BOSTON — Streamlining the preappointment assessment and management of new patients in clinical rheumatology settings can boost efficiency and improve care, according to Dr. J. Timothy Harrington Jr. of the University of Wisconsin, Madison.
Reviewing prospective patients' medical records, laboratory results, and imaging studies prior to scheduling an appointment ensures the most productive use of clinic time, Dr. Harrington said at the annual meeting of the American College of Rheumatology. The goal, he said, “is to distinguish between those patients who really need to see a rheumatologist and those who might be best served by seeing another specialist, such as an orthopedist, or who might be able to get the care they need from their primary care physician.”
Limiting “unnecessary” appointments—which can be as many as half of all appointment requests, said Dr. Harrington—substantially minimizes the wait time for new rheumatology appointments. By further classifying patients with appropriate rheumatologic indications as “routine” or “urgent,” and allocating the earliest available appointments to those with the most pressing conditions, rheumatologists are able to see new arthritis patients earlier in the disease process, when preventive interventions for joint damage are likely to have the most benefit, he said. The preappointment review of patient data also enables rheumatologists to determine how long an appointment to schedule for a given patient and reduces the likelihood of duplicity in terms of laboratory testing and imaging after the appointment, he added.
Another strategy is distributing the workload whenever possible “so the rheumatologist is not responsible for tasks that can easily be completed by support staff or even the patients themselves,” said Dr. Harrington. “This represents an enormous opportunity for us to transfer our resource use and efforts from low-value care to high-value care.”
For example, in a busy practice, rheumatologists should not be conducting narrative patient histories themselves, stressed Dr. Harrington. Instead, practices should implement a standardized data collection process with a history form that uses branching logic. “Typically, the top portion of these forms can be completed by patients while they are in the waiting room—that alone can save perhaps 40% of the time rheumatologists might spend just finding out what is going on,” he said. Physician assistants or nurse practitioners, when available, can help the patients with these forms and can provide the rheumatologist with a summary of the patients' history, he added.
The patient information can be used to generate an immediate disease activity score, such as the Global Arthritis Score, “which offers the rheumatologist an immediate sense of the patient's status and insight into optimal management,” Dr. Harrington noted.
Switching to electronic medical records and the use of standardized dictation templates, which replace word for word narratives, can also markedly reduce documentation time per patient. The end result is that “we can get more information in a more useful format and in less time than was previously possible,” said Dr. Harrington. “These measures change our focus from being information collectors to being problem solvers.”
The continuous application of process improvement methods is one of the most practical ways to address the growing deficit in the supply of rheumatologists relative to demand, said Dr. Harrington. “It's obvious, given the numbers, that we won't be able to provide care dependably to the population that needs it if we continue doing what we're doing. We have to play an active role in the scope of our practices, and we need to negotiate and plan with colleagues and other specialists so that we are involved primarily only in those services that we alone can capably provide.”
Dr. Harrington disclosed being a member of the Consortium of Rheumatology Researchers of North America (CORRONA) and receiving honoraria and grant support from Abbott Laboratories.