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Search is not for the faint-hearted, but you can cut through the hype
When personnel at the Cleveland Clinic Foundation began the search for an automated appointment reminder system, little did they expect to navigate a labyrinth of contradictory claims within a surprisingly "cutthroat" industry, says Carolyn McConnell, operations analyst.
After all, she notes, with systems available for as little as $8,000, it’s not as though the vendors are competing for big bucks. After more than a year of sifting through claims and counter claims and discovering the hidden costs of some systems, the Cleveland Clinic will pilot its new system the last quarter of 1999, with assessment and full rollout to follow. McConnell offers hard-earned advice to access managers involved in a similar search.
While checking vendor references, McConnell says, she was surprised to discover that many health care organi zations had no data on their no-show or same-day cancellation rates, thus rendering it impossible to measure any improvements a new system might make. To make sure this crucial infor mation is available, she suggests an organized approach beginning with identifying the need for such a system and ultimately measuring its effectiveness before it’s rolled out to the entire organization. (See related story, p. 87.)
When McConnell and marketing manager Peter Miller started looking for a centralized appointment reminder system for the Cleveland Clinic, there were already six such systems operating independently of each other in various departments, she says.
An e-mail survey on the no-show and same-day cancellation problem sent to administrators throughout the organization got an immediate and 100% response, Miller adds. "They were very interested, and they wanted to help and to learn about possible solutions."
The systems already in place represented the different departments’ efforts to combat an 11% no-show rate for appointments. "We’re a very large tertiary care facility with 11,000 employees and about 1.5 million patient visits a year," McConnell points out. "Although 11% is a relatively low no-show rate, it means that in our case, 160,000 people don’t keep their appointments," she adds. "That’s a huge problem — an awful lot of lost revenue and idle time, and we’re paying people who aren’t busy."
Some attempts to lower the rate — such as sending punitive letters, requiring deposits, or assessing fees for repeat offenders — proved less than effective, McConnell says. "It’s difficult to collect the money, and if you do, what do you do with it? There’s no accounting procedure in place for individual departments to take in money."
Solutions created new set of problems
The individual reminder systems spawned a new set of problems, she says. With some departments using the systems and others not, patients wondered why they got reminder calls for radiology appointments but not for cardiology appointments, she adds. "Much more often, the patient would say, I got four calls last night from the Cleveland Clinic.’ A lot of people come from out of town and have multiple appointments," she notes. "By the third call, they’re thinking we’re pretty stupid. Even worse, if they get a reminder for one appointment and not the other, they think the second one’s been canceled."
In addition, McConnell says, there is no uniformity to the systems. "Some use your name, others say, You or your family member have an appointment.’ Some allow you to press a button saying you want to cancel, others don’t."
Mailed reminders offered virtually no help, since they are sent only when appointments are made two weeks ahead of time, and most are scheduled only seven to 10 days in advance, she adds. The ultimate goal is to have a dual system, where the telephone reminder is a backup to the mailed reminder or supplants it for the shorter time frames.
Technical support for existing systems might come from down the street or from as far away as Alabama, McConnell points out, and sometimes problems weren’t discovered until patients became very irate. In one case, a system flipped "a.m." and "p.m.," and no one found out until the wrong person got a call in the middle of the night and complained to "someone high up in our food chain," she adds.
After sitting in on a satellite clinic’s meeting with the vendor it had selected for its own reminder system, McConnell says, she and Miller decided it was time to stop adding systems to the mix. They wrote a proposal for a centralized appointment reminder system and presented it to the foundation’s marketing strategy task force, McConnell says. "They got it right away, that we needed to centralize, and said, Go find a vendor.’"
Thus began an intensive, yearlong analysis that included the vendors already on campus and several others, she says. The search addressed issues under the following two categories:
McConnell and Miller discovered that start- up costs, including hardware and training, for an appointment reminder system range from $13,000 to $80,000. "But we found out that if [vendors] were low on the front end, they were high on the back end," McConnell notes. "How they charge is critical."
Some vendors charge by the batch, meaning the customer pays a certain amount for, say, 5,000 calls per month. One vendor who was on the high end in upfront costs charged a flat rate for monthly maintenance, so over time, that vendor likely would cost less. In most cases, she suggests, the flat rate is best. "With a time-specific contract, those charging by transaction fee could come back later with a higher processing fee, and you’re already hooked.
"We tried to figure out what the costs would be if you were making 130,000 calls a month," she adds, which is an estimate of the number of reminder calls that would be generated by the foundation. "Depending on how you figure it, it was $12,000 a month or $21,000. Now we’re talking maintenance costs approaching $200,000 a year."
2. Standard functionality
Under this category, McConnell and Miller looked at the following features:
• Voice quality
"With some vendors, a person at the facility must record the message, while others have a voice library and splice and dice’ sentences together," she notes. Good voice quality was high on the list of priorities for the clinic’s system. "We wanted to know, Does it sound human or computerized?’"
• Call blocking
Another important question was whether calls could be blocked at the department and individual level. Call blocking would allow the organization to prevent calls from going to, for example, psychiatric patients. And, McConnell adds, if patients request that they not receive the automated calls, those patients’ names can be eliminated from the call list. This also relates to the issue of patient privacy, she points out. "You don’t want to embarrass anyone or put anyone in danger or in an awkward situation by making the call."
• Database filtering
McConnell says she was surprised to find that the appointment reminder system of one of the largest vendors did not filter the database to determine if, for example, one patient had multiple appointments the next day. Its system would simply call the patient for each appointment, an alternative that was not acceptable, she says. Other systems had the capability of making one call and listing either the first appointment scheduled or the times of all appointments that day, McConnell adds.
• Bi-directional capacity (outgoing and incoming messages)
At one of the foundation’s health centers, McConnell says, half of all calls are requests for lab results or prescription refills. To significantly free up the telephone, therefore, the system must provide for incoming as well as outgoing calls.
• Interactive response options
How interactive the system could be was another concern. Some systems allow the patient, upon receiving the reminder call, to press a button saying he or she would like to cancel the appointment, while others do not, she notes. Another question is, "Can the patient be connected directly to a real person?"
Here are some questions to ask regarding the system’s operational and technical aspects, McConnell suggests:
• How much manual intervention is required to make this system run the way you need it to? Must someone push a button to start it, or does it happen automatically?
• Is there network connectivity? Can you connect the unit to the network, download or e-mail reports where they need to go, and eliminate paper reports?
• Where is the vendor in terms of product development? Is it a Windows or a DOS system? What version of software is the vendor on? What new products are in the works? Most vendors are working on Web-based applications, McConnell notes. "If you’re working with one who isn’t, that might be a concern."
• What is the maximum number of calls inbound or outbound that can be handled in a day? How many dedicated phone lines do you need?