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Learning Objectives

  1. Identify the benefits of implementing pre-visit planning

  2. Describe pre-visit team-based workflows

  3. Employ pre-visit planning tools and templates

Introduction

Quiz Ref IDPre-visit planning is a team-based approach to planning for patient appointments. Using pre-visit planning, at the end of the current visit:

  • Patients are scheduled for follow-up appointments

  • Pre-visit lab testing and other diagnostics are arranged

  • Necessary information for upcoming visits is gathered

  • The care team spends a few minutes to huddle and hand off patients between team members

Pre-visit planning communicates to patients that the practice is planning ahead in order to make their next visit as meaningful and productive as possible. Pre-visit planning saves time, reduces practice costs, and improves patient care, and can mean the difference between a clinic where physicians and team members are floundering and frustrated versus one where things run smoothly with the capacity to handle any unanticipated issues that arise.14

How Much Time and Money Will Pre-Visit Planning Save My Practice?

Use this calculator to estimate the amount of time and money you could save by implementing pre-visit planning in your practice. Enter the amount of time (minutes) per day spent by physicians and your team on activities that could be eliminated by pre-visit planning. Results should be verified for your specific practice and workflows. Calculations are for demonstration purposes only. Actual savings may vary.

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Q&A

Eight STEPS to Implement Pre-Visit Planning

At the End of the Current Visit

  1. Use a Visit Planner Checklist to Preorder Labs and Other Needed Tests for the Next Visit

  2. Schedule the Next Follow-Up Appointment

  3. Arrange for Tests to Be Completed Before the Next Visit

Between the Current and Next Visit

  • 4. Use a Checklist to Review Pre-Visit Tasks

  • 5. Send Patient Appointment Reminders

On the Morning of the Next Visit

  • 6. Hold a Pre-Clinic Care Team Huddle

  • 7. Use a Pre-Appointment Questionnaire to Gather Patient Updates

  • 8. Perform a Handoff of the Patient to the Physician

Figure 1. Eight STEPS to Implement Pre-Visit Planning

A reference for implementing the 8 STEPS of pre-visit planning

At the End of the Current Visit

STEP 1 Use a Visit Planner Checklist to Preorder Labs and Other Needed Tests for the Next Visit

A medical assistant (MA) or another team member who can schedule the appointments and tests indicated by the physician can use the visit planner checklist. Using a visit planner checklist allows the physician to indicate when the next follow-up appointment should be and any associated labs or other diagnostic tests required prior to the next visit. It should be quick and convenient to use, requiring no more than a few seconds of physician time.

For example, consider a patient with diabetes, hypertension, and hypothyroidism who will be due for their annual checkup in 3 months. During the current visit, the physician uses the visit planner checklist and indicates the appointment interval by typing “3-month follow up with annual checkup” then also checks “A1c, TSH, Na, K, creatinine, and mammogram.” A member of the physician's team can then schedule the upcoming annual visit, enter orders for the indicated laboratory tests, and provide the patient with instructions on how to schedule the lab tests and mammogram.

Which team members can enter orders during pre-visit planning?

According to the Joint Commission, any licensed, certified, or unlicensed team member, including registered nurses, licensed practical nurses, medical assistants, and clerical personnel, may enter orders at the direction of a physician. This includes orders based on standard office protocols or standing order sets that have been approved by the practice or organization.

Team members who are not authorized to “submit” orders should leave the order as “pending” for a certified or licensed team member to activate or submit after verification. The authority to pend vs activate or submit orders varies based on state, local, and professional regulations.

While the Centers for Medicare & Medicaid Services (CMS) is silent on who may enter orders, in general, CMS considers diagnostic test order requirements met if there is an authenticated medical record by a physician supporting their intent to order the tests. Again, this may vary by state, local, and professional regulations.

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Q&A

  • Our physicians are overwhelmed by the process of selecting a diagnosis code for each test, a process that can add several minutes to each appointment. Do you have any suggestions?

    When creating the visit planner checklist, pair each test with the 2 or 3 most frequently used diagnosis codes for that test. The physician can then easily check the appropriate diagnosis code for that patient, alleviating the need to search through a longer list of codes in most circumstances.

    For example, the default ICD-10 code might be D64.9 (anemia) for an iron panel with the option of checking for R53.83 (fatigue) or for R19.5 (blood in stool). If the iron panel is ordered for another diagnosis, a search can be undertaken for the correct ICD-10 code, but for most patients, the correct ICD-10 code will be one of the 3 options provided next to the test name on the visit planner. Practices should work with their IT department and/or EHR vendor to create an electronic checklist version.

  • Our physicians commonly order the same bundles of tests. Can the visit planner help with this?

    Yes. You can create “order sets” or tests that are bundled based on conditions. Order sets simplify the ordering process and reduce the likelihood of missed laboratory tests. For example, an order set for diabetes provides the diagnosis code and orders an entire panel of relevant tests—HbA1c, a basic metabolic panel, lipid profile, and urine microalbumin/creatinine ratio—with a single checkmark or click.1

STEP 2 Schedule the Next Follow-Up Appointment

Practices can plan ahead by scheduling patients for their next visit at the conclusion of their current visit, including scheduling any needed pre-visit laboratory testing. This saves time and reduces the number of “touches” to set up routine follow-up appointments.

Alternatively, practices that do not have the capacity to hold future laboratory orders may choose to have a team member order labs according to an established protocol based on the patient's medications and/or conditions a few days before the next appointment. Although having a team member order the labs a few days before the appointment involves more touches than scheduling at the time of the current visit, any amount of pre-visit planning is helpful.

As you consider how to implement pre-visit planning in your practice, you can use this checklist to guide you.

quote

“We think about the patient more inclusively before they come in for their visit so that we can take care of as much as possible at the time of the visit. This prevents work later.”

—Amy Haupert, MD; Family Medicine, Allina Medical Clinic
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Q&A

STEP 3 Arrange for Tests to Be Completed Before the Next Visit

It is ideal to schedule any pre-visit labs and other diagnostics ordered for the next visit at the end of the current visit to ensure that everything is scheduled as ordered and prevent slots from being filled up if these tests are scheduled too late. The care team can either schedule these directly for the patient during check out (eg, a bloodwork appointment) or give the patient clear instructions on how to schedule themselves (eg, the phone number for mammogram scheduling).

Some organizations arrange for the patient to come in for lab testing a few days before the visit. However, others have developed rapid turnaround or point-of-care testing for most tests to be performed the same day as the visit with the physician. Quiz Ref IDAs a result, both the patient and the practice save time as the practice no longer needs to spend time contacting the patient with results after the visit. Regardless of the approach, the goal is to have the test results available so physicians and patients can discuss the results and make management decisions together during the face-to-face visit.

quote

“An internal medicine practice in Boston found that pre-visit laboratory testing reduced the number of letters and phone calls for results by more than 80% and saved $25 per visit in physician and staff time.”

—J. Benjamin Crocker, MD; Internal Medicine, Ambulatory Practice of the Future, Boston, MA

Between the Current and Next Visit

STEP 4 Use a Checklist to Review Pre-Visit Tasks

Quiz Ref IDA nurse or medical assistant can do visit preparations a day to a week before the appointment. The nurse or medical assistant can conduct the following activities:

  1. Review the physician's notes from the patient's last visit as well as notes from other clinicians who delivered interval care. If any interval care notes or results are not in the patient's record, the nurse or medical assistant can contact that office or department to obtain the information prior to the visit.

  2. Ensure that the patient completed all pre-ordered laboratory tests. If not, the nurse or MA can call the patient to remind them to go to the lab before the upcoming visit.

  3. Identify other gaps in care, such as missing immunizations or cancer screenings. A health maintenance checklist in the EHR or separate registry provides an overview of preventive and chronic care needs. Below is a sample health maintenance checklist that your practice can customize to its needs.

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Q&A

  • We have a registry that identifies patients' prevention and chronic care needs as they come due. Why should we address these needs at a visit?

    Many practices use the in-reach approach within the medical setting as the primary method for addressing prospective care needs. An in-reach approach involves planning in advance so that gaps in care are closed at the time of each face-to-face visit. This is typically done at the annual comprehensive care visit and reserves the outreach approach for patients missed in the in-reach approach. In-reach is the most efficient method.

    An outreach approach involves communication occurring outside the medical setting. Practices that exclusively use an outreach approach will spend more time completing administrative tasks in the long term and may end up asking patients to come in for multiple visits when their needs could have been met in one visit. However, outreach is useful as a tool to close gaps in care for patients who have missed annual appointments or preventive care milestones.

STEP 5 Send Patient Appointment Reminders

Many practices send patients automated reminder emails, phone calls, or text messages a few days before their appointments, reducing no-show rates. If no automated option exists, team members can make these calls or send letters directly from the office. If time and resources do not allow all patients to be contacted prior to their appointment, review the schedule 2 to 3 days prior to clinic, and contact those patients with higher acuity medical needs or known social needs such as transportation insecurity.

Quiz Ref IDIn some practices, nurses or medical assistants also make a pre-visit phone call to their patients with more complex care needs, performing tasks such as medication reconciliation and agenda setting on the phone, and then pre-populating the next day's visit note with this information. Other practices email a link for the patient to complete a pre-appointment questionnaire, and the patient's responses flow into the next day's visit note. Both approaches save the team and physician time during the clinic session.

On the Morning of the Next Visit

STEP 6 Hold a Pre-Clinic Care Team Huddle

A 5- to 15-minute daily pre-clinic huddle brings the team together to review and share knowledge about the day ahead. The care team can use this time to announce last-minute staffing or schedule changes, discuss any particular patient or team member needs, and determine how best to share the workload.

During the huddle, the nurse or medical assistant who performed the pre-visit prep (STEP 4) can tell the physician about an abnormal x-ray result, a complex multi-disciplinary situation, or arrange for an interpreter. The huddle provides an opportunity for the physician to consult with colleagues or other resources before the patient's visit.

STEP 7 Use a Pre-Appointment Questionnaire to Gather Patient Updates

Provide a questionnaire to every patient electronically from home or on paper at check-in to complete before the appointment. The pre-appointment questionnaire allows the team to see what is most important to the patient and helps the physician plan the visit before entering the room. The pre-appointment questionnaire can include questions that would otherwise be asked during rooming, such as depression screens, pain assessment, smoking status, falls screening, and specific questions associated with the Medicare Annual Wellness Visit.

The patient can review and edit a printed medication list in the waiting room. Patients can highlight which medications need refills or which medications they are not taking. By shifting these questions to the questionnaire, the nurses and medical assistants have much of the information they need to obtain during the visit, giving them more time to engage with patients.

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Q&A

STEP 8 Perform a Handoff of the Patient to the Physician

The nurse or medical assistant will often learn important information about the patient during the rooming process. A brief 1-minute handoff to the physician can save time in the exam room by helping the physician focus the appointment to meet the patient's needs and expectations. The handoff also makes patients aware that their care team works together on their behalf. For example, the physician may say, “The nurse mentioned that you've been worried about side effects from your cholesterol medication—please tell me more.” The team will quickly see the importance of their initial discussions with patients.

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Q&A

Conclusion

Quiz Ref IDThe strategies, tools, and resources in this toolkit can assist you in adopting a pre-visit planning approach that fits your practice's specific needs. With pre-visit planning, your practice can benefit from improved communication with patients, streamlined scheduling of appointments, and enhanced care team efficiency during all patient visits.

You can measure the impact of pre-visit planning using this pre-visit planning measurement guidebook. It is designed with a quality improvement framework that will allow you to see positive changes in your operational efficiency.

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Graphic Jump Location
AMA Pearls

AMA Pearls

Avoid being caught off guard by unexpected patient agenda items.

Pre-visit planning reduces the chance a patient's unexpected agenda item will catch the team off guard. For example, suppose the patient indicates on a pre-appointment questionnaire that the main purpose of his or her visit is to get help with insomnia. In that case, it is less likely the physician will get to the end of the appointment only to learn that the patient's primary concern had not yet surfaced.

Seek to close potential gaps in patient care before the face-to-face appointment.

Pre-visit planning provides an opportunity to close gaps in a patient's care. During visit prep, for example, the nurse or medical assistant determines if a patient is due for immunizations or a colon cancer screening. Using established protocols, the nurse can close these gaps before the physician portion of the visit begins.

Take a long view: schedule several planned care appointments at once.

Use a visit planner to set up more than one future appointment. For example, at this year's annual comprehensive care visit for a patient with diabetes, hypertension, and hypothyroidism, the physician may check off both a 6-month follow-up (with HbA1c) as well as next year's annual visit (with a diabetic panel, hypertension panel, TSH, and mammogram). Practices using open-access scheduling can track the appropriate time intervals for appointments and associated labs in a reminder system.

Further Reading

Journal Articles and Other Publications

  • Jerzak J, Siddiqui G, Sinsky CA. Advanced team-based care: How we made it work. J Fam Pract. 2019;68(7):E1-E8. https://www.mdedge.com/familymedicine/article/207667/practice-management/advanced-team-based-care-how-we-made-it-work

  • Sinsky CA, Bodenheimer T. Powering-up primary care teams: advanced team care with in-room support. Ann Fam Med. 2019;17(4):367-371. doi:10.1370/afm.2422

  • Day J, Scammon DL, Kim J, et al. Quality, satisfaction, and financial efficiency associated with elements of primary care practice transformation: preliminary findings. Ann Fam Med. 2013;11 Suppl 1(Suppl 1):S50-S59. doi:10.1370/afm.1475

  • Crocker B, Lewandrowski EL, Lewandrowski N, Gregory K, Lewandrowski K. Patient satisfaction with point-of-care laboratory testing: report of a quality improvement program in an ambulatory practice of an academic medical center. Clin Chim Acta. 2013;424:8-11. doi: 10.1016/j.cca.2013.04.025

  • Crocker JB, Lee-Lewandrowski E, Lewandrowski N, Baron J, Gregory K, Lewandrowski K. Implementation of point-of-care testing in an ambulatory practice of an academic medical center. Am J Clin Pathol. 2014;142(5):640-646. doi:10.1309/AJCPYK1KV2KBCDDL

  • Shafer R, Kearns C, Carney M, Sagar A. Leveraging interdisciplinary teams for pre-visit planning to improve pneumococcal immunization rates among internal medicine subspecialty practices. J Prim Care Community Health. 2021;12:21501319211060986. doi:10.1177/21501319211060986

  • Hickey MD, Sergi F, Zhang K, et al. Pragmatic randomized trial of a pre-visit intervention to improve the quality of telemedicine visits for vulnerable patients living with HIV. J Telemed Telecare. 2020;1357633X20976036. doi:10.1177/1357633X20976036

  • Magnan E, Gosdin M, Tancredi D, Jerant A. Pilot randomized controlled trial Protocol: Life context-informed pre-visit planning to improve care plans for primary care patients with multiple chronic conditions including diabetes. J Comorb. 2021;11:26335565211062387. doi:10.1177/26335565211062387

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References:
1.
Sinsky  CA, Willard-Grace  R, Schutzbank  AM, Sinsky  TA, Margolius  D, Bodenheimer  T.  In search of joy in practice: a report of 23 high-functioning primary care practices.  Ann Fam Med. 2013;11(3):272–278. doi:10.1370/afm.1531Google ScholarCrossref
2.
Hunt  VL, Chaudhry  R, Stroebel  RJ, North  F.  Does pre-ordering tests enhance the value of the periodic examination? Study Design - Process implementation with retrospective chart review.  BMC Health Serv Res. 2011;11:216. doi:10.1186/1472-6963-11-216Google Scholar
3.
National Institute of Diabetes and Digestive and Kidney Diseases.  Pre-visit planning saves time.  July 24 , 2019. Accessed December 2, 2021. https://www.niddk.nih.gov/health-information/professionals/diabetes-discoveries-practice/pre-visit-planning-saves-time
4.
Gholamzadeh  M, Abtahi  H, Ghazisaeeidi  M.  Applied techniques for putting pre-visit planning in clinical practice to empower patient-centered care in the pandemic era: a systematic review and framework suggestion.  BMC Health Serv Res. 2021;21(1):458. doi:10.1186/s12913-021-06456-7Google ScholarCrossref

Disclaimer: AMA STEPS Forward® content is provided for informational purposes only, is believed to be current and accurate at the time of posting, and is not intended as, and should not be construed to be, legal, financial, medical, or consulting advice. Physicians and other users should seek competent legal, financial, medical, and consulting advice. AMA STEPS Forward® content provides information on commercial products, processes, and services for informational purposes only. The AMA does not endorse or recommend any commercial products, processes, or services and mention of the same in AMA STEPS Forward® content is not an endorsement or recommendation. The AMA hereby disclaims all express and implied warranties of any kind related to any third-party content or offering. The AMA expressly disclaims all liability for damages of any kind arising out of use, reference to, or reliance on AMA STEPS Forward® content.

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