Hi everyone,
I am trying to improve on a schedule for ophthalmology. In ophthalmology the evaluation is divided into several parts;
1)Paperwork
2)Visual screening by tech
3)First part of exam with Dr
4)Dialtion (about 20min)
5)Second part of exam eith Dr
Have tried creating separate Categories (with different colors) for these parts, which makes it very flexible, but this can be difficult for the person scheduling to see where to schedule additional patients when the schedule begins to to fill. The object being to not overlap the Drs time.
We used to have a fixed schedule having a variety of different types of exams for the scheduling person to chose from but I can’t find a way to do this with OpenEMR.
Scheduling types of exam rather categories of exams should be easier for the front desk. There are too many moving parts with the category approach. The simpler we make it for the front desk, the less likely scheduling conflicts.
I am sure that you, in the past, have given the appointment secretary a scheduling schema. For example, 30 minutes for comprehensive exams, visual fields and A-scans; 15 minutes for intermediate, pre-op and post-op exams; etc. I am sure you told her not to book the long appointments back to back.
Checking in to do the paperwork, visual screening by the technician and the patient waiting for the Tropicamide to work don’t need to be part of the appointment schedule because you are the “rate limiting factor”. If you get bogged down, it slows the entire schedule (like the day when you had to see 4 extra patients from being on call to the ER) and usually not the other way round.
It is quite simple for the secretary to go to the Add Event dialog to increase the length of the appointment to 30 minutes on a calendar with 15 minutes interval (as you already know). It is also good that she has this extra step so as to help her remember not to overbook. But it is nice that she can overbook, when you are on call. In case you are unaware of how to advance the months quickly or to change the start day in the Post Nuke Calendar from Monday to Sunday, see this.
Because you have the twin task of implementing OpenEMR and preparing for Meaningful Use Attestation simultaneously, each tall orders in their own right; I think it is better to adapt OpenEMR to sucessful office practices that had served you well rather than to devise new and untried practices which may or may not work. There will be plenty of time for experimentation and refinement next year.
is your answer not an over simplification of the tasks you call daily work scheme? There are at least three persons involved. One person can do only one task a time. These to be scheduled tasks are all sequential. One task has to be done after another on a first available to do a task scheme base. All involved for one patient have more things to do. If you plan a dilatation and the dilatation ends in OFF-time, there is trouble. If a patient is scheduled for dilatation before the paperwork is done there is trouble.
What this doctor needs is a schedule where there are free slots in sequential order for three investigating participants (doctors/assistants etc.) and four sequential tasks that won’t interfere with others schedules.
In daily practice it translates into:
Intake
Please sit down and the doctor will call you.
Examination etc.
Please sit down the assistant will call you for dilatation
Assistant give dilatation and examination follows.
Please sit down assistant will call you for a next appointment…
And all participants including the patient have their own time schedule and need their lunch hours and off time.
Or is this the wrong impression of the Ophthalmic work flow?
In scheduling appointments it should be as simple as possible for the poor secretary’s sake so that she does not end up with Alopecia secondary to an unwieldy and complex calendar but not so simple as to have scheduling conflicts.
Henry’s rate of work determines how fast the work gets done. It really does not depend on the front desk getting the Demographics nor the patients waiting for dilation so that should not be a part of the schedule. Usually the patients have been checked in (insurance cards scanned, copays collected, personal information updated), their eyes dilated to 7 mm; yet they are still waiting (patiently, we hope) for the doctor to see them.
I don’t think our work flow is markedly different from our colleagues. It is my impression from observing other non-Eye practices that the holdup is the physician (the rate limiting factor) and not anyone else. I am going on the assumption that the physician/office manager has staff working at maximal efficiency, which is why I said “maybe”. If staff is catching up on Facebook or texting friends instead of caring for patients, all bets are off.
Now suppose the bets are on, suppose everybody works with a tablet and,
likes to Twitter, Instagram, and FB… this doctor need a Web-base Openemr version, a version with activity alerts.
PING… Dr. is ready to see the next dilated patient… Ping doctor is ready to see the next medical intake… Ping Ping Ping, there is are crises in room 7 and 8 due to allergic reaction on some medication , …, …, …, ping ping ping Twitter … doctor, we need you to explain the procedures to be scheduled, ping … ping … OpenEMR can not be reached due to lack of Server connections… ping, ping, Pimm…
It makes you think,do we really need IT for scheduling everything?
Technology, be it paper or the Internet, is neither inherently good or bad; it’s how we use it.
Case in point.
A little resident, while on morning rounds, was told by the attending to take the patient off Warfarin because the coagulation studies were next to the critically low end. The little resident was about to d/c the order for the Warfarin on her I-Pad, when she receives a text for a party with friends that evening.
Of course, she texts back that she would love to; forgets to write the order; the patient expires from a massive Cerebral Hemorrhage 2 days later.
The rest of us gets to learn about it because the hospital was sued by the family; our malpractice mutual carrier had to settle instead of fighting the case and this becomes a case study of what not to do during morning rounds.
While distraction was certainly the root cause, errors like this occur because of system wide problems.
because of the robust CPOE system, neither the intern nor resident reviewed the medication list for the next few days so no one recognized that the patient was still receiving the warfarin.
I read about it in our mutual malpractice carrier’s quarterly news letter. Because the patient died and because it was not defensible, our malpractice company had to settle. I don’t recall the sum, but it was not a small amount.
Unfortunately no technology solves the problem of the paucity of common sense and attention to duty.
Regarding distraction, as an intern/resident there are many (in addition to lack of sleep); could of easily been an official page rather than a personal text that could of “caused” the debacle. One of the jobs of an intern taking care of the patient is to read/track the MAR (med admin record; the stuff a patient is actually getting) every morning for rounds; that’s likely where the breakdown was if you ask me.
-brady
Regarding distraction, as an intern/resident there are many (in addition to lack of sleep); could of easily been an official page rather than a personal text that could of “caused” the debacle. One of the jobs of an intern taking care of the patient is to read/track the MAR (med admin record; the stuff a patient is actually getting) every morning for rounds; that’s likely where the breakdown was if you ask me.
Before I specifically address your post, I will make 6 presumptions.
The Comprehensive Exam for new and established patients takes the same amount of time.
Only the patients with possible Retinal symptoms will have a dilated exam.
You, not the technician, elicits the History.
It takes you no more than 30 minutes to do steps 3 and 5.
All visits fall either in the 30 or 15 minutes (or their equivalent) blocks.
The technician gets done before you do.
If all 6 are true, then it is merely a matter of deciding which are the long exams and which are the short exams. For exams that may require a bit more than 30 minutes of your time, I would suggest scheduling them close to lunch time or at the end of the day when spillover is not a problem.
The front desk can be instructed to enter the reason for the exam and the anticipated type of exam in the Add Event dialog, giving you a detailed and panoramic view of the schedule. With your instructions and over time, the front will know not to book two Comprehensive Exam for new patients in close proximity.
If you don’t have a system of abbreviations for exam types, consider adopting one. For example: CN, comprehensive exam, new patient; CE, comprehensive exam, established patient; IE, intermediate exam, established patient; DM, Diabetic screening which would entail a comprehensive exam with dilation; et cetera.
Even if a 15 minutes slot is not completely used up, it provides a small reserve for catch-up with other appointments that run over despite your best efforts.
Things will be more choatic when you are on call. Patients are generally understanding of your office having to care for patients from the Emergency Room. For the less gracious patient, this rationale usually mollifies them: If you had an emergency, you would want us to work you in and you would want the other patients, who scheduled their appointments before you, to be understanding.
This is all OK, if you want a one doctor one patient encounter.
Streaming the flow with more examination rooms and patients overlapping during history and examination time and want to attend five clients at the same time you need some flow in the agenda where some patients can be scheduled at the same time in different states of work flow where the logic next steps can be followed as well as where the patient is located and what the assisting personnel know what to do.
Might sound crazy, but I once had a teaching doctor doing exactly what I try to get into my suggestions. See five patients at the same time, in the days there were no computers. Two hours patient waterfall, half hour free time to do some extra coffee and administration, and another one and a half hour consultations and examinations. Doctor and clients were happy and patients got treated good and efficiently. Only problem what really screwed up the scheme was the occasionally unexpected emergency, who was treated on a preference encounter base, who messed up the schedule.
This scheduling problem is not specific to Ophthalmology practices. Instead of dilation it could be EKG or treadmill or pregnancy test or allergy test to be followed by interpretation of results and plan.
It will be a great to consider functionality of appointment template that specifies related appointments with different resources. In your case it will 3 appointments - #1 with tech+ophthalmologist, #2 with a room(?) and #3 with ophthalmologist. If there is cancellation, all 3 are cancelled but you should have an option to ‘reschedule’ last 2 appointments as a group in case patient decides to come back at a later date.
Our experience shows patients appreciate when they are given option to come back rather than a long encounter. To ensure follow up, offer of no additional co-pay for deferred visit works well.