Third Next Available Appointment - TNA

Third Next Available Appointment – TNA

I heard this term being used in the healthcare circles when I moved from an HMO to a clinical group and wasn't sure what it meant and why does it matter, so I went about exploring the significance of this term and how it matters.

My first interpretation was a literal definition of this term, or sentence. I ended up with the third available appointment slot. This came out to be a pretty accurate definition but still did not make sense as to why do we need to skip the first two appointments. may be to keep slot open for last minute or urgent  appointments, but that would result in two slots being kept vacant for every appointment and that did not make much sense.

So after digging through a few links from google I was able to have a better understanding of the concept, its application and importance in the healthcare setting. The definition basically stays the same:

"TNA is the number of days from the current day to the third available appointment for a physician." 

Essentially, the first two available appointments are skipped, and the reason for this will become apparent shortly as we go further into the concept of TNA. This measure represents how quickly a patient can be scheduled for an appointment with a particular doctor, and this measure gives a good idea of how loaded is the doctors schedule. Simply put, it is a nice way of comparing available appointments (supply) versus appointment requested (demand).

The TNA should be measured at the same time and day at regular intervals (ideally weekly), to see the trend and compare it with other doctors within the practice. Another thing to take care of is to measure TNA by appointment types, for example new patient appointments, annual wellness visits, follow-up visits, etc. should be kept separate. Also, while counting the days, if third next available is available the same day of measurement then TNA is zero, if it is available the next day then it is 1 and so on. Holidays and weekends are generally not counted, but provider's days off are counted. Some practices do include the weekends and holidays to get a true measurement of how soon a patient is expected to be seen from time of appointment request. This is a patient focused approach as against the provider focused when these days are excluded.

High TNA numbers indicate an overloaded schedule and patients healthcare suffer due to delayed availability, and continuity of care is affected too. Target goals for primary care physicians are ideally set at zero and for specialists it is set at 2.

TNA reduction can be achieved by adopting certain measures but these vary from practice to practice:

·                     Have patients call in for next appointment instead of pre-scheduling.

·                     Extend re-visit intervals.

·                     Review current schedule and cancel/remove unnecessary appointments.

·                     Transfer patients to other physicians or APPs within the group.

·                     Use technology to offset face to face interactions/visits: this may include emails, live chats, patient portals, secure messaging, etc.

·                     Utilize patient care teams more effectively for services where interaction with the physician is not deemed necessary. These services may include refills, referrals, labs interpretations and results, preventive care and patient education, etc.

In conclusion, keeping TNA as close to goal as possible gives the physician a healthy work-life balance, the patients get timely healthcare services, and the panel size of physicians can be expanded by delegating certain services to technology and patient care team. Remember, not to use TNA as a tool for patient scheduling.

Team Based Primary Care - Part 1 : Why Team Based makes sense

Patient healthcare in a Primary Care model is owned by the Primary Care Physicians (PCP) as they receive all notes, labs and refill requests for their patients. Patients select their PCPs who then become responsible for every aspect of their healthcare. The workload on a PCP is measured in terms of the "panel size", defined as the number of unique patients under the PCP care. Generally, this count is based on the last 18 months, though occasionally a 12 month period is used. the 12 month period may result in under estimation as not every patient visits their PCP in a given 12 month period.

An ideal panel size under the traditional Primary Care model is about 1000. The US national average panel size for PCPs is about above 2000. The reason for such large panel sizes is the number of PCPs available for the patient population, which is at 1 PCP available for every 1500 patients, and this includes those physicians who are not working full-time.

The demand and supply differential causes variation in panel sizes. Demand is the number of patients seeking primary healthcare services and supply is the number of available appointment slots. Ideal situation is when Demand equals Supply.

Demand = number of unique patients seen by PCP in the last 18 months X visits per patient per year.
Supply = Appointment slots available per day X Provider days per year.

In the current situation with less number of PCPs available and more patients seeking primary care, the demand supply balance is tilted heavily towards demand, and the supply side has to overload themselves to keep it balanced.

One way to balance the panel size is to increase the supply, meaning increase the number of PCPs, which is only possible by a long time concerted and consistent effort and depends  upon more physician willing to join the PCP ranks.

Another option is to offload the PCPs by adding Nurse Practitioners and Physician Assistants to provide primary care by maintaining their own panels. This can be augmented by delegating those services that do not require clinician level training, to non-primary care personnel and to technology. Primary candidates for such delegated services are preventive and chronic care. Hence, it becomes a team based model where a team of care professionals and technology combine to share the load thereby offsetting the imbalance between demand and supply. In a team based primary care model, the panel size can be maintained between 1200 and 1500 for a PCP, which actually corresponds to the current supply of PCPs in the US. 

Additional costs incurred for implementing a team based model are training and technology. Exact numbers would vary depending upon the patient population age and health spread.

Implementing a team based primary care model requires a cultural and structural change in the practice, including clinicians' mindsets, training, re-mapping of workflows and most importantly patient education. Primary Care payment system would also require modification. 

Successful team-based Primary Care healthcare services result in increase in patient satisfaction, better overall health and wellness in the patient community, and at the same time providing a reasonable work life for all members of the Primary Care Team. 

Events, Meetings and Appointments in Outlook

Outlook calendar items can be designated into one of the three categories: Event, Meeting or Appointment. The difference between the three is very simple:

Event: Something that will last the whole day, used when something will utilize the whole day like a holiday, vacation, etc. Used to avoid cluttering/blocking out individual time slots o the calendar which you can still use to add other items such as those listed below.

Meeting: A calendar item will be designated as a meeting if there are other people involved in the event besides yourself.

Appointment: These items involve only you, like a doctor's appointment, block time to work on a project, etc.

Appointment

Meeting

Phone Scan !!!

I have been using Evernote on my phone for a few years now to store images of documents that I needed to archive, and it has great features to convert these into pdf documents and convert to text (OCR). Then I cam across an App called CamScan. This remained my favorite app and I considered it to be the most useful app I had on my phone. It did, and still does a wonderful job of converting captured images of documents into perfectly pdf files, by straightening the skewed images which is a result of phone camera not being perfectly parallel to the document being photographed. However, one limitation that bothered me was that it has a subscription based licensing model for full featured app, and at some point started adding an ink mark, rather a full colored logo on the scanned document which sort of was a way to (Ahem!) force  people to go for the paid subscription. In mu quest to find an equally good free app, I started searching around the app Market Place and found quite a few similar products with a wide range of good to bad reviews. And then by chance I came across an app that pretty much every smart phone (Android) comes pre-installed with, and other platforms (iOS and Windows) also had access to it. This is the Google Drive, when you click on the New icon (a plus sign inside a circle) in the lower right corner from within the Google Drive app, you get the options to create Folders, Google Docs/Slides/Sheets and Upload. Nestled besides these options is the option for Scan. Selecting the scan option open ups your camera and you can take a photo of your document which will be auto-corrected (unskewed, brightened and rotated) as a pdf document. You can save it or redo if the results are not to your liking. Also, you can add more pages to the same file if needed. Make sure you rename the file and select the correct location to save to. Not to be left out, Microsoft added similar feature to its OneDrive app. I will write a more detailed review of the three apps (CamScan, GoogleDrive Scan and OneDrive Scan) or will ask my sons to do that for me and post them here :).

OneDrive Scan

Google Drive Scan

CamScan

Business Intelligence - The Intro

BI Dashboard examples (Click to Enlarge)

Business Intelligence does not have a formal definition but the term is used for a variety of tools and activities used to analyze raw data and present it in a more meaningful and useful format for business analysis purposes.

The term Business Intelligence has been abbreviated to BI and is used alternatively. We will stick to using the abbreviated form BI for representing Business Intelligence in all our Articles, Blogs, Guides and Forums.

BI provides current performance status in relation to past performance and predictive  future views, and provides the target users (business leadership) the ability to modify (slice and dice) and dive deeper (drill down) or summarize (drill up) information. The data becomes even more useful when a comparison to industry specific benchmarks is incorporated.

BI helps organizational leadership to make informed decisions and take calculated risks in both operational and strategic spheres. KPI's can be established and performance can be measured against those. Performance Indicators breaching preset thresholds utilizing easy to read and at-a-glance visuals, can lead to further digging (slicing/dicing and drilling) into the data.



BI information is generally represented as Dashboards, which are collections of related visuals and reports, providing an at-a-glance . Raw data is converted into an OLAP cube. OLAP stands for Online Analytical Processing, which may be defined as a computer based technique for analyzing data and providing insights. Cube is used to define a mutli-dimensional data sets. traditionally a data set has two dimensions , rows and columns. OLAP cubes have more than two dimensions and those with more than three dimension are also sometimes refer to hypercubes. The advantage of cubes is the data is pre-processed and readily available for slicing, dicing and drilling, saving time compared to running queries in real-time against traditional relational data sets.

NULLs in SQL results Export to EXCEL

I was working on a project to export some data into a tab delimited file. Initially, we did some test files and it was simple enough to use a select query and export the results to a text file by right clicking the top left box of the results pane. However, the recipient indicated that the file had NULL columns with the text string 'NULL' in them which interfered with their processing. They requested us to remove the NULL string and instead pass on these fields as blank. I found a free tool called FnR, for Find and Replace, which replace text strings with whatever value is specified. It was all working fine till they asked us to send a full file with more than half a million records. FnR refused to work and would time out. I generated a command line command, another useful feature built into FnR, and tried that, but no joy. So i went to my trusted friend Google and asked for solutions. I found that this has been a very common issue and many people had asked for a solution, only t get lectures on what they are doing wrong and long debates of what DBAs and Analysts  deemed best practices. Some workable solutions were also discovered in the process, but when dealing with a large number of fields it becomes impractical to use REPLACE or COALESCE commands with every field to check if it contained a NULL and then replace it with blanks. While the debate lingered on from forum to forum, the person asking the question would eventually bail out due to frustration without getting a proper solution to their problem. I did however came across one suggestion that wasn't given much attention of using the query to export the results to text, rather than the right click process I was following. I decided to give it a try and, viola, no more NULL strings.