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Even in dermatology practices that function as well-oiled machines, ensuring proper coordination with other specialists involved in a patient's care - or simply making sure that the recommended test or treatment happens in a timely manner - isn't always easy. A temporary communication lapse or noncompliant patient can confound an already complex process, so practices are increasingly turning to various systems - from simple, paper-based mechanisms to automated electronic processes - to fill the gaps and provide checks and balances.
Dermatology Associates of Virginia, in Richmond, has developed a low-tech solution to the common concern: did it happen? Using a modification of the traditional pathology logbook as an adjunct to the patient chart, the nine-dermatologist practice includes a column for treatment so that clinical staff can readily check the status of a recommended action. In addition, the practice uses a flagging system: logbook entries are marked with self-adhesive flags, which remain in place until the needed action occurs. For example, if a biopsy results report is outstanding from the pathologist, the flag stays in. "As simple as it sounds, it's a visual - and it helps," says Anne Wolff, CMPE, clinical administrator.
To add further utility to the flagging system and ensure continuity of patient care, the practice checks all outstanding items. Every two weeks, medical assistants or nurses review the logbook for the scheduled date range to identify and resolve discrepancies or outstanding issues like missed appointments or missing consult notes. The staff member then signs and dates an accompanying tracking sheet to indicate his review, and passes the log along to the dermatologist. The physician reviews the outstanding items, and also signs and dates the tracking sheet.
"We've found that you really need to have checks and balances in place, and this system has helped us prevent [patients] falling through the cracks," Wolff says, adding that the practice is especially diligent about any outstanding pathology items or suspected skin cancer.
When working with other specialists or consultants, careful maintenance of relationships is key to ensuring the dermatology practice's patients are treated in a timely manner. Susan H. Weinkle, MD, a Bradenton, Fla., solo practitioner who also teaches at the University of South Florida, accomplishes that objective by strategic delegation.
"We often work with plastic surgeons or radiologists … and I've found it very effective to designate one staff member as the primary coordinator," Weinkle says. This nurse or other staff member can establish the relationship, and "get comfortable with who to contact and how to schedule. When our person calls the plastic surgeon's office, she knows who to talk to get the job done."
Winston-Salem Health Care Dermatology in North Carolina also uses relationship management, in concert with on-site appointment scheduling, to smooth the referral and team care coordination approach for its patients. "We're interested in ensuring that the referral gets done and that our patients are on the [consulting] physician's schedule, so we actually have the nurse make the appointment, whenever possible, while the patient is still in our office," says Kathryn Wheeler, the group's administrator. The goal is to ensure that the responsibility - especially if a near-term consult is in order - isn't left solely to the patient. In potentially serious situations, the dermatologist calls the other specialist directly.
Rosemarie Nelson, MS, a Syracuse, N.Y.-based consultant with the Medical Group Management Association (MGMA), acknowledges that "effectively and efficiently managing referrals - both incoming and outgoing - is often one of a dermatology practice's biggest challenges." The online referral authorization systems being introduced by health plans can help with the former by saving significant phone time for practice personnel.
Practices are left to their own devices, however, to figure out how to make sure their own outside referrals and results reporting are processed smoothly. Nelson thinks that even low-tech automation can help. She recommends that some practices use simple spreadsheets to automate the checking function (see "Keep Tabs on Patient Data to Optimize Care").
That spreadsheet enables a practice to record items - from biopsies and referrals to follow-up appointments - in a simple column format and generate reports as needed. "For example, the dermatology practice could sort [the data] only by items outstanding after two weeks [or] by patients who've not been responded to after test results come in," notes Nelson. "It can be a simple way to automate what is a very hands-on … process."
Dermatology practices wrestle constantly with how to ensure patients who need follow-up appointments or regular monitoring actually make it into the office for care. A few strategies that have proven successful:
To ensure that patients are seen at the recommended frequency, Spokane Dermatology in Washington uses a combined automated and manual process. Every six months, using the group's practice management system, clinical staff generate a patient list by primary diagnosis; in the case of patients who've been treated for cancer, a second, more tailored list that combines diagnosis and the last date the patient was seen by the dermatologist is generated. "It's a bit labor-intensive, but it works well to help us identify patients who may be overdue for a checkup," says practice administrator Kari Larson.
Any or all of these measures can help dermatologists improve continuity along the continuum of patient treatment, from primary care to the lab to subspecialists.
MGMA consultant Rosemarie Nelson recommends that dermatology practices convert their multiple paper logs to simple spreadsheets to automate tracking and enable multiple users to access patient information simultaneously. Dermatologists will see at a glance if any tests or appointments are outstanding.
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