Join the Internet revolution: Using electronic communications (Proceedings)

Each day across the United States, we leave work late due to an overload of work, much of which is self-imposed. These late nights take their toll on our staff and us. Too often, the clinic leaders fail to recognize the situation before it's too late. This chronic stress leads to embittered employees contemplating vacating their jobs, an employer oblivious to the dissent in her team and clients and patients who pay the price by experiencing poor client service and patient care from an over-worked and stressed-out veterinary healthcare team.

Keeping employees late is one of the key influencers in creating poor staff morale and high employee turnover. It is our duty as good stewards of our teams to ensure that they aren't over-worked and stressed-out. With that in mind, we must be sensitive to our employee's needs and creative in solving the challenges that cause our staff members to stay late after-hours completing certain tasks.

In addition to improving our employees' quality of life and enjoyment of work, we must discover new and better ways of performing the same tired tasks. Routine telephone calls and much of the one-way client communications we perform could perhaps benefit from re-invention. More importantly, if we could be more consistent in our client communications we could bolster client loyalty leading to increased satisfaction and referrals. And so I sat out to look for ways to redefine our common clinic-to-client communications using some of the more recent exciting technological.

One of the biggest time vacuums and morale busters in a busy veterinary practice is performing telephone call-backs after-hours. While this is an essential service that helps distinguish veterinary care from other medical services, we cannot perform it at the expense of our team's quality of life. We knew that a large percentage of our telephone calls were being left on answering machines, often multiple times without ever hearing back from the client. Over a year ago we began experimenting with technology to aid us in more effectively performing this valuable service and saving staff time. While this experiment is far from concluded, we have learned several valuable lessons and have enriched our relationship with our clients by providing better, more consistent communication strategies.

We targeted email as our first foray into virtual clinic-to-client communications because it was easily accessible, low-cost, simple to implement and widely used by our clients. According to the Pew Internet Project's February 2007 survey, over 211 million Americans report that they use the internet and 47% of American adults have broadband internet at home. We knew from our online store, online appointment scheduling and our other website services that internet-based communications were becoming increasingly popular. Our database of email contacts and the success of our email newsletters proved to us that our clients would be likely to accept this new form of communication and so we began to plan.

The first step we took was to employ email as a means of communicating with clients about their pet's recent medical visit. We used our existing call-back triage system to determine what types of client contacts would be appropriate for an email application. For example, a call-back on flea allergy dermatitis was deemed appropriate for email correspondence while acute pancreatitis was not.

Once we established basic guidelines for email versus telephone contacts, we began experimenting with the email "call-back" system. We first verified our client's current email address and asked them for their communication preference regarding their pet's condition. We asked if they would be interested in receiving follow-up information and inquiries about their pet's diagnosis by email. The vast majority of clients responded that they preferred to be contacted by email. We were surprised by the number of clients who remarked they preferred email over an evening phone call, unless it was an emergency. We were further impressed at the large number of internet-savvy senior citizens who had fully embraced the computer culture. We then entered a reminder in our practice management software system linked to a diagnosis that generated an email in a specified time period. For a flea allergy dermatitis case, we simply replaced a forty-eight hour phone call with a forty-eight hour email. The first email "call backs" sent simply asked how the pet was feeling and if they had any questions regarding their pet's condition, treatment or follow-up care. We attached information about the condition below the message. These first emails were very generic but served the purpose to see how effective this new mode of communication would be and if clients would use it.

The results were impressive. We received responses from over eighty percent of our "care-mails" during the first month. More importantly, we reduced the number of telephone call-backs dramatically. Instead of fifteen to thirty telephone calls a day, we were making ten or fewer calls. Staff morale soared and the attitude toward making telephone calls improved. What had once been a dreaded duty became what it was intended to be: a compassionate and concerned inquiry about a serious condition.

When we received a care-mail response, we cut-and-pasted the response directly into the patient's electronic medical record. Fast, easy and permanent. We discussed the service with several clients and the general consensus was positive. We have continued to evolve and enrich our system over the past year and are excited at the opportunities and savings this new tool has created.

Once we determined that our care-mails were well-received, we began looking for other ways to communicate with our clients. Our goal is to call our clients one to two days before a scheduled appointment. Our success rate was directly related to staff member's available time and ambition. In other words, it was spotty at best. Missed appointments cost veterinary practices big bucks. According to human medicine practice management studies, the average MD loses approximately $150,000 per year in missed appointments. This leads to the common practice of double- and triple-booking in human medical practices resulting in long waits, rushed appointments and decreased patient loyalty. In my practice, with less than 10% no-shows, it still costs us tens of thousands of dollars per year. Automated telephone reminder systems are helpful, but out of my budget. And so we began to dabble in email appointment reminders. Since we couldn't link our appointment scheduler with an email reminder (sounds logical to me!), we had to be cleverer than our software programmers. We started by entering an invoice code linked to an appointment reminder for all follow-up visits. If we wanted to see an osteoarthritis case for a recheck exam and blood tests in one month, the client would receive two emails reminding them of their upcoming appointment. We've also started adding email reminder codes for the next year's annual examination, follow-up blood tests, and so on.

We continue to mail postcard reminders for these long-range appointments and at this time view the email system as an adjunct to our well-established and proven postcard system. The email reminders cost us nothing and are a means of re-training our clients to look for virtual correspondence from us as opposed to paper and stamps. Since these reminders are very basic, they currently only indicate that the pet has a follow-up examination soon and to email or call if they have any questions about their appointment or need to change the day or time. Granted, these are a pale comparison to the slick systems used by large human hospitals that are tied to their appointment scheduling software, but it's a start for a small animal veterinary clinic.

It's too early to conclude how effective this system is. Our no-show rate is very low and we only occasionally have clients call or email to clarify or change an appointment in response to an email. We continue to call and remind certain clients about specific appointments on an as-needed basis. Our immediate gains have been in removing yet another time-intensive task that yielded a questionable return. Instead of ditching the appointment reminder telephone call service, we replaced it with a less expensive, more consistent client contact opportunity utilizing new technology.

Another key application that has been very well received is the ability to email test results, diagnostic plans and additional information to clients. Many years ago we started "prescribing a website" by providing clients with a handout of trusted and reliable internet information sites. Today we email that list along with any other patient discharge information. We often use email to communicate with clients during office hours to share digital radiograph findings, blood and urine test results, photographs of lesions, discharge instructions and even to schedule discharge times. This type of communication is often more reliable and takes less time than the telephone to contact and update busy working clients. This type of communication is used for minor and straightforward cases. An email is typically prefaced by a telephone call from a doctor or staff member promising additional information and details in the electronic message. This type of communication has also proven valuable when discussing a more serious case over the phone. I'll often email the results before I call and then have the owner look at the x-ray or photograph of a lesion virtually "with me" as I outline my treatment or diagnostic plan. This enriches the experience and keeps the owner well-informed and allows them to better understand the need for a given test or treatment. Another unexpected use came when we were able to use email to quickly alert our staff and clients about the pet food recall. Electronic communication allows a clinic to reach hundreds or thousands or clients effectively, quickly and cheaply in a manner no other communication system can match. Get creative and experiment with ways you can use electronic messages to connect with your clients in ways you've never been able to before.

Atlanta-based software company Sea Change Health has created a laptop-based system that helps veterinarians and their staff record physical examination, test results and diagnoses and creates personalized discharge reports and automatic email follow-up messages and surveys. This program allows the veterinary healthcare team to select the client's communication preference of home phone, cell phone, email or text message or a combination for follow-up contacts. This program creates a unique opportunity to develop two-way electronic communication with our clients. Sea Change Health promises to usher in a new era of technology to improve efficiency and efficacy within the appointment and subsequent follow-up communications. We can expect more innovative software solutions in our profession as the demand for ways to do more for our clients with less staff increases.

As we gained confidence with using email to communicate with clients, we began exploring other ways to stay connected to our clients. According to a June, 2007 Harris Poll and the Centers for Disease Control July to December 2006 National Health Interview Survey, what do over 75% of American adults have in their possession and is turned on over 90% percent of the time? Their cell phone, of course. The holy grail of practice-to-client communication is the cell phone. This is the most direct, personal and effective way to communicate with the vast majority of Americans. American Idol brought text messaging awareness to tens of millions and the iPhone promises to transform the internet experience into a handheld device. As the general public gets more and more usage out of their cell phones, we must be poised to take opportunity to leverage this technology to our advantage.

It's already happening in the human healthcare industry. Orlando-based Cellminder launched over a year ago with an automated reminder system utilizing cell phone technology to contact patients about upcoming appointments. The system is even more robust in that it will alert patients if their doctor is running behind schedule, needs to reschedule due to an emergency or inclement weather or to offer an earlier appointment due to another patient cancellation. This is an exciting product and I hope that it will become affordable and accessible to the veterinary clinic in the near future.

I was fortunate enough to hear the founder of Cellminder speak a little over a year ago. As he shared his vision of future physician-patient communication, I reflected on what we were attempting and how I could incorporate some of his company's ideas into my practice. The first step we took was improving our communication with our surgery and dental patients' owners. Many times we were calling to update clients on the status of blood tests and other pre-anesthesia test results during mid-morning. Often we were unable to speak with our clients because they are working, traveling or otherwise inaccessible. We brain-stormed and everyone acknowledged that they checked their text messages during work, dates or other events. We concluded that it was universally acceptable to quickly read a text message as opposed to making a phone call or checking voice mail. And so we began asking clients if they'd like a text message updating them on the progress of their pet throughout the day. We assured them that the text message would be used if everything was going well and that if there were any problems or questions we would call. We found that the majority of working clients and busy parents, clients with golf outings or bridge matches quickly took our offering. We used a clinic cell phone used by doctors and would use Short Message Service (SMS) to send messages such as "From Seaside Animal Care: Pre-op tests complete – all normal. Proceeding to surgery soon. Call 910-579-5550 w/questions." or "Dental complete. Will call to schedule discharge soon. Call 910-579-5550 w/questions." These messages were stored in our phone with other common text statements to speed the process. This simple act saved employee time, allowed us to more consistently and effectively communicate with our clients and ultimately provide better care and service.

We have since experimented using SMS with daily updates on boarding patients, complete with photos upon request (and additional fee), contacting those hard-to-reach clients about test results or appointments, reminders to give heartworm and preventives, and even to inform clients about the availability of earlier appointments. While we're a long way from a fully automated system such as Cellminder, we been recently exploring Google's free Send to Phone SMS service as well as other free internet based SMS applications.

The newest and least explored frontier is video conferencing. As this technology becomes more accessible, expect to see patients virtually in the near future. This will prove to be a boon to behaviorists who can watch in real-time the disturbing behavior of an affected pet patient, to clients that want their veterinarian to "see" their dog limping or a close-up of a tapeworm in their feline's feces. This new tool will bring with it challenges of how to charge for these consultations, the legalities involved with virtual examinations and balancing the ever-increasing demands of an "always on" society.

This is largely uncharted territory and we're all a bit like pioneers in the technology wilderness. I am excited of the unique opportunities presented by these emerging technologies. My medical philosophy is to use the latest advancements in the most compassionate manner. My business philosophy is to provide the best in patient care and client service and retain optimal profitability. The future of practice-to-client communications is clear to me: clients want to be in close communication with their veterinarian and other healthcare providers and are willing to embrace new technologies to preserve that connection. I believe that we can make bytes personal and warm and use them to bring us closer to our clients rather than relying on over-worked and rushed staff to perform duties they abhor. A hurried, uncaring, disengaged, "I'm so ready to go home" phone call from your clinic may be causing more harm than good. Get creative, explore new technologies and develop a strategy to best serve your staff and clients. In the end, what matters most is that we demonstrate our commitment to helping the people that love pets provide the best care possible regardless of whether or not that is a phone call, email, text message or video conference. This is a truly exciting time for our profession and the people who love pets. For more information and for staff training DVDs and training materials, visit www.E3Management.com.