J. Stephen Jones, MD
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According to a 2004 AUA survey, urologists are working harder and longer than ever. An aging population combined with the
training of fewer urologists (many of whom wish to limit work hours) has created an unprecedented workload.
Meanwhile, patients expect rapid and high-quality access to their urologists, regardless of such demographic changes. Few
established urologists have the capacity to easily increase either the number or duration of visits in order to meet this
need. Therefore, the most common solution is to overbook and limit the duration of visits at the potential cost to patient
satisfaction and quality of care (see table).
Raymond Rackley, MD
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Most urologists are too busy to implement individual interventions of behavioral modification, patient education, or emerging
technologies because we use a clinical model of acute-care delivery (one-on-one) for chronic-care conditions that make up
most of our established patient visits. Every busy urologist knows the frustration of repeating important clinical advice
many times a day.
Sandip Vasavada, MD
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Despite new clinical therapies and office technology (including an advanced electronic medical records system) we have employed
to offer these new services, one of the best clinical programs we have initiated has been the group shared appointment (GSA),
which is designed to help patients gain access to needed care and to keep urologists from burning out. This article describes
how this approach works, the time and economic efficiencies it provides, and the multiple other advantages it offers both
physicians and patients.
The GSA: What it is and is not
The GSA concept was originally developed by Edward Noffsinger, PhD, at Kaiser Permanente of Northern California, to improve
access and quality of care through enhanced patient education and support. This model has expanded to many academic and private
practices throughout the country, including The Cleveland Clinic, where urologists at the Glickman Urological Institute have
used GSAs for the past 3 years.
Gerald L. Andriole,MD, is professor of surgery and chief, division of urologic surgery,Washington University School of Medicine,
St.Louis.He is also the director of the Urologic Research Center at Barnes-Jewish Hospital.
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Physicians perform a series of one-on-one patient encounters in a group setting during a 90-minute visit to manage, educate,
and advise each patient in front of others. Patients benefit from improved access to their urologist and significantly increased
education, while the urologist can boost his or her access and productivity without increasing clinic hours or practice cost
(see, "Advantages and pitfalls of group shared appointments,").
It is important to understand that the GSA is neither "group therapy" nor a lecture. It is a one-on-one visit in the presence
of patients with similar conditions that allows the patient to benefit from the extended time of a GSA and to learn from the
interactions of the physician with other patients. Instead of a rushed follow-up visit in a few minutes, they will experience
a 90-minute visit shared with people with similar conditions. Insurers may need reassurance that this is the case, and that
the GSA will not devolve into a "class."
Solutions to access problems
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In urology, the GSA concept has been applied to such chronic conditions as overactive bladder, rising PSA, bladder cancer
post-cystectomy, and even sexual dysfunction (see, "The GSA at 3 years: What we have learned,").
How to establish, execute a GSA
Up to 15 patients make up a group, along with the physician and usually one to three staff members. Depending on the disease
state, participants may include a nurse, physician's assistant, urodynamic technologist, impotence coordinator, and possibly
a documentation specialist for E&M coding and billing.
Advantages and pitfalls of group shared appointments
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Patients with specific conditions are offered voluntary involvement in the GSA through two mechanisms. The first is by introduction
during the initial consultation. When scheduling follow-up, the physician suggests that the patient has a common condition
and that many patients experience improved follow-up care in the less-rushed GSA setting. Patients who understand that their
appointment will be in the presence of others sign up for a scheduled GSA at a time commensurate with that of the follow-up
visit.
The second method is through "Dear Patient" letters stating that the patient has been seen in the office for a specific condition,
notifying them that the GSA is an option for follow-up if they desire, and instructing them to call to schedule. Regardless
of the method, it is made clear to patients that traditional appointments remain available, and there is no pressure to use
the GSA.
The GSA at 3 years:What we have learned
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Appointments are scheduled for 90 minutes each and should always start and finish on time. A room to comfortably seat all
the patients is required, such as the reception area or a conference room. If the former is used, it is often most effective
to have the GSA be the first appointment of the day and to post a sign that the office will open after the GSA is completed
in order to prevent interruptions. Alternatively, lining up three to four GSA appointments in one day with 30-minute breaks
between them works well. We use the interims to allow staff to take a break, catch up on patient calls and e-mail, and, occasionally,
see urgent cases.
Prior to the appointment, patients fill out an interim history form that can be used as the day's documentation sheet for
physicians with paper charts or that can be noted with changes in the EMR. Spaces are provided on the form for patients to
list specific questions or issues they wish to have addressed and prescriptions to be refilled. Finally, the patient is asked
if he needs a private examination or if he is due for DRE, PSA, or other routine screenings.
Interaction encouraged
Because the appointment must be a one-on-one interaction with each patient, seating patients in a semicircle is preferable
to encourage interaction. Name tags facilitate a personalized approach. The physician initiates the appointment with minimal
desultory discussion. Each patient is approached in the same manner as in a traditional appointment, except that the schedule
and opening comments clarify that they are being seen for a common condition. Other patients are encouraged to respectfully
enter the discussion, as appropriate.
Unlike traditional appointments, there is no need to rush through this discussion. When appropriate issues have been addressed
with the first patient, attention is directed to the next. If a patient forgets to ask about a specific concern, it is likely
someone will mention it.
Because issues overlap and are rarely repeated after the group hears them, each subsequent patient takes less time. The first
patient may take as much time as a traditional appointment, but by the time the discussion reaches the final third of the
patients, most have only brief questions or clarifications or need prescription refills, laboratory orders, etc. If at that
point a patient raises a previously unexplored major point, there is adequate time to go in-depth.
Therefore, by the time the final patient has had his appointment, all patients have benefitted from in-depth discussion beyond
what could be feasibly achieved during routine follow-up appointments. Moreover, 15 patients have been cared for during a
90-minute period.
Confidentiality and billing concerns
Because in GSAs patients self-select, they are typically comfortable in the presence of other patients. The HIPPA form states
that they agree to discuss their own medical information in front of others and to not disclose personal information of the
others outside the group setting. Our experience is that patients take this responsibility as seriously as do health care
providers, and we are unaware of any breach of confidentiality. Their signed form ensures HIPPA compliance.
Most established patient visits require no physical exam for either medical or E&M coding reasons. However, some patients
have confidential questions or need exams, bladder scans, uroflowmetry, or other procedures during the appointment. They can
notify the physician on the interim history sheet and are given a private exam for needed care during the visit, after which
they return to the group. When the physician leaves the room for such interactions, another member of the team takes over
the discussion.
A GSA should be billed like a traditional appointment, except that it is inappropriate to bill based on time. The one-on-one
appointment during a GSA is no different from one without other patients in the room, so billing and coding should accurately
reflect services rendered and documented. Forms or an EMR facilitate accurate, complete documentation.
Some physicians are concerned that patients will feel they have lost individual attention. We have found the opposite to be
true. Instead of feeling that they have had an appointment lasting only minutes in which they are rushed to ensure that a
busy physician addresses their concerns, our GSA patients almost uniformly say that they had more time and attention from
the physician during the relaxed, 90-minute GSA because they shared concerns with other patients.
Another concern is that the physician must document the visits after the appointment, which would obviate the efficiency of
a GSA. Quite the opposite is true. We routinely complete patient notes as the appointment draws to a close, whether we use
paper charting or our EMR. The latter is especially convenient, as we use a template with the history and medications automatically
entered and a summary statement that is comprehensive for all patients in the group but also allows us to record specific
concerns, such as prescriptions, notable physical findings, residual volume, IPSS, or AUA symptom score.
Conclusions
In the medical prototype—diabetes care— the GSA leads to a lower risk of emergency room visits, fewer disability days, improved
general health status, and better HbA1c and weight control (Diabetes Care 2001; 24:695-700; Trento et al. Diabetologia 2002; 45:1231-9). At The Cleveland Clinic, we have experienced higher patient satisfaction with GSAs than with traditional
visits. Eighty-five percent of medical patients opted for another GSA, and 79% rated their visit "excellent" (Cleve Clin J Med 2004; 71:369-70). We believe the key factors for this level of satisfaction are improved access, visits that are not rushed
and allow greater one-on-one attention, and appointments that start and end on time.
Grouped shared urology appointments are an effective way to ensure patients access to the busiest physicians and to enhance
overall productivity. Both patient and physician satisfaction with these encounters has been high, and we continue to expand
their use. The key to success is to follow the requirements of the process carefully and to ensure that each patient receives
the most appropriate care for his or her individual urologic conditions or concerns.
Dr. Jones is associate professor of surgery (urology), and Dr. Rackley and Dr.Vasavada are co-heads of the section of female urology and voiding dysfunction,The Cleveland Clinic Glickman Urological Institute.
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