By: Benjamin G. Cox, MBA, FACMPE

Transcription

1 ACMPE Paper, October 2009 By: Benjamin G. Cox, MBA, FACMPE This case study manuscript is submitted in partial fulfillment of the requirements for election to Fellow status in the American College of Medical Practice Executives This manuscript was prepared as part of meeting various recognition criteria as set forth and may be changed from time to time by the American College of the Medical Practice Executives (ACMPE). The experiences, thought, ideas and opinions set forth are solely those of the author. They do not reflect any position on the part of ACMPE with respect to their completeness, correctness or accuracy of the paper s contents, for example, on points of law or accountancy in effect at the time of or subsequent to the date of paper completion Medical Group Management Association. All Rights Reserved.

2 American College of Medical Practice Executives Case Study Should We Use An Automated Call Reminder System? August 13, 2009 Submitted in partial fulfillment of the requirements for ACMPE Fellowship 1

3 I. Statement of the Problem: A constant frustration for medical practices is patients failing to show up for their scheduled appointments. Clinicians can become quite upset about this and angrily demand of the scheduling staff, What happened to my last patient? Where is my 11 o clock? Did you call to confirm? Are they planning to come in? More than one out of ten patients misses a scheduled appointment, with the MGMA median for no-show or missed appointments at 11.7%. Clinics use a variety of methods, directly and indirectly, to reduce the number and effects of no-shows. Primary care clinics may try to manage the number of same-day appointments by having patient waiting lists, mailing appointment reminder cards, or by calling the patients to remind them of their appointment. The family medicine clinic leadership was well aware of the value of calling patients to remind them of scheduled appointments and, for the past decade, has instructed staff to make daily calls to remind patients of upcoming clinic appointments. These calls have been quite successful with an annual no-show rate for the clinic of only 4.8%. However, this task required the staff to spend about five hours to contact about 120 patients every day (although the actual number of attempted contacts was usually much greater). Each of these calls averaged about 2.5 minutes (5 hours/120 patients) and, since the family medicine clinic did not yet have a phone tracking/reporting system, this average time of 2.5 minutes per call was used to calculate the time required to make each contact call. 2

4 Time trying to contact each patient included everything from looking up the correct phone number, recording the results of the call, and scheduled staff break times as well as other interruptions, to the actual phone conversation with the patient. These calls were made during the day so many patients were not at home to answer the phone. Most of these calls were answered by an answering machine often requiring the caller to listen to the entire answering machine message before being able to leave a reminder message. And many answering machines are used as screening tools so patients didn t answer the phone until after the staff began to leave a message. Even when the phone call was answered by a person, the caller might still be required to leave a message for the patient or to wait for the patient to come to the phone so the message could be delivered directly. Occasionally, patients wanted to cancel or reschedule an appointment during these calls, requiring yet more time. Not infrequently, calls received only a busy signal or no one answered the call at all. In this case, the policy was to make at least three attempts to contact the patient. Patient phone calls to the clinic in response to these reminder calls, to confirm, cancel, or to reschedule appointments, also required significant amounts of staff time and effort. The clinic is in a very ethnically diverse area, within a large metropolitan west coast city, and nineteen percent of the clinic s patients are non-english speaking. The language barrier was a constant frustration between clinic staff and these patients during these reminder calls. The clinic did have Spanish and Russian bilingual staff, but the majority of calls were made by English speaking only staff. The non- 3

5 English speaking clinic patients spoke primarily Spanish (4%), Russian (4%), Chinese (4%), Vietnamese (2%) and Somali (1%). The clinic staff did not like making these daily reminder calls: It is a never-ending process. This is the worst job in the clinic. What did I do wrong to get picked today? Reminder calls created extremely low employee morale and this was a strong motivator for the clinic leadership to consider other options than having the staff make these reminder calls. One employee even resigned because of the undesirability of making these daily patient reminder calls. However, the clinic leadership was committed to making these reminder calls to the patients but they were also constantly looking for opportunities to find a better process. In addition, the call volume was projected to grow to 160 calls per day within two years. II. Reason To Consider A Change Or Implications If No Action Taken: The clinic manager attended a presentation showcasing a new automated call reminder system given by their practice management (PM) vendor. The PM vendor had contracted with a company who had developed an automated call reminder system and, together, they had built an electronic interface between the two systems. Without utilizing staff time, the system could make unlimited calls and these calls could be made during the evening when the patients were more often at home. Patients could respond to a simple automated menu--press #1 to confirm or press #2 to cancel and their responses would be automatically uploaded into the 4

6 appointment schedule. The product, its functionality, and the cost involved were all very appealing. The presentation was so well-received by the clinic manager that a proposal for adopting this automated call reminder system was presented to the clinic leadership. Initially, clinicians were concerned that an automated call reminder system would be too impersonal. Patients might have a strong negative reaction to the automated call reminder system and, ultimately, patients might leave the practice. However, the prospect of improved staff morale plus the cost saving potential were enough for the clinic leadership to formally pursue the change to this new system. III. Discussion Of Alternative Solutions Considered: The clinic manager had several other options to consider besides the automated call reminder system. The first was to make no change at all and continue to have staff make the reminder calls. This system was already in place, worked relatively well, and produced an acceptably low number of no-show appointments. On the other hand, having staff make these calls created significantly low morale and had a direct effect on employee turnover. For staff to continue to make these calls the average hourly payroll cost, with taxes and benefits, was $19.60 per hour. The five hours needed to contact 120 patients had a cost of $98 (5 hours X $19.60) resulting in a cost of $0.82 ($98/120) for each patient contacted in this way. 5

7 The clinic manager had also previously looked at outsourcing the reminder calls to a local answering service company which could also make calls in a choice of several languages and in the evening hours when patients were more likely to be at home. The answering service company had the staff to make the calls at a cost of $0.70 per call, a moderate savings, but the service was not integrated with the scheduling system so no electronic exchange of information would be possible. The company provided a daily mailed call report: busy, no contact, confirmed, canceled, and need to reschedule. The answering service would improve staff morale but would also require added morning work for the staff because of this report. They would need to update the schedule or use the report as a check in tool and this extra requirement made the answering service much less appealing. The Automated Call Reminder System, integrated with the PM system, would be a complete system and was currently in use in a few clinic practices in the local area. A proposed one-year agreement would be directly with the current PM vendor, since they held a master contract with the automated call reminder company. That company passed on a group savings rate to clients, with no setup fee and only a $0.15 per call cost for all call types and volumes. The $0.15 cost per call, compared to the current cost per call of $0.82, represented a savings of $0.67 per call and a potential annual savings of $20,904. The service was provided in several languages and, with the integration of the two systems, the menu responses from the patients would automatically update the appointment schedule. Together, this would free the staff from these reminder phone calls, allowing them to focus on other work, 6

8 and it was hoped that morale in the clinic would be greatly improved. The impersonal and cold nature of this automated system may be the drawback; patients might find it much easier to get insulted and hang up on the machine and clinicians were still concerned that they would lose patients because of it. The clinic manager looked at other automated call reminder systems, but no others were integrated with the PM system. One system offered a greater discounted price per call, but only if the PM vendor developed and built an interface with them-- which the vendor agreed to, do but at the clinic s expense. The clinic leadership did not want to take on the additional financial risk or the time for building a new interface, especially since another very attractive system was already available. IV. Discussion Of Procedures Used To Select The Chosen Solution: The clinic leadership believed reminder calls were a critical operational process of the practice but they were willing to try a new approach. Outsourcing did not offer financial savings but might have a positive effect on the staff. Using an unintegrated system required an unknown financial and time risk. Utilizing an integrated system supported and recommended by the PM vendor was very appealing. The clinic leadership reviewed all options focusing on cost savings, language services, improving staff morale, and better utilization of staff time. Physicians still had a primary concern that the system would be too impersonal, 7

9 would lead to patient dissatisfaction, and, ultimately, would result in the loss of patients. The clinic leadership approached the cost savings from two points of view. One approach was to completely eliminate the five hours a day staff had used to make patient reminder calls, from total payroll, producing an initial savings of $20,904. The annual cost of the automated call reminder system was estimated at $4,680 ($0.15 per call X 120 calls X 260 days per year). Together this would produce a net savings of $16,224 ($20,904 - $4,680). The other approach would simply shift staff time to other duties which would actually be a cost increase of $4,680, the cost of the added automated call reminder system. There were currently other areas in the clinic which could utilize additional staff so the decision was made not to immediately reduce FTE but to re-evaluate replacing the next vacant front office staff position. A very positive feature of the proposed automated call reminder system was the ability to make these calls in up to six different languages. The clinic served a large population of patients who spoke Spanish, Russian, Vietnamese, Cantonese and Somali as their only or primary language. Perhaps because the appointment information was not clearly understood by them or the reminder calls to them were skipped, it seemed these patients had a higher no-show rate than the general patient population. If a patient missed an appointment, an automated call would be made two days later requesting the patient to call and reschedule the missed appointment. 8

10 When the clinic staff heard about the possibility of using an automated call reminder system they began to directly lobby for it to the clinic manager and to the clinicians. The possibility of never having to make reminder calls again was the best thing that would ever happen to the clinic and the staff promised they could get so much other work done if those five hours of reminder calls every day went away. V. Decision Made and Action Taken: Concerns that the automated call reminder system would be too impersonal, would lead to patient dissatisfaction, and, ultimately, might result in the loss of patients needed to be immediately addressed. The clinic manager requested references from other local medical clinics using an automated call reminder system. Reports from these clinics were very positive. Clinicians still had some concerns but agreed the issue of patient satisfaction could be readdressed after system implementation. The clinic leadership met with both the PM vendor and the automated call reminder system vendor and a decision was made to sign a six-month commitment. The staff would continue to make reminder calls until the new system was operational. VI. Report on Implementation of Plan Chosen: The clinic manager and lead front office personnel met with the implementation staff from the automated call reminder system company. Six weeks of preparation 9

11 were needed to go live with the new automated call reminder system. Messages were recorded in six languages: Spanish, Russian, Vietnamese, Chinese, Somali and Cambodian. Test calls were made to staff and clinicians. Two weeks prior to go live, signs were placed in the clinic lobby and mailers were sent to clinic patients informing them of the change to the automated call reminder system. To avoid the weekend and because Monday is a heavy incoming phone day, the system was implemented on a Tuesday. The clinicians wanted staff available if patients called with questions, concerns, or complaints. Since calls were made two days prior to appointments starting at 5 PM in the afternoon, Tuesday s reminder calls were for Thursday s appointments. No patients called the clinic to complain about the automated call system and no changes were apparent in the clinic patient flow on Thursday or Friday or in the following days and weeks. The clinic manager did receive some patient calls but these calls were mainly from patients wishing to update their telephone contact information and a few calls from bilingual patients requesting the message in the language of their choice. In addition, over the next several months the front office staff asked patients to update their current contact information and their preferred language which was then updated in the PM system. The main complaint about the automated system came from patients who wanted the option of being able to talk to clinic staff. The system menu initially only allowed two options: #1 to confirm and #2 to cancel. With help from the PM 10

12 vendor and the automated call reminder system company, the clinic added an option to push #0 which transferred the call directly to clinic personnel or, if the phone could not be answered, to a voice mailbox. There was an additional cost of $.08 for each call transferred in this way. VII. Significance of Outcomes and Lessons Learned: The new system automatically updated the PM with all responses from patients and the confirmed and canceled codes were visible on the appointment schedule. Daily, the clinic received an report listing each patient s name, phone number, and the time the call was made as well as the previous day s total calls and count by answered type: Answered & did not listen to entire message: hung up Answered and listened to entire message: no response Answered and pressed yes Answered and pressed no Answered and pressed call clinic Answered and delivered message to answering machine Phone busy (three call attempts are made and count as one call) No answer Invalid phone number Out of order 11

13 The front office staff did have to update the PM computer phone number field for invalid phone number and out of order responses. The clinic does not use any other report from the automated system and hasn t needed to do further analyses. The automated call reminder system has been in use for three years. One feature used many times is the instant messenger for urgent scheduling changes. This is especially helpful when the clinic is closed due to inclement weather or if a physician is sick and unable to keep scheduled appointments. During one week it was discovered that no calls had been made by the automated call reminder system, apparently caused by an error in the clinic s electronic interface. The error was resolved and daily s are now generated which confirm when files have been received from the system. A review of the first year s call volume bills revealed that volume grew from 120 to 157 calls per day. There were also some additional call charges for a few special situations and for no show follow-up calls. Transferred patient calls were about 7 per day and the clinic operated 251 days that year. The total cost for the first year was calculated at $6,051: (157 calls per day X 251 days X $.15 per call) + (7 transferred calls per day X 251 days X $.08 per transferred call). The cost per call has remained at $0.15 for the past three years although it is anticipated the cost may increase to $0.17 per call in the next year. 12

14 Perhaps the most significant outcome, patients were much more accepting of automated reminder calls than anyone expected and, in fact, many patients actually preferred the automated call because they were not required to talk to anyone if they did not really need to. Patients liked the ability to just push a button. The additional option, however, of being able to instantly talk to a person, if needed, was also a major satisfier for any patients who had issues requiring attention. In all cases patients appreciated a call, whether automated or from a person, rather than no call at all. VIII. Recommendations for Other Managers: Patient response to the automated call reminder system was far better than anyone anticipated and has only caused a few patient complaints. Patients have become much more accepting of new technology. The system is currently being reviewed for an upgrade with a new reminder call preference enhancement allowing patients to continue receiving phone calls or they can be contacted by or text message. Lab Ready Messaging is another enhancement available which interfaces with the lab component of an Electronic Medical Record (EMR) and notifies patients when they have lab results available. Patients can then call the clinic or log on by secure web access to the EMR to find their lab results. The clinic plans to incorporate this enhancement after the conversion from paper medical records to an Electronic Medical Record is complete. 13

15 The clinic leadership, clinicians, and the staff highly recommend the use of an automated call reminder system for practices using an electronic practice management system. The clinic s no show rate remained solid at 4.8%. When the math was done, the clinic did not save money by converting to the automated system because the clinic did not reduce staff. But what they did find was an efficient, cost-effective, and staff-friendly method to insure that patients make it to the clinic for their scheduled appointment. 14