Being able to identify where the patients in your practice are at any given time has a host of advantages, both in terms of monitoring what's happening in real time, and in terms of being able to analyze the information afterwards to identify bottlenecks (practical or human). With that in mind, several companies are now incorporating features designed to track patient location into their electronic office management products. To see how this concept might impact the field of ophthalmology, we spoke to three practices that are developing systems of their own.
Following the Patient's Chart
John S. Jarstad, MD, medical director of Evergreen Eye Centers in Federal Way, Wash., says he's been working with a couple of retired Microsoft engineers to create a system of total patient flow management they call Brevium. The system uses a reprogrammable, electronic chart insert whose presence is detected by radiofrequency transmitters located throughout the practice—including in the chart rack found outside every exam lane. The transmitters track each patient from the moment he arrives until he leaves the office.
The information about the current location of each chart is forwarded to a central computer system; that information can be called up on any computer in the practice. (See sample screen, below.) The system also tracks the time spent at each location—including how long each patient waits after check-in, how long it takes for the tech to work up the patient, how long the patient waits for dilation, and how much time the doctor spends with him.
In addition to exposing bottlenecks in patient flow, Brevium also reveals which patients routinely go through the system faster or more slowly. This information, combined with information about diagnosis, gender and language spoken, makes it possible to predict future scheduling needs with remarkable accuracy. Dr. Jarstad says this has allowed him to "smart schedule" up to 30 percent more patients per day, eliminating doctor downtime and patient wait time. "Before installing Brevium, I would gauge my practice efficiency by the number of ophthalmic journals or newspapers I could finish reading in a day's clinic," he says. "Since installing Brevium, I have yet to read through a newspaper in a clinic day." A sample Brevium patient flow monitoring screen. A map of the clinic appears on the right; room colors indicate use (tech, doctor, special equipment or waiting room). Patients are listed at the left as they arrive. A colored timeline shows: when they were scheduled to arrive (red dot); when they're waiting (light hatched pattern); when they're dilating (horizontal lines); and whether they are with a tech or doctor (color code for type of staff member). A white horizontal bar highlights patients who are not yet being seen. Clicking on a patient's bar lights up current room and staff member with the patient. (Here, Consuelo B, with technician Mary in Room 3, has been selected.) The system also times each part of every patient encounter for later analysis.
Working with EMR
Jeffrey B. Morris, MD, in private practice with the Morris Eye Group in Encinitas, Calif., is developing a similar system. Unlike Dr. Jarstad's Brevium system, Dr. Morris' system interacts with an existing electronic medical records system. It tracks patients by registering when a computer screen for a particular service is called up by the receptionist, tech, doctor or optician; it records the end of that segment of the office visit when the staff member clicks on a box (created by Dr. Morris) that indicates where the patient will be going next. Like Dr. Jarstad's system, this one shows where every patient is in the office and also tracks the timing of each segment of every visit.
"For example," says Dr. Morris, "when the tech picks up the patient and puts her in a room, he brings up her EMR and goes to the template we use to take the history. As soon as he clicks on that template, the workflow screen changes to show that the patient is now in that room with the tech. (This information is both labeled and color-coded on the workflow screen.) When the tech is finished, he calls up a decision tree listing all the places the patient might be sent next and clicks on the appropriate box. In this case, the options would include to the optical, to the doctor, to be dilated, or for ancillary testing.
"Let's say the tech is done with the refraction and workup, and the patient is interested in buying glasses," he continues. "The tech pushes the 'sent to optical' button. The workflow screen immediately changes to reflect this, with that patient's icon now a different color, and labeled 'waiting in optical.' When the optician brings up the patient's EMR, the color code changes to say 'with optician.'"
Dr. Morris is currently completing the part of the program that will collate all the captured timing information and print out a report showing all the most useful data. He plans to organize the data to show information about each office visit segment, average time taken by each technician or doctor, and time required by each patient. "The information is already in the system," he says. "I'm just organizing it so we can identify bottlenecks."
Although Dr. Morris is taking advantage of an existing EMR in this instance, he says the same type of set-up might be possible using any computer network. "It's nearly impossible to track patients without a system like this," he notes. "The beauty of this is that it captures timing as well as location. It's a great tool to help manage the office."
Richard C. Edlow, OD, chief operating officer of the Katzen Eye Group in Baltimore, says their practice is also working with Brevium to track patient flow, but with a paperless office, there's no paper chart to which they can attach a radio transmitter. As a result, they're investigating using a system like that being developed by Dr. Morris. (Some hospitals are trying similar systems that attach transmitters to each patient instead of the patient's chart, but this can be awkward for the patient, and tends to be considerably more expensive.)
"Our patient volume has been increasing 15 percent a year, with the same amount of physical resources," says Dr. Edlow. "We're constantly looking for ways to maintain quality of care, yet keep up with patient flow, so we look for any additional information we can get to tweak the system." He notes that the resource squeeze is likely to get worse. "With the changing demographics in this country, the demand for age-related eye care services will soon grow beyond what anybody can handle right now. Unless practices take advantage of options like patient flow operational analysis, there will be a real problem."
