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Clinic Operations Efficiency Analysis Report Conducted by:

Michael Sanford, Senior Analyst Client: DRNC Partners, LLP

DRNC Partners

Table of Contents Introduction ............................................................................................................................................................................................................................................................................................................................3 Organization Profile: ...............................................................................................................................................................................................................................................................................................................3 Project Overview .....................................................................................................................................................................................................................................................................................................................3 Organizational Analysis .......................................................................................................................................................................................................................................................................................................4 7S Model Word Cloud: ....................................................................................................................................................................................................................................................................................................4 Job Task Analysis - Physicians .............................................................................................................................................................................................................................................................................................4 Root-Cause Analysis ............................................................................................................................................................................................................................................................................................................5 Proposal ..................................................................................................................................................................................................................................................................................................................................6 Patient Centered Approach ............................................................................................................................................................................................................................................................................................6 Purpose: ..............................................................................................................................................................................................................................................................................................................................7 Business Objectives (if applicable): .....................................................................................................................................................................................................................................................................................7 Project Goals: ..........................................................................................................................................................................................................................................................................................................................8 Recommendations ................................................................................................................................................................................................................................................................... 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Cost-Benefit Analysis ..............................................................................................................................................................................................................................................................................................................8 Program Development Costs ..............................................................................................................................................................................................................................................................................................8 Tables ................................................................................................................................................................................................................................................................................................................................... 10 Organization Analysis ....................................................................................................................................................................................................................................................................................................... 10 7 S Model ..................................................................................................................................................................................................................................................................................................................... 10 7 S Model Word Cloud ................................................................................................................................................................................................................................................................................................. 12 Job Task Analysis: Physician – Details of Performance | Cognitive Task Analysis ....................................................................................................................................................................................................... 13 RVU Efficiency Analysis | Physician Efficiency ............................................................................................................................................................................................................................................................. 18 Intervention: Patient Education Series: Program Development Costs ............................................................................................................................................................................................................................ 19

Clinic Operations Efficiency Analysis

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DRNC Partners

Introduction DRNC Partners, a private medical practice in metro Atlanta, Georgia has contracted with our firm to perform an analysis of their organization to identify areas for improvement in the efficiency of their operations in order to identify opportunities for improvement that, will not diminish the quality of patient care or adding additional administrative work for the providers within their office. The initial request was for a training intervention for the nurses who work in the practice to improve their efficiency in responding to patient messages through the electronic medical record system. This report is a part of the overall needs analysis and assessment provided as a part of the strategic review of overall operations to verify a learning intervention is the most impactful investment option available to improve operational efficiency within their practice. Although the initial request was focused on providing an intervention for the nursing staff, it became clear early in our conversations that the physicians who own the practice are seeking a way to improve operations overall, including how they are spending their own time. This report includes analysis of the roles of all patient-facing staff.

Organization Profile: DRNC Partners is a private medical practice owned and operated by four physicians with distinct specialties/practice areas. Dermatology, Rheumatology, Neurology and Cardiology (DRNC) are the four practice areas focusing on serving the needs of patients in early middle age through advanced age. The specialties covered include the area’s most critical to maintaining quality of life for the patients as they age with a focus on preventive medicine. The practice employs a number of Advanced Practice Providers (APPs) which are either Physicians Assistants or Nurse Practitioners who, under the supervision of a physician within the practice, are able to provide patient care with limited oversight unless they have questions or need the assistance of the physician. This model allows for greater efficiency in serving the needs of the practice’s patients while allowing for the more specialized training of the physicians to be accessible for initial visits and consultations in the event of any significant changes, while providing follow up visits and maintenance of medications to be conducted by the APPs. In addition to their clinic patients, the physicians are also affiliated with a local hospital where their clinic is located. The physicians provide consultation services for patients admitted to the hospital in addition to seeing clinic patients. Terms/Acronyms DRNC APP EMR RVU

Definitions Dermatology Rheumatology Neurology Cardiology Advanced Practice Provider (Nurse Practitioner or Physician Assistant) Electronic Medical Record Relative Value Unit (the standardized unit of measurement in health care reimbursement calculations that designates a common measure of the effort and expense involved in delivering patient care)

Project Overview After initial interviews with the stakeholders for the project, it was determined that a full needs analysis would be conducted rather than simply developing and delivering the requested training intervention for clinic operations training to improve efficiency. Ultimately, we conducted Organizational Analysis, Job Task Analysis and Root Cause Analysis to understand the source of the concerns for operational efficiency that led to our engagement by the partners in the practice. Clinic Operations Efficiency Analysis

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DRNC Partners

Organizational Analysis To conduct the internal evaluation of the current state of the organization, we utilized the 7S Model to identify the structure, shared values, skills, systems, structure, style and staff dimensions that make up the culture of the organization. The model includes several questions that were posed to all employees via an online anonymous survey where each question could be answered in a long form response. This was possible given the limited number of employees within the organization. This provided us with a strong foundation for our systems centered analysis of the organization. The data is presented in two ways for this report: a table where the responses to each question have been summarized as a set of responses that covers the consistent elements in the responses received across all respondents and the second is a word cloud of the most used words or phrases within the dataset of all answers for each question from the model. The organization’s focus on patient care and fostering a collegial environment were evident throughout the survey responses. Of note was that under the Staff dimension, all the responses were centered upon Patient Communication and needing help with managing the volume of contact, whether by phone or email, from patients.

7S Model Word Cloud: See Tables for a full-size image of the Word Cloud and the Table of Summarized and Coded Survey Responses. To conduct the external evaluation of the current state of the organization, we were provided redacted transcripts of the voicemail messages received that qualified as patient feedback as well as redacted patient comments left through the clinic’s website for the preceding two months. The consistent themes shared many of the same characteristics that appeared in the internal evaluation. The complaints, such as they were, focused on the difficulty in reaching clinic staff by phone. Although with rare exceptions, the feedback was not disparaging so much as understanding of the fact that just as they were able to receive due care and consideration when they were able to reach the clinic staff, others were receiving the same consideration as well and that included an expectation of delays that they were willing to endure because of the differentiated level of care they receive from the practice.

Job Task Analysis - Physicians Traditionally, this type of analysis is conducted by interviewing an employee performing the role and then the findings are validated by the manager they report to before the final analysis report is prepared. In this instance, the role being analyzed is that of the four co-owners of the practice. To mitigate bias in the reporting of their own performance in their duties for the practice the process was divided into two parts. First, the four physicians participated in a group interview in order to develop a common understanding of what their job tasks were. The consensus that arose from that session was the identification of several Task Categories and within those categories, several Task Activities. Some of the activities identified were also a part of responsibilities within more than one category. Each physician provided their own unique explanation of what they include in their individual performance (Details of Performance) within that specific Task Category/Activity. In addition to providing their own unique details of performance, the physician provided a breakdown of how much of their time is devoted over the course of a month to each Category and then to each Activity within that Category. Additionally, the relative value unit (RVU) report for each physician was integrated into the analysis to reflect the reimbursement rate for the services the providers billed for over on average over the course of June 2022 through June 2023. These reports are the result of the services each physician has billed for over a given period (month) and correlate directly to the amount that the practice will be reimbursed by Medicare, Medicaid and insurance companies for the services provided during the reporting period. Physician performance goals are typically set in terms of RVUs and are directly tied to physician compensation in many instances. For our purposes, they are tracked as an indicator of the efficiency of the use of the provider’s time. The more that the provider can be reimbursed for a given activity, the higher its RVU efficiency metric will be. Some tasks are not reimbursable activities but are necessary to be able to document services for reimbursement (Order Entry in the electronic medical record (EMR), for Clinic Operations Efficiency Analysis

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DRNC Partners example). These dependent tasks are tracked within the model as well, although they are not relevant to the JTA. RVU efficiency was calculated by isolating the tasks that do not contribute to obtaining RVUs and then using the physicians self-reported time spent on each Task Category and Task Activity within the model to apportion the RVUs earned by reimbursable activity and the time spent on those activities to determine an efficiency of RVU accumulation during such an activity. The complete table of the job task analysis can be found in the Tables section. The RVU efficiency can be thought of as a percentage representing relative efficiency between the different tasks. This analysis is not as precise as tracking the individual RVU reimbursement activities directly, but to conduct such an analysis would have required access to the electronic medical record and considerably more time and cost in the analysis phase of this project. The partners agreed that this methodology would provide valuable insights without raising any questions as to violation of HIPAA or increased expense for the more extensive analysis. That level of detail would also lack the benefit of the time measurements included in this approach, in that the RVU allocation from reimbursement documentation process does not consider time estimations that are reflective of the time spent by the physicians in this practice, but the amount of time spent by the average physician. The differentiated care delivered in the practice is a function of the time spent by the staff with their patients and it is unlikely that the national average used in actuarial tables will more closely correlate than the averages of the estimates provided by the staff of this practice. The RVU efficiency analysis can be found in the Tables section.

Root-Cause Analysis Once we had analyzed the physician’s role responsibilities, and just by spending some in their clinic, it quickly became apparent that a major contributor to their efficiency circumstance was the volume of patient calls and messages coming through their systems on any given day. There were two members of the non-medical staff answering the phones all but non-stop from the time the clinic opened until it closed at the end of the day. With voicemail messages and patient messages through the EMR, a physician, an APP, a nurse, or an office worker was always in communication with a patient. Sometimes all of them would be receiving messages from the same patient, or a family member of the same patient. Rather than relying on anecdotal evidence about the call volume we also wanted to look at the numbers on patient communication. This is an area where the physicians can be reimbursed by the health coverage services, both government and insurer. Using the job task analysis data we had already collected, we incorporated the RVU data for the physicians into the analysis to assess the efficiency of their time being spent on so much patient communication. Using the standardized calculation above, the most efficient task in terms of earning RVUs that is a reimbursable activity is Consult Services Differential Diagnosis. The least efficient is Patient Education Communications, which is part of the extensive phone calls the clinic is receiving. Most other activities in the clinic are twice as efficient for RVU accumulation compared to the patient education communications. In reaching our conclusions about the root cause of the of the challenges DRNC is facing, we borrow from economics to present our findings. If we consider communications capacity in terms of supply and demand, the market (patient population) is currently using up all of the available supply but the price the clinic can charge for the product is fixed and unresponsive to the level of available supply. When price is inelastic to supply, particularly if the price is lower than what the demand would otherwise raise the price to absent any controls on price, then the market will continue to absorb any available supply of the product which erodes the ability of the supplier to sustain provision of the product over time. The more that the supplier provides, the more it costs to create but they are less and less able to afford to persist in the market if they try to produce to meet demand at such an unsustainable price point. In order to sustainably respond to this challenge within the practice, the intervention that will have the most impact will be one that acts to reduce the demand side of the equation. While there are programs and interventions that could be implemented such as hiring additional staff or creating a curriculum to improve the efficiency of communications by the staff members, these interventions affect the “supply” of communication available to meet the needs of the patients, and it is likely to be the case that any increase in supply would simply lead to an increased demand for the service given that the patient population is absorbing all of the existing supply available immediately. Although not all of the tasks in the clinic are as extreme in their improved efficiency as Consult Services, the fact remains that essentially anything they do is better than spending more time than necessary on patient education communication. The opportunity cost of the excess communications significantly impact the efficiency of all other aspects of clinic operations, based on both the anecdotal observations, selfreported experience by staff and managers, and all the evidence collected in our analysis of practice operations. Clinic Operations Efficiency Analysis

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DRNC Partners In order to impact the demand for communications, we assessed what the strongest drives of patient communication were from the data we had collected from redacted voicemail transcripts and messages. More than 30% of the messages were related to follow up questions where information related to the patient during their visit was forgotten or unclear to the patient or their family members. Another 35% were related to patients or their family members contacting the practice to ask about concerns they had based on things they had read on social media, or unreliable online resources. If 65% of calls could be mitigated, even with some increase in utilization of the communication due to more supply being available, we still find a demand focused intervention is more likely to be cost effective in actually improving practice operations than any attempt to increase the supply of communication capacity available through an efficiency intervention or increased staffing levels at the practice. In order to achieve this reduction in demand for direct contact, the practice will need to create a robust patient education resource spanning all of their practice areas that can serve as a resource for the patients who have follow up questions due to the emotional impact to their cognitive load during critical appointments when they receive their diagnosis. The program will also need to address the concerns of patient family members who may not have been able to attend the appointment with their family member, but who still have concerns and questions about their diagnosis that need to be addressed with reliable information that is specific to their family members situation.

Proposal Patient Centered Approach When patients are first informed of a new chronic diagnosis, it can be an overwhelming experience between whatever symptoms brought them to seek care initially, the emotional toll of the discovery, and the emotional reaction of friends and family. Physicians are often hurried in their visits to see more patients waiting for their care. This creates a scenario where the patient may not have considered any questions they should raise with their doctor, or if the cognitive load of the experience was excessive, they may have little to no recollection of what the doctor even told them about their condition or how they can best participate in their recovery. To enable the patient to access sound information about their situation at their own pace and when they are ready to cognitively engage with the knowledge, a medical practice has requested assistance in developing a patient education intervention for the different chronic conditions they treat among their patient population. Depending upon the diagnosis and individual details of a case, the physician will be able to assign the modules to their patients after an initial diagnosis to provide relevant and accurate information in cognitively manageable portions to help provide alternatives to calling the physician for information and to deter any inclination to explore WebMD for details that would confuse or unnecessarily distress the patient or their family members.

Clinic Operations Efficiency Analysis

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DRNC Partners

Purpose:

Business Objectives (if applicable):

Develop a sustainable, self-paced, asynchronous, patient education program that allows for the patient population of the client (a private clinical practice group with multiple medical specialties) to access reliable, physician-vetted educational modules that will reinforce conversations they had with their doctor at the time of diagnosis that may have been challenging to store in long term memory as a result of the emotional response to the discovery of their condition. •

Better patient outcomes result in better reimbursement rates for the practice. o

Reimbursement rates for physician time spent providing patient education are limited, both in the amount of time they account for and the amount of compensation offered for the time the provider spends explaining the details of a patient's diagnosis.

Many publicly available online resources can often cause patients or their family members extreme distress due to misunderstanding the risk of medication side effects, the potential progression of their diagnosis, or incorrect assumptions about the actual diagnosis for a given patient.

The resulting time spent with repeat office visits, phone calls from patients, patient messages in the electronic medical record, or the emotional and traumatic experiences of some patients as their family members lead them on a wild goose chase on WebMD can cost healthcare providers time and resources that are extremely limited in many instances. For a small private practice, just a handful of patients placing calls to the clinic repeatedly to seek reassurance that the diagnosis they have spun from thin air by spending a paranoia-fueled afternoon scrolling through medical information on the internet can upend the schedule of a clinic full of providers very quickly. •

Clinic Operations Efficiency Analysis

Providing credible, informative, and accessible patient education resources can address concerns that might lead to disruptive and unnecessary uncompensated care demands falling upon clinic staff.

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DRNC Partners

Project Goals: Instructional / Patient Care Goals: To improve patient outcomes by providing patient education options that are self-paced, asynchronous, and will not necessitate ongoing additional healthcare provider time commitment to facilitate. The subordinate goals are to increase learner’s medication compliance and improve patient confidence in their ability to actively participate in the management of their condition. Organizational / Practice Goals: In addition to positive outcomes for patients as outlined above, the intervention will also improve clinical operations by reducing incoming phone calls and messages regarding patient inquiries regarding their care. The aggregate impact of improved medication compliance will be reduced admissions for severe seizure activity and reduced instances of seizure generally. (The pilot cohort will be seizure patients in the Neurology practice.)

Cost-Benefit Analysis Program Development Costs The cost to create an intervention like a Patient Education Series are as follows, based on our current estimate of the time required to develop a curriculum of this scale: Expense Category Direct Direct Indirect Indirect

Indirect Indirect Indirect Indirect

Expense

Incremental Cost

Program Total

Instructional Designer Salary Project Manager Salary Licenses (Microsoft Office/Teams) for L&D Staff) L&D Staff Cellphone/Internet Stipend (Remote Staff)

$50/hour/ID $50/hour

$ 312,000.00 $ 104,000.00

$70/year

280.00

$150/Month/L&D Staff Member

7,200.00

Notes on Total Calculation Formula=Hourly Rate * 3 (Number of Designers) x 40 (hours per Week) x 52 (Weeks of Development + Program) Formula=Hourly Rate x 40 x 52 Formula= (License Cost / 12) x 12 (Months of Yearly License) x 4 (Number of L&D Staff developing and running Program) Formula=Monthly Rate x Number of Training Staff x 12 (Months in Program Development and Delivery)

$2,000/year/L&D Staff Member

8,000.00

Formula= (Annual Rate/12 - Monthly Cost) x 12 (Months in Program) 4 (Number of L&D Staff)

$55/month/ID $100/month/ID $52.41/Month

$ 1,980.00 $ 2,100.00 $ 628.92 $ 436,188.92

Equipment (Laptop/Office Equipment/Graphic Design Tools/Training Equipment) Adobe Creative Cloud Licenses for IDs Articulate Licenses for IDs Server Space Costs

Formula= $55 x 12 (months) x 3 (Number of IDs) Formula= $100 x 12 (Months) x 3 (Number of IDs) Formula= $52.41 * 12

Alternatively, the practice could hire two additional RNs and an additional receptionist to help answer patient messages. While the program would take one year to create, it would then be available to provide its impact for several year without additional costs other than server space. The increased staffing levels would require the ongoing cost of salary, benefits and other indirect expenses for additional hires. If we limit the useful life of the program to 3 years and compare its cost and the cost of the additional staff we estimate that each RN would cost $95,000.00 per nurse per year for all direct and indirect costs of each Clinic Operations Efficiency Analysis

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DRNC Partners nurse (based on average RN costs for the existing RN staff) and $70,000.00 for an additional receptionist (based on average Receptionist costs for the clinic and hospital). The total for three years of their salaries would be $780,000.00. The supply intervention would cost 44% more over three years that the demand intervention and would be far less likely to succeed in actually improving the performance of clinic operations. The additional cost of developing an efficiency intervention, while less than the cost of developing the patient education intervention, would further increase the cost of the supply approach to managing the performance challenges.

Clinic Operations Efficiency Analysis

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DRNC Partners

Tables Organization Analysis 7 S Model Elements

Questions

Answers

Strategy

How should we proceed to resolve the specific business problem?

Improve ourselves to be the team we know we can be.

Strategy

What is our strategy and its priorities?

Patient Centered Care that considers the Whole Patient, not the Symptoms of the day.

Strategy

How will we achieve our strategic objectives?

By delivering best in class patient care that leaves our patients with the certain knowledge they are being cared for by the best team there is for their needs.

Strategy

How do we compete in the market? What are our competitive capabilities?

By providing the comprehensive care where the patient is not siloed by the walls of our practice such that we are only seeing what is in front of us today, but instead the whole patient.

Strategy

What is the organization's response to changing market conditions?

Regulation is the master of all practices similar to ours. The ability to operate efficiently within the contraints that limit all practices of our type is the key to business success for our practice.

Structure

How is our organization organized?

The four partners of the practice lead together, all major decisions require unanimous votes to proceed. Day to day operations are managed by the Practice Business Manager.

Structure

How are reporting and working relationships structured (hierarchical, flat, silos, etc.)? Who reports to whom? What is our process for making decisions? Is it through centralization, empowerment, decentralization, etc.?

Structure

How are our employees aligned with the strategy?

Structure

How does the organization share information (formally and informally)?

Major decisions are made by the four Physician Partners of the practice. We align the interests of our employees with our strategy as a practice by providing a work environment where their professional capability is respected and utilized to the full extent of their ability. We use information radiators to disseminate any policy decisions that are made and anyone can bring any feedback to any of the partners via our open door policy or privately by speaking with the Practice Manager in confidence.

Systems

Is it possible to execute the strategy with the existing business system or do we have to develop a new one?

Yes

Systems

How do we track progress and evolution?

We use Project Management software to track our long-term goals as a practice and to document responsibility for any deliverables related to those goals.

Systems Shared Values

In order to maintain course, what internal processes and rules do we follow?

We utilize the EMR and billing practices as dictated by Medicare/Medicaid and the Insurance Industry so in many ways we are bound by regulatory constraints on many of our internal processes.

What principles help us to achieve our goals?

Professional Respect for Providers, be they Physician or APP.

Structure

Clinic Operations Efficiency Analysis

The practice has 23 employees total. Each APP has a physician they are assigned to who acts as their mentor and supervisor. All day to day issues like vacation requests and other HR related matters go through the Practice Business Manager.

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DRNC Partners Elements

Questions

Answers

What makes us do what we do in the way we do it?

Regulations set the minimum bar, but our commitment to patient centered care raises that bar to the level we practice medicine. We make the call to get prior approval for the drug that works better than what the insurance company would prefer. We cultivate relationships with pharmaceutical reps for the free samples for our patients who could not otherwise afford medications not for dinners or lunches.

What is the mission of our organization?

To provide comprehensive care for our patient population across our practice areas so that they are not subjected to the siloed consequences of the belief that an EMR will solve the problem of a lack of communication between providers. If anything, the excuse of the EMR has made it worse because providers only know what they bother to read in the EMR.

What is our vision to get there?

Coordination within our Practice and Beyond to make sure we care for the whole patient, not the symptoms that brought them to the clinic on that day.

What are our core values?

Patient First. Give the Respect You Expect. Know What You Don't Know. Always Ask Questions.

Shared Values

How are we incorporating them into daily activities?

APPs have the freedom to practice the way they are most comfortable, to cultivate relationships with their patients not as an ancillary provider but as the provider for their patients they manage.

Skills

What are the specific skills we will need?

Maintaining Knowledge of developments in Medical Science. Expanding the Practice to Include Obstetrics/Gynecology, Oncology, Orthopedics & Psychiatry.

Skills

What skills should we develop?

Business Management Skills and Marketing Skills.

Skills

Is the employee's skill set sufficient for the job?

Yes, but we need to be able to do more than we are doing currently.

Skills

How do we monitor, assess, and improve skills?

Currently we perform annual reviews, but we are not finding that any of our staff are lacking there is just a lot to do.

Style

What leadership style and cultural qualities will help us to achieve a strategic objective?

Respect and Open Communications.

Style

What is our current management approach?

Respect and Open Communications.

Style

How are our employees respond to it?

We have received rave reviews from staff and have experienced very little turnover in an industry where turnover is often greater than 30% in many similar practices on an annualized basis.

Staff

Is there anything we can do to support the growth of our team members??

Professional Development Opportunities and in-house training to improve efficiency.

Staff

What are the current staffing needs?

We are focused on empowering the staff we have to do the job more than trying to hire our way out of this issue. Our current staffing levels should be sufficient for the number of patients that we have.

Staff

Are there any gaps in required capabilities or resources?

We feel like we are always behind on responding to patient communication and our patients have a hard time reaching us because of call volume.

Staff

What is our plan for addressing those needs?

Efficiency training.

Shared Values Shared Values Shared Values Shared Values

Clinic Operations Efficiency Analysis

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DRNC Partners

7 S Model Word Cloud

Clinic Operations Efficiency Analysis

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DRNC Partners

Job Task Analysis: Physician – Details of Performance | Cognitive Task Analysis Task Category

Administration

Clinical Services Clinical Services

Task Activity

Details of Performance

Difficulty

Time

Importance

Frequency

Skill Level

Communication

Internal email correspondence with administrators and other members of the department or organization from the routine details of providing required human resource documentation, managing benefits selection, and personnelrelated matters that require physician input.

Low

Varies / Moderate

Varies/Low

High

Semi-Skilled

Meetings

All departmental planning, governance, clinical practice decisions and other meetings neccesary for the ongoing operation of the clinic and consulting service within the overall operations of the facility. These can include the mundane and bureaucratic as well as case review panels for reviewing facility procedures in instances where patient care has been impacted such that an intervention may be needed to improve health outcomes due to process issues within the system.

Varies/Low

Varies/Moderate Varies/Low

High

Skilled

Professional Development

This includes required continuing education to maintain licensure and credentialing, mandatory training arising from regulators, employer-mandated training related to organizational objectives, cybersecurity training to mitigate risks associated with the evolving threats due to the targeting of healthcare operations by cyber criminals, and duties related to any professional organization memberships.

Moderate

Low

High

Low

Highly Skilled

Moderate

Varies/Moderate High

High

Skilled

Varies/Low

Varies/Moderate Moderate

High

Skilled

Chart Review Communication

Clinic Operations Efficiency Analysis

Review reason for appointment, review reason for referral, analyze prior admissions and recent changes in any medications or variance in diagnostic tests results over time from available records, review current treatment plan for primary care provider and any other specialists that the patient has been referred to. Ensure on subsequent visits that medication compliance appears to be occurring, any symptoms are trending in the appropriate manner, review any test results for patients. Discuss differential and treatment plan with patient, family members, and other providers as needed.

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DRNC Partners Task Category

Clinical Services

Consult Services Consult Services

Consult Services

Task Activity

Details of Performance

Difficulty

Time

Importance

Frequency

Skill Level

Differential

Take patient history, conduct physical exam of patient, discuss reason for visit with patient and family members if available, review medications, review diagnostic test results, identify range of possible cause(s) for patient presentation, review literature, develop or confirm continuation of existing treatment plan.

Varies/ Moderate

Moderate

High

Highly Skilled

Order Entry

Document treatment plan in the EMR, place orders for any diagnostic tests to be performed, enter medication orders from treatment plan, confirm dosing and complete medication review for adverse interactions with any current treatments and reconcile with appropriate provider as needed. Record patient history, family information, and other details collected during the exam and patient education interactions.

Low

Varies / Low

High

Moderate

Varies/Moderate High

High

Skilled

Varies/Low

Varies/Moderate Moderate

High

Skilled

High

Highly Skilled

Communication

Review reason for admission, review reason for consult, analyze prior admissions and recent changes in any medications or variance in diagnostic tests results over time from available records, review current treatment plan for primary team and any other consult services engaged in patient care, ensure on follow ups that orders have been followed and that diagnostic tests ordered have been completed, review diagnostic test results on follow up patients. Discuss recommendations with primary team, patient, family members, and other consult services.

Differential

Take patient history, conduct physical exam of patient, discuss reason for admission with family members if available, review medications, review diagnostic test results, identify range of possible cause(s) for patient presentation, review literature, develop treatment plan.

Chart Review

Clinic Operations Efficiency Analysis

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Varies/Moderate Moderate

High

DRNC Partners Task Category

Task Activity

Details of Performance

Difficulty

Time

Importance

Frequency

Skill Level

Order Entry

Document treatment plan in the EMR, place orders for any diagnostic tests to be performed, enter medication orders from treatment plan, confirm dosing and complete medication review for adverse interactions with any current treatments and reconcile with the appropriate provider as needed, record patient history, family information and other details collected during exam and patient education interactions.

Low

Varies / Low

High

Moderate

Triage

Monitor Service census, documentation of census for sign-out/handoff, prioritize urgency of patient condition in the context of the other patients on the service list, assign providers to see patient.

Moderate

Varies/Moderate High

High

Skilled

Documentation in the EMR Billing

Documentation of patient exam, history, reason for the current visit, observations, and interpretation of test results. Also to include differential or diagnostic findings in a format sufficient to meet the standards required for reimbursement from the relevant health coverage entity.

Low

Moderate

High

Highly Skilled

Documentation in the EMR Communication

Responding to patient messages through the EMR. Recent statutory changes have expanded patient access to their electronic medical records and within those record systems a patient communication portal is frequently available whereby the patient may contact a physician they have been cared for by with questions about their treatment plan, condition, or their views regarding the observations made by the physician in their record. These messages are as varied as any online communication in their tone, length, content and the time commitment involved in processing these messages can vary between providers significantly on any given day.

Low

Varies/Moderate Moderate

High

Moderate

Documentation in the EMR Order Entry

EMR Data Entry to provide instructions, medication orders, details for the standard of care, testing/imaging instructions and other details requiring action on the part of other staff whether in clinic or for admitted patients.

Low

Varies/Low

High

Highly Skilled

Consult Services

Clinic Operations Efficiency Analysis

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High

DRNC Partners Task Category

Patient Education Patient Education

Patient Education Supervision of APPs

Task Activity

Details of Performance

Time

Importance

Frequency

Skill Level

Care Management

Communicating to a patient what their role will be in managing their care for the condition they are being seen for in the clinic or that led to their admission at the hospital. This can include medication compliance coaching, recommending lifestyle changes and detailing the impact of heeding this advice or not on their long term health outcomes, explaining potential side effects of different treatment options, answering family member questions about a diagnosis or prognosis, explaining the role of hospice in the healthcare system, withdrawal of care counseling, and needing to repeat some or all of this information if the patient or family members are overwhelmed by emotion and unable to retain focus on the conversation sufficient to comprehend the situation without additional explanation. Language barriers present a further challenge for this activity. Low

Varies/High

High

Highly Skilled

Communication

Communicating a new diagnosis to a patient and/or their family members.

Varies/Moderate Varies/Moderate High

High

Highly Skilled

Meetings

Family Meetings. The majority of these conversations are very brief and would otherwise not account for much of the time required for this task activity; however, a small overall number of patients have a diagnosis that leads to family meetings that require much more time than others due to the sensitivity of the topics to be covered which can range from evaluating limitations on the quality of life after anoxic brain injuries, consultations with hospice care, determining organ donor status and decisions regarding whether to continue to provide resuscitation measures in the event of any further cardiac arrests.

High

Varies/Moderate High

Varies/Moderate Highly Skilled

Chart Review

Reviewing the chart for both the patient history and to monitor the treatment plan for all patients being cared for by APPs for whom the physician is the licensed supervising provider.

Moderate

Low

High

Skilled

Low

High

Skilled

Supervision of APPs Communication Clinic Operations Efficiency Analysis

Discussing patients in the care of the APP to provide observations, differential assistance, and verify the APP has no other questions or concerns regarding the patients in their care. Page 16 of 19

Difficulty

DRNC Partners Task Category

Supervision of APPs

Task Activity

Details of Performance

Triage

Monitoring the work of APP (Advanced Practice Providers - Physician Assistants or Nurse Practitioners) to assist in diagnosis/differential, treatment plan, family communication, or communication with consulting provider as needed. Low

Clinic Operations Efficiency Analysis

Difficulty

Page 17 of 19

Time

Importance

Frequency

Skill Level

Moderate

High

Skilled

DRNC Partners

RVU Efficiency Analysis | Physician Efficiency

Category Hours per Month

Task Activity Hours Per Month

RVU Efficiency of Task by Provider

RVU Multiplier

Average Hours Per Month

Task Category

Task Activity

Administration Administration Administration Clinical Services Clinical Services Clinical Services Clinical Services Consult Services Consult Services Consult Services Consult Services Consult Services Documentation in the EMR Documentation in the EMR Documentation in the EMR

Communication Meetings Professional Development Chart Review Communication Differential Order Entry Chart Review Communication Differential Order Entry Triage

8 8 8 76 76 76 76 76 76 76 76 76

2.4 4.8 0.8 19 19 19 19 15.2 15.2 30.4 7.6 7.6

0 0 0 1 1 1 0 1 1 1 0 0

0 0 0 0.083333333 0.083333333 0.083333333 0 0.066666667 0.066666667 0.133333333 0 0

Billing

7.2

Communication

3.6

Order Entry

Patient Education

Care Management

Patient Education

N N N Y Y Y D Y Y Y D N

30% 60% 10% 25% 25% 25% 25% 20% 20% 40% 10% 10%

228 D

40%

228 N

20%

7.2

228 D

40%

0.087719298

228 Y

50%

Communication

0.035087719

228 Y

20%

Patient Education

Meetings

0.052631579

228 Y

30%

Supervision of APPs

Chart Review

228 N

30%

Supervision of APPs

Communication

228 N

60%

Supervision of APPs

Triage

228 N

10%

Clinic Operations Efficiency Analysis

Page 18 of 19

228 228 228 228 228 228 228 228 228 228 228 228

RVU Activity Percentage of (Y/N/Dependency) Category

DRNC Partners

Intervention: Patient Education Series: Program Development Costs Expense Category Direct Direct Indirect Indirect

Indirect Indirect Indirect Indirect

Expense

Incremental Cost

Program Total

Instructional Designer Salary Project Manager Salary Licenses (Microsoft Office/Teams) for L&D Staff) L&D Staff Cellphone/Internet Stipend (Remote Staff)

$50/hour/ID $50/hour

$ 312,000.00 $ 104,000.00

$70/year

280.00

$150/Month/L&D Staff Member

7,200.00

8,000.00

Formula= (Annual Rate/12 - Monthly Cost) x 12 (Months in Program) 4 (Number of L&D Staff)

Equipment (Lap[top/Office Equipment/Graphic Design Tools/Training Equipment) Adobe Creative Cloud Licenses for IDs Articulate Licenses for IDs Server Space Costs

Clinic Operations Efficiency Analysis

$2,000/year/L&D Staff Member

$55/month/ID $100/month/ID $52.41/Month

$ 1,980.00 $ 2,100.00 $ 628.92 $ 436,188.92

Page 19 of 19

Formula= $55 x 12 (months) x 3 (Number of IDs) Formula= $100 x 12 (Months) x 3 (Number of IDs) Formula= $52.41 * 12