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The role of a rules engine in transforming the patient care experience

Insight Article - July 27, 2021

Patient Access

Business Operations Technology

Patient Care Technology

MGMA Staff Members
The need for strategic automation of functions in a medical group practice didn’t disappear during the COVID-19 pandemic.

As many staff and providers shifted to quarantine or telework arrangements, a healthcare organization could turn attention elsewhere with the ability to eliminate manual work done in a clinic facility. The value of these improvements is also found when incorporating it into a digital patient experience to boost self-service capabilities that reduce staff time and effort while boosting volumes and revenue.

As clinical providers get back to something more akin to the pre-pandemic normal, “health systems need to think really carefully about how to make the experience for their consumers and providers stand out in their respective markets and regions,” said Joe Polaris, senior vice president of product and technology, R1 RCM, speaking during the 2021 Medical Practice Excellence: Pathways Conference.

That can start with many of the issues that lingered in practice workflows prior to the pandemic (see Table 1), according to Sherri Harris, a scheduling director for R1 RCM who previously worked as regional manager of scheduling for Ascension Sacred Heart, a faith-based healthcare organization with four hospitals and more than 100 other care sites in northwest Florida and the Gulf Coast region.



Decentralized processes often put pressure on patients, staff and providers, Harris noted. “The patients didn’t know where to call, and the providers didn’t know where to send their orders and who was going to get their authorizations,” Harris said. “There’s a tickle-down or a snowball effect of these errors,” such as scheduling errors that lead to the wrong authorization, which can lead to rescheduling and open spots on providers’ schedules.

That led Harris to look for ways to simplify those processes and create transparency for the providers and patients, with the goals of reducing provider workloads and making patient access to staff more effective than the traditional processes involving numerous phone calls and manual paperwork.

The role of technology in problem-solving

As with most initiatives within a medical practice, the first step to building a vision of a solution is engaging providers, staff and patients to understand what the problems are, Harris said, “talking to your scheduling teams, talking to your patient access teams [and] getting everyone on the same page and working toward a common goal.”

In examining the various needs, Polaris broke down the envisioned digital journeys for patients and providers (Table 2).



While each end of the digital experience is unique for patients and providers, what unifies them is ease of access. “Providers, they want … something that is not going to take them a great amount of time because they want to care for their patients,” Harris said, noting that the digitization of ordering and scheduling systems — paired with patient self-scheduling and completion of pre-registration to allow for prior authorization — adds a layer of comfort for providers once they have greater visibility and trust that those elements are being handled.

Harris said that this use of technology reduced cycle time — from placing an order to appointment time — from 10 days down to four days.

“The intelligence was in the chair. Those staff that were pulled away from patient care to do some of this scheduling, they really needed to be refocused to patient care,” Harris said. “These systems allowed us to put some of the intelligence into the system and redirect our clinical or more specialized staff back to our patients. … We’re actually directing our staff to a less stressful scheduling in a centralized manner.”

The benefits from those new capabilities (see Table 3) include fewer questions on what is valid in the ordering system, as orders can be pre-populated in the scheduling system and then linked to appointments, followed by a trigger for an authorization to be obtained. “There’s no delays, the patients are happier,” Harris said. “There’s no more excess calls to a provider office … and the scheduling process takes a lot less time per call.”



That level of simplification also makes onboarding of new patient access team members easier. What normally took 90 days for new employees to learn decreased to six weeks, Harris noted.

Making the technical side work

Those results for patients, providers and scheduling staff hinge on a rules engine built for a variety of scenarios to automatically adjust orders for appointment type and personnel and/or equipment needed.

“One of the greatest things about the system that we’re using now is that the same logic and rules that our scheduling team uses are implemented within the patient scheduling process,” Harris said. Alluding to the guidance in Figure 1, Harris said the rules engine can help account for the need for extra time with a patient regarding a screening mammogram or if the procedure should be changed to a diagnostic mammogram instead.



“All of this logic is embedded — it doesn’t require a nurse navigator or a clinician to make the decision and have a conversation with the patient,” Harris said. “These are scheduling questions.”

A similar use case (see Figure 2) would be the tricky nature of MRIs, as considerations such as patient weight, claustrophobia/need for sedation can determine which location is selected (e.g., one location has higher table weight limits). By establishing rules to guide these determinations at the scheduling phase, there are fewer errors and a lower chance that a patient is incorrectly scheduled, which leads to a better patient experience and a more efficient workload for providers who do not have to scramble to accommodate or, in many cases, reschedule altogether.

Change management

Based on Ascension’s experience with adding the rules engine, Harris suggested that organizations should try to look at each practice/office as an individual to find the right fit for these forms of scheduling updates. Some specialties will find much more usefulness to this approach than others.

“Our specialty practices really like the provider self-scheduling, because they’re able to schedule their patients’ diagnostic exam with the patient in the office, and then schedule that follow-up appointment at the same time,” Harris said.

For consumer adoption, Harris encouraged organizations to understand the community needs to determine what degree of consumer scheduling would make sense. In some cases, annual screenings such as mammography might be the main focus; however, more-detailed work such as CT scans and MRIs might have enough demand to justify a system to document all these considerations via an automated system at the time of scheduling.

Regardless of which procedures or screenings are chosen, the decisions should be driven by understanding your providers’ needs in their practices and reflected in the work of your marketing team or department to ensure patients have clear, consistent messaging about how to make use of the system.

Results

Giving Ascension Sacred Heart’s patient access teams and referring providers these rules-engine-based tools helped achieve:
  • An 80% increase in orders (from 5,000 to 9,000 monthly) in 18 months
  • 30% of all electronic orders using the full self-service workflow
  • A 70% reduction in patient call times
  • Less than 10% turnover for patient access team members (down from about 18%)
  • A 1% error rate in six years of using rules-based scheduling.
 
“There’s less frustration,” Harris said. “When you have a less frustrated patient, of course you have a less frustrated staff member as well.” All of this allows the team members to provide “more meaningful assistance to patients,” she added.
 
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