In American healthcare, there's a growing gap between hospitals and clinics that are being innovative and those who are stuck in the “way it's always been done” mode. For example, innovative primary care clinics are using a combination of better processes and better technology to deliver a patient experience that I wish I could experience.
My Story (And I'm Pretty Healthy)
Here's the story of my recent primary care checkup with my physician. It's not a HIPAA violation for me to disclose that I'm a 41-year-old male with slightly elevated cholesterol that was discovered eight months ago, for which I was placed on a statin drug. I also had some moderately high blood pressure that appeared at age 40 after a lifetime of 110 over 70 being my usual numbers, so I was placed on a low dose of a medication for that. For both conditions, I was advised to eat better and exercise more, which I've tried to do.
I dutifully appeared for my checkup after six months as requested of me. After a short 10-minute wait in the lobby (an improvement over some previous doctors who routinely ran an hour behind schedule), I had a chance to meet with my physician. After the medical assistant checked my blood pressure (reading 115 over 72 instead of 135 over 90), she asked me how I was doing and gave me a cursory exam. She couldn't tell by looking at me, of course, if my cholesterol was low, so it was time to order lab tests.
This was a late afternoon appointment and, while I had anticipated needing to get blood drawn, I hadn't been willing to fast all day. Maybe we should have agreed to schedule this in the morning to save a short trip back to the office and their blood draw station. The easiest thing was to come back the next morning, after fasting, to get blood drawn, which was done painlessly and efficiently.
That was the last part of the process that I'd describe as painless or efficient.
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What Are My Results?
Just over a month went by and it occurred to me that the clinic had never contacted me with my test results. I had, of course, received a bill and statement of benefits from my insurer.
I called the clinic and asked about the test results. “We can fax them to you. What's your fax number?” asked the woman on the phone.
My what?? I don't have a fax number. I could go sign up for a free internet fax account, but that's a bit of a hassle (or you could call me lazy for not doing this). I never fax anything. The physician office has an electronic health record (EHR) system that the doctor dutifully types and clicks on during my appointment, but I'm not sure if the lab results from the national laboratory testing company actually integrates into their EHR as anything other than a scanned document. The clinic gives me no capability to log in to see my health record or the test results online. The national lab company's website only allows me to view and pay my bill.
They all sure seem to have the billing piece figured out. That's (relatively) painless and efficient to them.
How Do I Get My Results?
I scoffed at receiving a fax and asked if they would mail me the printed report. They, in turn, scoffed at that idea. They can't afford 50 cents for an envelope and a stamp? I would have happily paid for the stamp, actually.
Their next offer was to leave the results at their front desk for me to pick up, in person. With my work travel schedule, I had a couple of weeks ahead where I was going to be on the road and away from home every single weekday. So, driving over to get some paper wasn't a great option either since they aren't open on Saturday.
What Do My Results Mean?
So, about two months went by between my blood being drawn and me getting those test results. Some of that delay was my fault, but a lot of it was theirs. My cholesterol is lower and back into good ranges, thankfully.
I can see that from the report, although it's not easy. The report format was clearly designed with a laboratory medical technologist or physician in mind, not a layperson patient. It was like the “before” in this “before and after” comparison of what good could look like in a lab report (see this great WIRED story from 2010).
Report format and usability aside, what I'm waiting for now is a discussion with the physician about the next steps in my health and care. I assume I should stay the course on medications. But, what about that one liver enzyme number that's barely into what I think is a high range that raises questions? Am I interpreting this correctly? What does that result mean? I guess I need to make a phone call (which undoubtedly will lead to being placed on hold to then just leave a message) or schedule another appointment.
The Lean Way – A Better Way – Exists
There's got to be a better way – and that better way actually exists. One such healthcare provider is ThedaCare, based in Appleton, Wisconsin. ThedaCare is considered to be a world leader in the application of Lean principles in the transformation of their health system over the past 12 or 13 years.
In this video, former CEO Dr. John Toussaint explains his own experience as a patient in one of their “new delivery model” clinics. John shared that first at last year's Lean Healthcare Transformation Summit (which is happening this week in Dallas, actually).
My physician's clinic sends out daily batches of lab specimens out to a large testing lab (which is likely deemed to be less the least expensive way). ThedaCare can do the most common blood testing on a small lab analyzer that they have placed in each clinic. I can't imagine they would have chosen to do that if it were outrageously expensive to do some tests locally, to be part of a better flow. Even if the unit testing cost were higher, does this help them reduce overall costs?
Because Dr. Toussaint had been apparently fasting for his early morning appointment, he was able to get his test results DURING that very same appointment. He and his physician could discuss the results and his plan of care just a few minutes later. Whereas, I would have waited at least a month and it was more like six weeks before I had the test results… and, again, I still haven't talked with my physician.
I'll compare and contrast in this table:
| My Clinic | Toussaint's Clinic | |
| Total time at MD office | 30 minutes (or possibly 60 minutes across two visits) | 25 minutes |
| Time until blood specimen was collected | Next morning | A few minutes |
| Time until blood specimen was placed on the lab analyzer | +2 days | A few minutes, “immediately” |
| Time until lab results were reported back to the physician | +3 days (6 days total) | 15 or 20 minutes total |
| Time until patient had lab results | 7 weeks total | Immediately |
| Time until MD discussed results and plan of care with patient |
Had appointment with MD on August 3 to talk results (15 weeks total elapsed) — see my comment below | 25 minutes total |
Dr. Toussaint also has access to his own health record through a patient portal that he is able to log into from home. ThedaCare's EHR system has that capability, it's turned on, and they are using that to provide a better experience for their patients.
My primary care physician has been putting the entire burden on me to ask:
- Where are my lab results?
- How are you going to get them to me?
- When are we going to talk about my care?
If my condition were life threatening or if my condition appeared to be getting worse, I'd have more urgency in following up with the physician. I hope she would feel the same way and would react accordingly. I'm a relatively healthy middle-aged man, but I'd still like to be treated better.
What Could My Clinic Do?
Even if my physician is not going to bring their lab testing in house and if they're not going to offer an online health record, I'd sure appreciate it if they would:
- Be more proactive in reaching out to share the test results
- Offer a way to scan and email the results rather than trying to fax them
It's not rocket science. It's not brain surgery. They would just need to put some effort into it. They might complain that they are not reimbursed for providing that level of service and that they're barely getting by. But, I'm not convinced that better service has to cost more when we are practicing Lean – engaging people, reducing waste, and improving flow.
I'm Tired of Waiting for Results
I'm tired of waiting for results in two different ways.
- I'm tired of waiting for test results. The best my clinic would do is about a week's turnaround time, instead of what's possible (<30 minutes at ThedaCare)
- I'm tired of waiting for everybody in our health system to get on board with improvement
My wife and I are moving from San Antonio to Fort Worth for her next career move. When we get there, I guess my option is to shop around and find a physician and clinic that does things differently.
Moving to Wisconsin is not an option (no offense… it's too cold).
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Good article, Mark. I’ve worked in healthcare for over 30 years and I’m currently leading our organization through ST/Lean/etc. And I, too, agree that the flow of information and processes at many healthcare facilities is very poor. I believe in part this stems from some cultural barriers that are still deeply rooted in healthcare. E.g. Patients aren’t seen as the customer. When those attitudes begin to change so will healthcare. (Don’t get me started on the whole payment cycle problems in healthcare!)
Hi Mark, curious to know if the ThedaCare did a CBC in the office? We used to run a small analyzer in our office as well, but without the CBC, so we still needed to send a sample out to a lab for that test. We then purchased a CBC-capable machine, and found we had to upgrade the lab from CLIA Waived to Moderate Complexity. This was a considerable expense, both time and materials. We found the reagent cost prohibitive for the chemistry analyzer, and ultimately shut down the office lab. For us, an added benefit of using an external lab is that the results port in and attach automatically to the patient’s chart in our EMR. Curious to know your responses and thoughts. Thanks.
Mark and Marian,
The lab equipment installed in Thedacare clinics cost about $50K as a one time purchase. The clinics are able to do CBCs, A1Cs, Lipid panels, LFTS, and simple chemistry such as sodium, potassium, glucose etc.
Thedacare found by installing this lab equipment the total cost to the clinic went down. This was because fewer people were needed for call backs since all the information was given to the patient at the time of the appointment. It’s important to look at at the total cost of the visit not just lab cost when deciding if this approach is feasible.
The other point which is even more important is that quality performance, which is publicly reported at the WCHQ (http://wchq.org) in Wisconsin, significantly improved. So they achieved higher quality at lower cost, that’s what the lean methodology is supposed to do.
John
That is so true- The Physician visit process should change to become more effective – by utilizing available and constantly improving technology. healthcare seems to be behind other industries.
The general patient population is getting more savvy and more knowledgeable of healthcare and there are more choices than ever. This will surely force the hand of change.
The baby boomers are more savvy population than ever, I look forward to changes in the nursing home facilities and the health care practices.
I was finally able to see my MD again to talk about my results and plan of care.
I tried scheduling an appointment in late June, but the next appointment was two weeks out… during my vacation. So, I tried scheduling one when I got back… two weeks out was the soonest.
The total time from test to follow up appointment was about 14 weeks.
To my MD’s office’s credit, we came up with a new plan for next time… rearrange the value stream (my words, not theirs).
This will work much better, even if it’s not ideal:
1) Two weeks before MD appointment, I call and ask them to order labs
2) I come in to get labs done
3) A week later, the labs are back
4) We talk about the results and plan during the single appointment
Again, there’s much about that plan that isn’t ideal… why do I have to remind them? Why does it take a week to get test results? But, it potentially saves months and it saves a lot of hassle on my part.
That’s really cool that ThedaCare gives you instant results in the same appointment. I’m still waiting on results to come back for a suspicious mole that my dermatologist removed on my shoulder a few weeks ago. I would absolutely love it if I could have gotten those results before I even left their office!
A mole takes a bit longer than simple blood work (getting results before you leave the office wouldn’t be realistic for that), but those types of lab processes also benefit from Lean. Good luck…
I hope that physician updates their medical records and communications. A lot of physicians in my area offer online documentation. You can sign up for an account, log in, view your appointment history, lab results, etc. I’m surprised they offer to fax that kind of data to anyone. Most people I know don’t use fax machines anymore, and if they do have access to one, it would most likely be through their employer. And I wouldn’t want my health information faxed to a company-accessible fax machine, in case someone walks off with a stack of papers without checking if all of the pages were intended for them!
Now in the DFW area, I am much happier with my primary care provider. He’s part of the Baylor Scott & White Health system.
1) I went in for a blood draw Friday morning
2) Over the weekend, I got a notification and could see the test result in their app
3) This morning, the MD office sent a message saying to continue the same dose and did I need another refill?
This is waaaaaay better than waiting for weeks…