Efficiency in the Urology Practice, Part 2: When the Patient Arrives at Your Office

Neil H. Baum, MD
Dr Baum is Professor of Clinical Urology, Tulane Medical School, and Principal, Neil Baum Urology, New Orleans, LA

In the previous article (April 2016), I discussed how to improve efficiency in your practice before a patient arrives at your office. In this article, I discuss how to enhance efficiency when the patient arrives at your office.

The patient has arrived, provided his or her demographic information and the health questionnaire, and has been taken to the examination room. The doctor should meet the patient, and have a 1- to 2-minute discussion about some areas outside of the medical or urologic concerns, asking questions such as, “What kind of work do you do?”, “Where do you live?”, and “Who referred you to our practice?”

These questions endear the patient to the doctor, without discussing the specifics of the urologic problem.

Enhancing Efficiency by Using a Scribe

One of the most effective methods to enhance the efficiency of my practice has been to use a scribe. A scribe is a person who shadows a physician and takes notes in the chart or on the computer on the patient’s history of present illness (HOPI), review of systems, and medical history; this allows the doctor to have more face-to-face time with the patient.

How Does a Scribe Work?

After the doctor has introduced himself or herself to a new patient, the scribe interacts with the patient, taking the patient’s HOPI, recording the patient’s medical history, and conducting the patient’s review of systems. The scribe then presents the HOPI to the doctor, and accompanies the doctor into the examination room.

At this point, the doctor may ask a few additional questions, or probe any aspects of the HOPI that require clarification or more in-depth questioning. The doctor then conducts a physical examination, and the scribe records any positive findings in the chart or in the electronic medical record (EMR).

At this juncture, the doctor can discuss the diagnosis and the plan of management with the patient, while the scribe records the doctor’s plan of action. The doctor can then answer any questions the patient may have, and the scribe can hand over the chart or computer to the nurse.

The nurse will make the necessary arrangements for any laboratory testing, studies, or surgeries; provide the patient with sample medications and written instructions for use of the medications; provide pertinent educational materials; and make the follow-up appointments.

While the nurse is taking care of one patient, the scribe moves to the next patient, always staying one patient ahead of the doctor.

Advantages and Disadvantages of Using a Scribe

There are multiple advantages to using a scribe. Since I started using a scribe, I am able to see 5 to 6 additional patients each full day in the office. Having a scribe also allows you more time to communicate with the patient face-to-face instead of writing or using the computer.

In addition, my coding has moved from level 2-3 to level 4-5, because my scribe is more thorough than I am in conducting the review of systems and medical history, and in recording the fine nuances of the physical examination that I had often neglected to document, such as a neurologic and dermatologic examination.

The disadvantages of having a scribe include cost, time required to train the scribe, and adapting to having someone other than yourself document patients’ medical details. In the beginning, this can be frustrating, but when you notice an improvement in your efficiency, you will enjoy the luxury of having a scribe.

As a matter of fact, when my scribe is absent or on vacation and I have to use the computer, I realize how valuable she is, and how effective the technique is to enhance my practice.

Getting Started

Before getting a scribe, you first have to decide if you need a scribe. The following scenarios will help you decide whether your practice may benefit from having a scribe.

If patients need to wait more than 4 to 6 weeks to make an appointment for a routine visit, then you have a backlog of patients, and a scribe will help you reduce this backlog.

If your last patient is scheduled at 4:00 pm or 4:30 pm, and you are not finished with patients until 5:30 pm or 6:00 pm, then a scribe can help to improve the efficiency of your practice.

If the majority of your codes are level 3 or lower, then you can improve your productivity by having a scribe.

Finally, if you are considering transitioning to an EMR system but are technophobic, then a scribe may be a natural segue to implementing the EMR.

Using Educational Videos for Patients

Historically, the formula for practice productivity was low patient volumes, substantial reimbursements in a fee-for-service arrangement, and good doctor–patient relationships. With the recent enactment of the Affordable Care Act, however, the situation has reversed–large patient volumes, decreased reimbursements for the same services that were performed a few years back, and less time spent with each patient are now the status quo.

Now more than ever before, urologists need to improve their efficiency to remain more productive. It was only a few years ago that doctors saw low volumes of patients, and were able to spend time educating patients about their medical condition and helping them understand the importance of adhering to treatment.

Today, urologists are seeing larger volumes of patients while spending less time with each patient; they do not have the luxury of providing patients with lengthy explanations about their health and having one-on-one educational discussions.

As a result, patients are relying more on the Internet and on other sources, such as social media, and less on their doctors to obtain medical information. Consequently, patients are often less adherent to their treatment plans, which may result in less-than-desirable health outcomes.

Creating educational videos for your patients can help educate patients with exactly the same message you would want them to receive if you were speaking to them in your office. This is a far more effective and appreciated method than the videos distributed by pharmaceutical companies and by vendors of equipment that you use in your office and in the hospital.

How to Create Educational Videos

When creating educational videos for patients, we suggest that you select topics you discuss with your patients on a regular basis. For example, if you have a discussion with patients about prostate-specific antigen elevation multiple times daily or weekly, then this would be an appropriate topic for a video. I like to select topics that are of current interest to patients.

Next, you will need to create a script. In most instances, the script can follow the format shown in Figure 1. By putting the bullet points in a PowerPoint presentation, you can create a script that serves as a teleprompter.

Table

The quality of a video created with the iPhone or an Android device from Samsung is excellent. The only other piece of equipment that we recommend is a flexible tripod to hold the iPhone (Figure 2). These are available on Amazon at www.amazon.com/dp/B017NA7V1U?psc=1.

Table

With the iPhone in the tripod attached to the computer, and the PowerPoint presentation serving as your notes, you are ready to create a video. I suggest limiting videos to 5 to 7 minutes, because this is the attention span of most patients.

The videos can be uploaded to your EMR or to separate computers in each of your examination rooms. Each video may end with the statement, “I hope you have found this video on <name of topic> helpful, and if you open the door at the end of the video, I will return to the examination room and provide you with a summary of <name of topic>, and will answer any questions you may have.”

We refer to this as the “sandwich” technique, in which the doctor interacts with the patient first, performs the examination, shows the video, and ends with returning to the room to answer any questions the patient may have about the topic. A written summary of the topic should accompany each video.

Advantages of Educational Videos

Educational videos can help to improve your office’s efficiency. For example, while patients are watching the video, you can see additional patients or perform brief office procedures; overall, you can anticipate a 15% to 20% improvement in office efficiency by using educational videos. In addition, patients will likely appreciate the education and the written summary accompanying the video.

Medical–Legal Protection

Documentation is necessary to protect ourselves from litigation. It is possible to demonstrate that the patient received all the necessary information and education provided in the video by documenting in the chart that the patient watched the video on a specific condition, procedure, or surgery.

We also suggest that you document in the chart that all the questions were answered before the patient left the office.

To confirm that the patient understood the condition, surgery, or procedure, you can use a true/false questionnaire that the patient can answer after watching the video, and include this in the chart.

An example of a questionnaire that I use after a patient watches a video on vasectomy is shown in Figure 3.

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This questionnaire and the results can be added to your medical records with the following statement: “ watched a video on the treatment of <name of condition>. The video discussed the procedure, risks, and complications; and alternatives of treatment, including <alternatives of treatment>. The patient agrees to proceeding with <name of procedure>, and understands the risks and complications associated with <name of procedure>.” We believe this makes the video an excellent medical–legal protection for the doctor, and that the video enhances the informed consent process.

Bottom Line

We are challenged to be more efficient with every patient encounter. You can enhance the efficiency of your practice by using a scribe and educational videos.

In the final article of this series, I will discuss how to manage the patient after the patient has left your practice.

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