The patient who shows up for a series of exams and procedures at Lahey Clinic Medical Center gets a tightly scheduled itinerary of times, places and people to see.
Lab tests are coordinated with radiology scans, followed by appointments with the appropriate specialists or internists armed with the just-finished diagnostic results.
To avoid a separate trip, other unrelated appointments-eye exams, for example-may be tucked into the schedule as long as the patient is in the neighborhood anyway.
When all is done, the patient may stop by one of 20 appointment desks throughout the seven-story complex and arrange for additional tests and follow-up visits.
What the patient won't see is what's happening behind the scenes. In a central appointment office, nearly 30 scheduling specialists are employed to pave the way for patient treatment ordered by 400 physicians and other clinicians in 29 clinics on six floors of the group-practice building, as well as coordinate 28 departments in the inpatient facility connected to it.
The scheduling drill is a familiar one at the multispecialty group practice and hospital in Burlington, Mass.
It's built around a homegrown information system that has been incrementally improved since its modest startup about 20 years ago, said Linda Cagle, director of the central appointment office. From two-dozen specialists back then, the staff has expanded more than tenfold to 275 physicians, including 40 primary-care physicians.
Across the country, newly formed networks of diverse medical facilities and services are trying to develop the technology and the close coordination of resources and personnel Lahey has built into its routine.
Industry experts say that as the arena of care widens beyond the hospital and begins to rely on moving patients around a scattered and diverse healthcare system, managers and clinicians will need a well-orchestrated method of keeping track of it all.
Healthcare systems also will have to deliver on the promise to payers of a seamless system of coordinated care for their insured workers. The scheduling of patients in that environment is key to executing the promise, experts say.
In fact, scheduling savvy is considered a potential competitive edge by forward-looking healthcare executives, according to specialists involved in an initiative by VHA, an Irving, Texas-based healthcare alliance, to identify the information systems priorities of its members.
The next level of competition in healthcare is the extent to which health networks can satisfy their customers-the enrollees and their employers, who contract for services, said Stacy Cinatl, vice president of information technology solutions at VHA. For plan members, "the way they touch the (healthcare) system is through scheduling," Cinatl said.
The main mission of Lahey's central appointment office is "a seamless experience for the patient" and the customer satisfaction that results from interdepartmental communication and problem-solving on the patient's behalf, Cagle said.
The ultimate benefit is a competitive advantage. "You can really turn your ability to relate to your members into a core competency," planting seeds for a long-lasting relationship, Cinatl said.
That competitive advantage also is prized by HMOs looking for ways to differentiate themselves from their competition in the eyes of employers, said Patricia Lawson, systems specialist with Presbyterian Healthcare System in Dallas, which plans to begin implementing systemwide scheduling this summer (See related story, p. 66).
Healthcare organizations angling for HMO contracts can make systemwide scheduling a point in their favor, Lawson said. Competitive pressures already are pulling HMOs even on price and in breadth of care coverage, prompting a search for additional ways to demonstrate benefits to employees that others can't provide, she said. One way to do it is through excellent customer service.
Healthcare organizations that don't anticipate the need for such a competency may find themselves trying to catch up to those that do, Cinatl said. "That's a completely different basis of competition than they've ever had to face before."
The urgency for scheduling. More than just a way for networks to gain strategic advantage, the move to systemize the scheduling process is being viewed as an operational necessity to avoid wholesale slip-ups.
As treatment moves to outpatient settings, any scheduling snafus become more glaring and inconvenient for patients, said Aarne Elias, managing associate with the healthcare consulting practice of Coopers & Lybrand.
An inpatient can just wait in bed for the X-ray department to find a free moment or for the right clinician to report for a shift, but cooling heels for three hours in a waiting room is a different story, Elias said.
It's especially annoying when networks are promoting the convenience of their expanded regional coverage: Patients, they say, can now be matched with the closest site.
To make that concept pay off in practice, the challenge for managers is to make sure a patient is set up with the right schedule and that clinicians are synchronized to see the patient at the appointed time and place with the proper supplies and chart information on hand, Elias said.
He calls it "the ultimate just-in-time" inventory scheme-but with a patient as the product.
The problem is, healthcare provider networks don't have years to tinker with the project and gradually get it right, as Lahey has been able to do. The heat is on to do it now and to quickly make it work.
Only about 12% of healthcare organizations have completed implementation of an appointment and resource scheduling system, according to the 1996 MODERN HEALTHCARE/Coopers & Lybrand survey of information systems trends (March 4, p. 97).
More than half the survey respondents said an implementation is in their plans (See chart, p. 60). But consultants and industry observers warn that the task of setting up a scheduling system could be among the most complex projects facing health networks.
"In theory and concept, resource scheduling is very important in order to be efficient," Elias said. "But implementing it is something else."
Behind the curtain. When Lahey patients follow the path chosen for them, they see the coordinated progression of multiple encounters, not how the system all came together.
But behind the scenes, the grunt work of scheduling nearly 1 million appointments a year-3,400 a day-is a mighty task of maintaining fluctuating schedules and continually updating data.
The system has to provide enough latitude to allow the central schedulers and outlying follow-up appointment desks to reserve time slots up to two months in advance as well as squeeze in a rush case within hours.
It also means devising and revising a game plan for deciding what scheduling can be delegated to inpatient departments under certain conditions.
For example, the department for gastrointestinal medicine has shown it can usually fill a number of same-day appointment slots for procedures. So the central appointment office sets aside a block of time slots under the department's control, Cagle said.
For other departments, slots are reserved for physician use until 72 to 96 hours beforehand. If not claimed, the times are turned over to the central office, she said.
Healthcare's new demands. The Lahey scheduling system has been extended to two other locations within the past few years. It's now incorporated in the operations of the new Lahey Clinic North in Peabody, Mass., about 15 miles east. The information system also is serving the oncology practice at the Medical Center at Symmes in Arlington, Mass., a Lahey joint venture about seven miles south of Burlington.
But as productive and flexible as it's been up to now, the scheduling system's longstanding technological foundation won't be adequate much longer and faces substantial upgrading to deal with escalating pressures.
"I think we were light years ahead," Cagle said. Like most provider organizations, though, times are changing.
Lahey is striking substantial new affiliations that bring entirely different computer software and hardware into the equation, complicating the integration of computer information and operations such as scheduling.
And like most other organizations, Lahey is grappling with business needs its information systems weren't built to tackle, such as managed-care stipulations and pre-authorizations.
Lahey is installing a new-technology billing and scheduling system at recently affiliated community-based group practices. The implementation, which is about 90% complete, involves 200 physicians at 15 locations in Massachusetts, Cagle said.
Lahey is financing the implementations and expects to spend about $1 million, including the computer hardware and preparation for the Burlington computer base to receive the incoming data, she said.
Meanwhile, the Burlington medical campus was scheduled this month to select a new practice management system to replace its vintage version.
Cagle said the project, which will include a new scheduling component, is expected to cost about $1.5 million for software and implementation. The cost doesn't include computer hardware or the salaries of the estimated 25 people it will
take to accomplish the implementation and build interfaces to existing information systems during an 18-month installation period, she said.
Longer-range plans envision a regional system where one call takes care of all scheduling in a three-state area. The plan incorporates the more than 40 sites of Hitchcock Clinic in New Hampshire and Vermont that merged with Lahey last year.
It's a daunting challenge, but Lahey's culture of coordination may be a more important legacy than its technical track record, Cagle said.
"Physicians are salaried and make decisions from a central standpoint" rather than fighting for departmental autonomy and control, she said. Hitchcock Clinic has operated much the same way, she added.
The same can't be said for the conglomeration of long-independent provider units that make up the typical fledgling provider network, consultants say.
For the majority of recent converts to the concept of large-scale integration, the message is this: Prepare to do a lot more than install a new information system for scheduling.
Shaking the foundation. Healthcare software developers have pounced on the premise of integrated scheduling of appointments and resources. They're piloting new products or adapting other workflow-related software to automate the process according to intricate medical and administrative protocols (See related story, p. 62 ).
But technology may not be the main consideration, said Frank Cavanaugh, a principal at Coopers & Lybrand and national director of its integrated healthcare consulting practice.
Built to the goal of systemwide scheduling, the new software schemes may have a hard time fitting onto a department-focused foundation and overcoming "the politics of allowing someone else to determine the schedule," he said.
"What you're upsetting is the historical organizational structure," Cavanaugh said.
To paraphrase the famous observation on politics by Tip O'Neill: All scheduling is local.
The way things are. An ambitious industry effort to break down departmental barriers and integrate the flow of computerized patient information is well under way nationwide (March 4, p. 97).
But when it comes to booking procedures, reserving resources and determining the time commitments of personnel, it's still unusual to let anyone outside the department make those decisions directly, said Michael Kreitzer, national director of systems integration services for Coopers & Lybrand.
Most healthcare organizations are arranged into "silos" of self-contained authority for their operations, Kreitzer said.
Even when a facility has a centralized appointment office, the scheduler likely won't be setting up things independently. While the person making the request sits on hold, the central scheduler likely will be making phone calls back and forth to multiple departments to broker the appointments and coordinate the schedules, Kreitzer said.
These departmental turf boundaries are bigger and more stubborn obstacles than technology barriers, he said.
That was one reason for bringing in a management engineer in addition to technical experts when Presbyterian Healthcare System launched its project to coordinate scheduling, said Jeffrey Pferd, vice president of programs and training at Insource Management Group, a Houston-based information systems and re-engineering company.
Like most information systems installations, the technology problems have been easy compared with organizational problems. In this case, Pferd said, the tougher problem has been changing the minds of employees to accept outside influences on their daily operations.
The same problem topped the list at Deaconess Incarnate Word Health System in St. Louis, said the Rev. Jerry W. Paul, its president and chief executive officer. "This was truly a monumental undertaking," he said about a reorganization to centralize scheduling (See related story, p. 64). "We had physicians who had fits."
He said a lot of the resistance revolved around the realization that "if you control your schedule, you control your life and your universe. `So leave that paper schedule right here."'
The threat to expertise. Top executives may see the clear organizational need for centralized scheduling, but employees need to be persuaded that the new system will be an improvement over what they're able to do now, Cavanaugh said. "It's a difficult case to build."
That's because for the most part, provider units have developed a proficiency dealing with all the variables that enter into the smooth handling of the patient-care duties entrusted to them. And much of the proficiency is vested in those who do the schedules and appointments, Kreitzer said. "On the phone, they're trained to be aware of the right questions to ask and when the answers are wrong," he said.
As schedulers ply their trade, "there's a real learning process," said VHA's Cinatl. "Some people really get good at this."
Automated scheduling systems rely on programmed rules that follow department protocols and prevent mistakes such as scheduling tests in the wrong order or allowing insufficient time for a procedure.
But Kreitzer said there's still no way for a scheduler outside a department to know the winks and cues picked up by someone familiar with individual physicians and situations. That expertise improves the collegiality and morale of the department.
Kreitzer and Cinatl gave some examples:
The scheduler may recognize a physician's interest in certain patient problems for teaching purposes and assign them accordingly.
A formal schedule may have a physician on duty Friday afternoons, but the scheduler knows the doctor typically wants his Fridays free. His availability is only for emergencies.
A doctor may owe another a favor, and that may enter into assignment of cases.
Departmental rules may call for a standard length of a procedure, but a scheduler knows a certain clinician usually runs late.
A procedure requires a wheelchair afterward, but one employee chronically forgets to make sure it's supplied and has to be double-checked to keep things on schedule.
A person scheduling time and personnel from outside the unit may be asked to understand all sorts of complex combinations of patients, physicians, technologists, rooms and timing of appointments, which if not done correctly could result in delays or other hindrances, Kreitzer said.
"If systems can't anticipate problems, it'll slow the process down," Cinatl said. "If it slows people down, people won't use it."