The Art of Panel Management

[SCPA]

My family medicine friends (and others!), would love to hear from those of you who've figured out how make the office run well thereby maximizing productivity and minimizing frustration ... Less post-patient encounter work (after visit paperwork/medical decision making - a biggie in family medicine!), charting smarter, maximizing nursing staff and front office staff, less stress!  

Thought I'd create a thread dedicated to running a rock star panel. 

Any tips, tricks, experiences would be great to share. 

Thanks! 

[rev ronin]

All paperwork is filled out in a face-to-face encounter only.  If you drop it off after your appointment, I will complete it during the next (billable) appointment.  A few reasonable exceptions, like sports physicals, apply.

[DizzyJ]

Training the front office staff has been key to cutting down on unnecessary emails/messages.  Many things can be handled by them without needing my attention.

1. Refills - did the patient perhaps call their pharmacy and see if they already have refills?  Also, staff is fully capable of looking to see when I wrote the last script and how many refills I provided to direct the patient to contact their pharmacy.  Also, refill requests from pharmacies should be reviewed by staff before coming to me.  I had one office who just gave me everything off the fax and didn't bother to look and see the patient has current refills (but perhaps two different rx's for same med and the pharmacy didn't combine them or bother to look) or the patient was just seen and refills sent already. 

2. Pharmacy - patient's often call wanting to get their med at another pharmacy...I don't need to be involved unless for controlled substance.  Patient can transfer their RX to any pharmacy they would like with no involvement from me so long as they have active RX/refill available. 

3. Paperwork - patient should complete all sections they are required to fill out.  I must have seen then recently.  If they need to ASAP then they should be sitting in front of me to fill it out.  Otherwise, it will be at my leisure 72 hours. 

4. Training staff about what I'll call a patient back for vs what I will not.  Patient seen 2 months ago for XXX and still not better...I don't need to talk to them.  They need to be seen. 

[mgriffiths]

I agree with what has already been said, except I do paperwork like rev ronin.  With few exceptions, if I am filling out paperwork the patient is sitting in front of me and it is a billable visit.  Too many times I sit down to fill out paperwork and don't have all the information I need.

I also have staff call to provide results to patients, unless it's something big like cancer or similar.  Usually I'll have the patient come back to discuss those anyway as I think it's worth more than a phone call.

My MA also has the patient fill out all paperwork, then she fills in the rest except for pertinent areas that I must fill out that require medical evaluation or my actual signature.  She fills in dates, addresses, medications, etc.

[camoman1234]

5 hours ago, dizzyjon said:

Training the front office staff has been key to cutting down on unnecessary emails/messages.  Many things can be handled by them without needing my attention.

1. Refills - did the patient perhaps call their pharmacy and see if they already have refills?  Also, staff is fully capable of looking to see when I wrote the last script and how many refills I provided to direct the patient to contact their pharmacy.  Also, refill requests from pharmacies should be reviewed by staff before coming to me.  I had one office who just gave me everything off the fax and didn't bother to look and see the patient has current refills (but perhaps two different rx's for same med and the pharmacy didn't combine them or bother to look) or the patient was just seen and refills sent already. 

2. Pharmacy - patient's often call wanting to get their med at another pharmacy...I don't need to be involved unless for controlled substance.  Patient can transfer their RX to any pharmacy they would like with no involvement from me so long as they have active RX/refill available. 

3. Paperwork - patient should complete all sections they are required to fill out.  I must have seen then recently.  If they need to ASAP then they should be sitting in front of me to fill it out.  Otherwise, it will be at my leisure 72 hours. 

4. Training staff about what I'll call a patient back for vs what I will not.  Patient seen 2 months ago for XXX and still not better...I don't need to talk to them.  They need to be seen. 

I agree with Rev: All paperwork needs an office visit, I am way to busy to being doing FMLA paperwork t/o the day and will not do it while at home/after hours. 

[sas5814]

I worked for a doc (who was admittedly a little nuts) who charge patients to fill out any paperwork that wasn't directly related to their visit and care like FMLA. I'm not sure how he got away with it but he had been in the same busy location and practice for a long time.

[GetMeOuttaThisMess]

I worked for a doc (who was admittedly a little nuts) who charge patients to fill out any paperwork that wasn't directly related to their visit and care like FMLA. I'm not sure how he got away with it but he had been in the same busy location and practice for a long time.

Good for them. Would an attorney do such a think for free (I don't really know)?


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[camoman1234]

1 hour ago, sas5814 said:

I worked for a doc (who was admittedly a little nuts) who charge patients to fill out any paperwork that wasn't directly related to their visit and care like FMLA. I'm not sure how he got away with it but he had been in the same busy location and practice for a long time.

I charge my patients a office visit while doing FMLA, but my patients will call and ask me if I will fill out their FMLA paperwork and I have not seen them in 6 months. I had a lady call about her FMLA for anxiety and I have not seen her in a year and never even addressed this issue with her (only saw her for sick visits, once per year). That is the type of patient I make come in for an office visit so I can address their diagnosis plus fill out their FMLA paperwork. Another example where I do NOT make patients come in for an office visit is if I see them several  times a year for pain management and they want to re-new their handicap placard, I will fill it out without an office visit as I think it would be wrong to drag them in here for a 30 seconds for me to sign a  form. So I can see where my initial comment could be taken out of context and I just wanted to give some example of how I do things. 

[sas5814]

Oh he didn't bring them back in for a visit. These were mostly people who were work comp evaluations but there were others too. He just charged the patient a fee. I want to say he charged $75 for FMLA and different rates for other things.

That is why I'm not sure how he got away with it. Work comp and most insurances have pretty strict rules about what you can and can't charge for and extra fees and charges are generally in violation of your agreement with the insurer.

[MCHAD]

9 hours ago, dizzyjon said:

Training the front office staff has been key to cutting down on unnecessary emails/messages.  Many things can be handled by them without needing my attention.

4. Training staff about what I'll call a patient back for vs what I will not.  Patient seen 2 months ago for XXX and still not better...I don't need to talk to them.  They need to be seen. 

I can't emphasize the importance of this enough.  If labs are normal or not "normal" but have something like creatinine of 0.8 I label them "unremarkable" and my nursing staff can inform them.

if it is anything else I don't feel comfortable with nursing staff discussing a patient needs an appointment.  I don't have time to spend 15 minutes reviewing labs on the phone with a patient.  It may sound cold but a provider could easily spend an hour or more per day making phone calls and I don't feel this is appropriate. 

[rev ronin]

Clarification re: Paperwork.  I do L&I paperwork on my "own time" since I'm getting paid for them.  I may still complete them in a visit, but when I actually get paid for the paperwork, it's a different social contract. :-)

[MCHAD]

Regarding imaging/lab/pathology results you may encounter a situation where patients have results sent to you or drop of results that you didn't order the test for such as mammography or labs done at a lab fair.  If they want me to interpret they need an appointment also. 

[HmTwoPA]

I worked as an LVN in Family practice at Sharp health system in San Diego. They began charging for paperwork up front if the patient did not have an appointment. I remember the patients being pretty upset that they had to pay money for the paperwork after not being charged for years. Of course the providers didnt have to deal with it, only front office staff and the MA/LVN. 

Although Im half way through my program so I cant give advice as from the PA side of the house, I did work as a float LVN and Corpsman in family practice for about 3 and half years total. The most successful providers are the ones that have the best relationships with their MA or nurse. If you can try to treat them good (coffee every once in a while, ask about family, remember birthdays... or just basic human decencies that a lot of providers seem to lack). I would say often the MA or nurse makes or breaks the providers schedule. They decide which phone calls go to you, which paperwork goes to you, what tasks your assigned. So if you train them (or a good seasoned nurse does) to work at the top of their ability, it'll make your life easier. Heres some advice specifics from what I've seen.

 

1. Have a set of standards easily understood with your MA, such as HCG for female with stomach pain, ask diabetes patient to take off shoes, screen paperwork that the patient brings in, remind patient that we might not get to all of their problems and complaints today so we may have to schedule another appointment. Ask them to undress them before a physical if you want. Remove articles of clothing that are obstructing the view of their complaint i.e. remove pants if they are here for a knee concern and wearing tight pants. Also remember that he/she is human so bound to forget every once in a while and a NICE reminder is appreciated when they forget. A tricky one to this is Xrays. If you have trust with an experienced MA/LVN sometimes its good to just set ground rules for them ordering xrays under your name i.e. If the patient is coming in with pain associated with trauma

2. Set up parameters for triage calls. When I floated in pediatrics the doctors would give us recommendations to give to patients with common baby complaints. Ask them to type up what they said to the patient and forward it to you as an FYI, so if you disagree you can call the patient, or if you agree you can sign your name to it. Talk to them about when you just want an appointment for the patient instead of talking to them. This will save you from getting stuck on the phone with the patient stating you wont write an "refill" on abx because they think they have the same rash from 2 years ago that you wrote an rx for. 

3. Refills, ask your MA to verify they need one. When you are prescribing medication write in your plan what you want to do for the next refill i.e. Patient will follow up in 3 months to verify medication is working, or patient will have labs done before next refill. 

4. Let your MA/LVN know if you're going to be late, or if you think a particular patient is going to take long so that way he/she can catch you up or let your next patient know. This also helps them send a patient to get labs while they are waiting or get their urinalysis, or hold off on getting the urinalysis. 

 

In my opinion, and in documented research, an open team with mutual respect shows the best patient outcomes and the smoothest day for you. Sometimes you'll work with people though that cant be trained to work and its best you talk to the nurse manager about more "training" for these people or letting them go. 

 

Sorry for the long post. Just my .02 cents from the other side of the house. 

 

 

[TWR]

Although Im half way through my program so I cant give advice as from the PA side of the house, I did work as a float LVN and Corpsman in family practice for about 3 and half years total. The most successful providers are the ones that have the best relationships with their MA or nurse. If you can try to treat them good (coffee every once in a while, ask about family, remember birthdays... or just basic human decencies that a lot of providers seem to lack). I would say often the MA or nurse makes or breaks the providers schedule. They decide which phone calls go to you, which paperwork goes to you, what tasks your assigned. So if you train them (or a good seasoned nurse does) to work at the top of their ability, it'll make your life easier. Heres some advice specifics from what I've seen.

The above paragraph is paramount for a successful and profitable, less stress practice.  Well said.

[camoman1234]

19 hours ago, sas5814 said:

Oh he didn't bring them back in for a visit. These were mostly people who were work comp evaluations but there were others too. He just charged the patient a fee. I want to say he charged $75 for FMLA and different rates for other things.

That is why I'm not sure how he got away with it. Work comp and most insurances have pretty strict rules about what you can and can't charge for and extra fees and charges are generally in violation of your agreement with the insurer.

Gotcha, I agree that does not sound fair and honest. That you for clarifying. 

[dchampigny]

We use Dragon, which is an absolute life saver. I can simply say "normal mammogram" and it will spew out all of the information that the patient needs. 

 

MA reads most of labs: for abnormalities/concerns I will sometimes call personally.

 

Forms continue to be a challenge. 

[SCPA]

4 hours ago, dchampigny said:

We use Dragon, which is an absolute life saver. I can simply say "normal mammogram" and it will spew out all of the information that the patient needs. 

MA reads most of labs: for abnormalities/concerns I will sometimes call personally.

Forms continue to be a challenge. 

I'm getting dragon medical shortly in the office. Can you elaborate? Didn't realize Dragon has this capability.. 

 

[south]

Where I rotated for EM, they used Dragon with EPIC.  You could do an entire note and encounter with followup in less than 30 seconds.  All the docs had custom phrases that they would pass to one another - since they were football crazy, you just heard providers sitting there saying "hike" "pass" "boom" "chest pain" "normal labs" "touchdown", etc.

We had a lady with a crazy history (BC mets, etc) come in unconscious, code and die.  The doc sat down and did the entire note including typing some sort of statement, in about 3 minutes.  He wanted me to look at it since I was a student and former scribe and EPIC trainer, and it was a thing of beauty.  I got verklempt! 

[dchampigny]

There is a function where you can put in a paragraph and then save it under a catch phrase: Example: I type a paragraph for well adult exam: it talks about USPSTF screenings, diet, exercise, stress. Each time I say "Dragon Well Adult" that whole paragraph comes in. For a healthy male in his 30s who comes in for a physical without any acute complaints, sometimes the note is already completed before I'm out of the room.

There is no limit to them, I have about 35. Maybe half I use regularly. But even for acute things you can say "Dragon viral URI" and have pre-typed up instructions

[Incognito]

I use Dragon too.  I have my dot phrases and the exam pops up on my screen.  I made my own exams up to be how I usually dictate. I can plug in the ROS and exam with a quick command.  I use it all the time for annual well exams and quick visits for UTI, URI, sinus, back pain. 

[rev ronin]

In my previous practice, we didn't have an EHR, and I did have Dragon Home & Office, which actually worked very well.  I used Word's autocorrect features to mimic dot phrases.  Couldn't pull any labs data in, but other than that it worked pretty well for so cheap a setup...