OCTOBER 15 - 30, 2006


Same-day booking makes the grade

US system that lets MDs see patients quicker could work here

Do you feel buried under a mounting backlog of appointments booked months in advance? Maybe you should consider seeing your patients today.

Same-day booking is an increasingly popular solution in the US for physicians who want to simplify their scheduling and put the kibosh on no-shows. More and more Canadian docs, such as Halifax GP Dr Vicky Mitchell, are successfully switching over to a same-day booking system, proving that the concept can work in Canada's healthcare context.

Same-day booking was brought into the mainstream in 1994 by Dr Anthony Cantelmi, chief of medicine for HMO giant Kaiser Permanente in California's Sacramento Valley. Dr Cantelmi first implemented a system for himself, but soon, with the help of some colleagues, made same-day booking the standard for his whole facility. Two of his staffers, FP Mark F Murray and nurse Catherine Tantau, went on to popularize the system by teaching the method to other practices.

Other people call the system "open access scheduling" but Dr Cantelmi prefers the simpler "easy access." "We don't force people to take an appointment that day, we just ask them, 'What do you want'? Do you want to be seen today, tomorrow, next Tuesday? What's your pleasure?"' he explains in an interview with NRM.

Dr Cantelmi recalls the origins of his easy access scheduling. "It was a system that I put into place after an extended leave and when I got back I had to work down my backlog," he says. "In October I decided to start seeing all my patients who called that day plus all my existing appointments — by December I'd cleared the backlog."

Once word got out that he was seeing his patients the same day they called they were incredulous. "I had a guy call in and make an appointment and he didn't even want it," recalls Dr Cantelmi. "He just wanted to see if he could really see me on that day!"

Was there any backlash? "No," he says. "My patients just love this system." Do you ever run into cases when patients have to call for days on end trying to see you? "No, it just doesn't happen."

He's been with Kaiser Permanente for 22 years; at the time he decided to try same-day booking he'd been with them for 10 years. Something about the way things were going just didn't sit well with him. "The mismatch was that same-day care — really urgent care — was being relegated to per diem physicians who didn't really have a big stake in the success of the organization," says Dr Cantelmi. "Patients don't like that — they want to see a familiar face. People who are bonded to me want to see me when their nose is running as well as when they're having chest pains. They don't say 'I'll see you when I'm fine' and they certainly don't say 'I'll just come in for a physical or preventive stuff but whenever I'm sick I'll see somebody else.'"

The logic behind the status quo puzzled Dr Cantelmi. "When you have the proper doctor to patient ratios and you're booking three months out — that never made sense to me," he says. "Supply and demand management says you need to do today's work today — why put it off until tomorrow?

"It doesn't matter who, it could be chest pain, shortness of breath, bleeding or whether you just need an update to go on a cruise," he explains. "In other words we don't triage the day's appointments, we don't put off things like physicals. We just lump everything together and say 'If you have a need to be seen, come on in.'"

Dr Vicky Mitchell told the Chronicle Herald that she put herself through 'boot camp' to get rid of the backlog before she could starting seeing patients on a same-day basis. Dr Cantelmi says that's something you can't avoid. "Whatever it takes to bring that backlog down you have to do — work evenings, weekends or bring in people to help," he says. "But once the backlog is cleared, and you have a pretty good match of the number of patients to the number of physicians then you're in pretty good shape to hit the ground running — it's easy."

"We definitely had our hard times in a switch-over," he recalls. "But I oversee 188 physicians and if I asked them, 'Would you like to go back to seeing pre-booked appointments and have urgent care go to someone else', there wouldn't be a single person in that group who'd say 'yes' — all of them like this system."

Dr Mitchell's experience confirms the set-up can work in Canada. She said she "felt as light as air" after her system was up and running.

The effect on no-shows has been staggering. "We went from an almost 20% no-show rate to virtually zero," says Dr Cantelmi. "When appointments are booked months ahead people just forget about them."

He said empty slots are not a problem either since his facility, like most in Canada, has an abundance of patients. "For us it's very rare that supply exceeds demand," he says. "Yet, here in the North Valley of California 85% of calls will be booked for an appointment the same day — that number has been as high as 94% at points."

"Certain days are a little bit busier and certain days are a bit light but you can calculate the ebb and flow. It works great for a population of 10,000-20,000 patients. It doesn't do as well for a single doctor," says Dr Cantelmi. "If I were in solo practice, it could be four or five patients one day and 40 another — that supply and demand is a little harder to calculate."

"I think to run a seven-day-a-week operation you need eight to nine with an 18,000-19,000 patient population," he adds. "With that it gets really easy to predict demand."



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