Changing the Way We See Patients

By Michael P. Horan, MD, DDS, PhD

Three nontraditional programs adopted by the Oral and Maxillofacial Surgery Section at Cleveland Clinic are allowing us to provide our patients with improved access to care by making better use of their time. The three programs are shared medical appointments (SMAs), virtual postoperative appointments (VPAs) and image sharing. The Oral and Maxillofacial Surgery Section is the first in the country to use SMAs and VPAs.

Shared satisfaction

Cleveland Clinic introduced SMAs more than a decade ago as an innovative way to efficiently provide care to small groups of patients who have similar medical issues. In brief, SMAs are 1.5-hour sessions that include approximately six patients.

SMAs were initially used to manage patients with chronic diseases such as diabetes and heart failure. We have adapted the SMA format to meet the needs of our patients who require third molar surgery, and soon we will be conducting SMAs for patients with temporomandibular joint (TMJ) disease and for others with obstructive sleep apnea.

During each SMA, one of our clinician moderators discusses the etiology of our patients’ condition as well as potential surgical and nonsurgical treatment options. For those patients who are candidates for surgery, we review the risks and benefits of surgery, as well as alternatives. Since chronic TMJ disease and obstructive sleep apnea can have a significant impact on the quality of life of the entire family, we invite family members to join us. In such a group setting, it is not uncommon for a freewheeling but focused discussion to ensue among all the participants. Discussions are typically led by the clinician who is moderating the session, and they provide patients and family members with an excellent opportunity to ask questions, gather information and be engaged.

Following the initial discussion, patients divide into two groups. One group undergoes individualized examinations with the clinician while the other group takes the opportunity to discuss with the clinical support staff what they can expect on the day of surgery or other treatment. When the first group has completed their physical examination evaluations, the groups switch roles. At the conclusion of the SMA, patients can schedule their surgery if they wish and if surgery is indicated.

Based on national satisfaction surveys, patients are more satisfied with SMAs than with traditional consultation appointments. Our own surveys confirm this finding, particularly our patients’ satisfaction with appointment access and our sensitivity to their needs (Figure 1). Overall, the number of SMAs at Cleveland Clinic is projected to rise from 1,211 patient visits in 2011 to 7,500 by the end of this year (Figure 2). SMAs are being used by 67 providers in 15 institutes at Cleveland Clinic.

Dialing, not driving

VPAs represent another way that we provide patients with better access to care. These appointments allow selected postop patients to “telecommute” to their follow-up appointments from whichever location they prefer, be it their workplace, school or kitchen table. No longer do patients have to take time off to travel to Cleveland Clinic and back for a 15-minute postoperative evaluation. These visits can now be completed remotely during the patient’s lunch hour or break.

VPAs are typically reserved for patients who have undergone minor surgery associated with low complication rates. These procedures include dental implant placement, allogeneic alveolar bone grafting for ridge augmentation, adjunct implant procedures and biopsies. In addition, they can be used for some patients who have undergone TMJ surgery.

Using any camera-equipped mobile device (e.g., cell phone, tablet, laptop) or desktop computer, patients can participate in a HIPAA-compliant videoconference with their clinician. The clinician is able to do everything that would normally be done during a traditional postop visit except for a hands-on clinical exam. If the clinician has any concerns about the patient’s recovery, an in-office visit can then be scheduled.

Figure 3. Our survey of VPA patients shows that the vast majority of users are pleased with the program.

In an in-house survey, most patients reported a high level of satisfaction with their VPAs, particularly those who would otherwise have to travel a significant distance to keep an appointment (Figure 3).

Sending scans ahead

In another effort to take advantage of the convenience of personal telecommunication devices, the Head & Neck Institute is participating in an image exchange program. This system allows our patients, as well as referring physicians and dentists, to transmit imaging studies (e.g., plain films, CT scans, MRIs, PET scans) to our HIPAA-compliant imaging server. Once an image is uploaded, our clinicians and radiologists have the opportunity to review and consult with each other prior to meeting with the patient. The advance preparation means patients enjoy a more efficient use of their time during their appointment. This is particularly helpful for patients who have a complex medical/surgical history.

Dr. Horan is Section Head of Oral and Maxillofacial Surgery. He can be reached at 216.636.4329 or horanm@ccf.org.