Small practice evolution: The open-access medical office

When FP Sumi Sexton in Arlington, VA, looks ahead a few days on her schedule and sees that 50 to 60 percent of her appointment slots are blank, she doesn't blink.

Instead, she tends to worry that she'll get too busy. By giving same-day or next-day appointments to people who desire them, her four-doctor practice, Premiere Primary Care Physicians, has become a patient magnet, attracting refugees from offices where six-week backlogs are the norm. "We live in an instant gratification society," says Sexton. "People don't want to wait."

While traditional practices leave a few slots open for same-day appointments daily, open-access practices reserve the majority of appointments for same-day callers (and patients who call late in the afternoon on the previous day). For doctors like Sexton, however, open access is not just a scheduling technique, but a back-to-basics approach to medicine: See patients when they want to be seen. And it's more than same-day appointments. Extended office hours and online visits also make it easier for doctor and patient to connect.

How important is open access? It's one of the seven core components of the medical office of the future as envisioned by TransforMED, a practice redesign initiative of the American Academy of Family Physicians. If you want more proof, witness the burgeoning growth of retail clinics and urgent care centers that patients can visit at the drop of a hat. For medical practices to compete, they'll need to be just as convenient.

Making it work for you and your patients

Beyond delighting patients with quick service, open-access scheduling produces a cascade of other benefits. Chief among them are a steep reduction in no-shows and cancellations (the further out you schedule patients, the higher the risk that they'll skip or cancel) and improved continuity of care (rather than be shoehorned into the schedule of any clinician who's available, acutely ill patients are far more likely to see their own physician). Open-access scheduling also makes physicians and staff more productive, since time once spent discussing which patients should be seen immediately, or dispensing uncompensated phone care, or directing patients elsewhere is converted into billable exam-room encounters. This roomier schedule also allows you to accommodate more new patient visits, which command bigger fees than those for established patients, and gives doctors and employees greater flexibility.

Nonetheless, every practice is unique, and you need to think hard about your situation before rushing to make drastic changes. Open access is like a medication: It comes in various dosages.

You're an obvious candidate for it if wait times for appointments are the same throughout the year, says Atlanta practice management consultant Elizabeth Woodcock. "That means that physician supply and patient demand are balanced. It's just a matter of reducing the backlog and keeping it at zero."

However, rising wait times indicate that you probably have more patients than you can handle, says Woodcock. Another way to spot an imbalance is to compare the number of appointment slots per doctor per day to the number of appointment requests received per day. If demand exceeds supply, one solution is adding a midlevel provider. Another cure is to decrease the number of same-day slots available to new patients.

The need for open access also varies by specialty. Do you perform a lot of procedures? If so, the prerequisite legwork-securing preauthorizations and medical records, prepping the patient-requires appointments well in advance, notes Woodcock. Likewise, you may have a large geriatric population and find that patients need a long lead time for appointments for the sake of arranging a ride to your office, says FP and TransforMED CEO Terry McGeeney.

Examine your own professional comfort level with open-access scheduling, particularly when it comes to follow-up visits. At Harbor of Health in Memphis, an innovative practice that mixes primary care with fitness and health education programs, diabetics routinely seen every three months aren't booked in advance. Instead, they're given a card at their last visit reminding them to make an appointment three months later. That's a purist approach to open access. The burning question is-can you trust patients to make the call? Harbor of Health works around that challenge by identifying and telephoning patients who haven't made their appointments, says administrator Steele Ford.

However, if you don't take pains to keep such patients from falling through the cracks, consider booking their follow-up visits in advance and issuing the usual reminders shortly before the appointment. To Julie Loomis, a risk management specialist at Tennessee malpractice carrier State Volunteer Mutual Insurance Co., it's a risk management issue. "You can't leave too much to the patient," she says. "You might miss the opportunity to follow up on an abnormal blood test." Most open-access practices, in fact, settle on a compromise, using at least one-third of their slots for advanced bookings. Tip: Schedule them for times when demand for same-day appointments is lowest.

Leaving two-thirds of the schedule wide open gives some doctors the economic jitters-where are my patients? That's a fear stemming partly from misguided tradition, says Elizabeth Woodcock. "Doctors have considered a schedule booked months in advance to be a sign of success, when in fact it's not. They need to get over that," she says.

Open access will be easier to implement with an electronic health record. Working with paper charts for short-notice appointments is more difficult, notes McGeeney. The chart may be hard to find, or perhaps lab results haven't been filed away. Sumi Sexton adds that her practice's EHR lets her quickly size up how complicated or easy today's patients will be, which helps her know if she can work in extra ones. "Open access and EHRs go hand in hand," she says.