IOM: The doctor will see you TODAY should be standard

Access to care remains a problem in the U.S because scheduling is based on providers' convenience, and practices fail to properly use nurse practitioners and physician assistants, according to an Institute of Medicine report.

The report, titled Transforming Health Care Scheduling and Access: Getting to Now, follows up on the IOM's landmark 2001 report, Crossing the Quality Chasm, which identified six properties of high-quality healthcare: safety, effectiveness, patient-centeredness, efficiency, equity and timeliness. Of those six, according to the new report, timeliness is probably the least studied and understood.

The report was partially funded by the Veterans Affairs Department and was prompted by the recent scandal at VA facilities in Phoenix, where 40 veterans died while waiting for an appointment. While their deaths were not necessarily caused by their inability to get healthcare, the IOM report cites studies showing how delays in care can have severe consequences for patients with cancer, diabetes, joint problems, kidney disease, and mental and substance-abuse issues.

The 137-page report includes 15 pages of citations of available research on the issue of access and wait times at facilities from multiple specialties and geographic regions that have developed best practices on this issue. These include: Dana-Farber/Brigham and Women's Cancer Center in Boston, Cincinnati Children's Hospital and the Southcentral Foundation's Alaska Native Medical Center in Anchorage. It also looked at manufacturing work-flow processes such as the Toyota Production System and the airline industry's Crew Resource Management system. And It touched on how Amazon.com and Netflix use data-mining to produce a better customer experience.

The report also cited October 2014 data that showed how wait times for new primary-care patients at VA facilities averaged 43 days and varied from two to 122 days across the system. The report also cites a 2014 study by the Merritt Hawkins physician-recruitment firm that found that patients in Massachusetts waited an average of 50 days to see an internist and 39 days to see a family-medicine physician.

“The healthcare system currently reflects mainly the priorities of providers and organizations, which has resulted in a focus on traditional scheduling systems that have not been engineered to engage or satisfy patients, but that instead are designed to fit a staff schedule that may be poorly aligned with patient perspectives or circumstances,” the report stated.

The effort was chaired by Dr. Gary Kaplan, chairman and CEO of the Virginia Mason Medical Center in Seattle. Kaplan has championed the use of the Toyota Production System and other Lean quality-improvement methods to eliminate variation and waste in healthcare.

When a patient calls a physician's office, often what happens is the start of a negotiation around when an appointment can be set. Kaplan suggests it should begin with the phrase "How can we help you today?"

“Healthcare that embraces this philosophy is patient- and family-centered and implements the knowledge of systems strategies for matching supply and demand," Kaplan said in a news release. "Care with this commitment is feasible and found in practice today, but it is not common.”

Dr. Robert Wergin, president of the American Academy of Family Physicians, said many of the initiatives his organization has taken on are connected to the patient-centered medical-home practice model that the IOM is calling for. But, he added, "Patients aren't widgets."

Enhanced access is a key principle of the medical home, and Wergin said a survey of AAFP members showed that 38% offered weekend hours, 54.6% offer extended morning or evening hours, and 81% offer same-day appointments.

He noted that his practice in Milford, Neb., has been offering Saturday appointments for almost 20 years—with many of the patients seen that day being high school athletes injured during Friday night football.

The report recommends that primary-care physicians who cannot see a patient with an urgent condition within 48 hours should refer that patient to another provider.

Wergin said that, in a highly competitive, fee-for-service environment, some doctors may have trouble following that advice. But he said the patient will probably see another provider anyway rather than sit and wait. So it's better for a doctor to refer patients to someone they know and trust rather than having them pick someone at random.

Wergin agreed that timeliness is one of the least-studied elements of healthcare quality. He lamented how a federal budget proposed by Republican members of the House of Representatives calls for eliminating funding for the Agency for Healthcare Research and Quality—which would mean the topic would receive even less attention.

He also agreed that many visits or consultations can be done electronically, even though that doesn't necessarily work with the patients he sees.

"My patients call me a lot," Wergin said. "I work in a Mennonite community, so they don't have computers."