Today’s focus on quality of care has a far-reaching impact on medical practices throughout the country. Driven by a commitment to improving patient health and by emerging payer incentives, physicians are exploring clinical and operational strategies to increase the number of patient visits for screenings and preventive care. Medical Associates Health Center (MAHC) consists of 90 providers at 12 locations throughout southeastern Wisconsin, and was among many practices challenged with finding effective methods for prompting patients to schedule recommended services.

Traditional education and communication tactics achieved limited success; therefore, MAHC began to explore alternative solutions. Ultimately, it adopted an automated patient outreach system that integrates with practice management (PM) and scheduling software with the ability to seek out and generate calls to patients due for care.

The Issue

Our management team was acutely aware that many patients were neglecting their routine and preventive care — in fact, there was a persistent downward trend in the numbers of patients scheduling these visits. Cancer screening rates in particular were suffering. When asked, some patients said they simply forgot to schedule appointments because of busy professional and family lives. Many believed they did not need this type of care because they felt “just fine.” A certain number cited lack of insurance coverage (particularly Medicare beneficiaries), while others noted that copays and out-of-pocket expenses were growing (specifically those who selected high-deductible plans).

Our physicians recognize that as the average age of the general population increases, preventive care becomes increasingly important to overall health. Additionally, growing pressure to report on quality measures served as an incentive to increase patient compliance. Like most medical practices, we dedicated time for staff to place reminder calls, totaling about 3,000 a day, to patients with upcoming appointments or who needed follow-up care. But this labor-intensive process was less than reliable. When we were extraordinarily busy, during flu season, for example, or when staff members were absent, this task was the first to fall off of the day’s to-do list. Nor was it carried out consistently throughout the practice. Some locations were better equipped to make the calls, while others had fewer resources.

We investigated whether or not our electronic medical record (EMR) system could help us remind patients and physicians about needed care at the point of service. However, we discovered that the necessary functionality had yet to be developed and would not be available in the near future. Even if the EMR approach were possible, it would be purely reactive in nature, reaching only patients who were regularly coming into the office.

For example, if a female patient was seen for joint pain, the EMR might someday be able to notify the physician if she was overdue for her mammogram and well-woman check. But if she had not made the initial appointment, we would have no idea she needed additional care, and would be unable to remind her to make other necessary appointments.

The Solution

Internally, our physicians began to discuss ways to become more proactive with patients, and we discovered a solution almost by accident while attending a professional conference. Our medical director and quality director happened upon the Phytel display booth and learned that the vendor offered an automated patient outreach solution that interfaces with PM systems and scheduling software. The system identifies patients overdue for preventive and chronic disease services, and then automatically generates calls to these patients, notifying them that they should telephone the office to schedule an appointment.

After discovering such a system existed on the market, we created a multidisciplinary committee to search for similar products. The group was comprised of departmental representatives from information systems, clinical operations and scheduling, and led by the medical director and director of quality. While the committee discovered a number of systems that offered similar capabilities, the Phytel Proactive Patient Outreach solution was best suited to our needs and we implemented it in July 2007. The committee appreciated how this system actively sought out patients who might otherwise slip through the cracks and, in addition, provided comprehensive reports on calls placed and subsequent responses.

Implementation

Our first step was to build interfaces between the Web-based outreach solution and our PM system. IT professionals typically allow from between 90 and 120 days for this process, but we were able to complete the work in about one month. The system was configured to provide HIPAA-compliant access to select patient information. Data that was made available included demographics such as age and phone numbers, as well as what preventive and disease management services individual patients required. The interfaces likewise allowed access to our scheduling software to provide information about which patients had already made appointments, and therefore required no reminders.

While these technical requirements were addressed, our medical staff reviewed the protocols that would guide proactive calling. The vendor provided a set of protocols based on national quality measures and evidence-based practice standards. Our medical staff reviewed each, determined which we would adopt and refined them to meet practice objectives. Ultimately, we implemented seven preventive services protocols (annual visits for adult females, annual visits for adult males, bi-annual visits for younger patients, well-child check-ups, colon cancer screening, breast cancer screening and osteoporosis screening) and six disease management protocols (asthma, diabetes, hypertension, cholesterol, thyroid and heart failure).

Like most medical practices, we dedicated time for staff to place reminder calls, totaling about 3,000 a day, to patients with upcoming appointments or who needed follow-up care. But this labor-intensive process was less than reliable.

We also established timing and frequency of proactive calling. Patients receive an initial call at the time they are due for a service and a reminder two weeks later if no appointment is scheduled. A third call is made in another two weeks, after which, notification is discontinued. If a patient is due for more than one service (e.g., colon cancer screening and a cholesterol check), the system makes only one call. Schedulers later determine how best to book the patient for all care needed.

Before go-live, we conducted training for clinical leaders and scheduling staff. Five 90-minute sessions were offered to ensure personnel had the chance to attend. Most of the training focused on schedulers, since their workflow would be most directly affected. For example, when reminder calls are made, patients have the option of confirming their appointments or indicating they want to cancel, or reschedule, via their telephone keypad. When schedulers arrive each morning, they immediately open the outreach report (through software hosted on their desktop) to note the changes in the day’s schedule.

They then contact patients and re-book appointments as necessary. As proactive preventive or disease management calls are made, schedulers need to be prepared to handle incoming requests for appointments. Because of HIPAA regulations, the automated outreach solution can indicate only that the patient is due for a follow-up visit, but cannot mention specific services or disease states. When the patient calls for the appointment, the scheduler accesses the outbound call log to determine what type of visit the patient needs.

The Results

We began to experience positive results within weeks of adopting the proactive patient outreach approach, as the numbers of patients scheduling follow-ups and proactive care appointments increased. In fact, within six months of implementation, we estimate that we scheduled approximately 13,000 additional visits triggered by the outreach program. In some cases, we reconnected with patients who had not been seen in two years or longer. After using the system for several weeks, however, we discovered areas that required fine-tuning.

Although training had been provided, some of our front desk personnel did not thoroughly understand how the outreach program operated and found it challenging to respond to the influx of patient calls. A second round of training with the vendor several months after implementation improved the process. In addition, some patients were understandably puzzled when they began to receive automated reminders from the practice because they had become accustomed to less-frequent, personal phone calls from our office.

We believed adequate notice informing our patients of the impending shift to the automated call system had been provided through on-hold messages, notices inserted into patient statements, announcements in our community newsletter, and postings at check-in and check-out. Nevertheless, some patients were cautious about embracing the new approach. Eventually, though, most realized the change was prompted by our genuine concern for their well-being.

We discovered that a number of the system protocols also needed further refining, and our own database needed cleaning up as well. For example, our colon cancer screening protocol indicated patients would be contacted when they turned 50 — but it placed no upper age limit on calls. One 95-year-old patient called our office in confusion because he had previously, and correctly, been informed by his physician that he no longer needed this screening. This triggered a re-examination of these parameters, with adjustments being made within a few weeks.

After making the first calls, we discovered that many of the patients’ phone numbers had changed, that some had moved out of the area and that others were deceased. Despite these issues, we are tracking compliance on a number of preventive care and disease management standards, comparing data before and after initiating proactive outreach. Baseline cancer screening statistics were recorded in May 2007 and will be re-evaluated in May 2008. Similarly, diabetes management was assessed in December 2007 and will be reviewed again at the end of this year. Overall, we estimate earning 10 times the amount of our initial investment within six months of implementation.

Overall, we are extremely satisfied with the results we have experienced through the use of the automated patient outreach. It has enabled us to increase the number of patients we see for preventive care and disease management, which will no doubt help us achieve our overarching goal of improving the health and lives of individuals in our community.

Vicki Fehrenbach,BSN, is director of quality and Alex Grahovac is director of information systems and telecommunications for Medical Associates Health Center in Menomonee Falls, Wis. Contact them at [email protected] or [email protected]