CME

Christine A. Sinsky, MD, FACP, Thomas A. Sinsky MD, FACP, and Ellie Rajcevich

PUTTING
PRE-VISIT PLANNING
INTO PRACTICE

J O H N W. TO M AC

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 Patient visits can be more effective if much of the
information gathering is done ahead of time.

W hen you walk in to see your next patient,

is all of the necessary information
assembled, organized, and ready? Or do
you spend the first five to 10 minutes of
each appointment determining who the patient is, why
he or she is here, which performance measures are due,
and what care the patient may have received from
tests for the next visit. The patient then may schedule
these appointments immediately instead of having to
remember to call back in several months to set them up.
In our practice, we use a checklist to help us plan for
the next visit. The checklist is part of a form that also
includes the date of the patients last annual exam as
well as any upcoming appointments and labs that are
another provider, the emergency department, or an already scheduled. This format allows the physician to
urgent care center since his or her last visit? put todays care and the next visits care within the con-
In our own practice, if the first time we think about text of the patient's ongoing care. The checklist features
a patient is when he or she checks in, we are already lab and other test options in three sections: those to be
behind.1-3 There is a lot to be done at each appointment. done before the patient leaves today; those due before the
Consider that the average family medicine patient age next follow-up visit; and those due before the next annual
65 or older presents with four problems per visit and, visit. The patient is then given the option at check-out
in our experience, one or more care gaps needing to be of receiving an automated reminder phone call, text mes-
addressed.4 This is more work than a physician can typi- sage, or letter closer to the time of the appointment. (The
cally handle alone yet is too important to leave to chance. "Post-appointment order sheet" is available in the FPM
Pre-visit planning can help make your patient visits Toolbox at http://bit.ly/1PaFg3z).
run more smoothly, giving you time to focus on what In an effort to be more patient-centered, weve also
matters most to the patient and even a little time to spare found that asking the patient when he or she would like
to simply visit with the patient. Furthermore, you may be to return is an effective way to share decision-making
able to head home an hour earlier, feeling satisfied with and give patients an active role in their own care. We
the day and a job well-done, knowing that your patients also believe this approach, combined with the reminder
and staff feel the same. system and pre-visit labs, have helped lower our no-show
rate, which is less than 4 percent.
2. Look back. Some practices do not begin pre-visit
Pre-visit planning
planning at the end of the current visit. Instead, it starts
The objective of pre-visit planning is to help the patient a week or so before the next visit when a nurse or other
and physician conduct the face-to-face visit more effec- staff member looks back over a patients record and orders
tively by gathering and organizing information ahead any tests indicated by protocol based on the patients
of time so they can devote more attention during the conditions or medications, as well as any instructions the
visit to interpreting, discussing, and responding to that physician left in his or her documentation from the previ-
information. ous visit. Practices that rely on physicians to enter future
Pre-visit planning takes place in several steps: orders into the electronic health record (EHR) on the day
1. Plan forward, or The next appointment starts of the visit will sometimes also employ this look back
today.5 The most efficient form of pre-visit planning process by the clinical staff. Physicians may feel they can-
begins near the end of the previous visit. As the visit draws not spare extra minutes at the end of the visit inputting
to a close, the physician and patient decide on next steps, orders when other patients are waiting, so the look-back
such as planning any lab tests that might be needed before process ensures the work has been done.
the follow-up appointment. The physician is already Reviewing the patients record outside of the office visit
familiar with the patients conditions and medications, so requires more time than planning forward, but it is still
it should take very little time to identify the appropriate more efficient than not doing any pre-visit planning.

About the Authors

Drs. Christine and Thomas Sinsky are internists at Medical Associates Clinic in Dubuque, Iowa. Christine Sinsky is also vice president
of professional satisfaction for the American Medical Association (AMA) and serves on the American Board of Internal Medicines
board of directors. Ellie Rajcevich is a senior practice development specialist at the AMA. Author disclosures: Christine Sinsky is an
adviser for Healthfinch, a company that develops prescribing software. No other relevant financial affiliations disclosed.

November/December 2015 | www.aafp.org/fpm | FAMILY PRACTICE MANAGEMENT | 35

PRE-VISIT QUESTIONNAIRE
Name: _______________________________________________________________________________________________________________________

TODAYS VISIT Depression screen: Over the last 2 weeks have you been
What are you hoping to accomplish today? __________________ bothered by little interest or pleasure in doing things, or feeling
_________________________________________________________ down, hopeless, or depressed? Yes No

Is there anything else youd like to work on to improve your Medications: Do you have any trouble taking any of your
health? __________________________________________________ medications? Yes No
_________________________________________________________ If so, what sort of trouble?__________________________________
If you have one of the following conditions, please answer: _________________________________________________________

Diabetes: Any problems with medications? Yes No Bladder control: Do you lose control of your urine to the point
Home glucose readings ___________________________________ you would like to know how to treat it? Yes No

High blood pressure: Any problems with meds? Yes No End-of-life care: Do you want to discuss end-of-life issues?
Yes No
Home BP readings ________________________________________
High cholesterol: Any problems with meds? Yes No UPDATE

Depression: Any problems with meds? Yes No Has anything new come up in your family history? (new illness
among blood relatives) ____________________________________
Any suicidal thoughts? Yes No
Have you developed any new drug allergies? ________________
BETWEEN VISITS Are you experiencing any of the following?
Have you been to the ER, hospital, or another doctor since Constitutional symptoms: fever weight loss extreme
last seen here? Yes No fatigue
Please explain: ___________________________________________ Eyes: double vision sudden loss of vision
_________________________________________________________
Ears, nose, mouth, and throat: sore throat runny nose
LIFESTYLE ear pain
Exercise: What do you do? ________________________________ Cardiovascular: chest pain palpitations
How long? __________________ How often? __________________ Respiratory: cough wheezing shortness of breath
Can you walk a block or climb a flight of stairs without getting Gastrointestinal: nausea vomiting abdominal pain
short of breath? Yes No constipation diarrhea blood in stools
Smoking: How much do you smoke? ________________________ Genitourinary: irregular menses vaginal bleeding after
Are you interesting in quitting? Yes No menopause frequent or painful urination bloody urine
impotence
Alcohol: How many drinking days do you have per week?_____
Skin: rash changing mole
On average how many drinks per drinking day? ______________
Sleep: snoring difficulty sleeping
Have you had more than 4 drinks in a day in the past 3
months? Yes No Neurological: headache persistent weakness or
numbness on one side of the body falling
Are you or others concerned about your drinking? Yes No
Musculoskeletal: joint pain muscle weakness
Falls: Have you fallen in the past year? Yes No
Psychiatric: depression anxiety suicidal thoughts
Do you have problems with walking or balance? Yes No
Endocrine: excessive thirst cold or heat intolerance
breast mass
Safety: Are you in a relationship where you feel unsafe or have
been hurt? Yes No
Hematologic: unusual bruising or bleeding enlarged
Do you regularly wear a seatbelt? Yes No lymph nodes
HIV testing: Would you like HIV testing? Yes No Allergic: hay fever
(If yes, please tell the nurse.) HIV testing is recommended for Please identify any issues above which are new or that you
anyone at risk for HIV infection, including persons with a sexually specifically want to address.
transmitted disease or history of injection drug use, sex workers,
sexual partners of HIV-infected persons, or persons at risk.
If you need help between appointments, please call our
Caffeine: How much caffeine do you consume per day? (e.g., office at ( _______ ) _______-______________.
coffee, tea, chocolate, soda) _______________________________
Our goal is to see you the day you call in or the next day.
Birth control method (if applicable): ________________________ It is helpful if you call first thing in the morning.
Sleep: Do you stop breathing during sleep or have concerns One of our nurses will help you decide if you need to be seen
about sleep apnea? Yes No and if any tests are needed prior to your appointment.

Developed by Christine A. Sinsky, MD, Medical Associates Clinic, Dubuque, Iowa. Copyright
2015 American Academy of Family Physicians. Physicians may duplicate or adapt for use in their
own practices; all other rights reserved. Related article: http://www.aafp.org/fpm/2015/1100/p34.
 PRE-VISIT PL ANNING

By having the labs available during the appointment,

patients can be part of the decision-making and are more
likely to adhere to the treatment recommendations.

3. Pre-visit lab testing. Pre-visit lab testing 5. Visit preparation. On the day of or
saves time, improves patient engagement in the day before a visit, the medical assistant or
health management, and reduces the amount nurse can do a quick review of the patients
of work needed to report and respond to record to see what needs the patient may have
results. Some practices arrange for patients to during the appointment. For example, they
come in several days before the appointment can identify if the patient needs an immuniza-
for lab testing. Others arrange for patients to tion, a cancer screening, or other prevention
have their blood drawn 15 minutes to an hour measures and close these care gaps during
before their scheduled appointment and then the rooming process. Conducting visit prep
use point-of-care testing or rapid turnaround can be an effective tool in panel management
of standard lab testing. In both cases, the goal and can positively affect the health of the
Pre-visit planning
is to time the tests so that the results are avail- entire patient population.
can make visits run
able to the patient and physician at the face- 6. Pre-visit questionnaire. A pre-visit
more efficiently
to-face visit. questionnaire is a list of questions the patient and provide more
By having the results available during the completes either on paper in the waiting room time for patient
appointment, patients can be part of the ensu- or through an online patient portal from concerns.
ing decision-making and are more likely to home. See the questionnaire our practice uses
adhere to the treatment recommendations on page 36.
than if they received those recommendations Questions explore the reason for the visit
later by phone or letter. In addition, the phy- (What are you hoping to accomplish today? The planning
sician and patient can avoid playing phone tag and Is there anything else youd like to process can begin
or engaging in several rounds of email after work on to improve your health?), which before the end of
the visit to resolve unanswered questions. One prevents the situation in which a patients the previous visit,
when physicians
practice found that pre-visit labs saved $25 in main goal is revealed just as the physician is
and patients iden-
overhead per patient visit.6 about to leave the exam room. Standardized
tify next steps and
Pre-visit labs can also aid safety. Because initiate scheduling
patients are able to review their test results any tests or other
together with their physician at the appoint- follow-up that may
ment, it is less likely that an important result be needed prior to
will be overlooked or lost in the system. the next visit.
4. Pre-visit phone call. Calling the patient
ahead of his or her visit can help the clinical
team prepare more thoroughly by clarifying
the patients agenda, anticipating any special Pre-visit testing
needs, and completing many of the tasks means the results
usually performed during rooming, such are ready to be
discussed at the
as reviewing medications or screening for
visit instead of
depression or falling. Some practices reserve
having to wait.
pre-visit phone calls for complex patients. A
pharmacist or pharmacy technician may also IN THE AUTHORS OWN WORDS
call these patients for in-depth medication Dr. Thomas Sinsky and Debra Althaus, RN,
reconciliation. In some cases, this process is discuss some of the benefits that pre-visit
aided by access to an all-payer claims database, planning provides for their practice in a
which staff can use to see what medications video available with the online version of this
the patient has actually filled. You can identify article: http://www.aafp.org/fpm/2015/1100/
and address nonadherence to medication in a p34.html.
non-judgmental way with this approach.

November/December 2015 | www.aafp.org/fpm | FAMILY PRACTICE MANAGEMENT | 37

 Our personal experience is that pre-visit planning definitely reduces
the time spent on a patients care during or after the visit.

questions applicable to the particular practice, which they can plan around. We plan ahead
such as screening questions for falls, depression, to make that next visit meaningful to them.
or domestic abuse, can also be asked. The They dont have to wait after the appointment
questionnaire can also be used to update the for lab results or instructions based on those
patients past, family, and social histories, as results, and they can speak with their physi-
well as to conduct a complete review of systems. cian about those management decisions.
All of these uses can save the staff, physician,
and patient time during the actual visit.
Finding the right strategy for you
In our own practice, we have a separate
pre-visit questionnaire for the Medicare Pre-visit planning can take many forms, and
Annual Wellness Visit that mirrors the tem- practices can choose the ones that make sense
plate in our EHR, which makes it easier for for them. Each component adds efficiency
the nurses to upload the information. Some and supports a rapid understanding of why
EHRs are designed so that the patients the patient is visiting and what his or her
answers to the pre-visit questionnaire can be comprehensive needs are. An organized sys-
imported into the visit note, reducing the tem to manage this complexity and volume
Staff can use amount of data entry required of physicians will allow physicians to relax and truly listen
pre-visit phone
and clinical staff. to patients, knowing that the standardized,
calls and other
7. Mini-huddle. The nurse or medical predictable work of the practice happens cor-
preparation to
identify care gaps
assistant often learns important medical and rectly by default and resting assured that they
and reconcile social information during his or her interac- have minimized the chance of overlooking an
patient medication. tion with the patient during rooming. We important piece of data.
have found that a brief mini-huddle with You can read more about pre-visit planning,
the physician before the physician meets with pre-visit labs, huddles, pre-appointment ques-
the patient can be helpful. The nurse can alert tionnaires, and building a culture of team-
Patients can use a the physician to the patients concerns (She work at the American Medical Associations
pre-visit question- is afraid she will lose all strength in her arm), practice transformation website, http://www.
naire to prioritize a change in social situation (His wife was stepsforward.org.
their goals. recently diagnosed with breast cancer, and he
is worried), or a teachable moment (Her sis- 1. Sinsky CA, Sinsky TA, Althaus D, Tranel J, Thiltgen M.
ter just developed diabetes, so she is willing to Practice profile. Core teams: nurse-physician partner-
ships provide patient-centered care at an Iowa practice.
work more on diet and exercise to prevent this Health Aff (Millwood). 2010;29(5):966-968.
Nurses and medical
from happening to her). 2. Sinsky CA. Improving office practice: working smarter,
assistants can com-
Although we have not found many studies not harder. Fam Pract Manag. 2006;13(10):28-34.
municate pertinent
last-minute details
measuring the overall financial savings of pre- 3. Kravitz RL. Improvement happens: an interview with
visit planning, our personal experience is that Christine Sinsky, MD. J Gen Intern Med. 2010;25(5):474-477.
with the physician
pre-visit planning definitely reduces the time 4. Beasley JW, Hankey TH, Erickson R, et al. How many
right before meet- problems do family physicians manage at each encounter?
ing the patient. spent on a patients care during or after the visit. A WReN study. Ann Fam Med. 2004;2(5):405-410.
A rough estimate is that pre-visit planning takes 5. Phrase coined by ThedaCare Health System, a commu-
about an hour of nursing time per day and nity health system based in Appleton, Wis.
saves about an hour of physician time and up to 6. Crocker JB, Lee-Lewandrowski E, Lewandrowski N, Baron
two hours of nursing time. It also increases the J, Gregory K, Lewandrowski K. Implementation of point-
of-care testing in an ambulatory practice of an academic
quality of care by identifying agenda items and medical center. Am J Clin Pathol. 2014;142(5):640-646.
care needed at the appointment, such as immu-
nizations or cancer screening.
We have received mostly supportive feed- Send comments to fpmedit@aafp.org, or
back from our patients regarding pre-visit add your comments to the article at http://
planning. When they leave an appointment, www.aafp.org/fpm/2015/1100/p34.html.
we reserve a time for their next appointment,

38 | FAMILY PRACTICE MANAGEMENT | www.aafp.org/fpm | November/December 2015