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Practice Matters

‘Lean’ Processes that Can Make Robust Changes to Your Practice

Avitzur, Orly, MD, MBA, FAAN

doi: 10.1097/01.NT.0000527858.04266.d0
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Figure. A

Figure. A

The chair of the AAN Practice Management and Technology Subcommittee shares four practice strategies that have made big changes in the efficiencies of a 20-person neurology practice in Texas.

Many of today's medical practices are but one additional regulation away from the brink of collapse. Inundated with red tape from governmental requirements, electronic health record (EHR) mandates, and expanding prior authorization demands from insurers; even heretofore well-run offices are under duress. It's no wonder that clinicians working in today's high-pressured environments are experiencing burnout. Many feel that they have little or no control over these forces and the overly-demanding job expectations that have come as a result.

But some practices have shown that even small changes can have a big impact. By applying process improvement mechanisms, they can streamline workflow and remove waste and non-value added steps from the system. One such system, known as Lean, was developed by Toyota to help eliminate gaps in the manufacturing process of cars. The system recognizes that delays at any point in the assembly chain can prolong the total time that it takes to make that car. This lack of efficiency not only costs time and money, but also may result in a lesser quality product.

The same principles can be applied to a medical practice. Imagine reducing the number of computer clicks needed to report your measures for the Merit-based Incentive Payment System (MIPS), or the time spent entering clinical data into your EHR (such as the steps you need to take to reconcile your patients' medications) or reducing the number of no-shows in your practice. Lean, or a similar technique to improve business management, can be applied to help achieve those goals and others in medical practice, whether at an academic institution or a private practice.

To help show you how, we asked David A. Evans, MBA, the chair of the AAN Practice Management and Technology Subcommittee, to share four practice innovations that he believes have led to the greatest efficiencies of Texas Neurology — a private practice that he has run for 20 years. Texas Neurology provides multiple lines of service including magnetic resonance imaging, infusion, routine and ambulatory electroencephalography and electromyography testing, sleep studies, and clinical research.

Figure. DAVID

Figure. DAVID

Here, Evans discusses how these four practices maximize the productivity of the practice, comprising 12 neurologists, nine advanced practice providers (APPs), one social worker, one pharmacist, and their throughput of over 200 patients a day.

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Earlier in 2017, the Centers for Medicare & Medicaid Services (CMS) approved the AAN Axon Registry as a 2017 Qualified Clinical Data Registry, enabling its participants to submit quality data to CMS for MIPS. The Axon registry includes 38 measures from which members of his group can select or “map” those pertinent to their subspecialty. They track measures for epilepsy, dementia and headache, as well as general measures such as falls and documentation of medication.

For example, if a patient answers a query that he/she has had a fall in the past 12 months, or since the last visit, a medical assistant (MA) from the practice will obtain additional information, document and alert the provider, and push educational resources to those patients about fall prevention. It may also include a resource to have a home assessment completed, if appropriate.

“We've also created the position of ‘physician champion,’ a neurologist who meets with me monthly to review our Axon measures and any other quality reports that were made available since a prior meeting,” said Evans. Together, they evaluate the Texas Neurology practice against CMS and Axon community benchmarks, look at each physician's dashboard, and compare intragroup variances and the aforementioned benchmarks. They review four to five accounts to confirm the measure is accurately reported. If it is, they create an action plan that the physician champion takes to the doctor and clinical support staff to address deficient areas.

“We review the measure, what is required to meet the measure, and each staff person's role in capturing each component of the measure, that is, the MA, advanced practice practitioner (APP), or MD,” Evans said. Feedback is documented to determine if their training documents or assignment of staff responsibilities require modification.

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The EHR used by Texas Neurology enables the practice to develop pre-visit questionnaires and tie them to specific appointment types. “We structure our established appointment types by primary neurological condition, for example, headache, epilepsy, dementia, multiple sclerosis, amyotrophic lateral sclerosis, etc., each with their own unique pre-visit questionnaire,” explained Evans. “Two business days prior to their appointment, we send a confirmation message to the patient's portal or via text with a link to the portal, directing them to complete the appropriate pre-visit questionnaire. For patients who are not web savvy, this form can be completed when they arrive at the office, via a kiosk or manually, by bubble sheet, or as a final resort, by an in-person interview with a MA. Responses are dropped into the clinical note for the clinician to edit or review, as necessary.”

“We have one or two kiosks at each registration area and location,” Evans added. “Kiosks can capture the entire pre-visit components, can take the patient's photograph, scan their insurance card and driver's license, complete the pre-visit questionnaire (or review if completed via portal), process payment of balances, any copays, or estimated coinsurance for each visit.”

Evans said the practice has strived to include as much information about the patient as possible to assist with capturing data elements for the clinician to use during the clinical visit and for any component of a quality measure that is patient-reported, such as headache frequency/severity, seizure frequency, or pregnancy in women with a history of seizures.

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“Practicing at the top of their license” is a term used to relay the concept that it is wasteful for physicians and other medical professionals to do work that involves procedures or tasks that they would have been permitted to do without the ‘top’ certification attained. In this way, the role of the MA is maximized so that the higher- level practitioners like the APPs are functioning at their optimal capacity, and the neurologists are operating as much as possible in the subspecialties in which they have been trained. Likewise, the social worker's skills are utilized in tasks that free up the providers to practice medicine.

“We utilize the MAs to capture as much information as possible prior to the MD or APP visit,” Evans said. This includes reviewing the information included by the patient, making corrections or providing additional details if necessary, highlighting items for the clinician that are significant or new, and items where normal is not indicated. Any changes in history or medications from the last visit are noted, and staff and clinicians highlight areas in the note that are substantive.

“This is extremely helpful when reviewing clinical visits and allows the reviewer to quickly monitor changes in patient's condition or treatment over a long period of time,” Evans explained.

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“We've also developed disease-specific templates or macros that allow the clinicians to capture information efficiently; these templates ensure that all the necessary components required for a clinical visit are captured, as well as support guidelines and quality measures components,” said Evans.

They also ensure consistency from visit to visit, he said. These can be further tailored by the provider to accommodate their preferences. Subspecialists have one to two such templates, depending on whether the patient is new or established, or whether they are utilized for a specific purpose, such as, for example, an assessment of quality-of-life, depression, or cognition. All others use a non-disease-specific one that is used since they see a broad range of neurological conditions.

These four processes not only help the practice operate efficiently and make effective use of resources and personnel, they also enable the physicians and APPs to feel more engaged and focused on care for the patient — an important antidote to the burnout that is affecting our field.

© 2017 American Academy of Neurology