Drowning in paperwork. Hunting for charts. Hearing patient gripes about calls not returned. Fearing that it’s impossible to get control of the work.

Many physicians have become familiar with these symptoms of staff workflow problems. Besides causing frustration, work bottlenecks can lead to medical and billing errors and can cost money if disgruntled patients leave.

“Insurer requirements have put a bigger burden on the office staff, despite giving less reimbursement,” says Kathryn I. Moghadas, RN, CHBC, practice management consultant and president of Associated Health Care Advisors in Fern Park, Florida. “Often, the first thing that alerts doctors to workflow problems is a decline in revenue. The second is when they’re getting patient complaints. The third is lifestyle — when the doctor’s getting so far behind that it’s a problem and he’s no longer enjoying his work. It’s time to step back and look at what’s going on in the practice.”

Several factors contribute to office overload. “Workflow problems can be the result of too few staff, the wrong mix of staff, or the wrong allocation of responsibilities among the staff,” says Robert C. Scroggins, JD, CPA, practice management consultant with Clayton L. Scroggins Associates, Cleveland, Ohio.

Another common culprit is lack of training: When staff members aren’t up to speed with technology or software skills and are struggling with software, many processes tend to get sidelined.

Identify the Trouble Zones

Physicians need to find and eliminate workflow bottlenecks. “Physicians may view the staff’s workflow as secondary to their own and not pay much attention to it, but it ultimately trickles over into the overall production of the office,” says Scroggins.

Some workflow problems are easy to spot; others are hidden within the process.

To identify and improve the backlog, enlist the staff to help solve work bottlenecks; perform a workflow analysis and restructure the process if necessary; reevaluate the division of tasks in the office and investigate technology as both a potential cause and cure of existing problems.

“It’s important to create an environment in which the staff feels comfortable enough to come to you and say, ‘This isn’t working well; can we think of another way to do it?’” says Gregory A. Hood, MD, internist with Drs. Borders and Associates in Lexington, Kentucky, and Governor-elect-designee of the American College of Physicians, Kentucky chapter. “We also ask that when the staff comes to us with a problem, they should also propose a solution. Some solutions are useful; some are less so but can be built upon.”

Staff members themselves may create bottlenecks. “In an effort to be useful and helpful, many staff members take on more aggravation and inefficient work for the sake of protecting and looking out for their doctors and pleasing patients,” says Hood.

Hood’s group holds an annual meeting to discuss work issues. “After the meeting, we come back to the office, walk around, and physically try to figure out what to do differently,” he says. “Often, we can solve things right there.”

It’s also wise to consider calling in a practice-management consultant. He or she can perform patient and physician flow studies and can evaluate and create effective job descriptions.

Analyze the Process: Follow the Work

A work activity should move linearly from start to finish. Yet some processes run like a Rube Goldberg gizmo, doubling back and forth and touching too many hands. Delays or missed steps could occur at each point.

To see what’s actually taking place and where the pain points exist, meet with your staff and diagram the existing workflow of each activity. Track where the paper or document goes after each person’s input, who deals with it at each juncture, and how much time each step takes.

Physicians should look for steps that can be combined or eliminated. The physicians may need to broaden a person’s authority to make decisions or divide responsibilities differently to create a less piecemeal process. If necessary, give the staff guidelines to help in making decisions.

“In some medical offices, we find people with a lot of responsibility but no authority. That compromises the workflow,” says Moghadas. “When a decision has to be made, it has to go to the physician but it sits on his desk waiting for his attention. Many things get bottlenecked there.”

While reviewing workflow, ask for each office employee’s feedback on their own role in creating bottlenecks. Determine whether the physician needs to change the way he or she interacts with the staff to speed up processes.

Set up the Right Staff Organization

The office organization that worked years ago may no longer match the work required. “You should review your staff structure every couple of years or whenever there’s a big change in the practice,” says Moghadas. “If the office moves, grows, or adds or loses an associate, it’s time to review what’s going on.”

If an office has added a physician assistant or nurse practitioner , ancillary services, a sophisticated scheduling system, or has new office software, it may now have too many or too few administrative personnel or duplication of responsibility.

To see whether true work demands are being met, have staff members log each of their work activities and time spent on them for at least a week. (Time-tracking requests often make staff nervous; reassure them that you’re not trying to eliminate jobs.)

Then add up the hours spent on each task, accounting for any activity performed by more than one person. For example, if the medical assistant, the receptionist, and the nurse are all doing referrals, count the total number of hours spent following referrals.

This analysis can determine whether an office has either the wrong number of staff or an inappropriate allocation of jobs.

Often, analyses show that the front desk is understaffed. “Front-desk personnel are being asked to take on more than is reasonable for that part of the practice,” says Scroggins. “They have to hurry through the gathering of demographics and other information. If good information isn’t collected at the point of contact, it creates problems in other areas and trickles through the whole practice.

“It’s also useful to measure your practice staffing against benchmarks,” says Scroggins.

Physicians can find staffing statistics from medical associations or through the Medical Group Management Association (MGMA, www.mgma.com) survey data.

For example, the median family practice/single specialty has 4.67 support staff per full-time-employee (FTE) physician, but better-performing family practice groups have 5.25 support staff per FTE physician, according to MGMA data.

Even with the right number of positions, job descriptions may be too fuzzy for efficient work. Although staff members are typically expected to help out where needed, each job description should be detailed and specific, and each task should have 1 person with ultimate responsibility.

Look for Technology Bottlenecks

Using an electronic medical record (EMR) is like piloting an airplane; it is an incredibly efficient piece of technology, but without expertise and practice using it, it won’t do what one wants. And although EMRs can solve workflow problems, they can also create them.

If the staff is struggling with an EMR or other office software, the workflow could get slowed down. Even if the EMR vendor has given some training, the staff still may not feel proficient.

“Doctors almost always underestimate how much training is required for using an EMR, unless they’ve had experience with it,” says Doug Gentile, MD, Chief Medical Officer of Allscripts, a leading provider of healthcare management software and systems.

“As a rule of thumb, you’re lucky if people retain 25% of what you tell them on the first go-through, because there’s so much information.

“It’s a big mistake to think that once you’re done implementing, you’re done with training,” adds Gentile. “People can get locked into inefficient workflows that add time to office tasks. People end up doing manual workarounds, or they’ve implemented workflows that require extra clicks that add up to time wasted over the day.”

Greg Hood said that his office took care to make sure that the staff was fully trained. “We did our EMR implementation in a couple of stages,” says Hood. “We gained some economies of scale and we were able to reduce the number of full-time employees for one department. We also found that we needed to shift some jobs.”

Consider an EMR as a potential solution for workflow bottlenecks. “For example, each time a patient calls, if a staff member has to find and pull a manual chart and then play phone tag with the patient, it involves time and many steps,” says Gentile. “If you have an EMR, the chart is right there; you address the issue while the patient is on the phone and it saves much time. It’s equally effective handling requests for medication renewals.”

Be aware that staff members may find the prospect of learning an EMR about as inviting as drinking battery acid. It’s vital to get the staff motivated.

“It’s definitely best to elicit buy-in on the staff,” says Moghadas. “Give yourself a timeline and allow your staff the opportunity to get advanced education through webinar training and basic training on the functionality so they can see how much it can save them in time and energy. Most offices that start out resistant to an EMR eventually come back and praise it and wonder why they didn’t do it years before.”

“A lot of doctors will say, ‘I just want to see patients,’” says Hood. “But seeing patients is just one checkbox on the list of running a practice.

“Physicians have to be interested in and attentive to every step, and keeping the office workflow efficient isn’t something you do just once,” says Hood. “It’s much like growing a bonsai tree; it takes constant attention and multiple small feedings. It’s better to grow a bonsai tree in small increments rather than flood it with water and then hack away at it every once in a while.”

Tips for Common Workflow Problems

1. Misplaced charts:  “This is one of the most common medical office bottlenecks,” says Robert Scroggins, JD, of Clayton L. Scroggins Associates. “If a chart cannot be located, everyone drops what they’re doing to go hunting for that chart.

Scroggins recommends using a quick-and-easy sign-out system for medical charts so that they’re always trackable. An extra step is to designate one person as the “sweep,” to gather all charts and return them at the end of day. “The doctor has to set the tone of rigor for managing the charts,” adds Scroggins.

Implementing an EMR will typically end missing-chart problems.

2. Phone call overload. Add extra hours or flexible scheduling to see more patients. Avoid quick fixes that drain money from the practice, advises Kathryn Moghadas . “A lot of offices try to fix problems by doing more work with patients on the phone rather than seeing them in the office. It translates to less revenue and more cost because the doctor can’t get paid if he’s taking care of the patient on the phone.”

3. Troublesome insurers. Consider getting rid of thorny insurance plans that create unnecessary paperwork and difficult situations. “Some plans work with the providers; others are not doctor-friendly,” says Moghadas. “We don’t want to work with insurers that create a disproportionate amount of work for the office staff and doctor.”

4. Exam-room musical chairs. Use a colored flag system on exam-room doors to indicate when a patient is in there and ready, or to signal the next activity that needs to be done, advises Scroggins. A manual flag system can be upgraded to an electronic signal system to move patients around in exam rooms.

5. Gaps in patient information. Collect patient registration information prior to the office visit so that the staff won’t be rushed during a crunch at the front desk. Send forms to new patients in advance, or allow online registration.

6. Absent employees. Cross-train functions where desirable, and build in flexibility to cover staff vacation time so that a given function doesn’t come to a halt when someone is out of the office, says Scroggins.

Read more articles at Medscape.com.

Everything in life is a balancing act, including the decision about what kind of practice setting will make for a satisfying medical career. That said, the choice of solo practice over a group or academic setting is one I’ve never regretted.

Being one’s own boss is usually thought of as the biggest advantage to solo practice. The flexibility to set the office hours to fit my schedule, especially the ability to shift hours around as my kids grew, made it possible for me to attend plenty of concerts, baseball games, and soccer matches. Patient scheduling is completely under my control and always has been. Staffing is entirely at my discretion.

The Advantages

The last medical assistant I had threw a hissy fit and walked out one day. Unable to face the prospect of hiring another, I’ve been working the back office alone ever since. I have 2 front-desk staffers to answer the phone, greet patients, and handle the billing and referrals, and my practice hums right along.

When I wanted to move to an open-access model, I just did it. There was no board of directors to convince; no managing physician to persuade; no partners to get to buy into a new paradigm. I chose which insurance plans I wanted to participate with and which ones seemed to be more trouble than they were worth. I got to design a filing system that worked for me, choose the billing software, and even shop for the computer hardware myself. There was a sense of ownership that would have taken years to develop — if it ever did — had I gone into a group practice instead.

Best of all, of course, is the intensity of the one-on-one patient relationships I enjoy. They come to see me, and I am the doctor they get. Taking my own call night after night, I am always the first to know about major events; there is no on-call partner to admit someone with a myocardial infarction or hear about a sick child in the middle of the night. The next morning, I am the one updating my staffers instead of getting a report from the on-call doc. Over the years, my patients have become my friends, deepening the joy of caring for them.

How to Be Alone

The disadvantages of solo practice are also very real; the major issue is call coverage. The flip side of constant availability is the illusion of indispensability. Each weekend out of town becomes a hassle; every vacation requires a negotiation. And none of those days off comes with pay. The opportunity cost of time away from the office is significant for everyone who is self-employed, as is the overall financial risk of the business endeavor. If the phone doesn’t ring or if I don’t manage my expenses carefully enough, I don’t take home a paycheck.

But the issue that has probably kept more doctors away from solo practice than any other is the perceived professional isolation. Think about it: throughout medical school and residency training, students and young physicians are always surrounded by colleagues. Study groups, teaching conferences, patient rounds in the hospital — you never have to think twice about bouncing random questions off your peers. “What’s the dose of amoxicillin?” “Should I get a stress test on this patient?” “What do you think about this EKG?”

There’s always someone around to answer a question; offer a second opinion; confirm your first impression. The further along you get in your training, the less you tend to do it, but even as an attending you are still surrounded by colleagues. You are never completely alone — until you choose to be by going into practice by yourself. Cutting yourself off from that kind of intellectual support might seem terribly scary. Still, many of those other advantages are significant enough to make it worthwhile to take the plunge.

But once the issues with call are squared away and you have enough of a patient base built up to assure a comfortable cash flow, the isolation remains. After all those years working as part of a team of physicians, how do you keep from getting lonely without any other doctors around, day in and day out?

Reaching Out

Whenever I have a question about a patient, a drug, a test, or a procedure, I never hesitate to pick up that phone. When I first hung out my shingle, I found myself calling one or more consultants almost every week. Orthopedics, urology, cardiology, allergy, neurology — everyone. I’d present the patient and explain what I was thinking and what I’d done so far. Most of them answered my questions and graciously offered suggestions for management, always including parameters for when they needed to see the patient themselves. The few who insisted that I just send the patient over right away got that referral but few after that.

As is customary, when I refer patients out, I get a letter back from the consultant. Those letters are my true continuing medical education (CME). I learn to do more for my patients; what the latest treatment options are for certain conditions; which new drugs seem to be working well and which ones aren’t worth the usually exorbitant prices.

I’ve never stopped picking up the phone to call colleagues, but over the years my purpose has shifted. Instead of asking what I should be doing for my patients, now I’m calling to give the specialist a heads up. By the time I refer a patient, you’d better believe he either needs a procedure that’s beyond my scope of practice or has something the specialist is going to have a tough time figuring out. If the diagnosis is something simple, I’m pretty certain to have already made it.

Over the years, I’ve become just as close to those telephone consultants as I have to my patients. I enjoy talking with them, sharing small talk and family news once the medical issues have been discussed. I know the affection and respect is mutual because they’ve told me so. Sometimes we’ll meet up at a hospital function or CME event, when it’s great to put a face with the voice. But on a day-to-day basis, it doesn’t really matter that we don’t interact face to face. We’re all too busy caring for our patients.

So even when I’m all alone in my solo practice, the whole world is only a phone call away.

Frustrating, time-consuming, often unsuccessful. Those words typically describe the experience of trying to collect patient balances.

According to the Commercial Collection Agency Association, the probability of collecting is 73% after 3 months, 57% after 6 months, and 29% after a year. For very small amounts, the figures may be even less. While you’re trying to collect, it’s costing you anywhere from 17% to 30% of each bill to run after payment.

To avoid having to chase after patients who dodge payments, make a point to collect payments at the time of service, especially when patients don’t have coverage. Some tactics can make that easier to implement.

Be firm about payment up front: “Historically, doctors are used to sending bills,” says Woodcock. Further, “If you go to WalMart, you know you won’t get out without passing the cash register and paying, but when patients go to a doctor’s office, everyone is trained to say, ‘send me the bill.’”

To change that mind-set, put up signs in the office to make it clear that payment at the time of service is required. Woodcock advises: “Instead of asking, ‘would you like to pay?’ ask, ‘how would you like to pay?’ As the staff member is asking, she should start writing out the receipt, demonstrating that she’s expecting payment.” Tell patients of the office payment policy when phoning for their appointment reminders.

Take credit cards: Most physician offices that accept credit and debit cards see an immediate spike in payments. Even accounting for the fee to the card company, physicians come out way ahead by taking credit and debit cards. Credit cards can be especially helpful with consumer-directed or high-deductible health plans, of which it’s difficult to know exactly how much the patient owes you at the time of service.

“I advise the front desk to take the imprint of the patient’s credit card; bill half the amount, and say they will bill the remainder and send a statement when they learn the final amount from the insurer,” says Madden.

Use a collection agency when necessary: There are as many collection strategies as there are ways to treat the common cold. Some experts suggest 1 phone call, a minimal number of statements, and then a collection agency.

Rather than send repeated invoices, keep the process short and sweet, advises Woodcock. “Doctors should only send two or three statements, not six,” says Woodcock. Furthermore:

Each time they send a statement it costs about a dollar, between postage and staff time. I recommend sending one statement immediately after the patient visit, and another 30 days after. The third statement should be a letter, letting patients know that they have 15 days to respond before the account will be sent to a collections agency.

Scroggins advises monthly statements with an increasingly strong message. “As statements age, put dunning messages onto the statement. At some point, the most effective step you can take is to send a separate letter — in its own envelope, not stuck in with the statement. Letters are more likely to get to the decision maker responsible for that bill.”

If you need to up the ante, look for a “soft” collection rather than harsh collection tactics. Before working with a collection agency, ask to see their letters to consumers and their phone call scripts.

Collection agencies typically charge a percentage of collections. The average national collections company fees range from 12% to 50% on the basis of age, type, and quantity of accounts, according to National Asset Management, a commercial collection service.

Woodcock adds: “Don’t tell the patient you’re going to send the account if you don’t intend to act on it.”

Summary Points

• Many denied claims are never resubmitted, or get resubmitted too late to receive payment;
• Physicians should examine monthly accounts receivable benchmarks to see where problems are occurring;
• Technology, such as scrubbing software, clearinghouses, and Web-based claims management services, can help create clean claims and prevent denials;
• Collecting from patients may become more challenging due to patients losing their jobs and high-deductible health plans;
• Chasing after payment costs physicians from 17% to 30% of the unpaid bill; and
• Getting paid at time of service helps eliminate collection problems.

Read more articles at Medscape.com.