I’m convinced that health IT can solve many of health care’s problems–but only when it is designed and rolled out with the greatest sensitivity to the needs of the users. The Rolodex of failed health start-ups confirms this principle through negative examples. This article covers a positive confirmation of the principle, through a talk with the large provider NYC Health + Hospitals, and the vendor Lumeon that provided their recent solution.
Everyone in health care will nod gravely upon hearing the problem that bedevils NYC Health + Hospitals: a high rate of missed appointments. Every provider is struggling with what they call “no shows,” but NYC Health + Hospitals facilities have even higher rates than usual–rarely below 20 percent, and often up to 40 percent of appointments missed–because they serve all patients regardless of ability to pay, thus caring for patients who have the most difficulties making it to the doctor. The demographics involve a lot of low-income patients, and more than half of the patients prefer to communicate in some language other than English.
The facilities face a complementary problem every day: lots of patients drop in without appointments and ask for care. Usually these are patients with a relationship to the facility, but a few are totally unknown to the provider. The organization’s policy is to turn nobody away. The unannounced drop-ins somewhat offset the missed appointments, but create an intensely high-pressure scheduling mess along the way.
Human-Centered Design: Defining the Problem Productively
One could dun patients repeatedly with messages in all media known to man, exhorting them to keep their appointments, but it would be a waste of time. Patients often have multiple jobs and are responsible for the care of children. Their time may not be under their control. Planning is even more difficult because NYC Health + Hospitals offers patients their next appointment, which can be months in advance, at the conclusion of their current visit. That leaves a lot of time for circumstances to change on the patient’s end.
In addition, patients may have trouble physically getting to the facility, especially if they have disabilities and depend on unreliable sources of transportation. A sick babysitter may require last-minute cancellation. Low-income, minority, and immigrant residents often distrust the medical system, and the threatening environment looming over immigrants these days discourages them from seeking treatment to which they are entitled.
In summary, missed appointments are not always a matter of choice or lack of concern. And even if a patient skips an appointment out of reluctance, lots of complex social factors impinge on the decision.
So NYC Health + Hospitals took a close and compassionate look at why patients miss appointments, according to Kaushal Challa, Senior Assistant Vice President of Ambulatory Care Services. The organization started by eschewing the term “no shows”, which blame the patients and suggest they’re careless of their health. Instead, accepting missed appointments as inevitable, the organization looked for ways to make it easy for patients to cancel or reschedule.
By means of several research efforts–analyzing missed appointments quantitatively through statistics, conducting a patient survey, interviewing and staff– NYC Health + Hospitals determined that the missed appointments are caused by myriad factors that can occur in combination:
* The patient might not have been asked how convenient the original appointment was. For instance: “our next appointment is Monday, July 1, at 5 PM” doesn’t give the patient a choice.
The further in the future the appointment lay, the more likely it was to be missed.
The patient might not have been reminded and asked to confirm the appointment.
New patients who are shopping around tend to miss appointments more than established patients.
Patients recently discharged from the emergency room or hospital tend more to miss appointments.
Technical and Organizational Upgrades
Upgrading their system for patient engagement took place in two stages. First, they integrated their electronic patient health records with their appointment system. They did this not through the fancy forms of interoperability that services such as the Direct Project promised us ten years ago, but by consolidating all their facilities on Epic, which provides both EHRs and appointment systems.
This facilitated the first major upgrade to their patient notification system. Now, cancellations or missed appointments could easily be recorded in the patient’s record. Epic would automatically notify the clinician of a missed appointment, whereupon the clinician could take appropriate action such as phoning up a patient who was at risk.
There was another clever advantage to having information travel the other way: all the information about missed appointments was now available to receptionists. When a walk-in arrived during a busy day, the receptionist could determine which of the upcoming appointments were likely to be missed, based on patient histories. They could then fit in the walk-in patient to the day’s schedule.
The second stage involved Lumeon, which integrates disparate systems. For NYC Health + Hospitals, Lumeon built a new patient reminder system on top of the Epic systems. According to Chief Operating Officer Andrew Wyatt, Lumeon is deeply intertwined with all the well-known EHRs. They participate in Epic’s platform for external developers, the App Orchard, and plan to integrate even more tightly by using Epic’s API. At NYC Health + Hospitals, the patient reminder system works together with the appointment system and EHR, exchanging data seamlessly.
The reminder system is very simple, using SMS text messages that 99 per cent of the patients can send and receive using cell phones. Each reminder asks the patient to press 1 to confirm, 2 to cancel, or 3 to reschedule. Cancelations are entered in the Epic system with no need for human intervention (although the clinician is notified). The hospitals made a decision, according to Challa, not to try to handle rescheduling automatically, but to connect the patient to an office staff person.
The results? In comparing two six-month periods just before and just after the transition to the Lumeon system, the hospitals found that missed appointments dropped by a quarter, from 27 per cent (which was already lower than before) to 21 per cent.
NYC Health + Hospitals introduced some other organizational improvements along with the enhanced reminder system. They translated reminders and other documents into 14 different languages, each patient choosing the one with which they’re most comfortable. This covers the preferences of 96 percent of all the organization’s patients.
They also set up a patient call center that can handle the scheduling and rescheduling of appointments with clinical and financial aid staff, information about their sites and services, and the routing of clinical questions to the proper place. The call center handles some clinical functions, notably prescription renewals (in consultation with the doctor) and connecting a sick patient to a nurse or doctor on call for triage.
The NYC Health + Hospitals experience strikes me as a fine example where technology was not allowed to control people, hem them in, or add extra burdens to busy work days. Instead, it fit deftly into patient lives and staff workflows. It didn’t even involve the baubles of artificial intelligence or other advanced technologies that grab so much of the industry’s attention right now (although I could see AI playing a useful role on top of the system, to add in predictive analysis). We need to celebrate the achievements of campaigns like this one with modest goals in health care.