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When Dr Carl Orr began his research in the Rheumatology Department at St Vincent’s University Hospital, Dublin, his goal was a simple one. He wanted to reduce the amount of time doctors were spending with returning patients to create more time for them to see new patients and, in turn, reduce the length of time patients were waiting to see a consultant for the first time.
With that goal on the cusp of being achieved, Dr Orr is also very pleased with the unforeseen secondary outcomes of his project.
A graduate of the RCSI, Dr Orr became increasingly interested in the whole area of creating better efficiencies in healthcare while undertaking his Masters in Leadership and Management Development at the College. There he submitted the very thesis (Increasing the efficiency and quality of follow-up clinic visits for patients with inflammatory arthritis) that was the pilot project for which he was awarded the Bernard Connor Bursary; an award established by the Irish Society for Rheumatology (ISR) to recognise and celebrate innovation in rheumatology, and sponsored by AbbVie.
Dr Carl Orr
The Bursary was one which Dr Orr had always been aware of, but after being encouraged to apply he decided to submit his study. “The application was extremely straightforward and I simply had to use material I had already worked on to synthesise a summary. In particular, it was especially good that there is a single application, as distinct from several rounds of a process that the applicant has to keep submitting material. I also think the selection process appears to be very clear,” he explains.
Dr Orr’s pilot study, which has now been extended, set out to examine the use of ‘physician extenders’ (PEs) to improve the quality and efficiency of clinical visits.
“Broadly speaking, the project idea was quite simple and based around the idea that most patients with inflammatory arthropathy are usually well when they come to see the physician and that there is a greater need to try to prioritise patients who are unwell and see patients referred to us for the first time within six weeks, as recommended by the ISR. If we could reduce the time the physician spends reviewing patients, then there would be more time to see new patients,” explains Dr Orr.
Key to the success of such a simple idea is following an equally straightforward protocol. Dr Orr says he knew that time could be saved in his department by ensuring that the physician had everything that would be required for a consultation before the patient arrived. “It’s about trying to make sure relevant results, such as bloods and x-rays, are there. It makes sense of course for these to be available, but a lot of the time, it wasn’t actually happening. A patient would come see the doctor, get a form to get their bloods done and then just get the bloods done on the way home. Unless there was something wrong, the bloods wouldn’t be reviewed until the next visit,” he explains.
Another key aspect to the project was encouraging patients to take more ownership of their disease to ensure they get the most out of their consultation. “One of the things we did was ask patients to provide a list of the medicines they are taking. It’s a great source of frustration when patients don’t know what medication they are taking. If we could focus the patient’s mind and the physician isn’t spending time opening packets of medicine, they can focus more on their interaction with the patient and the patient will get a better quality visit,” says Dr Orr.
Dr Orr’s project was framed using a straightforward methodology with three distinct aims. Firstly, the importance of preparing for the patient visit was highlighted. “We know what information we need from the patients and because we are seeing patients as outpatients and know sometimes weeks or months ahead that we will be seeing them, there is great opportunity to prepare for the visit before they come in,” points out Dr Orr. The second aim of the project was to protect the commodity of the doctor’s time so that it could be used to see more new patients, and the final aim of the project was to encourage patient responsibility.
“To help achieve all this we used a ‘physician extender’ (PE). This person is trained to access information about blood tests and x-rays and currently works two days per week,” explains Dr Orr. These hours are being funded by the Bernard Connor Bursary and will continue to be so until later this year. Dr Orr is hopeful that a business case can be made for the retention of the PE after this time.
“We also developed a four-page pro-forma. The first three pages of this are to be filled in by the patient. Our PE looks up which patients are coming in during the next two weeks. The pro-forma is then posted to these patients. The PE also looks at whether the patient has had bloods done in the last two weeks or x-rays in the last two years and if this is not the case, they will request an order for these, which then need to be signed off. The whole packet then gets sent to the patient with the pro-forma and forms for the walk-in blood clinic or for x-ray,” says Dr Orr.
Successes and challenges
An audit of the project is currently being undertaken however, while undertaking his pilot study in this area Dr Orr established that consultation times decreased by eight minutes from 23 minutes to 15 minutes by following the project methodology.
Perhaps, more noteworthy however, is the fact that it was noted that the quality of the consultation actually increased.
He outlines how having relevant results and information to hand regarding medicines meant the physician was able to spend more time answering questions and also had a greater opportunity to calculate patients’ disease activity scores, something which was being done on an ad hoc basis previously. “Full disease activity scores are now being done for around 92 per cent of patients,” he explains. This would be closer to 100 per cent save for the fact some patients didn’t attend for blood tests either because they were actively working or not living near the hospital and found it difficult to visit the hospital twice in two weeks or because they were feeling well. “When patients are well they don’t see the merit in getting bloods or x-rays,” notes Dr Orr.
The project is not without its challenges and Dr Orr continues that patient conformance is not always achieved. “One of the most challenging aspects of the project is actually getting patients to bring back the forms.”
Dr Orr acknowledges that while the presence of the PE has helped to reduce patient visit times, the limitations of the role can be frustrating. It still takes a lot of time to prepare for a patient visit and as the PE cannot sign off on booking bloods or x-rays, this process is not as efficient as he might like. However, he adds: “While there are some challenges, having a physician extender will makes things easier.”
Dr Orr says he is confident now that the project’s primary aim to reduce consultation times has been met, it is simply a case of translating this work to now see new patients in a shorter timeframe. This, he says, could not have been achieved without the support of all of the consultants he works with. “It’s rare for a NCHD to spend three years at a hospital. Usually you spend your first few months at a hospital figuring out the systems and getting to know your new colleagues and it is hard to try and implement anything, as you are doing all this against a background of continual migration. As an NCHD you also don’t know how much authority you have to try to implement any changes. I have been here in St Vincent’s University Hospital for three years as I am completing my PhD and so have had an opportunity to work with people longer, which helped me to implement the project. Prof Douglas Veale provided great help and support to me throughout the project. In fact all of the consultants have been very supportive, which is why I could do this project,” he says.
Dr Orr believes that the premise for his project can easily be applied in other specialities to help cut consultation times, improve efficiencies and reduce waiting times for new patients. “I think we can really make a business case for a physician extender, not just in rheumatology but in other disciplines, especially those areas where patients are being seen predominantly as outpatients.”
Over the coming months, Dr Orr says his focus will be on completing his PhD, which he will be submitting in October, but this is not the end of his research and he looks forward to a future as an academic researcher when he is appointed as a rheumatologist.