Before Asante Physician Partners Family Medicine adopted a streamlined pre-registration process, new patients to the Grants Pass, OR, practice had to complete a complicated and inefficient six-page registration packet before their first visit. The costs of this inefficiency were further compounded when the volume of new patients increased suddenly as more people received insurance coverage under the Affordable Care Act. Both care team members and patients were dissatisfied with this tedious registration process; thus, the practice decided to transition to an all-electronic pre-registration system.
David Gilmore, Director of Operations and a Lean Six Sigma Black Belt, noted, “Too many patients were arriving without complete registration paperwork, which delayed not only their visit but also had a trickle-down effect on the next visits on the schedule. The care team was documenting items in the exam room that should have been covered before the patient arrived. This process created time and cost concerns for both the patients and the medical practice. We needed to reengineer our value proposition for providers and patients alike, so we applied Lean principles to help us eliminate paper-based registration forms and switch to an entirely electronic process.”
The practice calculated the expected volume of patients who would require registration in the next two years. They discovered that they would need to hire two full-time employees to support the new pre-registration process. Using cost-driver analysis, they also examined the cost implications of staying with the paper-based registration process (Table 1). Assuming that 1000 new patients would be registered over the course of the next year, they estimated that the total savings for their seven-physician practice if they switched to electronic pre-registration could be as much as $216,760 per year —including the costs of new staff they would need to hire to perform data entry.
Table 1.
Cost implications of a traditional paper approach to new patient registration
| TASK | COST |
|---|
| Completing paper new patient registration forms at the clinic | $50 for each new patient registration packet completed after the patient arrives at the clinic |
| Receiving, scanning and abstracting medical history into EHR at the time of the visit rather than before | MA verbally completes history: $8 each patient ($.40 per minute) |
| MD verbally completes history: $32 each patient ($1.60 per minute) |
| Accommodating late arrival for check in if forms are not filled out in advance | Each minute the patient is late costs the practice money: delay in visit with MD costs $1.60 per minute, which can be multiplied by the time each additional appointment is delayed. |
| Secondary effects and costs must be considered: potential for no-show, patient completing forms at the clinic, MA/MD verbal completion of history, other patient appointments delayed. |
| Accommodating patient no-shows for appointment | Loss of scheduled patient's appointment - $100 |
| Loss of two potential appointments for established patients - $200 |
| Total: up to $300 lost because of a single no-show |
| Completing registration by MA during pre-visit rooming | Delay in visit with MD costs $1.60 each minute, which can be multiplied by the time each additional appointment is delayed |
Asante built the electronic pre-registration process into the daily routine and set aside time to train the entire team on an ongoing basis: first on what the electronic process would entail, then on how to accurately enter the relevant patient details and finally how to measure and report on progress. It took approximately one month to fully implement the new process.
In the electronic pre-registration process, a new patient coordinator (NPC) speaks with each new patient in person or by phone to collect all the necessary information prior to the first visit, including the patient's medication list, allergies, and medical history. The NPC enters the patient's responses directly into the electronic health record (EHR), ensuring accuracy and completeness of patient records. The process creates a strong connection with the patient and engages them early in their own health management. Patients appreciate the one-on-one attention from the NPC.
To evaluate the success of their time and financial investment, Asante started collecting baseline data before and after they rolled out the process, tracking new patient registration processing time, number of new patient registrations completed, and work allocation with costs per full-time employee (FTE). All of these metrics improved under the new process, as did team satisfaction. The physicians, nurses, and medical assistants (MAs) were no longer taking precious time away from the patient visit to collect missing information or do data entry.
Because of their success and the strong business case for their streamlined approach to new patient registration, this process was introduced at 21 practices in the Asante network, including primary care and medical and surgical sub-specialties. Going forward, the organization will utilize the patient portal to populate their EHR with discrete data in each patient's medical record.