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Introduction
Welcome to The Definitive Guide to Patient Access where we are proud to introduce, for the first time, a brand-new measurement for patient access, The Patient Access Score ™. But before we get into that…

Patient access is defined as, ‘The ability to ensure patients can obtain timely care from the right provider at a convenient location’. We specify “with a provider” because while telemedicine tackles patient access, an at-home blood pressure monitor doesn’t. Widening the definition too much would make the term patient access (joyfully, one of the shortest and most economical “buzz phrases”) meaningless.
What The Definitive Guide to Patient Access Will Cover

1) The Popularity of Patient Access
2) Scheduling Sisters: the relationship between no-shows and patient access
3) Why Patient Access is on the Top of Everyone’s To-Solve List
4) Two Components of Patient Access
5) Patient Access by Specialty and Geography
6) The Rural Challenge
7) Current Measurements of Patient Access
8) The Patient Access Score: A Brand-New Measurement of Patient Access
9) Best Practices for Improving Patient Access
10) Radical Ideas for Improving Patient Access
The Popularity of Patient Access
For the past six years, QueueDr has lived and breathed patient access. We’ve focused on consistently improving the ways we drive efficiency by allowing providers to see more patients, sooner.

Recently we did a study using Google Ads to examine what phrases “clicked” most with healthcare groups. We found that the click-through rate for ads with the words “patient access” was THREE TIMES that of any other keyword. After watching this multi-month trend continue, we knew we needed to create this guide, ASAP. But don’t take our word for it, drive down the highway and look at health system billboard ads. Every healthcare system either advertises the awards they’ve won or how conveniently fast it is to get an appointment with their providers.

In fact, part of the reason urgent care centers popping up everywhere is the drive for patient access http://www.medicaleconomics.com/business/whats-behind-growth-urgent-care-clinics.

The reason patient access matters can be summed up in one phrase of business logic, “if you don’t have customers, you don’t have a business”. As we often say, people aren’t in healthcare for the money, but it does matter.

If you don’t get a patient in, you can’t practice medicine.
Scheduling Sisters: The relationship between No-shows and Patient Access
The number one reason patients no-show is poor patient access. In fact, we wrote a whole guide on it here https://queuedr.com/resources/definitive-guide-to-no-shows/. Athenahealth also did a study on patient retention. In their review of over 4.2 million appointments, they found the longer the patient waits, the more likely they are to cancel.

Four Reasons Why Patient Access Tops Everyone’s To-Solve List
Poor patient access affects EVERYONE – Getting patients in to see the provider is the foundation of healthcare. Patient access impacts everything from finance, to clinical operations, to administration.

1) Patients are Demanding Consumers – If you’re a hair salon and it’s impossible to get an appointment, your customers will go elsewhere. It has become the same in healthcare. The Athenahealth study we referenced above found that if you book a patient more than 1 month out, there is a 32% chance you NEVER see them. Not just that they no-show, but that you NEVER see them. That means that $1 out of every $3 of your marketing budget that goes to attracting new patients is wasted!

A customer recently asked why it made any sense to bring a patient in 3 days earlier than their existing appointment?? As you can see, bringing some patients in three days earlier increases the likelihood they will show up by 33%!

2) Investments in Health Systems – 2017 was a record year for private equity investment in healthcare (https://www.bain.com/insights/global-healthcare-private-equity-and-corporate-ma-report-2018/). Poor patient access begets no-shows which represent empty utilization. For private equity investors, this means less money!

3) An Aging Population – The large baby boomer generation requires more care as they age. That, combined with the lack of growth in the number of physicians, means a mismatch in supply and demand. Healthcare systems cannot effectively get all these patients on the schedule with the current tools.

4) Staff Chaos – Poor patient access is throwing staff workflows into chaos. Staff are tasked with doing more work today than ever before due to government regulation and new technologies, patient access can often feel like one more thing on their plate.
Two Critical Components of Patient Access
Improving patient access has two fundamental components. Creating a good workflow for these will make improving patient access more obtainable for your healthcare organization.

1) The Ease of Making the Appointment – This encompasses whether the technology and staffing exist and is optimized so the patient can easily get on the schedule. Here are ways healthcare systems are trying to improve this component of patient access.

    Patient Online Scheduling
    Online scheduling is the natural complement to making appointments on the phone, but it is not revolutionary, there is a conundrum. If it is super easy to make an appointment for a patient, then a patient is more likely to no-show because they can easily make that appointment elsewhere.

    Primary Care to Specialty Direct Scheduling
    Talking with a Director of a large Pulmonology group, she talked about a different type of direct scheduling that’s more interesting (because it’s less covered), the are making it easy for referring PCP providers to book appointments for their patients directly on the specialist’s schedule. This hasn’t been built on a mass scale for one reason, EMR Integration (sometimes referred to as interoperability). With healthcare systems becoming more acquisitory, the trend has slowed down even more, since groups with different EMRs are being combined. As these groups move all their locations to the same EMRs then this will become more feasible.

    Shorter Phone Lines/More Efficient Phone Systems
    Time to use I statements (as the author). I believe that patients still want to talk to a human to book an appointment with a doctor. Unlike with hair salons or restaurants, there is greater uncertainty and higher stakes for a doctor’s appointment. I believe that people often go to the doctor for the placebo effect, to be cared for. They want to know they will be alright and talking to someone on the phone (notice how monotone and unstressed scheduling assistants are? That’s on purpose) makes them feel that.

    1) I’m backed up by the fact that patients still book over 90% of appointments via phone despite ZocDoc’s innovations being 12 years old and their product being very good.

    2) Telemedicine. You know what’s easier than driving to the doctor? Not driving to the doctor. Insightful, I know. Telemedicine has promise and is fantastic for certain specialties that heavily involve quick glances (Dermatology) or “all-good?” follow-ups. With luck, these appointments will be eliminated except in the most extreme cases.

    Side Note: We will briefly jump into the rural challenge, where telemedicine plays a much more pivotal role.

2) The Ease of Getting to the Appointment – this encompasses how easy it is for the patient to get to the actual appointment, including the wait time and distance to the appointment. This component of patient access is more elemental. Patients want an appointment nearby and soon. No matter how easy it is to make an appointment, if they fail this test, patients won’t show up.


    OnDemand Schedule Management (ODSM)
    A combination of processes and technology to make managing the schedule easier. ODSM solutions manage patients between the time they make their original appointment to when they are actually seen by a provider and can replace workflows like wait lists, physician bumps, patient cancellations, recapturing no-shows etc. ODSM maximizes patient access while optimizing for revenue.


    Waitlists
    Waitlists give patients hope that they may be seen sooner but the reality is waitlists are hard to manage and very time-consuming. For more information on waitlists and tips on how to make managing them easier, see The Definitive Guide to Waitlists, https://queuedr.com/resources/the-definitive-guide-to-waitlists/


    Open Scheduling
    Open scheduling or keeping parts of the schedule open for sick/urgent visits does help for same day visits. However, for routine appointments, (or patients who plan ahead) this fails completely and often leaves these patients booked out further than necessary.


    More Providers
    Have too many patients per provider? Hire more providers! Many are doing that, hence the astronomical rise in Nurse Practitioners. According to Nursing Online, from 2007 to 2017,/the number of NPs doubled!. This is a solution, but an expensive solution, without accelerating returns to scale. When made in a vacuum, hiring can also be very costly. Often, we find organizations with a high cancellation or no-show rate, hiring more providers without also addressing the cancellation or no-show rate. No matter how many NPs you hire, an NP can only take care of X patients. Operationally, filling up the schedules of the NPs is quite difficult (hence why QueueDr developed Schedule Balancing), but doable. Many patients express preference for MDs/DOs initially, but once faced with the wait, would prefer any appointment!


    Team Care
    Along the lines of adding more providers, emphasizing team care to patients can help. It’s part of why One Medical Group has been so successful. When managed correctly, it means that patients are happy to be seen by anyone in a group. Here are the steps to do it:
    1. Develop the Group as a brand
      - Advertise the benefits of being a patient at Your Healthcare System

      -Have each provider branding the Fake Healthcare System as well
    2. Create a standardized process across all providers
      This includes intake process, appointment booking, diagnosis etc.
    3. Intake
      For appointment booking, emphasis the group, not the provider, i.e. the appointment is with Your Healthcare System, not Dr. MadeUp
        - Let patients know up front that this is team care and make sure they know the benefits

        - Make transition between providers seamless

        - All notes are well done and easily accessible by other providers

        - Make sure the providers all know each other, it makes continuity of care stronger

        - Make sure compensation models for providers reflect team care

This is the tip of the iceberg for team care. Want more info? See what the Mayo Clinic found for ACOs, click here.
Patient Access By Specialty and Location
Geographical location and specialty both impact patient access but are often overlooked. In a study done by Merritt Hawkins, they looked at the average wait time for both specialty and location. In the city of Boston, the average wait time for a doctor’s appointment is 52.4 days! Dermatology had a wait time of 32 days! The most successful medical organizations in these locations (and specialties) are taking aggressive measures to improve patient access.
The Rural Challenge
Patient access in rural areas has a whole different set of challenges. This means fewer people get their care until it’s far too late and expensive. Primarily due to:

1) Staffing shortages – rural areas mean fewer people, and fewer providers
2) Location – rural areas also require patients to drive hours (instead of minutes) to get to their appointment. 
3) Affordability – rural areas tend to be lower income which makes it less appealing for for-profit hospitals.

These are particularly tough because they are challenges of distance and time, both of which are almost impossible the change in the universe. We are not experts on rural patient access. Here are some people who are:

Measuring Patient Access
Patient access does not have a simple measurement that stands out. There are several contenders which we will go through and show why they come up short. Then we will introduce a brand-new stat, The Patient Access ScoreTM.  

Average Wait Time In Days
The average wait time from when a patient is booked to when their appointment is. It’s very simple, but there is a major problem. Certain appointments may be booked out months because of medical necessity (example: annual physical). This should not count against a healthcare system’s patient access score. We must throw this one out.

Note: QueueDr does use this metric because we move up patients and thus can measure the delta between what a patient was booked for and the earliest they could be seen.

Average Wait Time in Days Per Appointment Type (for New Patients Only)
This is an improvement to the first but it ignores established patient appointments which we’ve seen can be 80-90% of a provider’s appointments.

Third Next Available Appointment
Average length of time in days between the day a patient makes a request for an appointment with a physician and the third available appointment for a new patient physical, routine exam, or return visit exam.”

This is a very popular measurement because it tries to control for the two biggest issues. First, it looks at the average instead of the next available appointment. Second, it considers the fact that a patient on a return visit (for example), may be booked out weeks for medical reasons, or because of a long wait.

However, it has failed to gain popularity for three reasons. First, it’s confusing, both to explain and to say. Second, it’s practically impossible to implement. It requires a schedule to be perfectly templated. We have NEVER seen a perfectly templated schedule. Schedulers modify appointment types or build new workflows to meet patient demands. Finally, many EMRs have not adopted this as part of their reporting.

A Brand-New Stat: The Patient Access Score™
QueueDr would like to introduce a brand-new measurement for patient access, The Patient Access Score ™. We hope this score will be used by healthcare systems and practices across the country to quantify their patient access and monitor improvements around it.

Calculation:
100*(1 - Total percentage appointments that are no-showed  aka your no-show rate)/(1 - Percentage of no-shows for appointments booked same day that the appointment happens)

Scale:
0 to 100. A score of 100 is perfect.

    The Perfect Patient Access Score = 100
    Very Good Patient Access Score = 90 to 100
    Ok Patient Access Score = 80 to 90
    Bad Patient Access Score = 80 and below

Explanation: No-shows are a patient’s way of indicating patient access can be improved. The no-show rate for appointments made on the same day they were created represents the baseline no-show rate with 100% access (ie no wait). Using this baseline, we can control for groups with higher no-show rates in general due to their patient population. The overall no-show rate for ALL appointments represents the no-show rate accounting for patients being booked far out. The difference represents the impact of patient access while holding the general no-show rate constant.

Examples: Let’s take the athenahealth study above and treat it as a practice.

Overall No-Show Rate = 23%
Same Day No-Show Rate =  10%
Patient Access Score = 85

Benefits of Patient Access Score

1) Simple to calculate and understand
2) Clear numerical goal to work towards
3) Implicitly accounts for differences in appointment types
4) Accounts for differences between healthcare systems

Two Extremes to Having The Perfect Patient Access Score

1) Same No-show Rates
Scenario: all appointments booked out are established patients who should be exactly where they are supposed to (no desire to move up) and are happy about it (no-show at the same rate they would if they were booked on the same day)! The Patient Access ScoreTM would be 100.

2) No Patients are Booked Beyond the Same Day
Scenario: If all appointments are booked the same day! Note, in this case, a walk-in clinic could change the time unit from days to hours to understand your patient access score. We go into this in more detail below. Again, The Patient Access ScoreTM would be 100.
Neither of these are realistic so the quest for 100 will be a combination of both of these. The Patient Access ScoreTM can be misleading if there is a large increase in same day no-show rate, while other no-show rates stand constant. This wouldn’t be an example of improved patient access. However, it is very unlikely that the same day no-show rate would increase without other no-show rates also increasing.

The Patient Access Score can be altered for urgent care centers by changing same day to mean within 3 hours (or whatever time period of choice) to account for the higher expectations on patient access.
Two Ways This Practice Would Improve Their Patient Access Score

1) Decrease the number of patients booked further out.
Patient Access Score 90.5

Total No-Show Rate = 18.6%
Same Day No-Show Rate = 10%

Decreasing patients booked further out resulted in the score jumping into the very good range!


2) Decrease the no-show rate of patients booked further out
Patient Access Score 90.5

Total No-Show Rate = 18.6%
Same Day No-Show Rate = 10%

Decreasing the no-show rate for those patients booked further out resulted in the score jumping into the very good range!

Decreasing the number of patients booked further out is a better path for practices. Many have tried decreasing the no-show rate of patients booked further out via reminders, however, they have found that time still causes no-shows regardless of reminders. That’s why the focus has correctly moved to decreasing the number of patients booked further out. 
What's Your Patient Access ScoreTM
What’s Your Patient Access Score? – share it with [email protected]

Editor’s Note: HT to QueueDr Senior Engineer Colin Williams for getting the math right for The Patient Access Score.
Robots and Stuff: Radical Ideas for Improving Patient Access
We have reviewed multiple ways to improve patient access within the confines of the current healthcare system. However, we want to end by having some fun and coming up with some more outside the box ideas for patient access 

    AI Doctors
    Google Deepmind has made progress with the NHS alerting doctors when patient condition deteriorates. However, the more interesting progress is made by Amazon with their Amazon Go stores. These are convenience stores without people. Combining the visual technology developed by Amazon for these stores with AI technology developed for healthcare, one can see the future where healthcare booths exist without doctors.

    Robots
    In Japan, where they are facing an age crisis, robots have already been deployed to support/replace providers at hospitals during off-peak hours. https://www.beckershospitalreview.com/artificial-intelligence/japanese-hospital-to-add-4-robotic-nurses-to-night-shift-in-year-long-pilot.html This allows providers to be redeployed to other areas where their expertise is in higher demand.

    Allow NPs to run practices in all states unrestricted
    Nurse practitioners can fully own practices in about 21 states, but it should be 50 states and be allowed for almost all appointments https://onlinenursing.simmons.edu/nursing-blog/nurse-practitioners-scope-of-practice-map/

    Make hospitals places you want to hang out
    Making it easy for patients to access care is important, but there is another way. By making healthcare facilities places people want to hang out at, people will be willing to work harder to get there. Some hospitals do this with nice restaurants, but there should be more of a concerted effort. Thins like pop-up restaurants, free movies and babysitting.

CONCLUSION
We often find healthcare systems focused on improving their new patient acquisition score but with the impending physician shortage, this focus is wrong. This method is not a long-term fix, it is like buying new groceries every day and putting them into a broken fridge. What if you instead spent the time and money improving the way your patients access care, getting them into the office for their visit and retaining them within your ecosystem for continued care. This is where you will find success and long-term growth. Fix patient access problems and new patient acquisition will come naturally, by word of mouth.

About QueueDr
Cancellations, bumps, and no-shows can wreak havoc on a medical organization’s bottom line, QueueDr fixes that. QueueDr is a web-based platform that automatically fills cancellations, reschedules no-shows and rebooks bumped appointments via text -- no apps to download. The QueueDr solution uses artificial intelligence (AI) to match patients with available appointments, filling gaps in your schedule in 3.4 minutes on average.

As the industry’s first truly automated solution, QueueDr is reducing administrative costs in healthcare and helping patients get the care they need, faster. Visit www.QueueDr.com for more information.
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The Definitive Guide to Patient Access

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