A magician's advice for pre-visit planning

I have been fascinated by the lives of famous magicians such as Houdini, Blackstone and David Copperfield. In the early 20th century, one of the most famous magicians was Max Malini, who was invited to perform for presidents, kings and other royalty around the world. Malini spent years bribing a Washington, D.C., tailor patronized by the city’s most famous politicians to custom-make suits and formal wear. Malini had the tailor sew certain playing cards inside the suits or evening jackets of several of the most prominent U.S. senators.

Malini was asked to attend a formal political affair in Washington, and he recognized one of the senators he knew was a regular customer of the tailor. Months before the event, the tailor had sewn a card into the senator’s coat, behind the silk lining of the jacket. The senator soon learned that Malini was a famous magician and cajoled him into performing a piece of magic. Malini removed a deck of cards he always carried and asked the senator’s wife to select one. Her card was shuffled into the deck, and Malini then asked her to find it, which she couldn’t do because it had disappeared from the deck. Malini produced a knife and asked the senator whether he could perform a minor operation. He began to cut through the elegant evening coat’s inner silk lining, where he found the missing card. Jaws dropped across the room.

You could say that Malini took years to prepare for the trick by enlisting the tailor to insert playing cards in the suit jackets of prominent Washington politicians. Of course, Malini offered to see that the jacket was repaired to its original condition, and I’m certain he handsomely compensated the tailor.

So, what does this story have to do with the practice of medicine? Successful doctors must be prepared in advance of encounters with patients. Medicine is never mundane; it is never conducted in an assembly-line fashion. There will be curveballs thrown our way, and if we are prepared, we can knock them out of the proverbial park.

This article will discuss how pre-visit planning for upcoming appointments enhances the value of each appointment for both patients and physicians and reduces the number of follow-up patient portal messages and phone calls. It offers suggestions for pre-visit labs, health maintenance and other routine items, as well as patient updates before the visit.

Pre-visit planning involves preparing the patient before their appointment with the doctor. It saves time, reduces practice costs, improves patient care and can mean the difference between an encounter where physicians and team members are mindlessly scrolling through the EMR for information and a visit where things run smoothly and there is capacity to handle any unanticipated issues.

Pre-visit planning includes:

• Ensuring health maintenance or other routine “checklist” items are up to date
• Ensuring pre-visit labs are completed and recorded in the EMR
• Gathering necessary information for the upcoming visit, such as screening questionnaires, goals for the visit and an updated health history

Pre-visit planning saves time because no one needs to look up information during the visit or record results after it. Practices that incorporate pre-visit planning have a support staff-to-physician ratio of at least 1:1.

I am aware that physicians and staff are already overwhelmed by data entry and the administrative burden of contemporary medicine, which has reduced face-to-face time with patients. I suggest starting small by ordering pre-visit lab tests and reviewing the results before the encounter. In the end, you will save time by implementing pre-visit planning.

Step 1: Engage care team members and patients

It is important to get team members’ buy-in, which requires explaining the rationale for and benefits of pre-visit planning. Explain that this is a method to maximize the limited time slot, reduce follow-up patient portal messages and phone calls and improve the quality of care provided.

It is also important to educate the team in the planning process before a visit. This includes appointment scheduling, chart review and electronic order entry. While some physicians may be accustomed to doing this themselves and won’t delegate tasks to team members, every moment a physician spends on a task that doesn't require their unique skill set is time they cannot devote to something that does. Minutes per task can add up to hours per day, reducing time spent with patients. The take-home message is that everyone on the team should work at the top of their license, and physicians should avoid spending time on administrative tasks that can be delegated to others.

Step 2: Schedule the next visit at the current visit

Scheduling patients' next appointments at the end of the current visit is a part of pre-visit planning that is relatively easy to implement. It saves time, promotes continuity and may improve adherence to follow-up visits. For many practices, this works best if physicians open their schedules a year or more in advance. For patients who require more frequent monitoring visits, such as every three months, team members can schedule the visits for the next year in advance.

Step 3: Implement pre-visit ordering of labs

A key component of pre-visit planning is proactively ordering labs and other necessary tests or procedures that are part of a “routine” algorithm-driven protocol so they can be completed before the next appointment. Identifying the appropriate pre-visit tests and procedures and having them completed before the next visit allows for shared decision-making and care planning based on the results, which can be fully discussed during a scheduled face-to-face conversation between the patient and physician. This process can save time by reducing the need to review, report and act on results out of context between visits. It can also improve patient care by making pertinent data available for medical decision-making at the time of a scheduled visit.

In primary care practices, pre-visit tests include bloodwork for chronic disease monitoring as well as routine health maintenance items such as mammograms, colonoscopies and vaccinations. While pre-visit labs for chronic disease management may be needed before each visit, ordering health maintenance items is only necessary for one appointment per year, such as the annual comprehensive care visit. In subspecialty practices, pre-visit tests may include specific imaging or blood tests.

For example, in a urology practice, a patient on testosterone replacement therapy (TRT) requires a semiannual testosterone level, CBC, liver enzymes, cholesterol level and a PSA test. By ordering these tests for the morning of the next visit, the patient can discuss the results with the doctor during the encounter.

Figure 1 illustrates the workflow options for pre-visit order entry for routine, algorithm-driven orders.

For a starting point, Alliance Health offers a pre-visit planning checklist that practices can adapt.

Step 4: Gather necessary pre-visit information from the patient

This is an important part of pre-visit planning that can happen at check-in or electronically a few days before the patient visit. Pre-visit information to gather from patients includes:

• The patient’s reasons for the visit
• Questionnaires based on the visit type, diagnoses on their problem list, physician preferences, social determinants of health and travel exposures
• An updated health history
• Medication, allergy and immunization updates
• Yearly consents, forms and billing information, including collecting co-pays in advance
• Updates to demographic and insurance information

This can be done through automated messaging and the patient portal, with responses automatically uploaded to the EHR. For practices without this technology, a team member can gather the information before the appointment, or the patient can complete a paper form at check-in.

Step 5: Conduct a brief pre-visit handoff

A one- to two-minute handoff from the nurse or medical assistant to the physician is an opportunity to relay both medical and social information obtained during rooming, which creates an efficient visit. In many practices, the nurse or MA is expected to seek out updates and share the findings with the physician. For example, the MA may ask how the patient did with a medication started at the last visit and learn that the patient never started it. Or a team member may learn that the patient’s main goal that day is to obtain a physical therapy referral. Knowing this helps the physician prepare for the encounter.

Bottom line

The next visit starts today. With pre-visit planning, your practice can benefit from improved care team efficiency, more thorough patient care and improved satisfaction for patients, staff and physicians. You may not be a magician like Malini, but you can use the same principle Malini used to create magic for your patients.

About Neil Baum, M.D.

Baum is a professor of clinical urology at Tulane Medical School in New Orleans, Louisiana. He is the author of Marketing Your Clinical Practice: Ethically, Effectively, Economically, which is in its fourth edition, has sold over 175,000 copies and has been translated into Spanish. He has also written The Complete Business Guide to a Successful Medical Practice, which was published in 2015. He also authored What’s Going on Down There?, which has served as a guide for women’s health. He has written 10 books on practice management and the business of medicine.

Baum was the columnist for American Medical News for more than 25 years. He wrote the popular column “The Bottom Line” for Urology Times for more than 20 years. He has authored or coauthored over 250 articles in peer-reviewed medical publications on various urologic topics, as well as articles on practice management.

He has also authored The Business Basics of Building and Managing a Healthcare Practice (Springer 2019), which emphasizes the importance of being involved in the business of a medical practice.