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    Christian Green
    Christian Green, MA

    When delivering quality care, continuity can go a long way in enhancing patient satisfaction. For Austin Regional Clinic (ARC), a multispecialty group with 25 locations covering more than 2,000 square miles in the Austin, Texas, area, provider-patient connectedness has been the cornerstone of its brand promise.

    As Norman Chenven, MD, founder, ARC, conveyed at MGMA19 | The Operations Conference, in Austin, Texas, this promise starts with accessibility. “You want people to relate to their primary care doctor, you want them to have access to their medical records and access to you (physicians). … We consider ourselves to be on call 24/7, 365 days a year.”

    In addition to being open year-round, ARC offers after-hours care, telemedicine and a patient portal to ensure connected care anytime, anywhere.

    Defining strategies and goals through team effort

    According to Chenven, there are three primary goals that define ARC’s strategy and drive its decisions, all of which are tied to the clinic’s patient portal:

    • Simplify access to services: Despite the complexities of delivering care, patients want easy access to care and to be able to engage with providers virtually in real time. To ensure this, ARC actively identified technology and systems that could provide easy access to group services.
    • Enhance patient engagement: Patients should be proactive in their care by coming in for regular visits, keeping their A1c levels down and having their glucose levels checked, for example. ARC’s patient portal made scheduling and accessing records and results easier.
    • Reduce clinical workload: EHRs by themselves do not reduce clinical workloads; however, in conjunction with patient portals, they can make a huge difference in helping to ease the burden on staff when providing services.

    For ARC, none of this could be accomplished without a dedicated cross-functional team that touched each part of the clinic. According to Heidi Shalev, director, marketing, customer service and online services, ARC, the team was composed of individuals from marketing, operations, learning and development, revenue integrity, information technology and customer service, as well as EHR analysts, nurses and providers, 12 to 20 of whom met on a weekly basis a year leading up to the launch of its EHR and patient portal in 2013.

    “We were constantly evolving, constantly deciding what needed to be improved, what new functionality did we need, how were we going to build it,” Shalev said about the group she headed. “We really had a very full, active and engaged team.”

    During the planning stages of the patient portal, the team pinpointed specific patient goals they could accomplish, such as the ability for patients to book online, communicate with their care team and review their test results. But over time, ARC broadened its goals. “After we rolled it out, we started getting a lot more requests and demands,” Shalev asserted. “Not just from our patients, but from our doctors and nurses … we had to find a way to prioritize the requests that came our way.”

    By keeping an open dialogue and addressing these needs, ARC made certain its patient portal was a selling point for existing and new patients. “There are patients who have told us that they’ve chosen [ARC] because of our patient portal, so it’s a huge marketing factor for us as well,” Shalev said.

    Rollout of the portal

    When it was time to launch the portal, the cross-functional team focused first on convincing staff and clinical providers about its numerous benefits. “If they don’t tell the patients to use it, the patients aren’t going to use it,” Shalev emphasized. “Until the doctor or nurse says, ‘Hey, check your test results online, or I’m going to send you a message, or send me a question after the visit,’ they’re not going to use it.”

    Much of this was accomplished through promotional material focusing on a call to action. Signs were placed in every exam room so that the nursing staff could activate patients when they entered the room. Although some practices use iPads or tablets in the waiting area to sign up patients, ARC found that activating patients in the exam room worked best.

    “We’re at about 57% activation rate,” Shalev noted. “We’re probably going to be at 60% by the end of the summer and we’re going for 70% by the end of the year.”

    Once patients begin to use the portal, staff and providers routinely engage them to keep using the portal. “We roll out new functionality every two months or even more often, so it’s really hard for us to make sure our staff and our patients stay abreast of what they can do,” Shalev said. “So we have monthly emails that go out to make sure patients know about all the new things happening.” 

    The clinic also provides training, information on its intranet, internal newsletters and leadership videos, and conducts regular meetings to educate staff about the portal. ARC markets the portal to its patients via snail mail, email and newsletter; through digital and print ad campaigns; via vanity URLs where users can view videos of patient success stories and access an appointment page and a questionnaire; and continually surveys patients to get feedback and make appropriate changes.

    Online scheduling: A big win

    An important feature of ARC’s patient portal is online scheduling. At first, the clinic opted for all primary care doctors to offer online scheduling. Despite some initial reluctance from the doctors, interest “trended up,” Shalev said, and many specialists began clamoring for that functionality as well.

    Another challenge ARC faced with online scheduling was determining visit types. Fortunately, by the time the clinic rolled out the patient portal, it had standardized them. To start, the clinic determined it would offer online scheduling on the basis of demand.

    “We knew that we had to allow scheduling four months in advance,” Shalev remarked, “mostly because if you want to book a physical, oftentimes you couldn’t even get an appointment less than two months in advance.”

    When ARC launched the portal, it offered six visit types: illness and injury, daytime; illness and injury, nights and weekends; new or ongoing problem; hospital, ER or urgent care follow up; follow up; and adult physical. Thanks to patient demand, the clinic now offers 14 visit types.

    Patients also have the option of booking an appointment on ARC’s landing page and on the individual physician’s page, which shows available appointments on a specific date. This is particularly helpful for new patients.

    As Shalev noted, new patients first create a skeletal medical record number (MRN). “They put in just enough information to create a medical record for themselves in our system,” she said. “Then we have a queue that our registration staff works and they call those patients to register them into our system.”

    In addition to providing the option to receive scheduling tickets and being placed on a wait list for available appointments, ARC’s patient portal offers several other features, including the ability to view test results and account summaries, ask questions, and review medications and health summaries.

    The same process was used when considering each of these features. First, the team created a decision document, then determined how they were going to roll it out, how they were going to offer training, what was going to be most efficient for patients and, finally, what was going to produce the biggest win for staff.

    Patient usage and industry success

    ARC has excelled at convincing patients to use the portal — the clinic averages 3,000 activations a month, a good portion of which are carried out by nurses. Its goal is to achieve a 70% activation rate, which is only the first step in the portal process. “It’s not just that we want our patients to be activated on the patient portal, we also want them to be using it,” Shalev insisted. As Figure 1 illustrates, usage rates increased substantially from Q1 2018 to Q4 2018.  

    The percentage change in the final category, history questionnaires submitted, was abnormally high because at the start of 2018 it wasn’t possible for patients to use the portal and other online services for many of the clinic’s specialties.

    Last year, ARC was recognized by its vendor for its exemplary online appointment scheduling rates, placing third in the United States behind only Group Health Cooperative (Wisconsin) and Kaiser Permanente (Colorado). This success is reflected in patient satisfaction and comments, which praise the portal’s user-friendliness and convenience, and staff and providers for promptly answering questions through the portal. And as Shalev maintained, there’s no correlation between portal usage and age.

    “Anybody who tells you that your older patients will not use technology has not looked at the numbers,” Shalev said. “What we find is that it’s not based on age, it’s based on how much you need healthcare.” 

    Lessons learned

    During its portal journey, ARC learned many valuable lessons. Some of the most important include:

    • Buy-in: Make it a point to convince providers of the many benefits of the portal and continually remind patients to sign up at their earliest convenience.
    • Messaging: Patients send a high volume of messages that don’t necessarily have to be seen by physicians (e.g., asking about lab results, referrals), so ARC decided to filter them through a nursing pool, which freed up time for physicians. The clinic determined that 60% to 70% of the messages didn’t need to be reviewed by physicians. Going forward, ARC plans to create protocols around this.
    • Refill requests: Similar to emails, refill requests can often be answered by someone other than a physician. As such, ARC purchased a product from a third-party vendor that has built-in protocols, which streamlined the approval process. Prior to implementation, only 40% to 45% of refill requests were handled by someone other than a physician; after implementation, that rate jumped to 60% to 70%.
    • Scheduling questionnaires: How do you determine patients are making the correct appointment type? Currently, ARC conducts a manual review of questionnaires, but the clinic has moved toward creating a questionnaire with additional questions to confirm the appropriate appointment type.
    • History questionnaires: Questionnaires for every specialty were created, but it was difficult to determine old vs. new patient information. As a result, the clinic has been working on improving its EHR workflow to help make this information more applicable. 
    • Referrals: Due to multiple steps prior to approval, a good deal of manual effort was put into the referral process. Although some of these steps are now automated, patients have had a difficult time determining where their record is located. ARC is addressing this issue, but it may have to use a third-party vendor to find the best solution.

    Despite a few hiccups along the way, the clinic’s patient portal has streamlined patient access, enhanced patient engagement and reduced clinical workload. From convenient scheduling to easily procurable medical records and test results, ARC’s portal has ensured continuity of care for thousands of patients.

    Christian Green

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