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Healthcare Practice Management

How to reduce communication overheads in your medical practice

In healthcare, we live and breathe faxes. Faxes are here to stay – no matter how many software vendors tell you otherwise or paint you another picture. The same goes for phone calls. No matter what you do, patients, providers, vendors, partners will call – no matter what software vendors with the latest and greatest technologies tell you. Phone calls, voicemails – they are here to stay.

Instead of picking a war on faxes, paper, phone calls, voicemails – I implore managers to look at the real, underlying problem. 

If you ask yourself “5 whys”, I bet you, your main complaint is that you don’t have a good handle on whether the loop is closed on those faxes, calls, voicemails etc. You don’t have a way to take stock of your “todos” (so to speak), your “doing” and your “done” items… not the communication channel in itself.

You don’t have a way to gauge how many incoming phone calls your practice received, how many were resolved to caller’s satisfaction, how many calls were dropped, how many of those dropped calls were responded to, how many voicemails were responded to, how this is really affecting your reputation..

Isn’t that what all this is about? “Customer satisfaction”?

So, you end up following up with your staff to find out what the status is. Or, if you do not follow up with your staff, you find out later on that there was an issue.. Issues like

  1. A referring partner isn’t receiving their patient appointments
  2. A partner is not getting their visit notes
  3. A vendor is not getting medical record requests responded to
  4. A patient is not getting their alternate prescriptions
  5. A surgical clearance fax never made it to the coordinator
  6. Patients complaining that they are not getting appointments
  7. Patients complaining of long hold times
  8. Patients complaining of voicemails not being returned
  9. Etc etc.. 

Don’t be a hater.. Deal with the underlying problem instead.

Just like we approach email or even use the super awesome tool Trello  – if you approached faxes, calls, voicemails the same way, would you have the same complaints?

When we deal with emails or Trello, we have:

  1. Inbox – where we get incoming TODOs
  2. Folders/labels – where we file away items that we have already tended to
  3. Snooze/reminders – that’s how we approach our workload, remind ourselves of things to tend to, things to follow up on, things to close out and file away
  4. Compose – that’s how we start a new task
  5. Forward/Assign to – that’s how we assign an incoming task to someone else
  6. Reply – that’s how we respond to incoming tasks and continue a conversation

And, by using these features, we, collectively know that a TODO was tended to, and we don’t have to spend time reporting to our bosses about how we are handling important tasks for them. We never have to spend another extra minute chasing down folks within our organization to find out what happened, whether it was done, who is working on it, what the status is, when it might be done, reminding ourselves to remind our staff to finish something.. The list is endless.

Take stock of the time you waste on activities like these that really suck up productive hours.. And away from patient care or practice management.

I hope you’ll see things my way after taking stock of the same.

How we deal with faxes and our daily workflow

One of the main challenges at a medical practice I manage is the volume of faxes we receive. Since most healthcare communications happens via fax, it is something that we cannot avoid using nor can we ever hope to convince everyone to move away from fax (many companies have tried it).

If you look at our daily workflow, for each fax, we are required to either:

  1. Assign it to someone on our staff that will work on it
  2. Follow up with the staff / project manage them to ensure that they took action on it and 
    1. Closed the loop OR
    2. Defined the next step and assigned someone to the next step
  3. Assign the task to someone else if the person assigned to is not available to do it
  4. Do something internally, then respond back to the sender via fax (whatever information they asked for)
  5. Do something internally then respond to someone else via fax (surest way of them getting the info across)
  6. Take action based on the fax and update our own systems where no responses are needed (e.g attach the PDF)
  7. Print the fax and manually key in information into our systems (mainly Carecloud and EMA)

Let’s take stock of how we do things with faxes today

  1. Right now, the fax servers are using FreePBX https://www.freepbx.org/. There are a few numbers in use as we printed them on referral pads over the years. As the years passed by, we grew from 1 location to 3 and some of our referring partners still have our old fax numbers.
  2. Of course, these were the same numbers that were shared on various websites / partners / vendors etc.. So, all kinds of faxes are sent/received at these fax numbers.
  3. Our first step was to single out the biggest contributing factor to our practice growth – physician referrals. We created a single fax number for referrals and started sharing that fax number with referring partners.
  4. Even though we decided on a new SINGLE referrals fax number that we are distributing to everyone – the transition hasn’t happened yet. We expect that this transition from 4 fax numbers for referrals to one fax number for referrals is going to take a year or so. We simply have to deal with this transition period. 
  5. Back when we got started, we had too many paper faxes. We had no clue who was closing the loop on each, so we decided to email our faxes from our private FreePBX server to our common email inboxes (one at each location). 
  6. As the practice locations grew, so did our faxes. And our common email inboxes started looking like data swamps… with 100s of emails in each inbox. We were back to square one.. No one knows whether something has been tended to or not and what the resolution for each such “incoming” was. 
  7. We only found out that there was an issue – retroactively.. When someone raised an issue, we dug into it further, found out the root cause .. it almost always was that someone had assumed someone else is taking care of something. And it fell through the cracks.. Leading to a complaint / dissatisfaction later on down the line.
  8. We decided that our immediate, non-hi-tech solution was to designate a “postmaster” for our faxes.. That person would route the faxes to the person that is supposed to tend to the fax. Then that person would follow up with the assignee to find out whether the loop was closed.
  9. Stupid as it might sound – that actually worked well. But, as we grow beyond 3 locations, having a “project manager” for faxes also becomes a pretty expensive proposition. 
  10. The faxes coming in are of various kinds including, but not limited to (new types are discovered every other week)
    1. Referrals
    2. Request for additional information from payers
    3. Request for additional information from providers
    4. Responses for authorization requests
    5. Medical record requests and their reminders
    6. Tests/Lab results
    7. Surgery clearances from referring providers or PCPs
    8. SPAM 
    9. Legitimate vendor faxes to follow up on
    10. Prescription requests from pharmacies and their alternate prescriptions
    11. Prior authorization follow ups and their reminders
    12. Visit notes from other providers
    13. Medical records (Transition of care) from other providers
    14. Etc.. 

How we will deal with faxes and our daily workflow moving forward

We leaned on our IT team and they gave us a solution that we believe will work pretty darn well. We need to use the fax server as we use email / gmail.. Or better yet, as the IT team tells us – as the task management tool – Trello.

We need to start treating faxes as gmail or Trello in healthcare. 

Once a fax comes in, our staff would be able to:

  1. Get an alert on our desktop via an alerter like ZocDoc’s (i.e desktop notification) since no one wants to keep a website open all the time and watching it for incoming faxes all the time.
  2. Claim it (i.e. I will work on it) OR Assign it to someone on our staff that will work on it. 
    1. Once we do that, the assignee would get an email + SMS (since most staff at the medical practice I manage do not use company emails)
    2. We would be able to add a note when we assign a fax TODO to someone that the person should get via email + SMS
    3. We would be able to assign a due date to it. If we don’t assign a due date, it should have an automatic due date of 2 days
    4. The system should remind the assignee and the assigner to complete the task on the due date at 9 AM EST
  3. Follow up with the staff by leaving a comment on the incoming fax “record” so that at least we know how many times we have reminded the person. This comment should go via email + SMS
  4. The person that the TODO was assigned to, can take actions (e.g.)
    1. Attach a label to each fax so that the fax can be moved to a “folder” like we do in gmail
    2. SPAM – mark it as spam and it moves to spam folder and that sender fax number is marked as a spam sender, so we don’t have to deal with that number anymore.
    3. For legitimate vendor faxes to follow up with, our staff will be able to
      1. call the vendor and mark the fax record as DONE + remarks = the outcome of the call 
      2. Define the next steps if needed and assign to whoever we feel is appropriate
    4. For request for additional information from payers, our staff will be able to
      1. Send a response fax to the same number where it came from or override that number with a different fax number if they want to/need to
      2. This way, we know what was requested and what fax was sent (to check if loop was closed)
      3. Define the next steps if needed and assign to whoever we feel is appropriate
    5. For request for additional information from provider, our staff will be able to
      1. Pull records from our EMR
      2. Send a response fax to the same number where it came from or override that number with a different fax number 
      3. This way, we know what was requested and what fax was sent (to check if loop was closed)
      4. Define the next steps if needed and assign to whoever we feel is appropriate
    6. For medical record requests and their reminders, our staff will be able to
      1. Pull records from our EMR
      2. Send a response fax to the same number where it came from or override that number with a different fax number
      3. This way, we know what was requested and what fax was sent (to check if loop was closed)
      4. Define the next steps if needed and assign to whoever we feel is appropriate
    7. For responses for authorization requests, our staff will be able to
      1. Since PAs are usually submitted from websites (parxs , covermymeds etc). We would be able to mark the incoming fax as DONE and add remarks to close the loop
      2. Define the next steps if needed and assign to whoever we feel is appropriate
      3. Note all PAs that are not electronic and try to sign up for ePAs instead of manually faxing PAs
    8. For tests/Lab results, our staff will be able to
      1. Attach it to a patient record in our EMR (not programatically – just manually), mark it as DONE, add remarks.
      2. Define the next steps if needed and assign to whoever we feel is appropriate
      3. Make progress on the planned surgeries
    9. For surgery clearances from referring providers or PCPs, our staff will be able to
      1. Attach the fax to a scheduled surgery that’s currently being tracked / co managed with our ASC partner so we are all on the same page
      2. Define the next steps if needed and assign to whoever we feel is appropriate
    10. For prescription requests from pharmacies and their alternate prescriptions
      1. Assign it to our techs as needed so they can confer with our providers and respond to it.
      2. Our techs could respond back via fax with the alternate prescription, mark it as DONE add remarks
      3. Probably update our EMR with this info (manually)
      4. Define the next steps if needed and assign to whoever we feel is appropriate
    11. For visit notes from other providers, our staff would be able to
      1. Attach the note to the patient record in EMA and Carecloud. Mark it DONE with remarks.
    12. For medical records / transition of care faxes from other providers, our staff will be able to 
      1. Attach the same to the patient record in EMA and Carecloud. Mark it DONE with remarks.
    13. For new referrals received via faxes, our staff would be able to 
      1. Create / log a referral received based on fax received as they would be able to see the fax page(s) on their desktop itself
      2. Create a patient in our EMR with info received from the fax
      3. Assign the referral to our referral coordinator agent to call,  as the next step
      4. Our referral coordinator agent would be using “click to call” from their desktop and each call has a disposition + remarks. This way, we never have to chase them down to find out what happened with the incoming referrals
      5. After the appointment is set, this will fall into our typical workflow of appointment reminders, then no-shows (if patient is a no-show), patient satisfaction survey, reviews request, recall etc.

At least, with this unified communications platforms solution from our IT team, we no longer have to project manage things and our departmental heads always know the status of each TODO + can report up/down based on outcomes they clearly see in front of them.

How we deal with phone calls/voicemails and our daily workflow

Just like any other practice, we get lots of calls. Last time I checked, we were averaging about 300 calls per day.. And growing. Of course, that’s just for 3 locations.. As the number of locations we manage grows, this number is expected to shoot up proportionately. 

Much like with any other practice, our inbound calls and voicemails are related to:

  1. Scheduling (schedule, reschedule, cancel, referrals etc)
  2. Billing
  3. Surgeries
  4. Pharmacy/prescriptions
  5. Customer service (general bucket for all other lesser volume calls)

We have a dedicated team for handling inbound calls as well – just like any other practice. 

When we started, our phones were using FreePBX https://www.freepbx.org/ (the same thing that we use for faxes). Our IT team has moved our phone systems to Amazon Connect to help us scale things out and to be able to handle call volumes by moving our agents between inbound calls, appt reminders, no-show calls, reactivation calls, community outreach etc.

However, reporting and closing the loop were not something that were easily resolved. We started with an “end of day”, “after call work” requirements that we imposed on our patient contact center team. 

Each day, at the end of the day, we get a report on

  1. Inbound calls. We measure a few things like
    1. The types of calls (scheduling, pharmacy, surgeries etc)
    2. The number of calls for each type of call
    3. How many calls were resolved on first contact
    4. Accuracy of such calls “resolutions” (i.e. correct patient data created, correct next steps defined/taken etc).. We have certain quality parameters we look at here
    5. How many calls were transferred to other company extensions
    6. How many calls were returned
    7. How many patients called back more than once
    8. How many calls were abandoned
    9. How many abandoned calls were returned
    10. Voicemails left
    11. Voicemails returned with a call back
  2. A/R calls where we measure
    1. Payer denials and no responses – outcomes achieved, next steps defined
    2. Patient balance collections – monies received and already in the bank, monies promised in the future, how much has been realized
  3. No shows calls where we measure total patients re-appointed
  4. Reactivation calls where we measure total patients re-appointed
  5. Appointment reminder calls where we measure total patients that promised to show up
  6. New patient referrals where we measure new patient referrals received from various calls our team made
  7. Community outreach calls where we measure how many new patients we acquired via our cold call campaigns

Again, just like with faxes, each one of these calls and voicemails go through a workflow wherein the resolution is recorded, the next step is defined and management can take a look at the overall efforts taken to acquire a patient and to service each patient. 

This helps us with capacity planning and forecasting our business. 

As examples.. Our inbound calls have a resolution and more often than not, some kind of next steps.

  1. Our team gets a call related to scheduling and addresses the same on the call using our EMR. The next step in this workflow are appointment reminders – an SMS is sent and if not responded to, the next team (appointment reminders) has a TODO of calling the patient to ensure that they will show up.
  2. If the patient does show up, the next step in our workflow is to send out a satisfaction survey text message. If the SMS is not responded to, the team has to call the patient to find out how we did. If the SMS is responded to, our next step is to send out a review request SMS. If the review request SMS did not result in a review, our next step is to get in touch with the patient to find out whether our work satisfied them enough for the patient to leave us a review.
  3. If the patient does not show up, the next step in our workflow is to send an SMS to re-appoint the patient. If the SMS is not responded to, the next step is for our no-shows team to work on calling and re-appointing these no-show patients.
  4. If the patient does show up this patient now moves into the bucket of “recall” patients and our recalls/reactivation team is in charge of the same. The patient gets an SMS reminder that it has been more than 6 months since their last visit. If the SMS is not responded to, the reactivation / recalls team is tasked with calling and re-appointing that patient.
  5. If the patient shows up and has not cleared their balance at the front desk, our A/R team is tasked with collecting balances from this patient. An SMS is sent out so that the patient can pay via an online payment portal themselves. If the SMS is not responded to, our A/R team is tasked with following up with those patients to collect the balance. Sometimes they need to set up a payment plan and other times, they do collect the entire balance. When this team sets up a payment plan for the patient, it is their responsibility to ensure that the future payment does go through. If it doesn’t go through, it is the A/R team’s headache to call and collect the balance payment
  6. Our inbound team might get a call for pharmacy related issues – they typically redirect these calls to techs. However, there’s a clear resolution and next step defined for these where in the tech gets a notification of their TODO and then the tech has to clear out the TODO as they are responsible for the next step.
  7. Our inbound team might get a call for billing related issues – same thing goes here. The call is redirected to the billing department (if it is something that the inbound team cannot answer) and then it becomes the responsibility of the billing department to clear out the TODOs from their “inbox”.. As they were responsible for the next step. Sometimes, the billing department has to follow up by making payment adjustments in our EPM.. 

You get the idea. We treat everything as a workflow – one task finishes and passes the task on to the next team and so on.. 

And each team has reporting parameters set up.. This allows management to keep a good control over how things progress over a patient’s care flow, care coordination and patient pipeline.

How we deal with practice emails and our daily workflow

We also have to handle incoming emails from various vendors, referral websites, ZocDoc, website appointment requests, facebook appointment requests etc.

We wanted to follow a similar task management/workflow management process with this as well – especially since most of these emails were time sensitive and needed to be acted upon ASAP.

While we could have easily turned all our business and concentrated only on one vendor to make our lives easier, nobody at the practice wanted to take on such a huge risk of limiting our appointment / patient pipeline sources.

So, we reached out to our IT team to find something that’s HIPAA compliant but still allows us to put our practice emails into some kind of a workflow – just like with our faxes and voicemails.

They came up with a brilliant solution that allows them to move our TODO emails into our workflow solution and also remained HIPAA compliant at the same time.

Since emails were already equipped with all the folders/labels, forwarding, assignment capabilities – we didn’t have to do much over here. This solution from our IT team simply hooked up emails to a similar workflow process that was set up for our team.

Over time, we noticed that we were able to reduce the total FTEs that were being utilized in such workflow related tasks as we were able to leverage technology to do a lot of these tasks, while humans (FTEs) overseeing the process as and when needed.

Having reporting included in our IT workflow solution allowed us to reduce our dependence on our data / process analysts as well. 

We didn’t have to reduce our headcount at all, so staff morale was not hit even by the slightest. In turn, it allowed us to serve more locations with the same number of staff. This in turn helped us reduce the staff (re)training and attrition headaches that we usually dealt with.

The process was standardized, the workflows were standardized, the reporting is well understood company wide and the KPIs / MBOs set for our staff is clearly defined – while allowing our staff to monitor their own performance week over week.

While technology is seen as a threat by most non clinical staff in healthcare, this allowed us to gain full buy-in of our staff, grow more with the same headcount.

Hopefully this helps someone out there reading this. If you have any questions, reach out to me.

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