Itinerary-based scheduling involves giving the patient a written agenda that specifies the timeline, expected services and location(s) for the visit. In contrast to the traditional “you have a 9 a.m. appointment with Dr. Smith,” this approach provides more detail for both the patient and the medical practice.
This concept is a value proposition for the patient. Consider the value of personal transportation services such as Uber and Lyft: their success is largely due to information provided to customers. Taxis have taken us from point A to point B for eons, but knowing where the vehicle is, watching it come to you and tracking its route has revolutionized the transportation business. Although healthcare is not as simplistic to map, it is an opportune time to recognize the value of transparency and how information can be delivered more effectively to the customer. The level of detail provided to patients via a formal itinerary not only enhances the patient experience, but also may bring value to their journey to health.
Destination-based practices operate successfully under this model, issuing itineraries extended to multiday courses. With patients who have traveled across the globe to receive care from a destination-based practice, these itineraries provide a roadmap for the patient. Evaluation, testing and treatment, as clinically appropriate, are formulated and adjusted during the patient’s stay, with the itinerary updated at each step in the care process. In a destination-based practice, since the patient does not live locally, priority is given to coordinating visits with the various primary care and specialty physicians needed to diagnose and treat the patient effectively and efficiently. Time is valued. The entire delivery system is coordinated around the patient during his or her finite stay.
Can the value proposition of this approach, which has been perfected by our nation’s leading destination practices, be adapted for a medical practice geared toward serving patients within its own community? Let’s explore steps that can be taken to replicate this model of care.
The why
Healthcare is fragmented. When patients seek services from multiple specialists, they are typically required to self-concierge. Coordinating health records among three specialists — say a neurologist, rheumatologist and cardiologist — can take hours on the telephone and can involve wait times of multiple weeks or months to be seen by each of the specialists. And that’s merely to manage the data and to obtain the visit, not the time for the provision of care itself.
Many patients we surveyed travel to a destination practice due to this challenge. Because prices are determined by payer allowables, not costs or charges, healthcare at a destination practice is not necessarily more expensive. Although destination practices may have “superstar” specialists, many patients cite the timeliness to care as the key reason for travel and their willingness to spend money on airfare and hotels in the process.
Waiting for a local, highly regarded specialist may take three months just to obtain a visit, let alone treatment. By traveling to a destination-based practice, the patient can be seen for an initial consultation within weeks, with treatment started immediately. In many cases, patients receive a differential diagnosis and treatment (including procedure or surgery) so efficiently that they would still be waiting for their initial consultation if they had stayed at home.
The term “medical tourism” has served as a reference for international travel for care typically based on price differential, yet patients are now traveling within the United States for domestic medical tourism. In this case, the focus is patients’ desire for access. Although time is important, the case study cited herein highlights another underlying issue — not only do we have an appointment access challenge, but we also have very little ability to collate or coordinate access to information.
Case study
Why are patients flying or driving to other cities to seek care? Have we lost sight of time from the patient’s perspective? Consider this example:
A 38-year-old healthy male has a stroke. Tests are ordered by his local physicians but no definitive diagnosis is determined; the patient is told to “go on with his life.” Following a second stroke eight months later, the urgency of the matter is heightened. A physician friend makes a personal introduction to a well-known neurologist associated with a large university in town. The patient is given an appointment two months into the future (the soonest available appointment with a personal introduction from a colleague physician).
Concerned that his condition cannot wait two months, the patient implores the scheduler to determine an alternative and is given an appointment with another neurologist at the university who sees him in two weeks, fitting the patient between meetings and limiting the visit to about five minutes. The patient is told that the tests he previously underwent are not definitive; as a result, the patient is instructed to make appointments with a rheumatologist and a cardiologist.
Many practices have improved lag time to new patient appointments, but this doesn’t address the issue of managing the patient’s velocity to treatment.
The patient is faced with the daunting task of becoming a self-concierge: coordinating the visits, medical records and forms himself. The first specialist he contacts is scheduling patients three months out. Frustrated, he turns to a well-known destination practice for care.
How does the destination practice work?
The patient goes online to the destination-based practice and makes an appointment with a neurologist. Detailed questions are asked of the patient (or his referring physician), records are gathered on the patient’s behalf, and the patient is given an appointment in two weeks. A preliminary itinerary for the patient’s visit is transmitted through the online portal, which is accessible via the patient’s smartphone.
WEEK 1
Wednesday: Two weeks after logging on to make an appointment, the patient flies in to see the neurologist. The neurologist looks at the patient’s past records and evaluates the patient. The neurologist indicates that the issue is likely related to a heart condition. Additional tests are ordered during the visit and, with the patient present in the office, an e-consult to the cardiologist is submitted. The cardiologist requests that an additional test be added to the panel of tests being ordered (thus saving valuable time). The patient is given a next-day appointment with the cardiologist as well as an updated itinerary with a bar code. The patient presents to each of the testing areas with the itinerary and it is scanned. That evening the patient views the results of many of the tests within hours of having them on his smartphone.
Thursday: The next morning, the cardiologist reviews the test results with the patient. The cardiologist believes the strokes are related to patent foramen ovale (PFO) — in layperson’s terms, a flap in his heart needs to be closed. The cardiologist submits an e-consult to the surgeon. The surgeon asks that an additional test be ordered and the patient is given an updated itinerary and an appointment on Monday with the surgeon.
Friday: A cardiac-related test is performed.
Weekend: Offices are closed. The patient and his family leave to visit friends nearby and return on Monday.
WEEK 2
Monday: The patient meets with the surgeon who explains the findings, and the patient grants consent for surgery.
Tuesday: Patient and family member(s) stay in the area.
Wednesday: Surgery is performed. During surgery, the patient’s vitals are live on the patient’s portal, and the patient’s family is given access to the portal to “watch” the vitals during the procedure.
Thursday: Recovery day. Both the cardiologist and the surgeon meet with the patient.
Friday: Patient flies home.
TOTAL DURATION OF CARE
- Wait time to initial appointment with neurologist: 2 weeks
- Time on-site at the destination practice: 1.5 weeks
- Total duration for definitive diagnosis/treatment: 3.5 weeks
Note that in this case, if the patient had not gone to the destination-based practice, he would still be waiting for his initial appointment with the neurologist. Importantly, his health issue was determined to not be neurological, but instead cardiac-related. Thus, the timeline would start over for the wait time to the cardiologist and likely once again when the transition was made to the surgeon.
How can this model be replicated?
The initial step required to replicate the itinerary-based model for treatment is to recognize and embrace the concept of lag time to treatment versus lag time to visit. Many medical practices have improved lag time to new patient appointment, for example, by establishing targets of 14 calendar days. While these efforts are laudable, they fall short of addressing the more strategic issue of managing the patient’s velocity to treatment.
The second step is to identify target times for diagnosis and treatment. Adopt the mindset of treating patients as if they are all “destination-based” patients who have flown across the country for needed care. Innovate work processes and care hand-offs to diagnosis and treatment so they can be conducted within a defined period, rather than linger for many weeks and months. There are significant corollary benefits: The practice has a better understanding of its actual demand (versus the inflated queue of patients, many of whom switch visit times or cancel before the appointment time); the practice experiences a higher show rate, thus improving the utilization of its finite capacity; and the practice improves its position in a competitive market.
The third step is to establish an initiating physician to assume the role of custodian. The custodian may be a primary care physician or the specialist who receives the referral for the episode of care (as in the case study). Furthermore, identify a process whereby specialists are available for real-time consultation with each other. This requires a twofold approach: a set of guidelines for common referrals related to tests or other pre-visit protocols, as well as an effective means of communicating. An EHR system with the ability to perform an e-consult can facilitate the communication between physicians on a near real-time basis with the advantage of having the explanation for the consultation as well as access to the patient’s information. This avoids a “curbside” consultation, replacing it with an informed one.
The fourth step is to ensure capacity to see and treat the volume and type of patients presenting for diagnosis and treatment. If surgery schedules are overloaded, for example, a patient will be waiting an extended time for surgery. Align capacity and infrastructure within the practice to facilitate timely treatment. This requires analytics focused on tracking current and predicting future demand, as well as understanding facility utilization.
Finally, there are logistics related to scheduling appointments in a coordinated fashion. Most practice management systems have been configured to schedule a single appointment, or a series of single appointments over time (e.g., an every-Tuesday 9 a.m. allergy shot). Coordinating appointments is a challenging task for all but a handful of systems. Explore the opportunities afforded by your practice management system to include the ability to schedule based on resources. In addition to coordinating appointments, it is vital to embed questions into the scheduling process. Establishing these algorithms aids in the assignment of accurate appointments, preventing a breakdown in the patient’s itinerary. This is an area of functionality that vendors must address. As alluded to in the third step, the flow of information is essential for creating value from this approach.
Velocity to treatment is the new competitive advantage for medical practices. Itinerary-based scheduling is integral to the success of this delivery model. From the patient’s perspective, itinerary-based scheduling allows patients to manage their health issue within a defined period, going about their personal lives without the anxiety of the unknown. Even if the time to the appointment is unchanged, the fact that the patient is informed about the journey replaces the discomfort, fear and frustration of not knowing what’s next. Transparency in healthcare is vital for future success.
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