In medicine, we talk about quality a lot. But most of the time that we are talking about it, we're really not talking about quality at all. You see, quality...
Does it sometimes feel like you are getting more and more patient phone calls? Well, maybe you just are. Twenty years ago, there were some days that I would get no phone calls from my outpatients. Now, if I get less than 10, it is a really good day. So why are patients calling their doctors more now than they did in the past? I believe that it is a confluence of several different factors:
- Office visit co-pays. As medical costs have become more expensive in the past decade, insurance companies have looked for ways to keep their costs down. One way that they have done it is by increasing the co-pays that a patient has for each office visit. These are typically $20-50 per visit. In order to avoid having to pay out of pocket to see a physician for acute bronchitis, patients are increasingly calling, in hopes of getting a free diagnosis and treatment over the phone.
- Office schedule templates. As more and more physicians have become employed by hospitals or large group practices, there has been more emphasis on improving office efficiency and from this has come the concept of schedule template optimization. The advantage of this is that a physician’s schedule of outpatient visits is highly organized so that there is minimal “down time” when an exam room is empty and the office staff are unoccupied. The consequence of this is that it can be very difficult to squeeze in a patient for a short notice sick-call. Although many primary care physicians will have some sick call slots on their schedule templates, on some days there are more sick calls than there are open slots. Many specialists do not have sick call slots on their schedule templates.
- The culture of immediate information access. Remember back when people didn’t carry cell phones with them 24 hours a day? Or when you had more letters in your mailbox than you had email messages on your computer? Americans today expect immediate access to information and to communication. A patient who would have waited 3 days until they could see their physician about a headache now wants their headache addressed in 3 hours.
- Complexity of care. Today’s patients are on more medications and those medications have more side effects. This adds up to more things that can go wrong and more side effects of treatments. This adds up to more worried patients calling their doctor.
- Formulary changes. Every January is formulary month for physicians who take care of outpatients. Health insurance companies annually re-negotiate their deals with pharmaceutical companies to get the lowest price on medications. And so Spiriva may be the preferred anti-cholinergic inhaler one year and Incruse the preferred inhaler the next year. In January, patients will get a letter from their insurance company that Spiriva is no longer covered by insurance and they have to call their doctor’s office to get a new prescription for a medication that is covered. The problem is that the letters usually don’t say which equivalent drug is now covered. So the physician either has to call the insurance company or find the new formulary listing for that insurance company on-line to determine that Incruse is now the covered inhaler. I think the hope of the insurance company is that physicians will get tired of the hassle and just discontinue the inhaler prescription.
So, what can you do to reduce the number of phone calls?
- Use email. OK, so you can’t exactly use regular email without violating HIPPA laws. But most electronic medical record programs will have encrypted secure messaging with patients. Typically, patients sign into their “patient portal” and then can send messages to their physician’s office. I can type in an answer to a patient’s question in about 30 seconds. If I am returning a call to that same patient for that same questions, it will take me about 3 minutes since there is always a wait time for the patient’s spouse who answers the phone to get the patient on the phone and then the patient inevitably will have “just one more question while I have you on the phone, doc”.
- Empower your nurses. In our practice, these messages are routed to a pool of office staff that screen messages. Those that are for appointment scheduling are routed to a scheduler. Those that are for refills are routed to a nurse to tee up the refill order and then route it to the doctor. And, those that are about medical questions are routed to the physician. However, a lot of medical questions can be answered by nurses. For example, a patient with COPD calls and wants to know if he can wear his nasal oxygen cannula in the shower – your nurse can answer that one, you don’t have to.
- Optimize medication refills. For maintenance drugs, it should always be 12 refills for 30-day prescriptions and 4 refills for 90-day prescriptions. Pharmacies will honor refills up to 1 year from the original prescription. So, if you give an initial prescription plus 11 refills (a total of 12 30-day prescriptions), that would be 12 x 30 = 360 (five days short of a full year). For patients who return to the office for an annual visit, they are usually coming in at 365 days (or, more often, a week or two after 365 days). Therefore, with 11 refills, they run out of medicine a week or two before their annual visit and have to call to get a refill. By doing 12 refills, they can still get their last refill inside of the 1-year refill limit but the last refill will last them until 390 days from their previous visit, plenty of time to get in for their routine check up and refill encounter without having to also have the the extra phone call to the office for a refill.
- Refill medications proactively. Here is where the office staff can really help. Lets say you prescribe hydrocholorothiazide for a patient’s hypertension in December and you give the patient a 90-day supple with 4 refills (390 days worth). But their next annual visit ends up being 11 months later in November because they’ll be wintering in Florida for the next 4 months. They will still have another refill until either the patient or their pharmacist calls your office to request a refill. But, if your office staff check the electronic medical record to determine the number of refills remaining when the patient is in the office in November, they can tee up another year’s worth of refills and eliminate a phone call in January when your patient runs out of medications on the beach in Fort Myers.
- Make use of patient information handouts. With most electronic medical records, there is something called an “after visit summary” that is printed out for the patient. It will include information about their visit such as the diagnosis and any changes to the patient’s medications. No matter what you tell them, patients will only remember 3 things. If you tell them 3 things, they will remember 3 things. If you tell them 5 things, they will remember 3 things. So, if you want them to remember all 5 things, add clinical information sheets to the after visit summary. If you just diagnosed a patient with chronic systolic heart failure, include printed information about what the disease is, the need for logging daily weights, sodium restriction, etc. If you are prescribing methotrexate for a patient with rheumatoid arthritis, include information about taking all of the pills at one time once a week, taking folic acid every day, and common side effects of methotrexate to be on the look-out for. These can eliminate the patient getting home, turning to their spouse and asking: “What did he say?” and then eliminating the inevitable phone call asking for a clarification of the doctor’s instructions.
- Make test results available. If I order a toothbrush from Amazon.com today, it will show up at my front door tomorrow. If a patient gets a blood test today, they expect to know the results tomorrow. We live in an age of immediate information. If a patient is signed up for a “patient portal” on your electronic medical record, then make sure that test results are released every day – either do it yourself or have the tests auto-released to the patient. We have auto-release of common blood test results such as CBC, chemistry panels, etc. Some of our physicians objected to this for fear that their patients “can’t handle the truth” of their test results and will call the office for every abnormal monocyte count on their CBC. That is not my experience – my patients love it and it reduces the phone calls from patients wanting to know what their annual cholesterol level was. In nearly a year, I’ve only gotten 1 call about an abnormal monocyte count. Also, set expectations. If you order a weird blood test that has to be sent to a specialty laboratory in northern Saskatchewan by dogsled, make sure that the patient knows that the results won’t be back for 3-4 weeks.
Currently in American medicine, we don’t get paid for phone calls – we just get paid for face-to-face office visits. In the future, if we have some form of capitated health care system where we get paid by the size of our patient panels rather than the number of office visits, then phone calls may all of a sudden be an efficient and desirable way of taking care of your patients. Until then, avoidable phone calls can clog up your day with uncompensated time. There are times when our patients truly need to speak with their doctor by phone and at those times, a phone call can equate to better care of the patient. Our challenge is to eliminate the phone calls about issues that could have been handled preemptively with better planning and office structure.
February 19, 2017