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Work flow advice

  • 1.  Work flow advice

    Posted 10-05-2017 11:02
    Looking for tips and advice on how you handle work flow in a small office. I have a small family practice clinic, my husband is the business manager, we have a FT receptionist, a PT book keeper (6 hrs per week) and a PT RN to help with CCM and a few other things (5-6 hrs per week). My issue is I see pts, draw blood, and take care of all the data input for each visit. I admit, I have this dislike of leaving people sitting waiting for me and thus will complete only the essential things from the previous visit before seeing the next pt. This leaves me a lot of charts to finish either at the end of the day, or worse yet, over the weekend. Any thoughts would be really appreciated. I'm 2 years into this adventure and the thought of working 7 days a week indefinitely is not very appealing. I know there must be some things to delegate some of this to the staff (the receptionist is just 2 weeks with us and learning very quickly, but certainly not seasoned.)

    Tracy Baum
    Mountain Sage Family Clinic
    Dubois, WY

  • 2.  RE: Work flow advice

    Posted 10-06-2017 00:53
    I think more information is needed. 

    How many patients in an hour?

    What kind of record system. Paper or electronic. ?


    Bruce Carlson, RPh, MD, DABFM
    Hermiston, Oregon

  • 3.  RE: Work flow advice

    Posted 10-06-2017 08:39
    I'm a believer in getting as much of the note done as possible while I'm with the patient. This results in a better note since I tend to forget things once I see other pts. I use macros to save time, and I am deliberately brief on my assessment/plans. 

    Also, could you train your secretary to draw blood?

    Michael Barron MD

  • 4.  RE: Work flow advice

    Posted 10-08-2017 14:36
    I'm finding doing more in the exam while with the pt very useful. Could you give an example of 'brief' assessment/ plan? I do have some macros that I use for these, along with templates for ROS and PE, but would appreciate other tips.

    Tracy Baum
    Mountain Sage Family Clinic
    Dubois, WY

  • 5.  RE: Work flow advice

    Posted 10-09-2017 07:35


    otitis media: amoxicillin 500mg tid x 10d
    HTN: stable, continue current regimen.  Will follow at visits.
    DM: stable, continue current regimen.  Will follow A1c q3m.  Needs eye appt.
    CAD: stable, continue current regimen.  Will follow patient report/complaint.

  • 6.  RE: Work flow advice

    Posted 10-06-2017 09:47
    Hi Tracey
     not enough information to help you
    -Lots of  people - mostly part time
    - Why a biller if have a practice manager?
    - a few ideas- patients can do their own bp and wt at a station  in hall or wait room

    -You could take hx with instant medical histry
     for both of these you could have an i pad the receptionist gives out and they input it themselves

     Drawing bood yourself would seem to slow lots of things down- cross train the receptinsit

    RNs are very expensive
     await more info

    Jean Antonucci

  • 7.  RE: Work flow advice

    Posted 10-07-2017 07:48

    I stopped drawing blood years ago.    Two main reasons:

    Much more efficient for our office flow to have patients go to the two national labs in the community within 2 miles of my office.

    More importantly - Patients have learned to do blood work prior to their visits and I have results available for discussion.   I think patients appreciate it also.   Much more efficient, less follow up phone calls, email discussions, etc.   I give them lab slip, if needed, for next visit visit when current visit is done.   It works very smoothly.

    If they need acute labs to complete assessment during a visit, they just go down the street.

    Of course, we do send out cultures, paps, etc.

    Only labs done in office are those I get results myself - U/A, micro, Strep, INR, very rare glucose.

    Michael S. MD

  • 8.  RE: Work flow advice

    Posted 10-08-2017 11:59
    A few other details about the workflow....

    1) Mountain Sage Clinic is located in a frontier area of Wyoming, 80 miles for the nearest hospital/ urgent care. We try to fill the gap providing family practice with after hour availability. (It's currently hunting season and I see alot of lacerations after hours this time of year.) There is a CHC across town that is actively trying to put me out of business. (that's a long story for another day.)

    2. Lab work is provided for these reasons. No real options for people. I know this is a drain on my time and hope to resolve this, just unsure how at this point. I do have the usual CLIA-waived tests in house.

    3. The patient load is approxamately 2-3 pts per hour. 45% of my pts are Medicare. We have been actively working on marketing to younger families, but I do a lot of Internal Medicine right now. I find this has it's pros and cons. The schedule is not full at this time, and hope to iron out some of the workflow glitches before attempting to increase the numbers. Avg pt/ day is between 12 and 16. 

    4. It seems that constant interuruptions is a BIG issue. Our receptionist is new - just 3 weeks into training and has a lot of questions at this time. 

    5 Currently using eClinical Works EHR and RCM and have to spend 2-3 hours a week fixing codes. (Don't even want to think about the time I have to spend updating information for MIPS! I really can't afford the penalties as since I am an NP, I already am subjected to a 15% decrease in reimbursement.) Considering switching to hiring a coder/ biller - would appreciate input on this issue. 

    6. Due to no pharmacy w/in 80 miles, I also have a dispensary for abx, etc. I am the one counting the pills. I plan to use some pre-packs to help with the time drain for this area. 

    7. The RN (5-6 hrs/ wk) is used for for the CCM and calling with lab results,refills at this time. Not a lot of rooming pts, VS etc. My goal is to have this be cost neutral or even help increase revenue with this program. We are just 3 mos into this and are still identifying pts and enrolling. 

    8. I have started shifting more clerical tasks to the receptionist - she is eager to take on additional tasks. Ex. DOT paperwork and data input. 

    9. A typical pt visit goes like this: I get the pt from the waiting room and we then sit and discuss HPI./ ROS. At this point I plug in a template that I have developed for the most freq complaints - URI, UTI HTN etc.  I then review meds, ask about any new hx. I then take VS and do the exam. Recently, I have started to stay in the room and order labs, meds, imaging right there. This allows me to tell the pt that is is completed (some pharmacies tell them - 'we didn't receive the order!) and prevents me forgetting to do this. Maybe spending a few more moments to just finish the note would help my sense of "oh crap, there's someone waiting in the waiting room" .

    10. The business manager is my husband and he is now moved out from the front desk (bless his heart for hanging in there as receptionist for as long as he did!) He also handles the IT stuff. The bookkeeper is 5 hrs a week. 

    What opportunities for smoothing out this work flow do you see? Do you use any 'blocked time' to do the lab reviews etc? I currently do this during the day or at the end of the day. I am open to all suggestions.


  • 9.  RE: Work flow advice

    Posted 10-09-2017 19:41

    Thank you for sharing your practice information.   12-14 patients daily after just 3 months is huge number.   You should be able to earn good income with proper billing and overhead control.

    With that volume so soon, after hours lacerations, etc., 24 /7 on call, no urgent care or hospital in region, I would be very concerned about potential burnout.   IMO, you will need an associate or colleagues to share call very soon.

    Here are a couple of work flow issues, but I fear coverage and lifestyle and time off issues will be much more important in the long run.  Hopefully others who are working in a rural community will chime in.

    I see why you need to draw blood.    Training an MA or your RN would make sense.   Is there a retired nurse or phlebotomist in community who you could hire to run a blood draw clinic twice a week for an hour?  Preferably when you are not there,  except in beginning to help train and assure competence.

    Most important things I ever did:
    Have labs available before the visit.
    Have patients bring in list of all meds, pharmacy, and number of refills (or bring in bottles)
    Have MA prepare perscriptions for signature or click.
    Always give enough refills until the next planned visit.
    Nominal charge for calling in refills between visits.
    Do my own INRs.
    Learn the billing dos and donts
    Most visits are 99214
    Bill for AWV or preventative visit once a year (usually along with a 99214-25)
    I offer telephone management (charged to patient) but much less of issue now that can finally collect for CCM.

    Sure, have patient take their own weight.  (That will save 15 seconds).  Having patient take their own BP is an option.  Although I am starting to update social history, and noting 90% of the physical exam while I am rooming patient and doing the VS.

    Also, cannot minimize value of "laying on of the hands".  If machine can do everything, will patients minimize your value?

    It takes 1-2 years to learn billing, work flows, know your patients, etc.   As a new doctor in town, you have lots of new patients, enter all their meds, new problems, record height, social issues, patients changing doctors, insurance issues etc., etc.

    It will get better if you can hold on.   I have been doing this for many years so very few surprises.   I schedule each visit for 1/2 hour (and occasional squeeze in of easy acute).  12 to 14 visits per day.   One employee,   Start at 830 or 9 and leave by 430 to 530.  Average $40,000 income per number of days per week in office.

    Not rich, but enough and happy.  My situation is very different from yours.   I am in 8 person call group.  4 of us are independent  and 4 are in a larger group.   2 urgent care facilities in area and hospital and ER.

    Hopefully others in rural areas will chime in with suggestions.

    Michael S. MD

  • 10.  RE: Work flow advice

    Posted 10-10-2017 05:39

    Thanks for your good/very practical points.  Could you please clarify in a bit more detail the phrase "average $40,000 income per number of days per week in office"?

    K Fite

    Kevin Fite
    Austin TX

  • 11.  RE: Work flow advice

    Posted 10-11-2017 10:23

    I will clarify but will start a new forum discussion, because income and expenses are not the same issues as work flow, which is what Tracy was asking about.

    Mike S

  • 12.  RE: Work flow advice

    Posted 10-08-2017 17:23
    On the other hand...... drawing lab can be a nice income stream depending on your patient population, payor mix and your overall business plan. If these determinants are favorable and you have the IT capabilities to streamline workflows, why not get paid? Plus you have the ability to set your lab charges at a level that can really benefit your under- or uninsured patients. I've done it both ways, depending on the specific business plan. Food for thought.

    Scott Turner
    PatientCare Family Clinic
    Springfield MO

  • 13.  RE: Work flow advice

    Posted 10-08-2017 18:24
    Hello all:
    I have a small family practice I opened in 10/2015. We are celebrating our 2nd anniversary, Of course no real celebration just in my heart and calendar, no budget yet for celebrations.  My wife helps me PT, no pay. She promised to be with me in the good and the bad ..LOL LOL.  My oldest son (21) works 38 hrs at front desk.  One suggestion with the information that you provided. Have your husband do the book keeping for free, ( Remember in the good and the bad).  Run the financial analysis of having a PT expensive (nurse) /CCM, or MA full time for quality reporting and even she could draw the blood vs stop drawing blood. I just sent patients to lab before the visit and I can review Blood work at their visit. I also have the same problem  that you have of not finishing the note after or while seeing the patients. I trained dictating my notes after seeing patients. I will try to implement that in the near future because I don't type fast and I like to make eye contact with the patients. I hope this helps.

    Just a quick question to Jean. The station for BP and wt for patient to do, is this populated automatically to chart or how do you do it if you do it? I have Practice fusion. Right now I am doing my own vitals.

    Edgar Cruz
    Cruz Medical Services
    Clermont FL

  • 14.  RE: Work flow advice

    Posted 10-09-2017 05:59
    I have PF also Edgar
    No not populated to Emr but  if they do their wt and bp I do not have to There is a  chair and a table  with pens and paper They write it down and come in and hand t o me.I think I got this idea form Avery in VT
     Why are you not making money at 2 yrs?? you are in the black and  it is tight yes- not in the red??

    The whole atmosphere in US health care is very hard

     The receptionist   is key  Ideally  no one should be a receptionist til they have  been in a practice for 6 mo and are well trained
     Consider limited blood draw times- am 7 30-9 or something
    No commercial lab that could  come to town once a week and do? Hospital?
    Sorry about the CHC wonder what is up with that

    You  a re trying to be a lab and a drugstore and a n   urgent care and a  family practice on sketchy untrained pt staff
     Blood drawing  usually is not a money maker is it better now?- but still I would shift it to someone else and organize it.
     Sounds like you  are busy Good  i guess. 16  a day gets to be  alot if you are doing all the  referrals etc If you are ON 24/7 and sewing people up a lot are you going to burn out?
    Can you  get a pharmacist to  staff a  pharmacy once a week satellite office?
    Using a portal to send people results?
     When the receptionist is fully trained you will be better off good luck

    Jean Antonucci