1. Alamo ST, Wagner GJ, Sunday P, Wanyenze RK, Ouma J, Kamya M, et al. Electronic medical records and same day patient tracing improves clinic efficiency and adherence to appointments in a community based HIV/AIDS care program, in Uganda. AIDS and behavior. 2012;(2):368-74.
Abstract: Patients who miss clinic appointments make unscheduled visits which compromise the ability to plan for and deliver quality care. We implemented Electronic Medical Records (EMR) and same day patient tracing to minimize missed appointments in a community-based HIV clinic in Kampala. Missed, early, on-schedule appointments and waiting times were evaluated before (pre-EMR) and 6 months after implementation of EMR and patient tracing (post-EMR). Reasons for missed appointments were documented pre and post-EMR. The mean daily number of missed appointments significantly reduced from 21 pre-EMR to 8 post-EMR. The main reason for missed appointments was forgetting (37%) but reduced significantly by 30% post-EMR. Loss to follow-up (LTFU) also significantly decreased from 10.9 to 4.8% The total median waiting time to see providers significantly decreased from 291 to 94 min. Our findings suggest that EMR and same day patient tracing can significantly reduce missed appointments, and LTFU and improve clinic efficiency
2. Crane S, Collins L, Hall J, Rochester D, Patch S. Reducing utilization by uninsured frequent users of the emergency department: combining case management and drop-in group medical appointments. Journal of the American Board of Family Medicine: JABFM. 2012;25(2):184-91.
Abstract: BACKGROUND: Patients with complex behavioral health and medical problems can have a disproportionate impact on emergency departments
3. Kallen MA, Terrell JA, Lewis-Patterson P, Hwang JP. Improving wait time for chemotherapy in an outpatient clinic at a Comprehensive Cancer Center. Journal of Oncology Practice. 2012;(1):e1-e7.
Abstract: Purpose: We conducted our study at the Ambulatory Treatment Center (ATC) of the MD Anderson Cancer Center, a network of six outpatient treatment units for patients receiving infusion therapies. Excessive patient wait time for chemotherapy was a primary source of ATC patient dissatisfaction. ATC employees expressed frustration, because often, patients arrived physically on time but were not treatment ready. Additionally, ATC staff emphasized challenges associated with obtaining fi- nalized treatment orders for prescheduled appointments (ie, placeholder appointments without associated physician treatment orders). We aimed to decrease mean patient wait time from check-in to treatment in one ATC unit by 25%. Methods: We studied appointment cycle time in the ATC Green Unit, stratifying appointments by type (ie, prescheduled [no finalized treatment orders] and scheduled [finalized treatment orders]). We obtained mean wait times at baseline (control) and again after our intervention period. We conducted interviews and observations in ATC Green, from which we developed a three-part plan to reduce wait time: increase process efficiency within ATC Green, enhance communications with MD Anderson clinics and centers, and incorporate information technology applications. Results: After our intervention, we observed a 15% decrease in wait time for patients with prescheduled appointments and a 29% decrease for those with scheduled appointments. Overall, there was a 26.8% reduction in mean patient wait time relative to baseline (control). Conclusion: We observed a significantly decreased mean patient wait time after implementing our intervention. This decrease may improve patient satisfaction, relieve employee frustration with appointment scheduling, and create opportunities for increasing institutional revenue. Copyright 2012 by American Society of Clinical Oncology
4. O'Neill S, Calderon S, Casella J, Wood E, Carvelli-Sheehan J, Zeidel ML. Improving outpatient access and patient experiences in academic ambulatory care. Academic Medicine. 2012;87(2):194-9.
Abstract: Effective scheduling of and ready access to doctor appointments affect ambulatory patient care quality, but these are often sacrificed by patients seeking care from physicians at academic medical centers. At one center, Beth Israel Deaconess Medical Center, the authors developed interventions to improve the scheduling of appointments and to reduce the access time between telephone call and first offered appointment. Improvements to scheduling included no redirection to voicemail, prompt telephone pickup, courteous service, complete registration, and effective scheduling. Reduced access time meant being offered an appointment with a physician in the appropriate specialty within three working days of the telephone call. Scheduling and access were assessed using monthly "mystery shopper" calls. Mystery shoppers collected data using standardized forms, rated the quality of service, and transcribed their interactions with schedulers. Monthly results were tabulated and discussed with clinical leaders; leaders and frontline staff then developed solutions to detected problems. Eighteen months after the beginning of the intervention (in June 2007), which is ongoing, schedulers had gone from using 60% of their registration skills to over 90%, customer service scores had risen from 2.6 to 4.9 (on a 5-point scale), and average access time had fallen from 12 days to 6 days. The program costs $50,000 per year and has been associated with a 35% increase in ambulatory volume across three years. The authors conclude that academic medical centers can markedly improve the scheduling process and access to care and that these improvements may result in increased ambulatory care volume
5. Patrick J. A Markov decision model for determining optimal outpatient scheduling. Health Care Management Science. 2012;15(2):91-102.
Abstract: Managing an efficient outpatient clinic can often be complicated by significant no-show rates and escalating appointment lead times. One method that has been proposed for avoiding the wasted capacity due to no-shows is called open or advanced access. The essence of open access is "do today's demand today". We develop a Markov Decision Process (MDP) model that demonstrates that a short booking window does significantly better than open access. We analyze a number of scenarios that explore the trade-off between patient-related measures (lead times) and physician- or system-related measures (revenue, overtime and idle time). Through simulation, we demonstrate that, over a wide variety of potential scenarios and clinics, the MDP policy does as well or better than open access in terms of minimizing costs (or maximizing profits) as well as providing more consistent throughput
6. Spellman KS, Timm N, Farrell MK, Spooner SA. Impact of electronic health record implementation on patient flow metrics in a pediatric emergency department. Journal of the American Medical Informatics Association. 2012;19(3):443-7.
Abstract: Implementing electronic health records (EHR) in healthcare settings incurs challenges, none more important than maintaining efficiency and safety during rollout. This report quantifies the impact of offloading low-acuity visits to an alternative care site from the emergency department (ED) during EHR implementation. In addition, the report evaluated the effect of EHR implementation on overall patient length of stay (LOS), time to medical provider, and provider productivity during implementation of the EHR. Overall LOS and time to doctor increased during EHR implementation. On average, admitted patients' LOS was 6-20% longer. For discharged patients, LOS was 12-22% longer. Attempts to reduce patient volumes by diverting patients to another clinic were not effective in minimizing delays in care during this EHR implementation. Delays in ED throughput during EHR implementation are real and significant despite additional providers in the ED, and in this setting resolved by 3 months post-implementation
7. Stubbs ND, Geraci SA, Stephenson PL, Jones DB, Sanders S. Methods to reduce outpatient non-attendance. American Journal of the Medical Sciences. 2012;344(3):211-9.
Abstract: Non-attendance reduces clinic and provider productivity and efficiency, compromises access and increases cost of health care. This systematic review of the English language literature (November 1999-November 2009) compares telephone, mail, text/short message service, electronic mail and open-access scheduling to determine which is best at reducing outpatient non-attendance and providing net financial benefit. Telephone, mail and text/short message service interventions all improved attendance modestly but at varying costs. Text messaging was the most cost-effective of the 3, but its applicability may be limited. Few data are available regarding electronic mail reminders, whereas open-access scheduling is an area of active research
8. Vilallonga R, Fort JM, Iordache N, Armengol M, Cleries X, Sola M. Use of images in a surgery consultation. Will it improve the communication? Chirurgia (Bucuresti). 2012;107(2):213-7.
Abstract: INTRODUCTION: The interviews and interactions with patients are part of everyday health care provider. However, there is sometimes a difficulty in communication, linked to several factors. For this reason, the use of images to illustrate the medical conditions in the outpatient clinic can improve patient communication. We report our initial experience with the use of images to manage the quality of care to surigcal patients
9. Brosan L, Hoppitt L, Shelfer L, Sillence A, Mackintosh B. Cognitive bias modification for attention and interpretation reduces trait and state anxiety in anxious patients referred to an out-patient service: results from a pilot study. Journal of Behavior Therapy & Experimental Psychiatry. 2011;42(3):258-64.
Abstract: It is well established that anxious individuals show biases in information processing, such that they attend preferentially to threatening stimuli and interpret emotional ambiguity in a threatening way. It has also been established that these biases in attention and interpretation can causally influence anxiety. Recent advances in experimental work have involved the development of a paradigm known as Cognitive Bias Modification (CBM), a constellation of procedures which directly modify bias using computerised tasks. Excitingly, these procedures have been shown to reduce bias in attention to threat (CBM-A), and to promote a positive interpretive bias (CBM-I) in anxious populations; furthermore, these modifications are associated with reductions in anxiety. We believe that these techniques have the potential to create a real clinical impact for people with anxiety. Initial studies involved volunteer participants who reached criteria for clinical diagnoses to be made, but emerging evidence suggests that patients referred for therapy also benefit. For the purposes of experimentation researchers have normally looked at one procedure at a time. In order to try to maximise the potential clinical impact we wished to investigate whether the combination of the procedures would be more effective than either alone. We also wished to investigate whether the procedures could be carried out in routine clinical settings with patients referred to an out-patient psychological treatment service. We therefore carried out a pilot study using a combined approach of CBM-A and CBM-I with a sample of 13 anxious patients referred to an out-patient psychology service for cognitive therapy. The results showed successful reductions in threat related attentional and interpretive bias, as well as reductions in trait and state anxiety. Participant reports describe the procedures as acceptable, with the attentional task experienced as boring, but the interpretive one experienced as helpful. While recognising the methodological problems of the pilot study we believe that these results give indications that the techniques could provide an effective intervention for anxiety, and that further study is well justified. Copyright Copyright 2011 Elsevier Ltd. All rights reserved
10. Brown S. Implementation of a computerized, automated referral system in improving participation rates to outpatient cardiac rehabilitation. Journal of Cardiopulmonary Rehabilitation and Prevention. 2011;(var.pagings):E2-August.
Abstract: Introduction: Despite American College of Cardiology and American Heart Association performance measures which state that patients with a primary diagnosis during hospitalization of chronic stable angina, MI, CABG, valve surgery, or cardiac transplantation are to be referred to an outpatient cardiac rehabilitation program, it has been well-established that both referral and participation rates in Phase II Cardiac Rehabilitation after hospitalization are low. To enhance participation to a broader population of patients, an automated, computerized referral system was implemented in a large, multi-hospital system. Purpose: To determine the efficacy of an automated, computerized referral system as compared to a traditional, non-automated referral strategy. Design: Systematic review with analysis of referral data pre and post intervention via a manual tracking method. Methods: Referral and enrollment rates to Phase II Cardiac Rehabilitation were analyzed before and after implementation of the computerized, automated referral system. Enrollment and participation data was tracked manually over an eight month period through utilization of a computerized database. Results: Prior to implementation of the automated, computerized system, an average of 58 patients per month were referred to outpatient cardiac rehabilitation after hospitalization following an MI, CABG, heart valve surgery or PTCA procedure via a traditional referral strategy. Of these, only 12 patients per month enrolled in the outpatient cardiac rehabilitation program (20.6% participation rate). After implementation of the automated, computerized system, an average of 200 referrals per month were received (increased referral rate by 243%). When sorted to exclude inappropriate patients (i.e.: those out of town or with an inappropriate diagnosis), enrollment increased to average 20 patients per month, which was a 67% increase. Conclusions: The implementation of a computerized, automated referral system significantly improved physician referral and patient enrollment rates. The results of this study support broad implementation of automated referral systems in providing evidence-based care to a wider population of patients
11. Cao W, Wan Y, Tu H, Shang F, Liu D, Tan Z, et al. A web-based appointment system to reduce waiting for outpatients: a retrospective study. BMC Health Services Research. 2011;11:318, 2011.:318.
Abstract: BACKGROUND: Long waiting times for registration to see a doctor is problematic in China, especially in tertiary hospitals. To address this issue, a web-based appointment system was developed for the Xijing hospital. The aim of this study was to investigate the efficacy of the web-based appointment system in the registration service for outpatients
12. Corrigan MA, McHugh SM, Murphy RK, Dhillon P, Shah A, Hennessy I, et al. Improving surgical outpatient efficiency through mobile phone text messaging. Surgical Innovation. 2011;18(4):354-7.
Abstract: INTRODUCTION: Currently, 175,000 people are on outpatient waiting lists in Irish hospitals. Many clinic slots are taken by patients returning for routine review postoperatively
13. Ellanti P, Manecksha RP, Flynn R. The use of text messaging to reduce non-attendance at outpatients clinic--a departmental experience. Irish Medical Journal. 2011;104(1):28-9.
14. Hasvold PE, Wootton R. Use of telephone and SMS reminders to improve attendance at hospital appointments: a systematic review. Journal of Telemedicine & Telecare. 2011;17(7):358-64.
Abstract: Patients failing to attend hospital appointments contribute to inefficient use of resources. We conducted a systematic review of studies providing a reminder to patients by phone, short message service (SMS) or automated phone calls. A PubMed search was conducted to identify articles published after 1999, describing studies of non-attendance at hospital appointments. In addition, we searched the references in the included papers. In total, 29 studies were included in the review. Four had two intervention arms which were treated as independent studies, giving a total of 33 estimates. The papers were analysed by two observers independently. A study quality score was developed and used to weight the data. Weighted means of the absolute and the relative changes in non-attendance were calculated. All studies except one reported a benefit from sending reminders to patients prior to their appointment. The synthesis suggests that the weighted mean relative change in non-attendance was 34% of the baseline non-attendance rate. Automated reminders were less effective than manual phone calls (29% vs 39% of baseline value). There appeared to be no difference in non-attendance rate, whether the reminder was sent the day before the appointment or the week before. Cost and savings were not measured formally in any of the papers, but almost half of them included cost estimates. The average cost of using either SMS, automated phone calls or phone calls was [Euro sign]0.41 per reminder. Although formal evidence of cost-effectiveness is lacking, the implication of the review is that all hospitals should consider using automated reminders to reduce non-attendance at appointments
15. Prentice JC, Fincke BG, Miller DR, Pizer SD. Outpatient wait time and diabetes care quality improvement. American Journal of Managed Care. 2011;17(2):e43-e54.
Abstract: OBJECTIVE: To examine the relationship between glycated hemoglobin (A1C) levels and the number of days spent waiting for primary care appointments
16. Webster F, Saposnik G, Kapral MK, Fang J, O'Callaghan C, Hachinski V. Organized outpatient care: stroke prevention clinic referrals are associated with reduced mortality after transient ischemic attack and ischemic stroke. Stroke. 2011;42(11):3176-82.
Abstract: BACKGROUND AND PURPOSE: Organized inpatient stroke care decreases mortality and morbidity irrespective of patient age, stroke severity, or stroke subtype. Limited information is available on whether organized outpatient care models such as stroke prevention clinics (SPC) improve outcomes after a transient ischemic attack or ischemic stroke. We compared 1-year mortality and stroke readmission in patients with transient ischemic attack or ischemic stroke referred versus not referred to an SPC
17. Woods R. The effectiveness of reminder phone calls on reducing no-show rates in ambulatory care. Nursing Economics. 2011;29(5):278-82.
Abstract: The objective of this study was to determine the effectiveness of daily reminder phone calls on reducing no-show rates in the ambulatory care setting. With the initiation of reminder telephone calls over a 6-month period, the no-show rate dropped by 50% from 8% to 4%. The no-show rate with reminder letters over 3 months was reduced by 29% from 8.5% to 6%. Reminding patients by telephone call 1 day prior to their appointment significantly increased the number of patients who arrived. Reminder phone calls also allowed patients to cancel their appointments if they weren't able to attend, rather than not showing up. Patients were given the option of rescheduling their appointments while on the phone at that time or calling back to reschedule. Most patients took the opportunity to reschedule at that time
18. Chen BL, Li ED, Yamawuchi K, Kato K, Naganawa S, Miao WJ. Impact of adjustment measures on reducing outpatient waiting time in a community hospital: application of a computer simulation. Chinese Medical Journal. 2010;123(5):574-80.
Abstract: BACKGROUND: As an important determinant of patient satisfaction, waiting time, has gained increasing attention in the field of health care services. The present study aimed to illustrate the distribution characteristics of waiting time in a community hospital and explore the impact of potential measures to reduce outpatient waiting time based on a computer simulation approach