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Optimizing speciality clinics in a telemedicine world

  • Mohan Giridharadas
    Mohan Giridharadas

    Founder & CEO, LeanTaaS

  • Sanjeev Agrawal
    Sanjeev Agrawal

    President and COO, LeanTaaS

Patients resign themselves to this simple fact every time they have an appointment with a specialist: nearly half of the total time that they spend in the clinic will be spent waiting alone.

This clinic “alone time” begins in the waiting room, both before and after check-in. Then there is the time spent perched on the paper-covered bed in the examination room, the time spent waiting for paperwork or prescriptions after seeing the physician, the time spent hanging out in the intake area of the phlebotomy lab waiting to have your blood drawn, and so on. It is not at all unusual to spend an hour or two in a clinic in order to receive less than ten minutes of “face-time” with your treating professionals.

It doesn’t have to be this way – most providers establish their appointment templates using “rules of thumb” such as 4 new patient visits and 10 return patients visits per day in clinic or “administrative standards” such as new patient appointments will have a 60 minute slot while slots for returning patients will be 30 minutes in duration. This level of oversimplification is doomed to fail before the day even gets going. This is because the demand signal (number of patients, type of patient, duration of their visit, etc.) is impossible to precisely predict for a given day in the future and the supply signal (availability of the provider, staff, examination room, equipment, etc.) is also difficult to predict. Added to this, is the reality that there will be cancelations, add-ons and no-shows, providers and staff will run late, rooms will be occupied and equipment will be suddenly unavailable. Therefore, any attempt to simply “wing it and hope it works out” cannot possibly succeed.

One of the most profound insights we struck upon when studying the processes of specialty clinics was this: providers are dramatically different from one another in the manner in which they treat each type of patient. However, they are remarkably consistent with themselves as to how they execute each type of patient visit.

The choreography for each type of patient visit is an elaborate “dance sequence” that is unique to each provider. This includes activities that may be taken by their Medical Assistants, Nurses or Residents. One step may take three minutes while another takes eight minutes – but the steps need to be performed in a specific order every time.

This “dance sequence” can be captured in mathematical terms, and then modeled using simulation techniques so that it is possible to predict the manner in which the day will unfold for any given sequence of appointments. A clinic template can therefore be optimized without changing how providers see their patients, but instead changing the order in which the patients show up to the provider. We call this mathematical capture of the “dance sequence” the “provider fingerprint” since it is intended to describe the unique manner in which that specific provider executes each type of patient visit.

Each specialty clinic deals with a substantial number of last-minute changes that need to be addressed on a daily and a moment-to-moment basis. These include cancellations, requests for new appointments, modifications to existing appointments that may change the duration of those appointments, and so on.

Today, most specialty clinics use a gut-feel approach to solving scheduling problems. They look at a calendar and make intuitive adjustments. “Calendar-inspection” methods can work for scheduling conference rooms or tennis courts, but it does not work well for complex appointments with variable durations needing a different set of constrained resources.

Front-line staff need tools that help them rapidly make intelligent decisions by simulating various scenarios and observing their likely impact on key operational parameters, such as average visit length and expected end-time for the clinic on that day. A source of interpersonal tension is also removed, as individuals no longer blame one another for causing operational delays that adversely affect everyone.

Clinics and health systems had spent the prior 3-4 years talking about deploying a virtual platform to enable telemedicine. Suddenly, within the initial weeks of the COVID crisis, clinics went from zero telemedicine appointments to conducting 60-70% of their appointments over a virtual platform. Although the level of telemedicine appointments has somewhat reduced, virtual appointments are here to stay – and their steady state usage level will vary significantly by practice area.

The new reality of a subset of appointments being conducted over a virtual platform does not in any way undermine the logic of a provider “fingerprint” – all it does is create a new type of appointment – the telemedicine appointment – which has its own unique sequence (e.g., it probably does not rely on the choreography of various support team members going in and out of the examination room – instead it is likely a simple 15-20 minute Zoom call that requires the provider to be in a fixed location for the duration of the call).

The presence of telemedicine appointments interspersed with physical appointments in a specialty clinic leads to a core planning decision – should the provider set aside “blocks of time” (e.g., all morning or all afternoon) for telemedicine appointments and then use the remainder of the time for physical appointments?

It is likely to be more effective to keep small blocks of time (20 minutes) at several points in time throughout the day for 1-2 quick telemedicine calls. It is important to schedule physical appointments earlier in the day so that follow-up appointments are possible within the same day. Pushing telemedicine appointments to the end of the day will work well since it is unlikely that any follow-up actions will be needed that very day (e.g., a biopsy or a procedure).

Once we obtain some real world evidence on the volume, duration and mix of telemedicine appointments, we will be able to mine the historical patterns of telemedicine appointments and modify the fingerprint and simulation approaches to incorporate this new type of appointment and be exactly as effective in improving patient flow, reducing wait time for patients and, above all, improving access for all patients by creating more appointment slots in any given week than were possible using simple rules of thumb.

This post originally appeared on the Forbes Marketplace blog.

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