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Peering into the Office of the Future

September 2003

I magine an office where prompt appointments are the norm, with patient visits scheduled the same week if not the same day patients call. In this office, mid-level providers such as physician assistants (PAs) and nurse practitioners (NPs) deliver much of the routine care, while the dermatologist spends the bulk of his or her time on the most complex and challenging cases. Also imagine that the patients who come to this dermatology practice have first received an appropriate level of care at their primary care provider (PCP), and that only after the case extends beyond the PCP’s reach is the patient referred to the dermatologist. Imagine, too, that patient information and clinical data are stored and accessed electronically, so that the dermatologist can call up information quickly. If that scenario characterizes your current dermatology practice, congratulate yourself on having an advanced office. If not, know that forces today are propelling the dermatology practice in this direction. Experts are exploring ways to restructure the clinical office to make the most effective use of clinicians’ time, press ahead with technology, and enhance patient care. In this article, we’ll look at the forces driving this change and offer practical steps to move your practice into this brave new world. But first, let’s examine how extensive the problem of delivering care has become. Big changes “Health care harms patients too frequently and routinely fails to deliver its potential benefits. Indeed, between the healthcare that we now have and the healthcare that we could have lies not just a gap, but a chasm.” So says a summary of the March 2001 Institute of Medicine report Crossing the Quality Chasm: A New Health System for the 21st Century. “Merely making incremental improvements in current systems of care will not suffice,” says the summary of this widely disseminated report. The report offers 10 rules for reshaping care (see “10 Rules for Redesigning Healthcare”). Meanwhile, at the Boston-based Institute for Healthcare Improvement (IHI), the Idealized Design of Clinical Office Practices (IDCOP) initiative has taken on no less task than the “comprehensive redesign of the office system as a whole.” The aim, IHI says, is to significantly improve the performance of clinical office practices through dramatic and sustained system-level changes. Begun in 1999, the redesign initiative was predicated on the understanding that today’s office “fundamentally is broken,” according to Charles M. Kilo, M.D., fellow at IHI and former leader of the IDCOP initiative. He’s also CEO of GreenField Health, Portland, OR. Given such a “dysfunctional” office setting, rethinking care delivery forms a duty, he suggests. “These are deep meaningful, system-level redesign issues” that will take years to get into place, he says. Four themes The IDCOP initiative forms a tangible way to think about tomorrow’s clinical office. IDCOP framed its work around four major themes: 1. Access 2. Interaction 3. Reliability 4. Vitality. We’ll look more closely at each area, and delve into related areas of technology and the physical layout of the office. Currently, the IDCOP initiative continues in a follow-on IHI effort called Impact. Launched in June 2002, Impact is designed to deploy the findings from IDCOP more widely. Gaining Access The first theme, access, means that care should be available 24 hours a day, 7 days a week, 365 days a year, according to IDCOP. For optimal access, various major processes are needed, among them group visit models and open-access scheduling. In group visits, a number of patients meet with a provider, perhaps a nurse. This provides an efficient way to deliver the same message to a collection of patients, instead of one-on-one encounters. Open-access scheduling enables patients to schedule non-emergent appointments today, or within the week. That’s a far cry from the months that it typically takes for appointment. Open access does work in specialties, according to Gordon Moore, M.D., a faculty member at IHI and associate professor of family medicine at the University of Rochester Medical Center, Rochester, NY. Bringing open access into reality involves a careful process, including working down the backlog of patients. And that can involve help from midlevel providers, as we’ll discuss in a moment. Certainly, demand can exceed capacity, says Dr. Kilo, and that can mean long wait times — an important point given today’s dermatology shortage. But if there is “relative equilibrium,” you can work down the backlog, leave much of the workday open, and fill the schedule based on daily demand, he says. Some 30% to 50% of slots will still be booked ahead, he notes. Scheduling represents one of the most “antiquated” parts of U.S. healthcare, suggests Casselberry, FL-based consultant Inga Ellzey, CEO of Inga Ellzey Practice Group, Inc. Try open access one day a week, she recommends — though you’ll need appropriate staffing and support. Quick access to services is a competitive advantage in many businesses, notes consultant Jack Valancy, M.B.A., Cleveland Heights, OH. If you have a 3-month backlog, you’re vulnerable to a competitor who has a smaller or no backlog, he points out. “You’re immediately at a competitive disadvantage,” he says. Sounding a more critical note, consultant Gil Weber, M.B.A., Davie, FL, regards open access as a wonderful idea, but somewhat impractical in implementation. Unless another doctor can help, how can a practice offer same-day scheduling, he asks. (And at a specialty level, same-week scheduling is probably an appropriate level of open access, suggests Dr. Moore.) Service Agreements To move toward a more responsive scheduling system, specialists and PCPs can create service agreements to detail appropriate referral criteria, suggests Dr. Moore. Recently, for instance, gastroenterologists in Rochester, NY, discussed this idea with the family practice community there, says Dr. Moore. Such agreements can help avoid the “primary care dump” says Dr. Moore. “It’s turning down some of the noise.” Such a setup would go far in reducing a patient backlog, agrees Syracuse, NY-based consultant Rosemarie Nelson, M.S., an independent consultant with the Medical Group Management Association. But she worries about a backlash from primary care providers, in that the specialist may be perceived as telling the PCP that he isn’t doing his or her job. Such behavior, she suggests, might alienate a key referral source. Midlevel Providers Streamlining scheduling and care delivery also involves the effective use of midlevel providers. The effective use of these providers forms part of her future vision of dermatology, according to Pat Rutherford, R.N., M.S., IHI vice president and current coordinator of IHI’s Office Practice redesign effort. Such providers can handle simpler conditions or manage the patient with a chronic condition who needs multiple appointments. Doing so involves leveraging the expert time of the dermatologist, she says. Using a PA or an NP is “absolutely the way to go to increase your volume without taking on the full cost of a physician,” says Mr. Weber. In dermatology, a PA who is well-trained in dermatology can be a tremendous practice enhancement, he suggests. On a related note, Ms. Ellzey promotes the concept of “one room, one nurse.” With this plan, a medical assistant or nurse is assigned to each exam room. When the patient arrives, the nurse has already taken the patient history and, if needed, had the patient undress, speeding the doctor’s time. At present, dermatologists often use mid-level providers. Over one-third of respondents to a late 2002 American Academy of Dermatology (AAD) member survey said they used physician extenders in their practice. Some 15.5% reported having a PA; 7.7% an NP; other nurse, 14.6%; and aesthetician, 10%, says Alexa Boer Kimball, M.D., M.P.H., assistant professor, dermatology at Stanford University Medical Center and chairperson of the AAD Workforce Task Force. Norfolk, VA-based Pariser Dermatology Specialists, Ltd., has created the position of dermatology technician to help manage the 10,000 patient visits per month handled by the practice’s nine dermatologists in six locations. The practice also has one PA. These dermatology technicians, who are unlicensed, perform the technical portion of minor procedures, such as tiny biopsies, dermatologist David Pariser, M.D., says. He stresses that these individuals do only technical procedures that don’t involve medical judgment. Each dermatologist works with at least one of these dermatology technicians. Finally, Ms. Rutherford sees in her vision of dermatology that PCPs can use digital cameras to send pictures to specialists for “real-time” consultations. Currently, teledermatology is being used to deliver care across long distances (see “Teledermatology: The Future of Medical Dermatology?” March 2003). Interaction The second of IDCOP’s four themes, interaction, suggests that “every patient is the only patient.” Among the major processes needed for optimal interaction: customizing the style and timing of communications; shared decision-making technologies; Web-based care and information; and electronic communication with patients such as e-mail. In customizing the style and timing of communications, clinicians can use a standard approach, suggests Dr. Moore, that helps them tailor recommendations. For instance, asking questions in a standard manner, such as in assessing depression, can help uncover patient problems without the doctor’s bias entering in. Shared decision-making technologies attempt to understand the context in which a person lives. The clinician and patient might look at clinical information together, tailoring the therapy based on the patient’s values. As for Web-based care, with coaching, patients can also use the Web to access information on their own. While not yet common, trading e-mail with patients can provide an interaction when an in-person patient visit isn’t needed. Reimbursement and security issues need to be addressed here. Supporting Staff While interaction with patients is crucial, staff interaction also plays a major role in effective clinical office design. “The boss is a role model,” notes consultant Valancy. Not only must the doctor model appropriate behaviors and skills, but also has to give feedback to staff. Hiring well is part of the key. “Hire for attitude, train for skill,” notes Mr. Valancy. It’s much easier to train someone with a good attitude than to try and change a skilled practitioner with a poor attitude. Make sure to encourage business office staff to attend educational seminars, suggests Jill Whitney, M.B.A., senior consultant at The Coker Group, Atlanta, GA. The doctor’s office should pay for seminars and CE credits, she says. Reliability IDCOP’s third theme, reliability, means that “‘all and only’ effective and helpful care is given.” All of the practice’s activities are based on best-known science (referred to usually as evidence-based medicine); overuse, underuse, and misuse of care are avoided. The major processes for optimal reliability, says IDCOP, include master scheduling of resources; proactive patient population management with registries; and incorporation of new science into practice and the adoption of best practices. Clinicians, notes Dr. Kilo, have to feel humbled by the rapid expansion of the medical knowledge base. Realistically, humans can’t manage that torrent of information, so that clinicians need assistance from technology. Master scheduling involves appropriate use of room, staff, providers, and equipment. “The capacity,” says Dr. Moore, “has to match the demand or else we suffer.” In managing patients, clinicians need to develop systems that allow appropriate follow-up. If, for instance, car care company Jiffy Lube can notify customers when a car’s oil change is due, “how can we in healthcare be less proactive?” questions Dr. Moore. In using best science, the healthcare team not only must be aware of the science, but bring it to bear on clinical work. Vitality Last, vitality means that “the practice is sustainable and continually innovating,” according to IDCOP. This includes financial viability, as well as continual improvement. “We have to decompress our work,” says Dr. Moore; working in or close to burnout mode must cease. What’s more, clinicians have to be “reasonably compensated for our work.” That not only includes adequate payment, but finding ways to reduce costs. Having the appropriate provider do the work can aid in that effort. Technology Advances In tomorrow’s clinical practice, few forces are likely to have greater impact than technology. This ranges from sophisticated electronic medical record (EMR) systems to e-mail interaction with patients, as noted earlier. For instance, practices should investigate scanning technology, says Ms. Ellzey. You can scan patient registration forms, superbills, end-of-month reports, and more. For medical records, maintain 1-1/2 to 2 years of active paper charts; the rest you can scan, she says. This dramatically saves on storage space and can improve your ability to access records. Make sure, says Mr. Weber, that the EMR integrates with your practice management system. The two need to communicate with each other. For patient communications, patients could, for instance, enter a query on a practice website or via e-mail instead of making a phone calls, says consultant Ms. Nelson. This could start the documentation for the patient interaction. Even intake information might be placed on the Web site. In 1996, Pariser’s practice instituted a homegrown online EMR system. Records are accessible instantly. What’s more, all office forms, as for procedures and policies, exist on the network. Looking at Layout Although electronic communication may change some of the ways in which care is delivered, dermatologists in the future will physically deliver care as they do now — in the office. The office’s physical design must help the practice make the best use of staff time and provide a warm environment. Make sure to provide enough room for patient care as opposed to administrative services, notes Ms. Ellzey. Consider outsourcing such operations as billing or perhaps moving administrative staff to a less expensive setting. Waiting rooms tend to be too small, says Mr. Weber. And avoid handwritten notes plastered all over your front reception area, which detract from your office’s professional look. Make the environment patient-friendly, notes Ms. Ellzey. Consider, for instance, installing an automatic door. Also consider traffic patterns. Traditionally, doctors walk up and down a long hallway to visit patients, says Mr. Valancy. A pod-type arrangement might be far more convenient. In this setup, patient rooms are located on two or even three sides of the area with a shorter hallway, cutting down on physician walking. Also, he suggests, locate business and clinical areas so that front-desk staffers can talk to administrative staff, instead of being isolated from each other. Equip your exam rooms identically. You’ll save time if supplies and equipment are in the same place in every room. Everything you need, says Mr. Valancy, should be just a few feet away — you want to have things “literally at your fingertips.” Reinventing the Practice One clear lesson from IDCOP, says Dr. Moore, is that “we can’t just do more. We’re working too hard. “We have to retool; we have to redesign,” he says. “When a practice chooses to reinvent itself, to retool, [it] can achieve different outcomes.” The forces affecting healthcare are too numerous, diverse and powerful to pinpoint what the dermatology practice of the future will be. But given these broad outlines of the future, you can start to morph your practice into a top-notch setting for tomorrow’s delivery of care.

I magine an office where prompt appointments are the norm, with patient visits scheduled the same week if not the same day patients call. In this office, mid-level providers such as physician assistants (PAs) and nurse practitioners (NPs) deliver much of the routine care, while the dermatologist spends the bulk of his or her time on the most complex and challenging cases. Also imagine that the patients who come to this dermatology practice have first received an appropriate level of care at their primary care provider (PCP), and that only after the case extends beyond the PCP’s reach is the patient referred to the dermatologist. Imagine, too, that patient information and clinical data are stored and accessed electronically, so that the dermatologist can call up information quickly. If that scenario characterizes your current dermatology practice, congratulate yourself on having an advanced office. If not, know that forces today are propelling the dermatology practice in this direction. Experts are exploring ways to restructure the clinical office to make the most effective use of clinicians’ time, press ahead with technology, and enhance patient care. In this article, we’ll look at the forces driving this change and offer practical steps to move your practice into this brave new world. But first, let’s examine how extensive the problem of delivering care has become. Big changes “Health care harms patients too frequently and routinely fails to deliver its potential benefits. Indeed, between the healthcare that we now have and the healthcare that we could have lies not just a gap, but a chasm.” So says a summary of the March 2001 Institute of Medicine report Crossing the Quality Chasm: A New Health System for the 21st Century. “Merely making incremental improvements in current systems of care will not suffice,” says the summary of this widely disseminated report. The report offers 10 rules for reshaping care (see “10 Rules for Redesigning Healthcare”). Meanwhile, at the Boston-based Institute for Healthcare Improvement (IHI), the Idealized Design of Clinical Office Practices (IDCOP) initiative has taken on no less task than the “comprehensive redesign of the office system as a whole.” The aim, IHI says, is to significantly improve the performance of clinical office practices through dramatic and sustained system-level changes. Begun in 1999, the redesign initiative was predicated on the understanding that today’s office “fundamentally is broken,” according to Charles M. Kilo, M.D., fellow at IHI and former leader of the IDCOP initiative. He’s also CEO of GreenField Health, Portland, OR. Given such a “dysfunctional” office setting, rethinking care delivery forms a duty, he suggests. “These are deep meaningful, system-level redesign issues” that will take years to get into place, he says. Four themes The IDCOP initiative forms a tangible way to think about tomorrow’s clinical office. IDCOP framed its work around four major themes: 1. Access 2. Interaction 3. Reliability 4. Vitality. We’ll look more closely at each area, and delve into related areas of technology and the physical layout of the office. Currently, the IDCOP initiative continues in a follow-on IHI effort called Impact. Launched in June 2002, Impact is designed to deploy the findings from IDCOP more widely. Gaining Access The first theme, access, means that care should be available 24 hours a day, 7 days a week, 365 days a year, according to IDCOP. For optimal access, various major processes are needed, among them group visit models and open-access scheduling. In group visits, a number of patients meet with a provider, perhaps a nurse. This provides an efficient way to deliver the same message to a collection of patients, instead of one-on-one encounters. Open-access scheduling enables patients to schedule non-emergent appointments today, or within the week. That’s a far cry from the months that it typically takes for appointment. Open access does work in specialties, according to Gordon Moore, M.D., a faculty member at IHI and associate professor of family medicine at the University of Rochester Medical Center, Rochester, NY. Bringing open access into reality involves a careful process, including working down the backlog of patients. And that can involve help from midlevel providers, as we’ll discuss in a moment. Certainly, demand can exceed capacity, says Dr. Kilo, and that can mean long wait times — an important point given today’s dermatology shortage. But if there is “relative equilibrium,” you can work down the backlog, leave much of the workday open, and fill the schedule based on daily demand, he says. Some 30% to 50% of slots will still be booked ahead, he notes. Scheduling represents one of the most “antiquated” parts of U.S. healthcare, suggests Casselberry, FL-based consultant Inga Ellzey, CEO of Inga Ellzey Practice Group, Inc. Try open access one day a week, she recommends — though you’ll need appropriate staffing and support. Quick access to services is a competitive advantage in many businesses, notes consultant Jack Valancy, M.B.A., Cleveland Heights, OH. If you have a 3-month backlog, you’re vulnerable to a competitor who has a smaller or no backlog, he points out. “You’re immediately at a competitive disadvantage,” he says. Sounding a more critical note, consultant Gil Weber, M.B.A., Davie, FL, regards open access as a wonderful idea, but somewhat impractical in implementation. Unless another doctor can help, how can a practice offer same-day scheduling, he asks. (And at a specialty level, same-week scheduling is probably an appropriate level of open access, suggests Dr. Moore.) Service Agreements To move toward a more responsive scheduling system, specialists and PCPs can create service agreements to detail appropriate referral criteria, suggests Dr. Moore. Recently, for instance, gastroenterologists in Rochester, NY, discussed this idea with the family practice community there, says Dr. Moore. Such agreements can help avoid the “primary care dump” says Dr. Moore. “It’s turning down some of the noise.” Such a setup would go far in reducing a patient backlog, agrees Syracuse, NY-based consultant Rosemarie Nelson, M.S., an independent consultant with the Medical Group Management Association. But she worries about a backlash from primary care providers, in that the specialist may be perceived as telling the PCP that he isn’t doing his or her job. Such behavior, she suggests, might alienate a key referral source. Midlevel Providers Streamlining scheduling and care delivery also involves the effective use of midlevel providers. The effective use of these providers forms part of her future vision of dermatology, according to Pat Rutherford, R.N., M.S., IHI vice president and current coordinator of IHI’s Office Practice redesign effort. Such providers can handle simpler conditions or manage the patient with a chronic condition who needs multiple appointments. Doing so involves leveraging the expert time of the dermatologist, she says. Using a PA or an NP is “absolutely the way to go to increase your volume without taking on the full cost of a physician,” says Mr. Weber. In dermatology, a PA who is well-trained in dermatology can be a tremendous practice enhancement, he suggests. On a related note, Ms. Ellzey promotes the concept of “one room, one nurse.” With this plan, a medical assistant or nurse is assigned to each exam room. When the patient arrives, the nurse has already taken the patient history and, if needed, had the patient undress, speeding the doctor’s time. At present, dermatologists often use mid-level providers. Over one-third of respondents to a late 2002 American Academy of Dermatology (AAD) member survey said they used physician extenders in their practice. Some 15.5% reported having a PA; 7.7% an NP; other nurse, 14.6%; and aesthetician, 10%, says Alexa Boer Kimball, M.D., M.P.H., assistant professor, dermatology at Stanford University Medical Center and chairperson of the AAD Workforce Task Force. Norfolk, VA-based Pariser Dermatology Specialists, Ltd., has created the position of dermatology technician to help manage the 10,000 patient visits per month handled by the practice’s nine dermatologists in six locations. The practice also has one PA. These dermatology technicians, who are unlicensed, perform the technical portion of minor procedures, such as tiny biopsies, dermatologist David Pariser, M.D., says. He stresses that these individuals do only technical procedures that don’t involve medical judgment. Each dermatologist works with at least one of these dermatology technicians. Finally, Ms. Rutherford sees in her vision of dermatology that PCPs can use digital cameras to send pictures to specialists for “real-time” consultations. Currently, teledermatology is being used to deliver care across long distances (see “Teledermatology: The Future of Medical Dermatology?” March 2003). Interaction The second of IDCOP’s four themes, interaction, suggests that “every patient is the only patient.” Among the major processes needed for optimal interaction: customizing the style and timing of communications; shared decision-making technologies; Web-based care and information; and electronic communication with patients such as e-mail. In customizing the style and timing of communications, clinicians can use a standard approach, suggests Dr. Moore, that helps them tailor recommendations. For instance, asking questions in a standard manner, such as in assessing depression, can help uncover patient problems without the doctor’s bias entering in. Shared decision-making technologies attempt to understand the context in which a person lives. The clinician and patient might look at clinical information together, tailoring the therapy based on the patient’s values. As for Web-based care, with coaching, patients can also use the Web to access information on their own. While not yet common, trading e-mail with patients can provide an interaction when an in-person patient visit isn’t needed. Reimbursement and security issues need to be addressed here. Supporting Staff While interaction with patients is crucial, staff interaction also plays a major role in effective clinical office design. “The boss is a role model,” notes consultant Valancy. Not only must the doctor model appropriate behaviors and skills, but also has to give feedback to staff. Hiring well is part of the key. “Hire for attitude, train for skill,” notes Mr. Valancy. It’s much easier to train someone with a good attitude than to try and change a skilled practitioner with a poor attitude. Make sure to encourage business office staff to attend educational seminars, suggests Jill Whitney, M.B.A., senior consultant at The Coker Group, Atlanta, GA. The doctor’s office should pay for seminars and CE credits, she says. Reliability IDCOP’s third theme, reliability, means that “‘all and only’ effective and helpful care is given.” All of the practice’s activities are based on best-known science (referred to usually as evidence-based medicine); overuse, underuse, and misuse of care are avoided. The major processes for optimal reliability, says IDCOP, include master scheduling of resources; proactive patient population management with registries; and incorporation of new science into practice and the adoption of best practices. Clinicians, notes Dr. Kilo, have to feel humbled by the rapid expansion of the medical knowledge base. Realistically, humans can’t manage that torrent of information, so that clinicians need assistance from technology. Master scheduling involves appropriate use of room, staff, providers, and equipment. “The capacity,” says Dr. Moore, “has to match the demand or else we suffer.” In managing patients, clinicians need to develop systems that allow appropriate follow-up. If, for instance, car care company Jiffy Lube can notify customers when a car’s oil change is due, “how can we in healthcare be less proactive?” questions Dr. Moore. In using best science, the healthcare team not only must be aware of the science, but bring it to bear on clinical work. Vitality Last, vitality means that “the practice is sustainable and continually innovating,” according to IDCOP. This includes financial viability, as well as continual improvement. “We have to decompress our work,” says Dr. Moore; working in or close to burnout mode must cease. What’s more, clinicians have to be “reasonably compensated for our work.” That not only includes adequate payment, but finding ways to reduce costs. Having the appropriate provider do the work can aid in that effort. Technology Advances In tomorrow’s clinical practice, few forces are likely to have greater impact than technology. This ranges from sophisticated electronic medical record (EMR) systems to e-mail interaction with patients, as noted earlier. For instance, practices should investigate scanning technology, says Ms. Ellzey. You can scan patient registration forms, superbills, end-of-month reports, and more. For medical records, maintain 1-1/2 to 2 years of active paper charts; the rest you can scan, she says. This dramatically saves on storage space and can improve your ability to access records. Make sure, says Mr. Weber, that the EMR integrates with your practice management system. The two need to communicate with each other. For patient communications, patients could, for instance, enter a query on a practice website or via e-mail instead of making a phone calls, says consultant Ms. Nelson. This could start the documentation for the patient interaction. Even intake information might be placed on the Web site. In 1996, Pariser’s practice instituted a homegrown online EMR system. Records are accessible instantly. What’s more, all office forms, as for procedures and policies, exist on the network. Looking at Layout Although electronic communication may change some of the ways in which care is delivered, dermatologists in the future will physically deliver care as they do now — in the office. The office’s physical design must help the practice make the best use of staff time and provide a warm environment. Make sure to provide enough room for patient care as opposed to administrative services, notes Ms. Ellzey. Consider outsourcing such operations as billing or perhaps moving administrative staff to a less expensive setting. Waiting rooms tend to be too small, says Mr. Weber. And avoid handwritten notes plastered all over your front reception area, which detract from your office’s professional look. Make the environment patient-friendly, notes Ms. Ellzey. Consider, for instance, installing an automatic door. Also consider traffic patterns. Traditionally, doctors walk up and down a long hallway to visit patients, says Mr. Valancy. A pod-type arrangement might be far more convenient. In this setup, patient rooms are located on two or even three sides of the area with a shorter hallway, cutting down on physician walking. Also, he suggests, locate business and clinical areas so that front-desk staffers can talk to administrative staff, instead of being isolated from each other. Equip your exam rooms identically. You’ll save time if supplies and equipment are in the same place in every room. Everything you need, says Mr. Valancy, should be just a few feet away — you want to have things “literally at your fingertips.” Reinventing the Practice One clear lesson from IDCOP, says Dr. Moore, is that “we can’t just do more. We’re working too hard. “We have to retool; we have to redesign,” he says. “When a practice chooses to reinvent itself, to retool, [it] can achieve different outcomes.” The forces affecting healthcare are too numerous, diverse and powerful to pinpoint what the dermatology practice of the future will be. But given these broad outlines of the future, you can start to morph your practice into a top-notch setting for tomorrow’s delivery of care.

I magine an office where prompt appointments are the norm, with patient visits scheduled the same week if not the same day patients call. In this office, mid-level providers such as physician assistants (PAs) and nurse practitioners (NPs) deliver much of the routine care, while the dermatologist spends the bulk of his or her time on the most complex and challenging cases. Also imagine that the patients who come to this dermatology practice have first received an appropriate level of care at their primary care provider (PCP), and that only after the case extends beyond the PCP’s reach is the patient referred to the dermatologist. Imagine, too, that patient information and clinical data are stored and accessed electronically, so that the dermatologist can call up information quickly. If that scenario characterizes your current dermatology practice, congratulate yourself on having an advanced office. If not, know that forces today are propelling the dermatology practice in this direction. Experts are exploring ways to restructure the clinical office to make the most effective use of clinicians’ time, press ahead with technology, and enhance patient care. In this article, we’ll look at the forces driving this change and offer practical steps to move your practice into this brave new world. But first, let’s examine how extensive the problem of delivering care has become. Big changes “Health care harms patients too frequently and routinely fails to deliver its potential benefits. Indeed, between the healthcare that we now have and the healthcare that we could have lies not just a gap, but a chasm.” So says a summary of the March 2001 Institute of Medicine report Crossing the Quality Chasm: A New Health System for the 21st Century. “Merely making incremental improvements in current systems of care will not suffice,” says the summary of this widely disseminated report. The report offers 10 rules for reshaping care (see “10 Rules for Redesigning Healthcare”). Meanwhile, at the Boston-based Institute for Healthcare Improvement (IHI), the Idealized Design of Clinical Office Practices (IDCOP) initiative has taken on no less task than the “comprehensive redesign of the office system as a whole.” The aim, IHI says, is to significantly improve the performance of clinical office practices through dramatic and sustained system-level changes. Begun in 1999, the redesign initiative was predicated on the understanding that today’s office “fundamentally is broken,” according to Charles M. Kilo, M.D., fellow at IHI and former leader of the IDCOP initiative. He’s also CEO of GreenField Health, Portland, OR. Given such a “dysfunctional” office setting, rethinking care delivery forms a duty, he suggests. “These are deep meaningful, system-level redesign issues” that will take years to get into place, he says. Four themes The IDCOP initiative forms a tangible way to think about tomorrow’s clinical office. IDCOP framed its work around four major themes: 1. Access 2. Interaction 3. Reliability 4. Vitality. We’ll look more closely at each area, and delve into related areas of technology and the physical layout of the office. Currently, the IDCOP initiative continues in a follow-on IHI effort called Impact. Launched in June 2002, Impact is designed to deploy the findings from IDCOP more widely. Gaining Access The first theme, access, means that care should be available 24 hours a day, 7 days a week, 365 days a year, according to IDCOP. For optimal access, various major processes are needed, among them group visit models and open-access scheduling. In group visits, a number of patients meet with a provider, perhaps a nurse. This provides an efficient way to deliver the same message to a collection of patients, instead of one-on-one encounters. Open-access scheduling enables patients to schedule non-emergent appointments today, or within the week. That’s a far cry from the months that it typically takes for appointment. Open access does work in specialties, according to Gordon Moore, M.D., a faculty member at IHI and associate professor of family medicine at the University of Rochester Medical Center, Rochester, NY. Bringing open access into reality involves a careful process, including working down the backlog of patients. And that can involve help from midlevel providers, as we’ll discuss in a moment. Certainly, demand can exceed capacity, says Dr. Kilo, and that can mean long wait times — an important point given today’s dermatology shortage. But if there is “relative equilibrium,” you can work down the backlog, leave much of the workday open, and fill the schedule based on daily demand, he says. Some 30% to 50% of slots will still be booked ahead, he notes. Scheduling represents one of the most “antiquated” parts of U.S. healthcare, suggests Casselberry, FL-based consultant Inga Ellzey, CEO of Inga Ellzey Practice Group, Inc. Try open access one day a week, she recommends — though you’ll need appropriate staffing and support. Quick access to services is a competitive advantage in many businesses, notes consultant Jack Valancy, M.B.A., Cleveland Heights, OH. If you have a 3-month backlog, you’re vulnerable to a competitor who has a smaller or no backlog, he points out. “You’re immediately at a competitive disadvantage,” he says. Sounding a more critical note, consultant Gil Weber, M.B.A., Davie, FL, regards open access as a wonderful idea, but somewhat impractical in implementation. Unless another doctor can help, how can a practice offer same-day scheduling, he asks. (And at a specialty level, same-week scheduling is probably an appropriate level of open access, suggests Dr. Moore.) Service Agreements To move toward a more responsive scheduling system, specialists and PCPs can create service agreements to detail appropriate referral criteria, suggests Dr. Moore. Recently, for instance, gastroenterologists in Rochester, NY, discussed this idea with the family practice community there, says Dr. Moore. Such agreements can help avoid the “primary care dump” says Dr. Moore. “It’s turning down some of the noise.” Such a setup would go far in reducing a patient backlog, agrees Syracuse, NY-based consultant Rosemarie Nelson, M.S., an independent consultant with the Medical Group Management Association. But she worries about a backlash from primary care providers, in that the specialist may be perceived as telling the PCP that he isn’t doing his or her job. Such behavior, she suggests, might alienate a key referral source. Midlevel Providers Streamlining scheduling and care delivery also involves the effective use of midlevel providers. The effective use of these providers forms part of her future vision of dermatology, according to Pat Rutherford, R.N., M.S., IHI vice president and current coordinator of IHI’s Office Practice redesign effort. Such providers can handle simpler conditions or manage the patient with a chronic condition who needs multiple appointments. Doing so involves leveraging the expert time of the dermatologist, she says. Using a PA or an NP is “absolutely the way to go to increase your volume without taking on the full cost of a physician,” says Mr. Weber. In dermatology, a PA who is well-trained in dermatology can be a tremendous practice enhancement, he suggests. On a related note, Ms. Ellzey promotes the concept of “one room, one nurse.” With this plan, a medical assistant or nurse is assigned to each exam room. When the patient arrives, the nurse has already taken the patient history and, if needed, had the patient undress, speeding the doctor’s time. At present, dermatologists often use mid-level providers. Over one-third of respondents to a late 2002 American Academy of Dermatology (AAD) member survey said they used physician extenders in their practice. Some 15.5% reported having a PA; 7.7% an NP; other nurse, 14.6%; and aesthetician, 10%, says Alexa Boer Kimball, M.D., M.P.H., assistant professor, dermatology at Stanford University Medical Center and chairperson of the AAD Workforce Task Force. Norfolk, VA-based Pariser Dermatology Specialists, Ltd., has created the position of dermatology technician to help manage the 10,000 patient visits per month handled by the practice’s nine dermatologists in six locations. The practice also has one PA. These dermatology technicians, who are unlicensed, perform the technical portion of minor procedures, such as tiny biopsies, dermatologist David Pariser, M.D., says. He stresses that these individuals do only technical procedures that don’t involve medical judgment. Each dermatologist works with at least one of these dermatology technicians. Finally, Ms. Rutherford sees in her vision of dermatology that PCPs can use digital cameras to send pictures to specialists for “real-time” consultations. Currently, teledermatology is being used to deliver care across long distances (see “Teledermatology: The Future of Medical Dermatology?” March 2003). Interaction The second of IDCOP’s four themes, interaction, suggests that “every patient is the only patient.” Among the major processes needed for optimal interaction: customizing the style and timing of communications; shared decision-making technologies; Web-based care and information; and electronic communication with patients such as e-mail. In customizing the style and timing of communications, clinicians can use a standard approach, suggests Dr. Moore, that helps them tailor recommendations. For instance, asking questions in a standard manner, such as in assessing depression, can help uncover patient problems without the doctor’s bias entering in. Shared decision-making technologies attempt to understand the context in which a person lives. The clinician and patient might look at clinical information together, tailoring the therapy based on the patient’s values. As for Web-based care, with coaching, patients can also use the Web to access information on their own. While not yet common, trading e-mail with patients can provide an interaction when an in-person patient visit isn’t needed. Reimbursement and security issues need to be addressed here. Supporting Staff While interaction with patients is crucial, staff interaction also plays a major role in effective clinical office design. “The boss is a role model,” notes consultant Valancy. Not only must the doctor model appropriate behaviors and skills, but also has to give feedback to staff. Hiring well is part of the key. “Hire for attitude, train for skill,” notes Mr. Valancy. It’s much easier to train someone with a good attitude than to try and change a skilled practitioner with a poor attitude. Make sure to encourage business office staff to attend educational seminars, suggests Jill Whitney, M.B.A., senior consultant at The Coker Group, Atlanta, GA. The doctor’s office should pay for seminars and CE credits, she says. Reliability IDCOP’s third theme, reliability, means that “‘all and only’ effective and helpful care is given.” All of the practice’s activities are based on best-known science (referred to usually as evidence-based medicine); overuse, underuse, and misuse of care are avoided. The major processes for optimal reliability, says IDCOP, include master scheduling of resources; proactive patient population management with registries; and incorporation of new science into practice and the adoption of best practices. Clinicians, notes Dr. Kilo, have to feel humbled by the rapid expansion of the medical knowledge base. Realistically, humans can’t manage that torrent of information, so that clinicians need assistance from technology. Master scheduling involves appropriate use of room, staff, providers, and equipment. “The capacity,” says Dr. Moore, “has to match the demand or else we suffer.” In managing patients, clinicians need to develop systems that allow appropriate follow-up. If, for instance, car care company Jiffy Lube can notify customers when a car’s oil change is due, “how can we in healthcare be less proactive?” questions Dr. Moore. In using best science, the healthcare team not only must be aware of the science, but bring it to bear on clinical work. Vitality Last, vitality means that “the practice is sustainable and continually innovating,” according to IDCOP. This includes financial viability, as well as continual improvement. “We have to decompress our work,” says Dr. Moore; working in or close to burnout mode must cease. What’s more, clinicians have to be “reasonably compensated for our work.” That not only includes adequate payment, but finding ways to reduce costs. Having the appropriate provider do the work can aid in that effort. Technology Advances In tomorrow’s clinical practice, few forces are likely to have greater impact than technology. This ranges from sophisticated electronic medical record (EMR) systems to e-mail interaction with patients, as noted earlier. For instance, practices should investigate scanning technology, says Ms. Ellzey. You can scan patient registration forms, superbills, end-of-month reports, and more. For medical records, maintain 1-1/2 to 2 years of active paper charts; the rest you can scan, she says. This dramatically saves on storage space and can improve your ability to access records. Make sure, says Mr. Weber, that the EMR integrates with your practice management system. The two need to communicate with each other. For patient communications, patients could, for instance, enter a query on a practice website or via e-mail instead of making a phone calls, says consultant Ms. Nelson. This could start the documentation for the patient interaction. Even intake information might be placed on the Web site. In 1996, Pariser’s practice instituted a homegrown online EMR system. Records are accessible instantly. What’s more, all office forms, as for procedures and policies, exist on the network. Looking at Layout Although electronic communication may change some of the ways in which care is delivered, dermatologists in the future will physically deliver care as they do now — in the office. The office’s physical design must help the practice make the best use of staff time and provide a warm environment. Make sure to provide enough room for patient care as opposed to administrative services, notes Ms. Ellzey. Consider outsourcing such operations as billing or perhaps moving administrative staff to a less expensive setting. Waiting rooms tend to be too small, says Mr. Weber. And avoid handwritten notes plastered all over your front reception area, which detract from your office’s professional look. Make the environment patient-friendly, notes Ms. Ellzey. Consider, for instance, installing an automatic door. Also consider traffic patterns. Traditionally, doctors walk up and down a long hallway to visit patients, says Mr. Valancy. A pod-type arrangement might be far more convenient. In this setup, patient rooms are located on two or even three sides of the area with a shorter hallway, cutting down on physician walking. Also, he suggests, locate business and clinical areas so that front-desk staffers can talk to administrative staff, instead of being isolated from each other. Equip your exam rooms identically. You’ll save time if supplies and equipment are in the same place in every room. Everything you need, says Mr. Valancy, should be just a few feet away — you want to have things “literally at your fingertips.” Reinventing the Practice One clear lesson from IDCOP, says Dr. Moore, is that “we can’t just do more. We’re working too hard. “We have to retool; we have to redesign,” he says. “When a practice chooses to reinvent itself, to retool, [it] can achieve different outcomes.” The forces affecting healthcare are too numerous, diverse and powerful to pinpoint what the dermatology practice of the future will be. But given these broad outlines of the future, you can start to morph your practice into a top-notch setting for tomorrow’s delivery of care.