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If your practice is considering an office redesign or building a completely new space, make sure you ask the right questions first.
Medical practices are rapidly changing: EHRs have largely replaced paper charts, mobile devices are able to chart patient notes, and video chat enables remote access to patients. But how does that affect a practice's physical design and space requirements?
Bruce Puffer, founder and president of Plymouth, Mass.-based design firm Pro Medical Interiors, says he's seen monumental change in design requirements for medical practices over the past 38 years. "As time has gone on, the exam room really [has become] the center of the interaction with the patient. And [it] has grown in size because of the nature of the work being done in there," he says.
Puffer can remember when patient charts "would gobble up three filing cabinets" per physician, and a new medical office design for a solo physician would include a couple of exam rooms, a consultation room, and a small lab or processing station. Now, he says, the theme is consolidation and partnership with other physicians, a hospital, or integrated health system so that providers can share space and disperse overhead costs for items such as new technology or additional staff to manage practice administration.
If your budget is limited, don't despair. The beauty of undertaking a practice redesign or new build is that you can customize the scope and timeline of the project to suit your practice's individual needs. Here are some of the factors you'll need to consider before building your new space.
CHANGING NEEDS FOR SPACE
Practice design and configuration has undergone significant changes over the years. There are several factors at play: The incorporation of new technology, the need to improve patient flow and staff efficiency, and reassigning new space that has opened up. Experts say these are some of the ways that practices are changing up their physical space:
The physician office. Many physicians no longer have a dedicated office with the accoutrements of their profession like medical diplomas on the wall, human skeletons, and pharmaceutical swag. Often several physicians will share a single space for patient consultations, freeing up practice real estate for more exam rooms or what Puffer calls a "touch-down space," where providers can brief clinical staff on next steps for their patients.
Private patient registration area. Due to HIPAA privacy rules, seating patients close to the check-in desk could compromise patient privacy. Many practices are opting for a second patient registration area that offers more privacy for check-in, payment, and completion of the medical and social histories.
Brenda Bosma, executive director for Annapolis, Md.-based Anne Arundel Gastroenterology Associates (AAGA) and ambulatory surgery center, the Maryland Center for Digestive Health, says the design of the surgery center was focused on giving patients a positive experience while waiting to be seen by the physicians.
Larger exam rooms. Now that medicine has adopted a more consultative relationship between patient and physician, more patients are bringing a family member along to help them remember what the physician has to say and be an advocate. To accommodate three or even four people, exam rooms are increasing in size. "You have to have … a triangulation between the physician, the guest, and the patient. And the doctor needs to have access to the computer so he can be inputting all the pertinent information from interviewing the patient," Puffer notes. "We used to be able to do exam rooms at 7-6 by 9-6; now we are really more like 11 by 9."
Implementation of EHR. With the elimination of paper charts, chart rooms are becoming a thing of the past; freeing up not just physical space, but staffing needs as well. AAGA has used an EHR since 2002, says Bosma, and currently uses a tablet to accomplish patient registration, payment, and questionnaires. "… We were trying to cut down on the number of trees we kill,” she says. “So instead of having patients fill out all these paper forms that had to be scanned manually into our EHR system, we chose to do the [tablet] which integrates with our EHR …."
Cloud-based IT solutions. Depending on the size of the practice and its technology choices and infrastructure, there may not be a server room or centralized computing center with desktop computers, printers, fax machines, and scanners. If a practice chooses a cloud solution, they may only need a local area network (LAN) and devices with Wi-Fi capability, like laptops or tablets. Derek Kosiorek, principal consultant with the Medical Group Management Association's Healthcare Consulting Group, says not only do you save on space requirements with a cloud solution, "but [also] facilities requirements like air conditioning for [the server] room, and the electricity needs."
When the physician-owners at AAGA decided that they needed to expand their ambulatory surgery center to accommodate functions like in-house billing and administration, they chose to build a new facility, rather than redesign the old one.
A well-designed practice has multiple benefits for both patients and staff, say experts. Eliminating chart rooms can open up space for things like multiple waiting rooms, consultation rooms, and separate check-in and check-out areas - all of which can improve patient flow and staff efficiency.
At AAGA, the physician-owners chose to build a self-contained patient registration room, separate from the greeting area at the front desk. After patients have registered, they are moved to a second waiting room, big enough to accommodate family members or escorts for patients undergoing an outpatient surgical procedure.
Not only does that facilitate patient flow, but Bosma says it gives patients more privacy and a sense that they are being moved through the practice in a timely manner. Patients sitting in a crowded waiting room often wonder how long they will wait to be seen. Bosma says patients "are not sure how many doctors are there. Are you one of 100 waiting for the same person? Or are there 10 doctors seeing all these patients?"
Another boon to patient flow is providing a fixed computer in each exam room, so that the medical assistant (MA) can chart patient vitals and reconcile med lists directly in the EHR prior to the physician's arrival. Puffer says the MA can return to the exam room after the patient has seen the physician to schedule follow-up appointments or even diagnostic testing - eliminating the need to return to the front desk for check out.
"That's the advantage of having a computer system [in the exam room], it provides you access to the information no matter where you are … So now you can have a private experience," he says.
It's important for practices to decide on the types of technology they want to include in their new/redesigned practice. It is always better to know what your design needs will be upfront, rather than having to go back and retrofit your space because of a last-minute technology change or addition. Depending on the size of your budget, you may or may not be working with an IT consultant, but it is always a good idea to speak to a tech expert before starting construction, says Puffer.
While the IT person is going to give the physician the "tools of technology," Puffer says, "I will physically give him the space to utilize the technology. We'll sit down and do the dynamics of 'How do you want to work? Are you going to shift with your right hand or left hand?'"
Aside from the benefits of EHR, new technology can facilitate patient comfort, satisfaction, and expedite patient registration and insurance verification, to name just a few benefits. It is also a patient pleaser: for example, in-office Wi-Fi, made available to patients with a guest login, allows them to use personal mobile devices like smartphones and tablets while waiting for the physician.
Patient registration tablets or kiosks allow patients to register, pay their copays and deductibles, complete social and medical histories, and even fill out short patient surveys at the conclusion of their visits. All without the additional work of transferring information from paper forms to the EHR.
Kosiorek says that despite the supposed expedience of using mobile devices like laptops to chart patient notes, he's not seeing a major shift away from fixed computers. "I'm seeing more practices staying with fixed PCs because it's easier not to have to lug [the laptop] around. I'm not sure what will happen with tablets. I have a feeling that tablets might get more prominent use because they are lighter and easier to carry around."
Kosiorek says practices should be wired with Ethernet cables, which allow for greater and faster data transfer. Ethernet cables are also a much more secure way to move data than a wireless connection which could possibly be accessed by hackers; at least with current technology. For that reason Kosiorek recommends using fixed computers in exam rooms, rather than wireless devices, but suggests equipping the practice with a wireless network as well, if funds permit.
PATIENT PORTAL OR PHONE TREE?
Most experts will tell you that the advent of the patient portal was a game changer for physicians and their practices. In fact, Kosiorek says, "The portal is probably the most significant change to a practice work flow that I've ever seen." Prior to the implementation of portals, he points out that staff members were dedicated to answering, triaging, and returning patient phone calls. Now it is possible for patients to leave secure messages for their physicians and/or nursing staff using the portal, and to receive e-mail notification that their question or request has been answered.
However, not all practices have implemented a patient portal; they might be using an older EHR system that does not have that capability and do not have the funds to expend on a new system. Or, perhaps their patient population does not have access to personal computers. Whatever the reason, that means a large front office with plenty of room for telephone operators.
Most practices make use of an automated attendant to route routine calls to the prescription refill line or appointment scheduler; the rest are put in a queue to be answered by an operator. Depending on the number of physicians in your practice and the size of their patient panels, this could mean a lot of phone calls.
At AAGA, Bosma says it is a matter of pride at her practice that phone calls are answered by a live person. "We actually have an operator who handles the calls and puts them into the queue … so that helps the patients get directed and not have to wait on hold very long. We have a system that monitors the phone calls so we know how many calls are dropped, if we need to have more staffing at particular days or times," she says.
So what are the first steps once your practice has approved the plan for a new build/redesign? Well before approaching an architect, your practice should assemble focus groups in each department. Puffer says it is vital that the practice has a clear vision about what it wants and needs from a new space, and it is also important for staff members to voice their opinions on what doesn't work in the current environment. "Everyone needs to be involved in the process. It's just not the provider input, it needs to come all the way down to the greeter," he says.
Once that is done, Puffer says the best way to proceed is to designate a project chair, and create individual teams that will take on decision-making responsibility for elements such as physical layouts, color palettes, selecting furniture, job timelines, and deciding on budgets.
Erica Spreyis associate editor for Physicians Practice. She can be reached at email@example.com.
This article was originally published in the April 2016 issue of Physicians Practice.