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Elevating the patient experienceA five-step strategy

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Consumers are demanding more across every sector of the economy, and healthcare is no exception. Patients want the same experience they get everywhere else: easy access to services and information, cost transparency, excellent customer service, and the ability to make a personal choice.


A Holistic Approach To The Patient Experience ................................................................ 6

Healthcare, Meet Your New Patient ..................................................................................... 7

Where Systems Are Failing ..................................................................................................... 8

Table Of Contents

The Alarming Cost to Healthcare Organizations of Not Getting the Patient Experience Right ...................................................................... 11

Customer service ...............................................................................................................................9The under-recognized role of front line personnel ....................................................................9Appointment lead times ....................................................................................................................10Referral breakdown ............................................................................................................................10

Patient leakage .....................................................................................................................................11No-shows ..............................................................................................................................................11Provider burnout .................................................................................................................................12Referral gaps ........................................................................................................................................12Lost Patient Payments .......................................................................................................................12


5-Part Strategy for Elevating the Patient Experience ....................................................... 13

Take Stock ................................................................................................................................. 17

A Patient Experience Solution ............................................................................................... 17

Reference Guide ....................................................................................................................... 18

Customer service ...............................................................................................................................9The under-recognized role of front line personnel ....................................................................9Appointment lead times ....................................................................................................................10Referral breakdown ............................................................................................................................10

Patient leakage .....................................................................................................................................11No-shows ..............................................................................................................................................11Provider burnout .................................................................................................................................12Referral gaps ........................................................................................................................................12Lost Patient Payments .......................................................................................................................12

Look for a comprehensive solution. ...............................................................................................13Provide excellent, personalized customer service ......................................................................13Address physician needs and preferences for patient encounters. ...................................... 14Enable smart outreach and scheduling. ........................................................................................14Blend technology with live support. ...............................................................................................14


Holistic Approach To The Patient Experience

Successfully meeting patient’s needs begins with a holistic view of the patient journey. The patient journey extends far beyond the actual visit, and includes patient outreach, pre-visit interactions with providers and staff, and post-visit follow-up. A healthcare organization’s ability to deliver the best possible experience at every touch point of the journey will determine whether or not patients show up for their visits, and drives patient loyalty. The ultimate goal of managing the patient experience is to serve patients well for a lifetime while keeping providers and administrative staff focused on delivering great care.

Looking at the patient journey as a whole, and supporting each point along the way, can drive patient satisfaction, staff engagement, and better clinical and financial outcomes.

Patients are increasingly shopping for healthcare services, and seeking the best possible overall experience when they need care. As a result, leading hospitals are growing profitability not by cutting costs, but by improving patient experience and satisfaction.1

- Jean-Pierre Stephan, managing director of Accenture’s customer-relationship management offerings

As more and more healthcare dollars are at risk for wellness and patient experience, we need to start thinking about the patient’s entire journey, not just each episode of care. Patients need a foundation from which they can connect all the dots of their healthcare experience. Patient access services will play a key role in the future of medicine.

- Dr. Alfred Belding, in family practice at Northwell Health


Healthcare, Meet Your New Patient

Health systems can no longer stand by while patients struggle to get convenient appointments, understand costs, and navigate care.

Patients are starting to exert their power by making more demands on the provider-patient relationship—and seeking more convenient care if their needs are not met. Healthcare organizations are feeling the impact of these expectations, even if they don’t know it yet. In fact, most patients now expect to be treated the same way they are treated in their daily interactions with retailers. Most patients search online for provider reviews and ratings, and are likely to switch providers if they do not receive the customer experience they expect.

More than ever, patients are looking for convenient care with great customer service. Consider retail clinic growth: there are over 2,300 healthcare clinics in retail pharmacies today, and the figure is expected to grow to 3,000 by 2020.4 One study concludes that “retail clinics are becoming increasingly popular options for those seeking care… offering convenience, high-quality care and favorable prices compared to an ER or doctor’s office visit.”5 This is especially true for the younger generation of millennials.

You see the pattern in every other industry: people are much more discerning about the value of what they buy. Why should healthcare be immune? 3

- Dr. Rod Hochman, president and CEO of Providence St. Joseph Health

Consumers hold healthcare organizations to the same standards as any other business Expectations regarding “great customer service,” “making life easier,” and “delivering on expectations” are almost identical across healthcare and non-healthcare companies.2

Source: McKinsey

As millennials age and have increasing contact with the healthcare system, they will form connections with the organizations that provide the right offerings and support. There is now real opportunity to tailor offerings and create with millennials the sort of emotional connection that is at the heart of loyalty. 6

- Helen Leis, partner in the Health & Life Sciences practice of Oliver Wyman


Where Systems Are Failing

Few organizations have an enterprise-wide view of where their non-clinical services are falling short—and even fewer know what to do about it.

Research shows there are four key areas of the patient experience where health systems are having the most trouble. Targeting these areas can bring real improvements.

Getting the patient experience right

YES NO

Pre-visit

• Are patient scheduled quickly based on preferences?

• Do they receive reminders based on preferences?

Revenue increases, schedule density is improved and your no-show rate drops.

Revenue suffers due to high-no show rate and poor schedule utilization

Registration

• Patients arrive with all necessary information and per-authorized completed?

• Are they aware of obligation and pay at time of visit?

Patient satisfaction in-creases making them more likely to pay and return. Denials decline.

Patient satisfaction suffers, payments aren’t processed, denials increase, and the waiting room experience is negatively impacted.

Exam

• Does clinical staff have all patient information they need?

• Does staff provide12 hrs focusing on care versus data entry or responding to complaints?

Patient satisfaction increases, patient loyalty improves, on-time visits are more likely

Patient satisfaction drops, loyalty suffers, and wait times increase

Follow up

• Was the patient scheduled for follow-up care based on preferences?

• Is a system in place to ensure they receive their care and know how to pay?

Satisfaction and quality scores increase, leakage decreases, and more payments captured

Higher patient turnover, lower quality scores, difficulty securing payment


YES NO

Pre-visit

• Are patient scheduled quickly based on preferences?

• Do they receive reminders based on preferences?

Revenue increases, schedule density is improved and your no-show rate drops.

Revenue suffers due to high-no show rate and poor schedule utilization

Registration

• Patients arrive with all necessary information and per-authorized completed?

• Are they aware of obligation and pay at time of visit?

Patient satisfaction in-creases making them more likely to pay and return. Denials decline.

Patient satisfaction suffers, payments aren’t processed, denials increase, and the waiting room experience is negatively impacted.

Exam

• Does clinical staff have all patient information they need?

• Does staff provide12 hrs focusing on care versus data entry or responding to complaints?

Patient satisfaction increases, patient loyalty improves, on-time visits are more likely

Patient satisfaction drops, loyalty suffers, and wait times increase

Follow up

• Was the patient scheduled for follow-up care based on preferences?

• Is a system in place to ensure they receive their care and know how to pay?

Satisfaction and quality scores increase, leakage decreases, and more payments captured

Higher patient turnover, lower quality scores, difficulty securing payment

Customer serviceCustomer service is patients’ chief frustration with their healthcare experiences. A 2016 study, published in the Journal of Medical Practice Management, reveals that 96 percent of patient complaints are related to customer service, while only 4 percent are about the quality of clinical care or misdiagnoses.7

While efficiency is an important component of customer service in healthcare, empathy could be even more critical. One study pointed out that answering a call quickly was less important than the “friendliness” of staff and getting needed information.8 Overall, getting better service is the number one reason why patients switch practices—above even the office or patient moving locations or the desire for better care.9

The under-recognized role of front line personnelAdministrative staff—including a healthcare system’s call center—often have long-term interactions with patients. They are the first to greet patients, the last to see them out the door, and the ones who follow up. For administrative staff, getting things right has important implications. They set the tone for the patient experience and can put a patient at ease, generating patient trust and satisfaction.10

But health systems are only beginning to consider phone and front desk staff as part of the care team. One study points out that Veterans Health Administration (VHA) clerks’ contributions, often unrecognized, improved care coordination, access, and the delivery of patient-centered care.11

Unfortunately, patients often have less than optimal experiences with these administrative processes. In fact, 12 percent of complaints in the Vanguard study were related to rude treatment by front desk staff.

Communication and Appointment

Process53% Waiting Room Wait Times35%

Deloitte pointed out that the role of a contact center is becoming much more important in healthcare, as it serves to deliver an integrated experience across the major contact points in the patient’s lifecycle. But while 85% of organizations view patient experience provided through contact centers as a competitive differentiator, only 50% of organizations believe that the contact center plays a primary role in customer retention.12

Asking administrative staff to deliver excellent customer service is a tall order. One study identified the complex emotions that front line administrative staff are called upon to manage, often without specialized training. On top of an already overwhelming front desk environment, they are typically the first and last contacts for patients facing illness and recovery.13

Customer Service Complaints


Referral breakdownReferral management is an important part of the patient experience and coordinating care, but half of all patients are at risk for slipping through the cracks. According to the Institute for Healthcare Improvement, more than 100 million subspecialist referrals are requested each year in ambulatory settings across the country, but only half of those referrals are completed.20

Patients face multiple barriers following through with a referral. There is the perplexing authorization process, long wait times for appointments, and confusion around required testing and documentation. In about one-quarter of cases, patient records from one provider do not reach another provider in time for the appointment. Studies have found that up to 50 percent of referring physicians did not know whether their patients had seen the specialist to which they were referred. Similarly, up to 45 percent of referrals result in no communication from the specialist back to the referring provider.21

The nearly unanimous consensus is that in terms of impact on patient satisfaction, the waiting room trumps the exam room. 19

- Ron Harman King, CEO of Vanguard

Appointment lead timesLong wait times to appointments lower patient satisfaction, increase no-show rates, and increase use of emergency departments.14 For example, one study showed that same-day appointments had a no-show rate of less than 10%, but next day appointments had a no-show rate of 15%, climbing to 20% for appointments within a week, and eventually rising to over 30% for appointments a month or more away.15 More than just decreasing no-show rates, scheduling appointments promptly can increase patient satisfaction. One study found that switching from a traditional scheduling system to a system that allowed more access to same-day appointments improved overall patient satisfaction from 62 percent to 90 percent.16

There are clear benefits of scheduling appointments promptly, but few health systems do so. It now takes an average of 24 days to schedule a new patient physician appointment in 15 of the largest cities in the U.S., up by 30 percent from 2014 to 2017. Average wait times are even longer in mid-sized metro areas—32 days. About one-quarter of Americans have to wait six days or more for a medical appointment.17 In addition, almost two-thirds of patients find that it is very or somewhat difficult to get after-hours care.18

Less than 10% no-show

Next day 15% no-show

Climbing to 20% no-show in a week

Climbing to 30% no-show in a month

0 5% 10% 15% 20% 25% 30%

Long wait time cause same-day no-show to climb in a monthLong wait times to appointments lower patient satisfaction, increase no-show rates, and increase use of emergency departments.


The Cost of Not Getting the Patient Experience Right

Poor patient experiences can cost health systems much more than low patient satisfaction scores. Health systems that lack a coordinated approach to the patient experience can rack up significant finan-cial and clinical costs.

Patient leakagePatients are more empowered to switch providers when they feel their needs are not being met. In a 2017 survey, 24 percent of baby boomers (ages 52-70) had switched practices within the past year. And 54 percent of millennials (ages 21-34) had switched in the past two to three years. Further, millennials and generation Xers (ages 35-51) reported that they were very likely to switch physicians in the next few years (43 percent and 44 percent, respectively).22

Just a few dissatisfied patients who publicly complain about a poor experience can be a considerable drain. An Advisory Board study estimated that one 370-bed hospital system was forfeiting $700k in new patient revenue because of negative word-of-mouth and migration of dissatisfied patients.23 Research suggests that each patient represents $200,000 in lifetime income for the typical practice. Even a single patient lost due to a poor patient experience is one patient too many.24

Leakage is a hot term these days and for good reason. Patients should be entitled to see the provider of their choice. But from a system perspective, we’ve invested a lot in building up our network of physicians, and we like our referrals to stay within that network.

- Dr. John D’Angelo, senior Vice President and executive director of emergency medicine, Northwell Health

No-shows No-shows wreak havoc on daily schedules, and exacerbate underutilization of medical equipment and personnel. Missed appointments can delay disease detection and follow-up, which may ultimately lead to complications, unnecessary suffering, and costly hospital admission.

In one study, no-shows and cancellations represented about 31 percent of overall scheduled appointments at a large family practice center with an estimated total annual revenue shortfall of 3 percent to 14 percent. Another study estimates the average cost of a no-show at $196 per patient. 25 Although no-shows might temporarily free up provider time, they are a huge drag on health systems.


Provider burnout

Patients’ experience is directly linked to provider satisfaction. It is upsetting to both physicians and patients when patients are angry and stressed about office wait times, reimbursement issues, and sub-optimal customer service. When physicians have to address patient’s frustrations about non-clinical issues (known as “service recovery time”) they have less time and energy to focus on the work they were trained to do. Service recovery time detracts from the clinical experience, and imposes an undue burden on physicians, which increases the likelihood of burnout.

Physician burnout creates tremendous financial loss for medical practices and health systems. For example, it costs between $500,000 and $1 million to replace an existing physician.26 Even if burned out physicians do not leave, their organizations suffer losses when dissatisfied physicians see fewer patients, go part-time, or provide lower-quality care.

Referral gaps The referral process often results in frustration and risk for both patients and providers. “Some patients give up on receiving care altogether, while others seek care outside the network,” say management consultants at ECG. “Today this results in significant lost potential downstream revenue. In tomorrow’s value-based world, the ability to keep patients in network will have a larger-scale impact, with financial penalties attached to patients exiting the system.”27

Addressing referral gaps can improve care as well as revenue. In an NIH-funded study, providers who adopted a “guided primary care” approach to following-up on referrals decreased total healthcare costs by 11%, with an average net annual savings of $1,364 per patient.28

As an ED doc, I rarely get feedback about how my patients do after I see them. And an important part of our clinical growth is not just thinking about one episode, but how you impacted a person’s care long-term. We now have a centralized patient access center that can make those connections and do it at the time that we have the patient in front of us. That’s a critical piece of ‘systemness’ that will help us survive in the future.

- Dr. John D’Angelo, senior Vice President and executive director of emergency medicine, Northwell Health

Lost patient payments

The payment process is another key area of patient dissatisfaction and cost to the health system. Many health systems do not have an enterprise-wide system to manage the payment process, including very little infrastructure to conduct prior authorizations, insurance verifications and co-pay collection before each appointment. This can lead to unpleasant payment surprises at the office visit, chaotic front desk experiences, and significant uncollected patient obligations.


A 5-Part Strategy for Elevating the Patient Experience

As an industry, we need to do better. We must facilitate our patients’ smooth journey through the non-clinical aspects of care. The following five-part strategy aims to provide a superior patient experience. It has been tested by healthcare organizations across the country—with a proven track record for success.

Look for a comprehensive solution

Organizations need a centralized, coordinated approach to building lifetime relationships with the right mix of patients. That means implementing an end-to-end solution that encompasses proactive outreach, better scheduling, visit prep, follow-up, and ongoing communication and care coordination.

Patching problems with individual services such as automated reminder calls or population health software isn’t effective. This approach doesn’t allow an organization to see the big picture of patient engagement, proactively target and follow up with high-risk patients, identify and address care gaps, strategically plan for growth, track results, and improve where needed.

There is significant benefit to finding a partner that can take on administrative work on behalf of the system. This allows the system to access dedicated expertise, such as a contact center, that they don’t have the capacity to develop and manage themselves, while getting a centralized solution instead of piecemeal services.

And a system-wide solution needs to easily integrate into existing EMR and PMIS software. Look for services that seamlessly support the patient experience, helping providers and staff be more efficient, instead of adding to an already significant administrative burden.

Provide excellent, personalized service around each appointment

Every patient touch point before and after the visit needs to be carefully optimized. This means having the ability to identify and address the individual needs and preferences of patients across their entire journey through the health system. Health systems should provide:

• Easy, prompt scheduling with the right provider at the right time

• Communication via the channels that patients prefer, such as online, texting or email, with the frequency they want. For some patients, this might mean multiple channels

• An intuitive, easy-to-use customer interface, just like the consumer products patients are used to

• A human touch to complement technology, with trained, empathic staff available to assist with every step in the patient’s journey


Address physician needs and preferences for patient encounters

Physicians need the right support in order to deliver great care to patients. In order to ensure success, health systems need to provide physicians with:

• Scheduling that responds to their preferences for the type and number of appointments each day

• A patient mix based on their skills and specialties

• Insight and control over daily appointments and workflow

• Patients that arrive prepared, so the visit can be about care, not administrative problems

• Support in helping patients adhere to post-visit care plans

Enable smart outreach and scheduling

Health systems must attract and retain the right patients for their providers and facilities. Technology should be leveraged to ensure that the right patients are matched with the right providers at the optimal time. Artificial intelligence, data gathering, and UX design should be used to proactively identify patients in need of care, surface available appointments, and link patient/provider needs and preferences.

Find a solution that ensures that patients are prepped for their visits—arriving on time, with all clinical and payment information gathered so that clinical staff can focus on delivering great care. This same solution should help ensure that patients get all the follow-up care they need, and are compliant with their care plans.

Blend technology with live support

Technology alone can never be the solution. Human support, especially staff trained to serve in a healthcare setting, must always be available to complement technology-enabled patient services. As research has indicated, patients often need a human touch that technology—no matter how customized and targeted—can’t deliver on its own. In order to provide the best possible human support, health systems need the ability to scale up during busy times regardless of their own internal capacity. Therefore, organizations need a solution that can provide flexible backup support, or even take on all pre-visit and post-visit administrative tasks, to reduce staff workload. Finding the right combination of intelligent technology and best-of-breed support staff is the foundation for successfully managing the patient experience.


CASE STUDY

During a period of rapid expansion, Northwell Health needed a way to avoid losing the cohesion their patients had come to expect. Patients, providers and staff became unhappy with the lack of standardization, particularly around administrative processes like appointment access, payment and referrals.

“We’ve seen about 65 percent growth in top-line revenue over the last five to six years,” said Gene Tangney, Senior Vice President and Chief Administrative Officer of Northwell Health. “Patients saw us as one entity, but they couldn’t call one number and talk to somebody who had knowledge of the whole system. It created a lot of confusion for patients trying to access services.”

At the same time, providers struggled with a lack of communication across the growing system. Practices were either under- or overbooked, and did not have easy insight into their patients’ progress after an office or ED visit. Patient complaints rose and satisfaction scores dropped.

Northwell knew they needed a comprehensive approach to the patient experience—a solution that worked for providers, staff and patients. They partnered with Formativ Health to take on a significant amount of patient contact on behalf of the health system.

Formativ Health implemented a centralized, holistic service that provided a single point of contact for patients across the enterprise. With a blend of in-person support and intelligent technology, Formativ Health took on the work of identifying and closing scheduling gaps, connecting patients with in-network referrals, and conducting pre-visit registration and insurance verification. The service was able to provide customized support to every office, accommodating individual physician scheduling and appointment preferences, and could flex to accommodate busier times.

Front desk and clinical workflow improved, patient complaints declined and provider and staff engagement rose. Patients who were frustrated about access are now able to speak with a trained, empathic operator, and front desk staff are no longer confronted with daily administrative chaos.

“Our clerical staff now have the time to have conversations with patients—to welcome them, and deal with their questions and anxieties,” said Mr. Tangney. “We can redeploy some of those staff towards making sure that each patient moves seamlessly through the practice. Are their blood tests being organized? Are their CAT scans being scheduled? Now, when patients leave each practice, they know exactly what they need and it’s already booked.”

Continued on the next page

Hospitals23

Hospital & long-term care beds

6,500+Affiliated physicians

15kOutpatient facility650

NORTHWELL HEALTH


Physicians are now scheduled with the patients and appointment types they prefer. And each patient arrives fully briefed on payment expectations with necessary records in hand. “Physicians understand their day,” says Nick Stefanizzi, chief administrative officer at Formativ Health. “Because of the centralized contact center, patients arrive prepared with the distinct set of questions and expectations each physician requires. We’ve pulled the noise out of the patient experience. So the patient and the physician can focus on the clinical encounter, unencumbered by unnecessary paperwork.”

Even better, the solution did not require a significant capital expenditure and fit right into existing PMIS and EMR systems. That translated into significant return on investment for the system.

“On average, Northwell has seen anywhere from a five to a 22 percent increase in patient volume without adding new providers,” says June Scarlett, chief patient access officer for Formativ Health. “They’ve also seen a prevention of leakage. Patients are remaining loyal simply because we’re there as a conduit to get that patient from one provider to a specialist within the same system.”

They have also been able to boost revenue with simple pre-visit procedures. “We consistently verify insurance at the outset, so there are far fewer denials on the back end,” says Ms. Scarlett. “So in addition to adding patient volume, we’re adding patient revenue because we’re now preventing those patients who show up with the wrong insurance, and we collect more patient responsibility up front.” Long-term, this solution will support the system’s cohesive growth, boost patient and provider engagement, help with proactive outreach campaigns, and ultimately free up revenue to invest in programs that serve the mission.

increase in patient volume

increase in already-busy

primary care offices

overall increasein booked

appointments

Including

22%

7%

6%

When patients show up at one of our facilities, they are seeking help for a clinical condition. They shouldn’t have to worry about looking through their wallet for their card or trying to make a co-pay. So we do everything we can to eliminate obstacles to a good experience—before, during and after each visit.

- Gene Tangney, senior vice president and chief administrative officer of Northwell Health


Take Stock

Organizations need a holistic approach to the patient experience, or they will suffer the financial and clinical consequences that come with failing to serve patients well.

The good news is that getting this right will:

• Increase revenue with more “booked and kept” appointments, reduced leakage, and full patient payment

• Strengthen staff, provider and patient satisfaction and loyalty

• Keep the focus on clinical care, not administrative work at the time of appointment

• Create lifetime relationships with satisfied patients

It’s time to take stock—and take action.

• What are the pain points in your patients’ non-clinical experiences?

• How is patient and provider loyalty suffering?

• Where are you losing revenue?

• How is burnout affecting your providers and front desk staff?

• Do you have the information and tools at hand to improve to the patient experience?

Interested in learning more? Visit formativhealth.com or call us

today at 844.818.1020

A Patient Experience SolutionFormativ Health makes it easier for patients to schedule, keep, and pay for appointments by clearing the administrative barriers to high-quality service.

That makes for happier patients, and providers who have the breathing room they need to deliver excellent care.


Reference guide

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ence/#399a5fc30955 4 http://www.ccaclinics.org/images/PDF/CCA_IncreasingAccess_2017.pdf 5 https://www.bcbs.com/sites/default/files/file-attachments/health-of-america-report/BCBS.HealthOfAmericaReport.Retail.pdf 6 http://www.oliverwyman.com/media-center/2017/jun/-what-do-millennials-want-from-health-reform--more-.html 7 https://www.beckershospitalreview.com/hospital-management-administration/patients-no-1-complaint-front-desk-staff.html 8 LaVela and others, “Optimizing Primary Care Telephone Access and Patient Satisfaction,” Evaluation and the Health Professions, June 2011. http://journals.

sagepub.com/doi/abs/10.1177/0163278711411479?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed&9 https://altarum.org/sites/default/files/.../CCCHCResults03_LikelihoodSwitch_0.pdf 10 Samantha L. Solimeo, Greg L. Stewart, Gary E. Rosenthal. The Critical Role of Clerks in the Patient-Centered Medical Home. Ann Fam Med. 2016 Jul; 14(4):

377–379. doi: 10.1370/afm.1934. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4940470/ 11 Samantha L. Solimeo, Greg L. Stewart, Gary E. Rosenthal. The Critical Role of Clerks in the Patient-Centered Medical Home. Ann Fam Med. 2016 Jul; 14(4):

377–379. doi: 10.1370/afm.1934. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4940470/ 12 https://www2.deloitte.com/content/dam/Deloitte/global/Documents/Life-Sciences-Health-Care/gx-us-lshc-enterprise-contact-center-providers.pdf 13 https://www.sciencedirect.com/science/article/pii/S0277953611001791 14 J Ryu and TH Lee, “The Waiting Game—Why Providers May Fail to Reduce Wait Times,” NEJM, June 15, 2017. 15 “Large-Scale No-Show Patterns and Distributions for Clinic Operational Research,” Healthcare (Basel), March 2016.16 Tulli and others, “Improving Quality and Patient Satisfaction in a Pediatric Resident Continuity Clinic Through Advanced Access Scheduling,” J Grad Med Educ,

2010. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2941381/ 17 Osborn and Schoen. 18 Commonwealth Fund, International Profiles Table 3, page 8, 63 percent.19 https://www.advisory.com/daily-briefing/2016/04/28/top-patient-complaints 20 https://www.aafp.org/news/practice-professional-issues/20180130ehrreferrals.html 21 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3160594/ 22 https://www.solutionreach.com/rethinking-the-patient-provider-relationship23 https://www.advisory.com/technology/iround-for-patient-experience/infographics/4-hidden-ways-patient-experience-may-be-costing-you 24 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3047732/ 25 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4714455/ 26 http://www.medicaleconomics.com/medical-economics/news/calculating-financial-costs-physician-burnout 27 http://www.ecgmc.com/thought-leadership/articles/harnessing-the-power-of-your-physician-network-through-centralized-referral-management 28 https://www.ncbi.nlm.nih.gov/pubmed/19670959