Dr. Dowling is president of Dowling Medical Director Services, a private health care consulting firm specializing in quality improvement, clinical informatics, and health care policy affecting specialty care. He is the former medical director of a large,
Robert A. Dowling, MD, examines a key part of the new patient intake process-the “new patient form.”
Declining reimbursement and rising costs have resulted in economic pressures for many practicing urologists in the past decade. The usual response to such pressures in a fee-for-service system, where reimbursement rates are largely fixed by outside influence, is to increase production (see more patients) or increase efficiency (reduce the cost of seeing patients).
An efficient, high-volume urology practice must prioritize new patient visits-often on short notice-to remain competitive and profitable. In this article, I will examine and challenge your thinking about a key part of the new patient intake process-the “new patient form.” (For a look at how this form came to be used in urology practices, see “The evolution of new patient forms.")
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In my experience, it is not unusual for the new patient form to be at the center of inefficiency in the urology practice. Some practices mail the forms to new patients with instructions to fill out prior to the visit; others direct the patient to download the form from a patient portal or website.
Despite these efforts (which come at some cost), a significant number of patients will arrive for their appointment having to complete the paperwork on site; an admonition to “arrive early to complete paperwork” is neither a patient satisfier nor likely to consistently achieve results. This can begin an interruption in the smooth flow of patients, create a bottleneck, and contribute to the “trains not running on time.” The bottleneck is exacerbated as the medical assistant or provider verifies, corrects, and transfers the information to the EHR. New patient visits-especially with a complex patient-can become dreaded rather than welcomed, and result in a less-than-optimal first impression.
Next:A better way
A better way
What if there were a better way-even if just for a fraction of your new patients? I recently visited a practice where there is no new patient clinical form. The new patient process works like this: At the time of a referral or appointment, meticulous attention is given to obtaining the patient’s medical records. In most cases, the referring physician or hospital faxes a copy of their new patient visit form.
Next, a strict chart preparation process for the following day’s office visits is undertaken by the medical assistant. In the case of a new patient, the EHR is populated with as much information (medical history) as possible from the outside records. Using the EHR, the medical assistant generates a call to a national prescribing network to obtain the medication history of the patient. Finally, where relevant and possible, a local health information exchange is queried for lab results-such as a recent PSA that may itself be the reason for the visit.
Once the new patient arrives for their appointment, the medical assistant verifies the second-hand information, corrects any significant errors or omissions, and completes the intake. Of course, the system is not perfect, and when a new patient arrives without such information, the medical assistant gathers the information in real-time interview style.
I made several observations of this approach. First, it requires an investment of time on the front end, before the patient arrives. The assistants I observed-the same ones who will see the patient-can do this chart prep more quickly and efficiently than waiting for the actual visit. The time spent on the front end is returned and more when the appointment occurs.
Second, it requires “training” referral sources to consistently and willingly push the records of new patients; minimizing that burden on referring physician offices would be important in a competitive marketplace to keep your sources happy. Third, it results in an excellent first impression for the patient; they travel quickly from the reception area to the clinic, where they are met by someone who already knows their story. They feel like their providers are clearly communicating and coordinating.
Fourth, this approach identifies potential problems with the new patient visit before they occur-missing information, inappropriate referrals, or even a need for a different site of service; these problems can be addressed before they disrupt a busy clinic day. Finally, and perhaps most importantly, the well-trained medical assistant can gather and transfer this information more efficiently and accurately from another medical professional’s document than trying to do so from a patient. When it isn’t available, it is faster to ask the patient once than to read a form and ask the patient to verify the form.
Bottom line: Look at your new patient process to see if intensive EHR chart prep can completely eliminate the need for new patient clinical forms. This approach can save time, create a favorable new patient experience, and strengthen your relationship with referral sources.
Next:The evolution of new patient formsThe evolution of new patient forms
In training and a career spanning over 30 years, I have seen many ways to gather the medical history from a new patient in urology. Before the advent of reimbursement based on “evaluation and management” (E&M) codes, it was common for specialists to fall back on history-taking skills learned in medical school and residency and concentrate almost entirely on the “specialty” problem and pertinent major medical problems that could impact treatment of that problem.
The medical record in this era was paper based, highly personalized, and not widely shared with payers or other providers. Its main purpose was to memorialize the thoughts of the treating physician from encounter to encounter, and it was used almost exclusively by a physician.
The introduction of coding guidelines and the E&M reimbursement paradigm changed the landscape significantly for urologists and other specialists. First, the history documentation requirements for a new patient visit were explicitly different and more comprehensive than for an established patient. Second, the requirements included information that traditionally was not gathered or used in the evaluation and treatment of urologic patients-most notably a general family history and a thorough review of all organ systems with positive and negative symptoms.
Third, the coding guidelines were highly proscriptive and quantitative in requirements for documentation; reimbursement was tied to the amount of information collected, the manner in which it was documented, and the complexity of the presenting problem. Finally, the adoption of these guidelines by Medicare brought the specter of benchmarks, audits, and enforcement of fraud and abuse statutes.
Coding guidelines, then, were a major influence on how new patient information was gathered and documented. A very common response to this influence was to ask the patient to fill out this information on a “new patient form,” which was designed and configured to meet the requirements of the coding guidelines. New patient forms filled out by the patient often served as the only documentation of current medications, past medical history, family history, social history, and review of systems. The forms were simply part of the chart, and were archived to be retrieved in the event of an audit.
New patient forms were further institutionalized with the widespread adoption of EHRs. The EHR itself was organized primarily to support the E&M level model of billing and reimbursement. Many EHRs can calculate the E&M level from the data entered, and this created incentives to systematically populate long templates, problem lists, and pertinent negative findings for a new patient that arguably add little to patient care-but are necessary to defend a level of reimbursement. Some vendors developed systems that could digitally scan patient forms and populate the EHR.
Most urology practices simply modified their new patient form to resemble the EHR form, or vice versa; many then delegated the transfer of that data to medical assistants. As a result, new patient forms have become an ingrained part of the intake process and typically consume significant time to fill out (by patients) and transfer (by physicians or their delegates). Many practices then scan the forms into the medical record, adding more cost but no value.
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