Better healthcare workflow management and business process management are key to expanding your medical group practice without losing your mind. There’s a reason that large corporations depend heavily on systems, processes and the workflow / business process technologies that enable those systems and processes. Systems and processes work. They help you scale. They help you delegate and get out of working in the business, allowing you to work on the business.
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Why use healthcare workflow management or healthcare business management tools
Most medical practice owners that are growth focused, inherently also fear growing/expanding. We have talked to several medical practice owners that want to get to and beyond the $10 million dollar club but are afraid that they won’t be able to get there with their current staff.
If you really dig into why they are afraid of their inability to scale with their current staff, you will invariably find that they are currently operating in a start up mode. There are no well defined / loosely defined systems, processes, workflows in their medical practice. There is no accountability defined in their practice. No documented, well defined onboarding process, no well defined training process, no well defined patient intake process, no well defined surgical scheduling process, no well defined front desk / call center process – nothing.
Things are working today and they will continue to work.
Achieving economies of scale
You can of course, continue to work this way – but you will NEVER achieve economies of scale that growth requires and process / workflow management can bring.
You will never achieve economies of scale afforded to larger practices by having centralized back office operations that are systemized, have standard operating procedures, standard processes, use a set of standard systems and tools.
Your margins will remain the same or, possibly, go lower because you are going to need more and more staff to do the same things – just on a larger scale. The problems or “cracks” will be magnified.
You will have even less visibility than you have today and will never really be able to tell what’s slipping through the cracks nor would you be able to tell where to improve.
Lack of set systems and processes
Because you have no processes set up. You have no ways to measure accountability. You have no way to get visibility into processes. No KPIs defined. If you do not measure, you cannot improve. It’s an old adage but it rings true today and will ring true forever.
It’s not your staff’s incompetence or fault either. They just have too many systems to interact with, where no system really talks to the other. So, you end up following up with your staff to find out what the status is. Or, if you do not follow up with your staff, you find out later on that there was an issue.. Issues like
- A referring partner isn’t receiving their patient appointments
- A partner is not getting their visit notes
- A vendor is not getting medical record requests responded to
- A patient is not getting their alternate prescriptions
- A surgical clearance fax never made it to the coordinator
- Patients complaining that they are not getting appointments
- Complaints of long hold times
- Patients complaining of voicemails not being returned
Taking a page from the tech industry’s books
These are problems that industry faces. Some industries have already solved these challenges. What does the tech industry do?
Just like we approach email or even use the super awesome tool Trello – if you approached faxes, calls, voicemails the same way, would you have the same complaints?
When we deal with emails or Trello, we have:
- Inbox – where we get incoming TODOs
- Folders/labels – where we file away items that we have already tended to
- Snooze/reminders – that’s how we approach our workload, remind ourselves of things to tend to, things to follow up on, things to close out and file away
- Compose – that’s how we start a new task
- Forward/Assign to – that’s how we assign an incoming task to someone else
- Reply – that’s how we respond to incoming tasks and continue a conversation
And, by using these features, we, collectively know that a TODO was tended to, and we don’t have to spend time reporting to our bosses about how we are handling important tasks for them.
We never have to spend another extra minute chasing down folks within our organization to find out what happened, whether it was done, who is working on it, what the status is, when it might be done, reminding ourselves to remind our staff to finish something.. The list is endless.
Take stock of the time you waste on activities like these that really suck up productive hours.. And away from patient care or practice management.
Basic healthcare workflow management starts with your fax machine
We, in healthcare, live and breathe the fax machine every day.
No tool is ever going to completely eradicate it – they’ve been trying for a while now and have not succeeded.
Instead, we advocate looking deeper into the problem with fax machines and using superior workflow management tools to address those problems.
Typically, faxes are associated with these problems:
- Manual process to send and receive faxes
- Addition burden of using paper
- Does not allow you to leverage electronic processing as you typically do with other business processes
- Manual effort to check send and delivery of faxes
- Information sent via fax has to be typed into the EMR or patient CRM systems that your practice uses
- Staff bypasses the data entry tasks and instead scans the fax into a PDF and attaches it to the EMR
- Faxes received are usually in image format, and the technologies available to convert those into readable text are limited (providers like Amazon Textract, Tesseract do have OCR technologies in place).
- If data is not entered in various fields in the EMR or CRM, we consider that data to be lost forever.. Because no software is able to run reports/analytics or provide tangible value without actual data… which, is locked inside scanned faxes
- Filing faxes away requires additional storage and additional real estate. Even if they were actually filed away, searching through those faxes itself is an onerous process. There’s no indexing, no “google search” – nothing. Again, you have to spend valuable staff time (and money) in solving problems that have been solved EONS ago.
Now, just rethink this process thus:
- On an average, your office might be getting 50+ faxes daily.
- First step could be to transition from a physical fax machine to using a web based fax server. This step alone will cut down on various paper based faxes. Take a look at various electronic faxing vendors like efax, mfax, srfax, faxage (make sure they are HIPAA compliant and will sign a BAA with you). Even Twilio is now taking HIPAA compliant workloads (including fax) but the pricing is exceedingly high (starting at $15K/month).
- Most of these online fax websites and fax servers give you a nice “inbox”, “sent”, “outbox” etc. Make use of these folders.
- Once those faxes arrive, you typically have an action to take:
- Forward that fax to someone in some department within your practice to act upon the information in the fax
- Based on the information faxed to you and take some action on it – it could be related to surgery scheduling, appointments, electronic prior authorizations, pharmacy related, SPAM, medical records request, referral request etc. (RELATED – Our referral management software handles this easily)
- Update the EMR and / or HIPAA compliant patient CRM with some information from the fax.
- Create a task for yourself to be done later on.
- Create a reminder for yourself to take action on the faxed information and do something with it
- Respond to the fax received via email
- Respond to the fax received via another fax
- Get signatures from your provider or manager or someone else from your practice and then respond to the incoming fax
- After you are done with the pending action, file the fax away for future retrieval
So, if you really look at the medical workflow here, it is a series of defined steps and you receive information + handle the same almost like an email inbox
Referral request faxes – inbound
Your front desk/ referral coordinators call the patient to:
- Get them an appointment
- Update your EMR with the patient and appointment information
- Update the transition of care information (CCDA) into the EMR
- Upload the referral note into the EMR as an attachment. (NOTE – our referral management software does this easily)
- Once they are done with getting the patient an appointment, the inbound fax (let’s call it a ticket) can be closed and archived.
- Until the patient has an appointment or has declined getting an appointment, your referral coordinator cannot close the “ticket” and it remains “Open”.
Medical records /chart retrieval request – inbound
- You either charge for medical records or you don’t. Either way, you respond to the medical records request.
- You might forward it to your billing department to generate an invoice for the medical records request so the requested can pay for it.
- After you send this payment request over to the requester, you move the fax into a “Pending, waiting customer reply” status.
- Once the payment has been made – you do not get notified, rather, the billing department gets notified.
- Once the billing department changes this “incoming fax medical records request” to “payment received”, you have the green light to go ahead and release the medical records.
- After you do so, you can mark this fax record as “Closed”.
- Or, when a patient requests their own medical records, your next step is to request them for a medical record release consent form.
- Then you mark this record as “Pending, waiting customer replyOr, you go to your EMR, download the visit note(s) requested and fax it over.
- Once the patient faxes over their medical record release consent form, you attach this form as a proof to their EMR patient record, then you download their medical record (TOC) or visit note PDF from the EMR and fax it to the patient provided fax number
Inbound prior authorization fax responses
- Someone from your practice had started a prior authorization request for a patient for whatever reason – could be surgery scheduling, could be medication/pharmacy refill related etc.
- You, or that person that sent the prior authorization request would be looking at this fax, then taking the next step on it.
- The next step could be to resubmit the prior authorization request based on information presented in the fax.
- Next step could be to attach the prior authorization response based on information sent via fax
- The next step could be to to start the medical clearance for a patient via their primary care provider.
- It could be to start the pre admission tests
- It could be to request additional patient history and medication history from patient’s provider(s)
Provider verification requests – inbound
- Payers and CMS are required to maintain accurate information about providers, locations, credentialed status at all times (depends on each state).
- You might receive these faxes and your credentialing staff could be assigned this task to handle / take forward. The credentialing staff would of course, not be looking at this incoming fax queue everyday because the faxes they receive are infrequent.
- That requires someone from your practice (usually a practice manager) to forward those faxes to the credentialing department to act upon.
- The credentialing manager could then update the payer portals or CMS portal with accurate information on the providers and then would come back to this fax task manager to update the ticket as “Closed”.
- You could also receive similar requests from medication prior authorization websites (e.g. CoverMyMeds) and have to keep an accurate profile of all prescribers (providers). This request would typically be handled by the technicians that take care of drug prescriptions daily.
Information faxes from vendors, payers
- Though not everyday, one every couple of weeks, your staff will be receiving informational faxes from various vendors and payers that need to be routed to appropriate staff within your practice.
- A payer could send information on updated payer policies or CPT codes that are being reimbursed or changes in reimbursements or the code they want your billers to use for reimbursements. These faxes are VERY important to route to the right person.
- A payer like HealthFirst could send your billing team notification on nonpayments that the billers then need to update the claims system with this denial information.
- A payer could send a retrospective drug utilization review (RDUR) request and your provider plus technician might need to get involved in this request – hence this has to be forwarded to both parties
Visit notes from referral partners
- You get visit notes from referring partners (read how to create a great physician marketing team).
- Your referral coordinator needs to download the visit notes you received via fax and upload/attach it to the patient’s record.
- If your practice is a bit further ahead, then the medical data team would type in the data into the EHR to make it usable in the future. However, rarely do practices have enough time or the bandwidth to do this. Instead, visit notes go into a PDF of an image (faxes are image files) and the practice rarely ever looks at them again.
- The referral coordinator or staff member then needs to ensure that these reports are included in reporting back to the payer to prove that they “closed the loop” for MIPS purposes. (NOTE – our referral management software does this easily)
Signatures on faxes
Many times, you are going to need signatures on faxes being sent out. There are many e-signature vendors in the marketplace, however very few are HIPAA compliant. The HIPAA compliant vendors include but are not limited to:
However, do keep in mind that most of these vendors that allow HIPAA compliant esignatures (are willing to sign a BAA) do ask you to sign up for their enterprise account. Granted, HIPAA compliance in the cloud does come with a heft price.
Before you balk at the pricing, do a simple back of the napkin calculation on how many hours that would save your practice in emails, calls, chasing down the right person to get signatures from, reminding them to sign etc.
More often than not, these vendors’ pricing ends up being cheaper – IF they charge you on a per signature basis rather than a flat rate per month.
Healthcare workflow management for your telephone
Phone calls and phone tags involved in healthcare workflows are nothing short of legendary.
You get various phone calls per day at your practice. Phone calls are burdened with issues similar to those of faxes.
- No way to get a good handle on phone calls that were resolved
- Unless you really take some time to listen to call recordings (no one does), there’s no way to judge whether that was tended to or not.
- Whatever information was provided during the phone call does not get recorded anywhere as follow ups, todos etc. This has to be done manually.
- For someone to pass on information about a call, they have to remember the conversation, type it out, pass it via email and note. That’s when an audit trail starts.
- Once the voice call is transformed into an electronic message of some kind, it can then be forwarded around, snoozed, reminded of, followed up on etc.
- More often than not, you get voicemails as you are never really tied to your desk. So, you return the voicemail when you remember to. The other party, at that time, is tied down, so they return your voicemail when they can.
- This voicemail and phone tag loop continues and is one of the reasons things fall through the cracks.
We posit that a lot of the phone call and fax challenges can be solved by using the same tools as you are currently using – the phone and the faxes. However, we recommend adding a layer of workflow and process management tools on top of these tools.
Unfortunately, most task management tools in the marketplace are not HIPAA compliant, so you cannot use them anyways.
On top of this, most task management tools do not necessarily tie into your phone and fax servers.
Email healthcare workflow management as well
Most healthcare practices have multiple email addresses that they need to deal with.
- Your email address on the website goes to a general mailbox. This email address typically gets appointment requests, questions, spam, vendor queries etc.
- Your social media emails from facebook, google my business go into another email inbox. If they do not, they get merged into the big, general email inbox that EVERYONE monitors and NO ONE is really accountable for.
- Your referral requests come from various 3rd party referral management websites like referwell, par8o via emails.
- Company fax server might be sending you the faxes as attachments via emails or just sending you a notification that you have a new fax.
- Your phone server might be converting voicemails into attachments and sending you the same via emails or just sending you a notification that you have a new voicemail.
- EPAs are coming via emails (updates on those EPAs)
- Your surgery center sends you emails with signature requests
- Some of your referring partners send you emails to ask for updates
- Candidate resumes come via email from indeed, craigslist, healio (or wherever else you advertise)
- Your patient reviews software sends you emails with alerts
- Patient satisfaction survey software sends you emails with alerts
- Many more
Payment posting – Healthcare workflow management for this
Most of our Medicare/Medicaid go straight to the bank. Our patient collections payments go to Stripe. Our billers do not have access to either one of these, but are tasked with posting the payments to appropriate accounts to reconcile the same.
The fact that these systems sit separately and do not necessarily integrate with each other requires us to use the task manager for these purposes as well.
HIPAA compliant healthcare workflow management tool we use
On top of this, since our healthcare call center and billing / revenue cycle management teams are remote (offshore vs onshore vs onsite) – our challenges are even more pronounced.
We use our workflow management tool that ties into our phone server and our fax server.
This way, we are able to consolidate:
- Emails to common inboxes (not personal – although, if a staff member wants to attach their direct email to this, they can)
- Faxes to our common fax servers (not personal – although, if a staff member wants to attach their direct fax to this, they can)
- Voicemails to our common voice mails (not personal – although, if a staff member wants to attach their direct voicemail to this, they can)
From an operations management POV, this gives us managers a very easy way to track closing the loop on our staff’s pending tasks.
We have worked with cloud hosted fax servers (this solution only works for fax servers that have Web services APIs available for applications to connect to).
Each fax can be viewed right on the website / software itself inside an internal fax viewer.
Our phone system affords us the same capabilities as well – our call center uses the phone system via soft phones and our onsite staff uses desk phones.
This system is used in conjunction with our HIPAA compliant patient CRM, call center software, surgery coordination, telemedicine, digital patient intake, patient reviews, physician referrals , Patient SMS texting software systems. Finally, this integrates with our healthcare analytics software to give us a good handle on reporting, business intelligence and analytics.
How we handle inbound referral request faxes
- Each day, faxes come in as usual.
- Our workflow software, being connected to the fax servers, gets notified of the same.
- Based on previously defined business rules the notifications are sent out to the appropriate staff(s).
- The staff member logs into the workflow software and sees all assigned faxes
- The task, at that point in time, is in “pending” status.
- The staff member might have to update the EMR with some of the information that they received via fax. The fax is enhanced by the help of Amazon Textract to discover as many fields of information as possible from the fax image. It doesn’t deduce the entire faxed document entirely, but it does cut down on the total amount of time spent by staff to type the information into the EMR. Instead, they can copy/paste this information from the workflow manager to the EMR.
- The fax might be a referral request and in this situation, the staff member might just assign this to a referral coordinator right from the software itself.
- When the fax “task” is assigned to a referral coordinator (or a front desk staff) the person that the task is assigned to, gets an email notification about a new task being assigned to them.
- That “reassigned” staff member then logs into the workflow management software to manage the referral. This staff member might need to call the patient to make an appointment and would proceed to use the click to call feature in the software itself to place that call.
- They can also choose not to use the click to call feature in the task manager software but in doing so, they would have to manually update the status of the task so it can be reported upon appropriately. If they use the soft phone and click to call feature of the software, their call is automatically logged, the task activity is automatically logged and the outcome of the call can be logged right in the software itself. The staff member does not have to do anything special nor spend any extra time after call (After call work) for reporting purposes.
- Since this task manager software is tied to the call center and patient CRM, the staff member doesn’t necessarily have to login to the EMR either. They can create a new patient or update patient information right from the software. They can even create a new appointment for the patient right from the software (again, since the workflow manager works in conjunction with the patient contact center software, everything flows smoothly).
- At any point, staff would be able to assign a due date to it. If we don’t assign a due date, it should have an automatic due date of 2 days
- The system should remind the assignee and the assigner to complete the task on the due date at 9 AM EST
- Anyone can follow up with the staff by leaving a comment on the incoming fax “record” so that at least we know how many times we have reminded the person. This comment would go via email + SMS
- Any staff member can attach a label to each fax so that the fax can be moved to a “folder” like we do in gmail
Managing inbound medical records request faxes
- When a new medical records request fax comes in, the medical records coordinator staff does not get the fax automatically – since they do not login to the task manager that often to monitor faxes. Instead, based on business rules defined, the practice manager and anyone else assigned can get those faxes. It is left up to them to route the fax and assign the fax to the medical records coordinator. In our case, our front desk usually handles these requests, so it is routed to the front desk.
- The person assigned the medical records request then decides based on who originated the request / requester whether the medical records request needs to be routed to the billing department to generate an invoice or not.
- The billing department could be assigned that task and they get an email about the same. The billing department staff then generate an invoice and upload it to the workflow manager. Then, they send out a fax right from the workflow manager to the requester (or send an email with the same right from the workflow manager) requesting payment. This ties into our billpay portal (that leverages stripe). Once the invoice is sent out, the requester can easily pay via credit or debit card using the link sent to them.
- The fax record at that point in time, shows “Pending, waiting for customer” because the requester is yet to pay the invoice.
- Since our task manager ties into our payment processor (stripe), each day, there’s a reconciliation process that brings in all the payments made by various parties (patients, vendors etc).
- Every time there’s a payment using our billpay portal, this triggers a task for the medical billing team (billers) to apply these payments (aka payment posting). Typically, they get notified on payments posted via stripe (either from online payment or payments collected at front desk etc).
- The billing team then can give the clearance for this medical record to be faxed over. Since the billing team also has access to the EMR, typically, they download the medical records (either visit notes only or the entire transition of care CCD document, save it as a PDF) and send it to the requester. This then marks the record as “Closed” for reporting purposes.
- This way, we know what was requested and what fax was sent (to check if loop was closed)
How we handle prior authorization request faxes
- This process is not very different from the above either. Again, the challenge is that prior authorizations are processed on completely different websites (e.g. covermymeds, parXsolutions).
- Our techs typically initiate the prior authorization requests from these websites. When there’s a response from these websites, our team gets an inbound email or fax about the same, directing them to login and see the update on the respective website(s).
- The technicians are usually with patients all day long and do not have the bandwidth to check incoming emails/faxes, hence the inbound team simply assigns these inbound EPA emails/fax tasks to the appropriate tech groups based on the location of the patient (where the patient was seen).
- The technicians get the notification on their mobile devices and as soon as they get a chance to, they login to these websites to make any corrections as needed or take the next steps based on the inputs from these EPA websites.
- They then return to the task manager and update the ticket as CLOSED.
Managing prescription requests faxes
- Typically the pharmacies call in the prescription requests for alternatives or refill requests etc. However, if the pharmacy has sent a refill request fax, this ends up in the task manager inbox as well.
- One of the inbound staff then simply routes and assigns this task to an appropriate tech, again, based on the location where the patient was seen.
The tech gets the email notification of this assignment, logs into the task manager and sends a prescription either via fax (from the workflow manager itself) or via electronic prescription facility available in the EMR. Or, sometimes these have to be done on the vendor site itself (e.g. surescripts)
How we handle phone calls with our workflow management software
Much like with any other practice, our inbound calls and voicemails are related to:
- Scheduling (schedule, reschedule, cancel, referrals etc)
- Customer service (general bucket for all other lesser volume calls)
We have a dedicated team for handling inbound calls as well – just like any other practice.
Each day, at the end of the day, we get a report on
- Inbound calls. We measure a few things like
- The types of calls (scheduling, pharmacy, surgeries etc)
- The number of calls for each type of call
- How many calls were resolved on first contact
- Accuracy of such calls “resolutions” (i.e. correct patient data created, correct next steps defined/taken etc).. We have certain quality parameters we look at here
- How many calls were transferred to other company extensions
- How about how many calls were returned
- Measure How many patients called back more than once
- How many calls were abandoned
- Measure how many abandoned calls were returned
- Voicemails left
- Voicemails returned with a call back
- A/R calls where we measure
- Payer denials and no responses – outcomes achieved, next steps defined
- Patient balance collections – monies received and already in the bank, monies promised in the future, how much has been realized
- No shows calls where we measure total patients re-appointed
- Reactivation calls where we measure total patients re-appointed
- Appointment reminder calls where we measure total patients that promised to show up
- New patient referrals where we measure new patient referrals received from various calls our team made (NOTE – our referral management software does this easily)
- Community outreach calls where we measure how many new patients we acquired via our cold call campaigns
Again, just like with faxes, each one of these calls and voicemails go through a workflow wherein the resolution is recorded, the next step is defined and management can take a look at the overall efforts taken to acquire a patient and to service each patient.
This helps us with capacity planning and forecasting our business.
As examples.. Our inbound calls have a resolution and more often than not, some kind of next steps.
- Our team gets a call related to scheduling and addresses the same on the call using our EMR. The next step in this workflow are appointment reminders – an SMS is sent and if not responded to, the next team (appointment reminders) has a TODO of calling the patient to ensure that they will show up.
- If the patient does show up, the next step in our workflow is to send out a satisfaction survey text message. If the SMS is not responded to, the team has to call the patient to find out how we did. Consider when the SMS is responded to, our next step is to send out a review request SMS. If the review request SMS did not result in a review, our next step is to get in touch with the patient to find out whether our work satisfied them enough for the patient to leave us a review.
- Consider when the patient does not show up, the next step in our workflow is to send an SMS to re-appoint the patient. If the SMS is not responded to, the next step is for our no-shows team to work on calling and re-appointing these no-show patients.
- If the patient does show up this patient now moves into the bucket of “recall” patients and our recalls/reactivation team is in charge of the same. The patient gets an SMS reminder that it has been more than 6 months since their last visit. If the SMS is not responded to, the reactivation / recalls team is tasked with calling and re-appointing that patient.
- If the patient shows up and has not cleared their balance at the front desk, our A/R team is tasked with collecting balances from this patient. An SMS is sent out so that the patient can pay via an online payment portal themselves. If the SMS is not responded to, our A/R team is tasked with following up with those patients to collect the balance. Sometimes they need to set up a payment plan and other times, they do collect the entire balance. When this team sets up a payment plan for the patient, it is their responsibility to ensure that the future payment does go through. If it doesn’t go through, it is the A/R team’s headache to call and collect the balance payment
- Our inbound team might get a call for pharmacy related issues – they typically redirect these calls to techs. However, there’s a clear resolution and next step defined for these where in the tech gets a notification of their TODO and then the tech has to clear out the TODO as they are responsible for the next step.
- Our inbound team might get a call for billing related issues – same thing goes here. The call is redirected to the billing department (if it is something that the inbound team cannot answer) and then it becomes the responsibility of the billing department to clear out the TODOs from their “inbox”.. As they were responsible for the next step. Sometimes, the billing department has to follow up by making payment adjustments in our EPM..
You get the idea. We treat everything as a workflow – one task finishes and passes the task on to the next team and so on..
And each team has reporting parameters set up.. This allows management to keep a good control over how things progress over a patient’s care flow, care coordination and patient pipeline.
How the workflow management software helps with practice emails
We also have to handle incoming emails from various vendors, referral websites, ZocDoc, website appointment requests, facebook appointment requests etc. (NOTE – our referral management software does this easily)
We wanted to use the same task management/workflow management process with this as well – especially since most of these emails were time sensitive and needed to be acted upon ASAP.
Since emails were already equipped with all the folders/labels, forwarding, assignment capabilities – we didn’t have to do much over here. This solution from our IT team simply hooked up our common email inboxes to a similar workflow process that was set up for our team.
Over time, we noticed that we were able to reduce the total FTEs that were being utilized in such workflow related tasks as we were able to leverage technology to do a lot of these tasks, while humans (FTEs) overseeing the process as and when needed.
Having reporting included in our IT workflow solution allowed us to reduce our dependence on our data / process analysts as well.
We didn’t have to reduce our headcount at all, so staff morale was not hit even by the slightest. In turn, it allowed us to serve more locations with the same number of staff. This in turn helped us reduce the staff (re)training and attrition headaches that we usually dealt with.
The process was standardized, the workflows were standardized, the reporting is well understood company wide and the KPIs / MBOs set for our staff is clearly defined – while allowing our staff to monitor their own performance week over week.
While technology is seen as a threat by most non clinical staff in healthcare, this allowed us to gain full buy-in of our staff, grow more with the same headcount.
Hopefully this helps someone out there reading this. If you have any questions, reach out to us.