In my last column, I discussed the golden rule of practice growth (stay, pay and refer) and the influence of technology on that universal chiropractic truth.Though my colleagues are well-aware of my endorsement of technology as a way to build a successful practice, all of us must also be cognizant of the importance of human interaction in supporting growth.
I've built 18 practices during my career, turning 15 of them into high-performing businesses, and through that experience, I admit to some mistakes along the way. But I've also gained valuable insight that can be applied to my current interdisciplinary clinic and business decisions, as well as those of other practitioners.
One of the discoveries I've made centers on the key role clinic staff play in the success or failure of a practice. In our efforts to move toward automation, we must not forget the influence our staff can have on a patient and their ultimate satisfaction with the clinic itself. Obviously, staffing needs in a clinic will evolve as new technology is introduced. In fact, the entire health care profession is trending toward full automation. Some clinics offer check-in procedures that utilize thumbprint identification or card swiping. In those practices, no human being welcomes the patient to the practice or calls the patient back to the exam room. This all may seem to be an efficient way to move a patient into and out of the practice quickly, and on the surface, it may seem ideal for high-volume practices desiring low overhead. But is it the most effective way to manage a patient?
The Power Struggle Between Technology and Human Contact
A few months ago, my wife and I went to see a film called "He's Just Not That Into You." In the movie, the character played by Drew Barrymore laments how much dating has changed. She talks about the reliance on technology to begin a relationship through voice mails, texting, BlackBerries, Facebook, MySpace, etc. She recalls a dating experience in which she and a gentleman had eight "meetings" via technology before they ever actually met face to face or had a verbal conversation.
The truth is, as people become more tech-savvy, they may be less inclined to seek human interaction. In fact, in some instances, they may prefer the automated version to the human version - but when they want a human, they want a human. Chiropractic is a high-touch field that necessitates human interaction. For that matter, health care in general should be high-touch. And while technology can make us more effective, high-tech and high-touch are not mutually exclusive. One of our goals in achieving clinical efficacy is to strike the right balance between personal and technological contact.
Elements of many industries, not just health care and chiropractic, are served exceedingly well by technology. Consider the airline industry: Consumers select their flights based on price and schedule, often booking them online, and when they arrive to the airport, they can check in using an electronic kiosk. The kiosk lines move quickly, and from there, passengers can select their seats and even submit their frequent flyer numbers quickly and efficiently. The ticket purchase and check-in procedures are not emotional, but rather pragmatic. Passengers need to get from point A to point B, the plane can accommodate that need, and the flights they have selected fit with their time and their budget. The experience only gets emotional if the consumer has been wronged in some way, such as lost or damaged luggage or a delayed or cancelled flight. At that point, emotion has trumped pragmatism, and the consumer will seek a human for assistance.
In health care, we skip pragmatism at the start because we are sick or hurt and require a doctor or clinician to care for us. Health care is an emotional service. When a person seeks care, that person is vulnerable and needs help. Being met with a card swipe machine instead of a live person does not necessarily breed comfort and empathy in that time of need.
People going to a maintenance or wellness visit may have different expectations than someone suffering from a major health issue. Those on the maintenance or wellness visit have developed a bond with the doctor, have trust in their services, and expect to go in and out quickly. But those with more significant problems want someone who will take the time to listen to their problem, assure them they are in the right place, and convey confidence that they can be helped.
We are in a transition period with regard to high-tech and high-touch. Studies have yet to be conducted on patient preferences in terms of technology versus live personnel in a practice. While a Wall Street Journal survey reported that 74 percent of all Americans want a high-tech doctor, referring to diagnosis and treatment, if your office is completely high-tech, you may alienate those patients who are not as comfortable with automation. And if you go completely high-touch, you may annoy those who expect electronic processes. It is a careful balance indeed.
Staffing for Performance
I've found that staff can increase practice performance by as much as 25 percent, and decrease it by the same amount - that's a 50 percent possible swing, all based on staff interaction with the patient. Clearly, staff can and do impact a practice's success.
Staff should be trained to understand the critical role they play in our success or failure. Doctors only have a few minutes with a patient, but a front-desk employee is likely the first and last person the patient sees on a visit. That person knows almost as much about the patient as the doctor does, especially elements of their personal life, and the patient is also very likely to confide in that staff person. Making eye contact, smiling, being personable, energetic and compassionate - staff members should exhibit these behaviors. Patients should feel that they are important and special.
Staff should also be heavily trained on managing patient flow to ensure the process is smooth and timely. Automation alone cannot effectively manage all parameters of patient flow, but it does serve as a tool to assist staff with efficient, consistent, and accurate management of flow.
When patients share information with front-desk personnel, it is often pertinent to the visit with the doctor - even though the patient may not share it again with the doctor. Staff can keep a pulse on your practice and give you beneficial insight. When a patient is emotional, the staff person is able to make them feel secure and supported. That relationship builds credibility, loyalty and trust. Eventually, this is the lifeblood of your practice. It results in referrals, compliance and retention. Reading the patient and giving the doctor feedback can only happen with human contact, not with a card swipe. Carefully consider why you would ever remove such a valuable information source.
Finding the Right Balance
When we first integrated electronic health records (EHRs) into our practice, we asked every patient to complete patient information at a private kiosk in our waiting area. We learned an important lesson: Half of our patients weren't technology savvy enough to handle this task. It actually took longer for the technologically challenged people to complete the digital forms, and the staff had to assist more than they would have for the paper versions. We adjusted our approach to allow those who preferred the electronic option to complete their records at the kiosk, and those who preferred paper submitted their materials by more traditional means, such as forms. A staff member could transfer the paper-based information into our EHR system in about four minutes, far less time than it took to assist the non-techies at the kiosks in the first place.
Recently, we implemented a voice-automated answering system that helps us manage the more than 120 calls we receive at our practice daily. I admit, I struggled with the loss of human contact as part of the first impression for a patient, but in this case, our call volume necessitated the automation. However, we chose to implement a hybrid system, such that when you press one of the options given in the voice menu, you are then transferred to a live person. Plus, the first option was "press 1" to make an appointment.
Some patient activities are well-suited for technology, especially those with little variability. For example, our patients complete a computer-based outcomes questionnaire that includes 10 simple multiple-choice questions. Many progress examinations and outcome assessments that require simple answers can be administered very effectively using EHR and documentation technology, with little or no involvement from staff. Why? Because these digital surveys involve limited variability and offer the added benefits of being scored automatically and giving the doctor instant feedback. By comparison, new-patient paperwork involving customized answers and descriptions of the chief complaint may require typing; however, the multiple-choice answer selection that typifies an outcome assessment can be easily automated.
When thumbprint or smart-card technology was considered for my practice, we took a survey of existing patients; 90 percent were uncomfortable with thumb scanning because they feared the information would be used for other purposes. Approximately 80 percent didn't like the idea of swipe cards because they were anxious about what would happen if they forgot their card or found it impersonal and didn't want their full name announced over a loudspeaker. Automating our phone system met with far less resistance, mainly because people could do what they needed to do within the system. The options were fixed and matched their needs, and patients found themselves one selection away from speaking to the correct department or person to address their issue.
We listened to our patients and opted to stay with human personnel for managing check-in. They wanted a personal touch when entering our clinic, and when provided with just that, their comfort level and ultimately, their satisfaction with their visit was enhanced. And your reward: a satisfied patient who stays and refers.
Proof of Concept
While the evidence hasn't been collected and analyzed yet to validate the areas in which human contact is critical, common sense tells us where it is necessary. With airlines, grocery stores, hotels and banks, much of what you need to accomplish can be done through automation. However, health care has so many variables, and without sufficient data to support the dissolution of human representation, careful calculation must be undertaken to avoid the high risk of alienating your patients, losing patients and decreasing referrals by going with automated check-in, for example. Technology should support and improve the effectiveness of the clinic team, not replace it.
Because this move to digital clinic management is now passing the early adopters phase and moving into mainstream acceptance, doctors who are already tracking patient referral sources would be well-served to begin to categorize these patients by their automation preferences. Does the patient who swipes a card for their appointment appreciate the speed of the experience and share their opinion with others, or does that same patient tell friends and family, "Don't bother - no one talks with you at that place." We won't know until we start documenting.
Start tracking your referral activity now. What are your tech-savvy patients doing? What do your patients on wellness care plans expect, and what are their technology preferences? How about a newer patient who is coming to you for a serious injury? How does technology influence their desire to refer? Profile your patients and their referral behaviors; get the data now, rather than waiting for the industry to bring it to you.
Over the next five years, the entire U.S. health care system will be transitioned to EHR, which will result in billions in cost savings across our nation. However, we must pay close attention to the balance that is necessary with implementing other related technologies and the influence of humans, specifically your staff, in the process. While I am a huge proponent of technology, I still recognize the value of human interaction. Focus on allocating the right balance of resources, including technology and people, to the right areas of your office, and you'll be on the path to clinical efficacy.
Click here for previous articles by Steven Kraus, DC, DIBCN, CCSP, FASA, FICC.