Open Access at Primary Care Partners

Family practitioner Gregg Omura, MD, sounds just a bit like a slick salesman when he talks about open access: "If you want to double your take-home pay, work less hard, and have happier staff and patients, this is the way." But he has more than enthusiasm to support his claims. He has data.
 
Since implementing open access scheduling, along with some other improvements that support it, Omura has:
  • Increased patient visits by 22 percent
  • Increased gross revenue by 32 percent Increased net revenue by 87 percent
  • Decreased "no-shows" from about 1.9 per day to 0.75 per day
And anecdotally, he says:
  • His personal workload has decreased substantially
  • Patients and staff are much happier
  • Improved productivity allowed him to take six weeks of vacation this year, instead of his usual three
 
Omura is part of a 25-physician, three-site primary care group practice called Primary Care Partners, located in rural western Colorado, USA. He is the self-appointed "pilot person," the one who tries new ideas such as open access, an appointment scheduling system that eliminates virtually all patient backlog, and enables patients to come in at the time of their choice, generally on the same day they call.
 
Omura implemented open access with his patients in October 2000. A year later, several of his practice partners are following his lead, convinced by his success that it is a worthwhile endeavor.
 
Intriguing and Perplexing
Open access is a concept that many find both intriguing and perplexing; it makes intuitive sense, and yet at the same time seems impossible. Developed by Mark Murray, MD, and Catherine Tantau, RN, consultants in Sacramento, California, USA and promoted by the Institute for Healthcare Improvement (IHI) through its Idealized Design of Clinical Office Practices (IDCOP) program, open access uses queuing theory to reengineer the standard appointment scheduling system, leaving the majority of slots on any given day open for patients who call that day.
 
"It made theoretical sense to me," says Omura, "and I liked the idea of meeting patients’ needs in a more timely fashion." So Omura began by studying his appointment patterns to understand how best to reconfigure his schedule. Like many practices, his appointment book offered short, medium and long slots, and the day would fill in randomly, and not always completely, depending on patients’ needs. To support the transition to open access, Omura decided to offer only two appointment types: long ones to accommodate physicals, and shorter ones to accommodate everything else.
 
Often the most painful step in implementing open access is to work down the current backlog. This is generally done by adding extra slots and working longer hours, and/or adding additional staff temporarily. Omura also began "doing today’s work today," one of the mantras of practices that use open access. "Before open access, if a patient came in with an abnormal skin lesion, I would examine and diagnose it during one visit, and schedule them to return for an excision," he says. "Now I do it all at the first appointment."
 
With open access, says Omura, the day’s schedule fills like a glass, from the morning up. "You’re much less likely to have empty slots or no-shows during the day," he says, "and if the schedule doesn’t fill up, it’s better to have down time at the end of the day when you’re tired."
 
Another benefit of open access scheduling is that it reduces the use of urgent or emergency care settings by patients who couldn’t get a same-day appointment under the old system. Omura reports that "our local urgent care facility says they rarely see my patients anymore." And his patients’ hospital days are also dropping. "Our group as a whole runs about 120 commercial hospital days per year. My patients are well below 100."
 
Not surprisingly, Omura reports that patients love the new approach to appointment scheduling, and so do staff. "The staff used to spend forever triaging patients, teasing out information so they could make the proper appointment." Open access often improves telephone access as well, since the need for lengthy negotiations about appointments is eliminated.
 
Adjusting to Change
Open access has worked well for Omura because he has been able to analyze how it changes his needs, and adjust his practice accordingly. "When I started doing more for patients in a single visit — doing today’s work today — I realized I couldn’t do that the way I was structured. I didn’t have enough nursing staff to prep the patients."
 
He now has three clinical staff supporting him: a Registered Nurse (RN), a medical office assistant, and a lay person who has been trained to take vital signs, initiate prescription refills, and triage patient phone calls.
 
Omura knows what many doctors will say at this point in his story. "They’ll say, ‘I can’t afford three people in the back office.’ But if you do today’s work today, you can do more services, and get paid more. If you are more efficient, you can delegate more. I have added about eight more slots to my schedule because of increased efficiency," he says, "but I feel like I’m not working as hard as I used to. Just imagine eight more slots filling at about $110 per slot, that’s a lot of increased revenue that more than pays for additional staff."
 
Two Important Tools
Omura also employs two important practice tools that support efficiency: electronic medical records, and about 150 medical history-taking templates that enable him and his staff to gather consistent information from patients. The computer-based templates, which Omura developed himself, range in focus from abdominal pain to depression, with from ten to twenty questions each. Clinical staff enter patient responses directly into patient records using computers in the exam rooms.
 
"The templates are crucial to efficiency," he says, "because they allow a tremendous amount of delegation and participation by the nurses in patient care." They also have a cost benefit. "With the templates, I don’t spend a dime on dictation," says Omura.
 
Omura also employs an effective low-tech device to keep his open access schedule working well and to avoid the concern that many physicians have about same-day scheduling: how to ensure that follow-up visits are scheduled when needed. "I allow follow-up visits to be scheduled ahead if they are within two weeks of the initial appointment," says Omura. "For the rest, I give patients a follow-up card, just like an appointment card, that gives them a specific date to call for their next appointment." Omura emphasizes to patients that the card should be treated just like an appointment card. "I tell them to put it in their calendar."
 
Omura has some advice for practices that are thinking about trying open access scheduling. "Either do it or don’t do it," he says. "Don’t do it halfway. Some practices try to do it only partly, to test it, which just causes confusion." Omura also is learning about one of the less desirable aspects of having more room in his schedule: "I’m seeing a lot of overflow patients from other practices," he says. And although the overflow patients are helping his bottom line, he would rather fill all his slots with his own patients. "My practice is getting close to full," he says, at which point seeing overflow patients may be a moot point.
 
Omura’s data shows that open access has been good for the practice and good for the bottom line. He feels it has also been good for patients, who are getting better access and more continuity of care because they see him more consistently when they need care. But he also notes an important personal benefit: "I feel renewed and invigorated as we do things better and better. I’m almost as excited about my work today as when I first started practicing 20 years ago."
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