What is pre-visit planning?
Pre-visit planning includes scheduling patients for future appointments at the conclusion of each visit, arranging for pre-visit lab testing, gathering the necessary information for upcoming visits and spending a few minutes to huddle and handoff patients. Pre-visit planning can mean the difference between a clinic where physician and staff are floundering and frustrated, and a clinic that runs smoothly with the capacity to handle any unanticipated issues that arise.
How much time and money will pre-visit planning save my practice?
This calculator allows you to estimate the amount of time and money you can save by implementing pre-visit planning in your practice. Enter the amount of time (minutes) per day spent by physicians and staff on activities that could be eliminated by pre-visit planning.
Source: AMA. Practice transformation series: pre-visit planning.. 2014.
Ten steps to pre-visit planning
1Re-appoint the patient at the conclusion of the visit2Use a visit planner checklist to arrange the next appointment(s)3Arrange for laboratory tests to be completed before the next visit4Perform visit preparations5Use a visit prep checklist to identify gaps in care6Send patients appointment reminders7Consider a pre-visit phone call or emailHold a pre-clinic care team huddle8Use a pre-appointment questionnaire9Hand off patients to the physician10
During the current visit
Plan forward: Re-appoint the patient at the conclusion of the visit
Practices can plan ahead by scheduling patients for their next visit at the conclusion of each visit, including scheduling any needed pre-visit laboratory testing (“plan forward”). This saves time and reduces the number of staff touches in setting up planned care appointments. Alternatively, practices that do not have the capacity to hold future laboratory orders may choose to employ a “look backward” strategy, where a staff person orders laboratory according to an established protocol based on the patient's medications and/or conditions a few days before the next appointment. Although the “look backward” strategy involves more staff touches than the “plan forward” approach, any amount of pre-visit planning is helpful. Pre-visit planning gives the message to patients, “We want to see you again and we are planning ahead to make our next visit as meaningful as possible.”
We think about the patient more inclusively before they come in for their visit so that we can take care of as much as possible at the time of the visit. This prevents work later.
Our schedules are open only a few weeks in advance. How can we adopt pre-visit planning?
For practices that do not schedule appointments months in advance, a reminder file can be used to queue up follow-up visits and laboratory test orders and to prompt staff to contact patients closer to their follow-up visit dates.
Can I use pre-visit planning with the open-access scheduling approach?
Yes, you can use pre-visit planning with open-access scheduling. Staff can use a reminder file to queue up follow-up visits and associated laboratory tests and then contact patients closer to the ideal follow-up visit date (see step 4).
Use a visit planner checklist to arrange the patient's next appointment(s)
The visit planner is a checklist that allows the physician to indicate the interval until the next appointment and any associated labs required prior to that visit. It should be quick and convenient to use, requiring no more than a few seconds of physician time. The visit planner checklist can be used by a medical assistant (MA) or clerk who can schedule the appointments and tests indicated by the physician.
The next appointment starts today.
Can you provide an example of when to use the visit planner checklist?
Consider a patient who has diabetes, hypertension and hypothyroidism who will be due for their annual comprehensive care visit in three months. During the current visit, the physician uses the visit planner checklist and indicates the appointment interval and type: “Three month physical exam,” and also checks “diabetic panel, TSH, Na, K and mammogram.” A member of the physician's team can then schedule the patient's annual visit, the indicated laboratory tests and the mammogram.
Our physicians are overwhelmed by the process of selecting a diagnosis code for each test, a process that can add several minutes to each appointment. Do you have any suggestions?
When creating the visit planner checklist, pair each test with the two or three most frequently used diagnosis codes for that test. The physician can then easily check the appropriate diagnosis code for that patient, alleviating the need in most circumstances to search through a longer list of codes. For example, the default ICD-9 code might be 285.9 (anemia) for a hemoglobin workup with the option of checking for 780.79 (fatigue) or for 578.1 (blood in stool). If the hemoglobin is ordered for another diagnosis, a search can be undertaken for the correct ICD-9 code, but for most patients the correct ICD-9 code will be one of the three options provided next to the test name on the visit planner. Some practices work with their IT department and/or EHR vendor to create an electronic version of the checklist.
Our physicians commonly order the same bundles of tests. Can the visit planner help with this?
Yes. You can create “order sets,” or tests that are bundled based on conditions. This simplifies the ordering process and reduces the likelihood that laboratory tests are missed. For example, an order set for diabetes provides the diagnosis code and orders an entire panel of relevant tests— A1c, lipid profile, urine microalbumin test and creatinine blood test—with a single checkmark or click.
As a physician I have had the experience of re-appointing a patient in three months, only to later discover the patient was due for their annual wellness visit and mammogram in four months. To avoid this scheduling snafu I spend a lot of time searching through the medical record for the dates of these past services. Do you have any suggestions?
It is helpful if the visit planner checklist also includes key information about the dates of the patient's previous annual appointment and any upcoming appointments and laboratory tests. This allows the physician to place today's visit in the continuum of care. In the situation described above the physician would see that the patient was due for an annual appointment in four months and would schedule the follow-up for diabetes at the same time. Some IT departments and/or EHR vendors create a program that automatically pulls this information into the visit planner; other practices arrange for reception staff to manually add this information to the checklist before the appointment.
Arrange for laboratory tests to be completed before the next visit
By performing lab tests before the visit the physician and patient can discuss results and management decisions at the visit. Some organizations arrange for the patient to come for lab testing a few days before the visit; others have developed rapid turnaround or point-of-care testing for most tests so they can be performed the same day as the visit with the physician. Regardless of the approach, the goal is to have the test results available so physicians and patients can discuss the results and make management decisions together during the face-to-face visit. Because the practice doesn't need to spend time contacting the patient with results after the visit, both the patient and the practice save time.
An internal medicine practice in Boston found that pre-visit laboratory testing reduced the number of letters and phone calls for results by more than 80 percent and saved $25 per visit in physician and staff time.
Before computerized order entry our physicians ordered the next visit's labs at the conclusion of each visit. Now our organization requires that all test orders done within a visit encounter be entered by the physician. Our physicians don't have the extra two to three minutes per appointment to do this. How can we address this challenge?
Some practices have responded to this type of policy by ordering pre-visit testing outside of the visit encounter. With this approach, nursing staff contact the patient one week before their next appointment and arrange the necessary laboratory tests using standing orders based on the patient's clinical conditions and medications. Another solution could be using a team documentation care model, where a team member supports the physician during the encounter by entering requested orders and aiding with documentation during the visit.
See Team Documentation module for more information on team-based approaches to managing orders.
Does Stage 2 Meaningful Use (MU2) require physicians to personally enter laboratory and x-ray orders or suffer a financial penalty?
No. According to MU2, “Any licensed healthcare professionals and credentialed medical assistants, can enter orders into the medical record for purposes of including the order in the numerator for the objective of CPOE [computerized provider order entry] if they can originate the order per state, local and professional guidelines. Credentialing for a medical assistant must come from an organization other than the organization employing the medical assistant.” For more information, please visit the Centers for Medicare & Medicaid Services website regarding MU2 requirements.
Perform visit preparations
Visit preparations can be done by the nurse or MA the day before or just prior to the appointment. This will save time and reduce mistakes during the visit. The nurse or MA can conduct the following activities:
AReview the physician's notes from the patient's last visit as well as notes from other providers who delivered interval care. If any interval care notes or results are not in the patient's record, the nurse or MA can call that office or department to obtain the information prior to the visit.
BPrint copies of laboratory test results, x-rays or pathology reports to share with patients. If a patient portal is available, the nurse or MA can later refer patients to these results.
CIdentify gaps in care that need to be closed, such as immunizations or cancer screenings.
Use a visit prep checklist to identify gaps in care
A visit prep checklist or health maintenance screen in the EHR or separate registry provides an overview of the preventive and chronic care needs (e.g., immunizations, cancer screenings and testing for patients with diabetes). In practices without an EHR or a clinical registry, staff may choose to manually collect this information before each visit. This important step will help the clinical team address any patient needs during the upcoming visit.
Send appointment reminders to patients
Many practices send patients automated reminder letters, emails, phone calls or text messages a few days before their appointments. This reduces no-show rates. If no automated option exists, these calls can be made by practice staff or letters can be sent directly from the office.
Decrease no-shows and increase efficiency and patient engagement #STEPSforward
Consider a pre-visit phone call or email
Nurses or MAs in some practices also make a pre-visit phone call to their more complex patients, performing tasks such as medication reconciliation and agenda setting on the phone, and then pre-populating the next day's visit note with this information. Other practices email a link for the patient to complete a pre-appointment questionnaire; the patient's responses flow into the next day's visit note. Both approaches save staff and physician time during the clinic session.
Our providers become unglued if there isn't pre‑visit lab.
Hold a pre-clinic care team huddle
A five to 15 minute pre-clinic huddle brings the team together to review and share knowledge about the day ahead. In addition to being alerted to last minute staffing or schedule changes, as well as any special needs of the patients or team, the care team can use this time to determine how best to share the work. It is also a time where the nurse or MA who performed visit prep can tell the physician about an abnormal x-ray result or a complex multi-disciplinary situation, giving the physician an opportunity to consult with colleagues or other resources prior to the patient's visit.
Use a pre-appointment questionnaire
Provide each patient with a questionnaire to complete before the appointment, either electronically from home (see step 7) or on paper at check-in. The pre-appointment questionnaire allows the team to quickly see what is most important to the patient and helps the physician plan the visit before entering the room. The pre-appointment questionnaire can include questions that would otherwise be asked during rooming, such as depression screens, pain assessment, smoking status, falls screening and specific questions associated with the Medicare Annual Wellness Visit. By shifting these questions to the questionnaire, the nurses and MAs have much of the information that they would otherwise need to obtain during the visit, giving them more time to actively engage with patients.
Should I scan the pre-appointment questionnaire into the EHR?
It is not necessary to maintain a copy of the completed pre-appointment questionnaire. It is a worksheet to facilitate discussion during the visit. Important information from the questionnaire can be recorded in the visit note.
Hand off patients to the physician
The nurse or MA will often learn important information about the patient during the rooming process. A brief one minute handoff to the physician can save 10 minutes in the exam room by helping the physician focus the appointment to best meet the patient's needs and expectations. The handoff also makes the patient aware that her team is working together on her behalf. For example, the physician may say, “The nurse mentioned that you've been worried about side effects from your cholesterol medication—please tell me more.” Staff will quickly see the importance of their initial discussions with patients.
Frequently referred to as a warm handoff, this exchange can also be used to alert the physician to the emotional status of the patient so the physician can better calibrate their initial tone to match their patient's needs. An example of this could be if the nurse says, “Her husband is in the hospital and she is worried and upset.”
I like the idea of a handoff. However, I don't always see my MA between patients. She is often in a different room when I am ready to attend to the next patient. How can we address this?
There are innovative ways to hand off patients. First, the MA can brief the physician about several patients at once. This way, if the MA is in a different room when the physician is ready to meet the next patient, the physician is already prepared. Second, the MA can hand off information by listing key information in the patient's chart. While a verbal handoff is preferable, a short note is still beneficial.
Do I need to hire more staff to implement pre-visit planning?
Not necessarily. Overall, pre-visit planning saves staff time because less time is spent looking for information during the visit and less time is spent on reporting results post-visit. Practices that have success with pre-visit planning often have a 1:1 physician to support staff ratio. That staff member is able to save time through effective pre-visit planning.
We have a registry that identifies patients' prevention and chronic care needs as they come due. Why should we address these needs at a visit?
Many practices use the in-reach approach as the primary method for addressing prospective care needs. This is typically done at the annual comprehensive care visit and reserves the outreach approach for patients who were missed in the in-reach approach. In-reach is most efficient approach.
Practices that exclusively use an outreach approach will spend more time completing administrative tasks in the long term and may end up asking patients to come in for multiple visits when their needs could have been met in one visit. Outreach is useful as a tool to close gaps in care for patients who have missed annual appointments or preventive care milestones.
Our physicians and staff are overwhelmed. How can we find time to implement pre-visit planning?
While it may sound overwhelming to implement a new process, successful pre-visit planning can enhance teamwork and operational efficiency. Some practices save an hour or more of physician and staff time per day with pre-visit planning.
Disorganized visits can be stressful for everyone: patients, staff and physicians.
Having all needed information available ahead of the appointment minimizes trips in and out of the room and disruptions in patient flow to create a healthier, happier work environment.
Avoid being caught off guard by unexpected patient agenda items.
Pre-visit planning reduces the chance the team will be caught off guard by a patient's unexpected agenda item. For example, if the patient indicates on a pre-appointment questionnaire that the main purpose of his or her visit is to get help with insomnia, it is less likely the physician will get to the end of the appointment only to learn then that the patient's main concern, difficulty sleeping, had not yet surfaced.
Seek to close potential gaps in patient care both during and before the face-to-face appointment.
Pre-visit planning provides an opportunity to close gaps in a patient's care. During visit prep, for example, the nurse or MA determines if a patient is due for any immunizations or a colonoscopy. Using established protocols the nurse can close these types of gaps before the physician portion of the visit begins.
Close the loop of care during the visit.
Pre-visit planning allows the team to complete all of the tasks for the visit (i.e., to “close the loop” of care) during the appointment, rather than having multiple follow-up items, such as laboratory results or medication adjustments, left unfinished at the close of the visit.
Take a long view: schedule several planned care appointments at once.
A visit planner can be used to set up more than one future appointment. For example, at this year's annual comprehensive care visit for a patient with diabetes, hypertension and hypothyroidism, the physician may check off both a six-month follow-up (with A1c) as well as next year's annual visit (with diabetic panel, hypertension panel, TSH and mammogram). For those using open access scheduling, the appropriate time intervals for appointments and associated labs are tracked in a tickler file.
The strategies, tools and resources in this module can assist you in adopting a pre-visit planning approach that fits your practice's specific needs. With pre-visit planning, your practice can reap the benefits of improved communication with patients, streamlined scheduling of appointments and enhanced care team efficiency during a patient's current visit, between visits and during the next visit.
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STEPS in practice
How's it working in Lincoln, NE?
Dr. Michelle Ellis’ team at Prairie Lake Family Medicine in Lincoln, NE, focuses on pre-visit planning as a strategy to improve efficiency and patient care.
The trigger for this new approach was the implementation of a system-wide, patient-centered medical home transformation that began two years prior. This organizational change required more preparation before each visit and advance planning of preventive care needs, contributing to more work for the clinical staff.
The team preps for scheduled visits 24 hours in advance and same day add-on patients are prepped prior to Dr. Ellis entering the exam room. The two nurses who support Dr. Ellis are the primary team members responsible for prepping the charts and each have specific responsibilities. One nurse prepares for mammograms, DEXA and colonoscopies; while the other preps for needed vaccines, pulmonary function testing, preoperative EKGs, follow-up imaging and Pap smears. All clinical updates are documented on the care team’s huddle prep sheet and reported to Dr. Ellis. This “divide and conquer” approach ensures that Dr. Ellis’ thoughts and priorities for each visit are organized and she is able to efficiently get the most out of each patient encounter.
Pre-visit planning can also have its challenges; finding the right ratio of staff to patients to accommodate this new workflow has been an ongoing process. Dr. Ellis works with two nurses and shares a scheduler, a front office staff member and a lab technician with her office partner. In addition, she shares two part-time team members with other offices and administration, one who helps with referral coordination and one who provides health coaching. Each team member is cross-trained and thus can cover for each other and perform additional duties as required. Strong team communication was also essential.
To create the best patient experience possible, Dr. Ellis, her partner and their teams frequently evaluate and make small changes to any new process or procedure they are trying out. They learn what’s working and what’s not through open dialogue in team meetings. They will soon be using patient satisfaction surveys to measure the impact of their new workflows and continue augmenting the processes until they are fully optimized.
As a result of pre-visit planning, the practice is able to provide more preventive services, such as pap smears, mammograms, immunizations colonoscopies and bone density scans and improved outcomes for patients.
How's it working in Lincoln, NE?
Dr. Todd Johnson’s team at Autumn Ridge Family Medicine in Lincoln, NE, has used pre-visit planning for more than two years. An informal process was initiated by a desire to be prepared for the upcoming clinic day. As the team began to investigate the criteria for certification as a patient-centered medical home, they began to organize their informal process into a standardized checklist within the EHR. This new checklist had a dramatic effect on the flow of their day.
The checklist covers:
• How many patients were seen the previous day
• How many patients were sent to an urgent care center or the emergency room
• How many openings there are in the schedule and at what times
• The third next available chronic visit, acute visit or wellness exam
The team continued to formalize their pre-visit planning activities by adding reminders for overdue labs and orders for upcoming lab tests into the EHR. The team scheduler’s role expanded to include reminding patients about lab tests when she called to confirm their appointments. The scheduler relies on standing orders and written protocols to know which tests to discuss with patients. In addition, new nurses were trained to fulfill standing orders as part of the pre-visit planning process. Every person on the team now plays a role in pre-visit planning in some capacity, leading to one hour saved over the course of a clinic day.
Every day, Dr. Johnson’s team attends a pre-clinic huddle. The team scheduler kicks off the huddle with a summary of the previous day’s work followed by an overview of the upcoming day’s schedule and case load. This overview includes openings in the schedule and which team members are out for the day. Dr. Johnson’s nurse then takes over and discusses the details of the day’s more complex patients. She focuses on addressing any gaps in care identified by the practice reminder system for patients with asthma, chronic obstructive pulmonary disease, hypertension and/or diabetes. Reminders are set for items such as pre-visit labs, deficient immunizations and diabetic eye exam deficiencies. All other tasks needing attention are covered by others on the team. By the end of the meeting, there is clear understanding of the plan for the upcoming day.
Dr. Johnson’s team measures their success based on no-show rates, which have dropped dramatically since they formalized their pre-visit planning process. In fact, Dr. Johnson and his team now have one of the lowest no-show rates in the network.
“I can’t imagine not doing pre-visit planning. Everyone’s contributions make things run so smoothly that when someone is missing from the huddle, it results in a chaotic day,” said Dr. Johnson. “Pre-visit planning changed the energy in the office and made this a better place to work.”
The other two physicians in the clinic with Dr. Johnson use their own unique versions of pre-visit planning with their teams. Like Dr. Johnson, they recognize the benefits of pre-visit planning, but have found that there is no one-size-fits-all approach to preparing for the day.
How's it working in Rosemount, MN?
At Fairview Health Services, in Rosemount, MN, the MA conducts a pre-visit phone call two days before the appointment. During this call she addresses medication review, agenda setting, lifestyle issues, advance directives, depression screening and updates the patient's social and family histories. MAs place these calls during short breaks between rooming throughout the day. They then pre-populate the next day's clinic note with this information. For the most complex patients, the pharmacist may also make a call to perform pre-visit medication reconciliation.
How's it working in Boston, MA?
Example 1: In Dr. Ben Crocker's practice at the Ambulatory Practice of the Future at Massachusetts General Hospital in Boston, each clinic session begins with a team huddle. The nurse practitioners, nurse, MAs, health coach, schedulers, greeter and four physicians review the day's list of patients on a large wall-mounted computer monitor, including patients in the hospital and patients scheduled for phone visits. For a patient presenting for evaluation of abdominal pain, the nurse raises the role his recent divorce may be playing. The health coach alerts the team that another patient is now unemployed and has had trouble filling his prescriptions. This is how one team is fulfilling the promise, first created as a guiding principle of Borgess Health in Michigan, “We will know who you are and are ready for you.”
Example 2: Like most physicians, Dr. Ben Crocker at the Ambulatory Practice of the Future in Boston used to see his patients first and then send them to the lab after their appointments. As the results came back he reviewed each one individually. When all tests results returned he would eventually write a letter to the patient or try to reach them by phone. This often required him to relearn the scenario for which the labs were ordered, and did not provide an opportunity for important face-to-face counseling on certain medical conditions. It was common for patients to call back with questions about their results that they did not understand from the letter or phone message.
The system of post-visit lab required handling each test result individually as it was released from the lab. Dr. Crocker was awash in results as multiple lab results from multiple patients returned to his inbox individually and were intermingled with other messages. He realized that it was not only a lot of work for him and for his staff to sort through and manage, it was inconvenient for the patient and it prevented him from being able to discuss the test results with the patient at the visit.
In 2012, his practice instituted point-of-care pre-visit laboratory testing. They compared the number of follow-up phone calls and letters from before and after implementation of the system. Pre-visit lab testing reduced the number of phone calls to the practice by 89 percent and reduced the number of letters sent to patients about lab results by 85 percent. There were significantly fewer (61 percent) revisits due to abnormal tests and fewer lab tests (21 percent) ordered overall since the results were reported in real-time. This saved the practice $25 per visit in physician and staff time. Importantly, patient satisfaction with their care also increased.
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PPT, 64 MBPreview
Visit planner checklist
A checklist that allows physicians to indicate the need for another appointment and any associated laboratory tests to be completed before the next patient visit.
MS WORD, 49 KBPreview
Visit prep checklist
A checklist that allows the clinical team to compile a list of screening and immunization needs to be addressed during the next patient visit.
MS WORD, 52 KBPreview
Set the agenda for the next patient visit and save time during the clinic session by having patients fill out this questionnaire over the phone or by email.
MS WORD, 57 KBPreview
Pre-visit planning implementation checklist
A checklist to help assess, improve and reassess the implementation process of pre-visit planning in your practice.
MS WORD, 51 KBPreview
Pre-visit planning metrics
Measure the impact of pre-visit planning.
MS WORD, 98 KBPreview
The AMA is committed to helping you implement the solutions presented in this module.
If you would like to learn about available resources for implementing the strategies presented in this module, please call us at (800) 987‑1106 or send us a message.
Obtaining CME credits with STEPS Forward™
AMA PRA Category 1 Credit™ will be available for the activity. Physicians should claim only the credit commensurate with the extent of their participation in the activity. In order to claim AMA PRA Category 1 Credit™, you must: 1) view the module in its entirety, 2) successfully complete the quiz by answering 4 out of 5 questions correctly and 3) complete the evaluation.
Already completed this module?
If you have already completed this module, you can claim AMA PRA Category 1 Credit™ or receive a certificate of participation through the AMA Education Center.