costs. JONA’S healthcare law, ethics and regulation. 2002;4(3):50-54.

5. Marć M, Bartosiewicz A, Burzyńska J, Chmiel Z, Januszewicz P. A nursing shortage – a prospect of global and local policies. International Nursing Review. 2019;66(1):9-16. doi:https://doi.org/10.1111/inr.12473

6. Jarrar Mt, Rahman HA, Minai MS, AbuMadini MS, Larbi M. The function of patient-centered care in mitigating the effect of nursing shortage on the outcomes of care. The International Journal of Health Planning and Management. 2018;33(2):e464-e473. doi:https://doi.org/10.1002/hpm.2491

7. Haddad LM, Annamaraju P, Toney-Butler TJ. Nursing shortage. StatPearls [Internet]. 2020.

8. Zhang X, Tai D, Pforsich H, Lin VW. United States registered nurse workforce report card and shortage forecast: a revisit. American Journal of Medical Quality. 2018;33(3):229-236.

9. Spurlock D. The Nursing Shortage and the Future of Nursing Education Is in Our Hands. Journal of Nursing Education. 2020;59(6):303-304. doi:doi:10.3928/01484834-20200520-01

10. Hung DY, Harrison MI, Truong Q, Du X. Experiences of primary care physicians and staff following lean workflow redesign. BMC Health Services Research. 2018/04/10 2018;18(1):274. doi:10.1186/s12913-018-3062-5

11. Dill J, Morgan JC, Chuang E, Mingo C. Redesigning the Role of Medical Assistants in Primary Care: Challenges and Strategies During Implementation. Medical Care Research and Review. 2021;78(3):240-250. doi:10.1177/1077558719869143

12. Vilendrer S, Brown-Johnson C, Kling SMR, et al. Financial Incentives for Medical Assistants: A Mixed-Methods Exploration of Bonus Structures, Motivation, and Population Health Quality Measures. The Annals of Family Medicine. 2021;19(5):427-436. doi:10.1370/afm.2719

13. Ferrante JM, Shaw EK, Bayly JE, et al. Barriers and Facilitators to Expanding Roles of Medical Assistants in Patient-Centered Medical Homes (PCMHs). The Journal of the American Board of Family Medicine. 2018;31(2):226-235. doi:10.3122/jabfm.2018.02.170341

14. Seay-Morrison TP, Hirabayshi K, Malloy CL, Brown-Johnson C. Factors Affecting Burnout Among Medical Assistants. Journal of Healthcare Management. 2021;66(2):111-121. doi:10.1097/jhm-d-19-00265