The telephone in primary care

Developing and Evaluating a Radio-Linked Telephone Helpline for Hispanics

The goal of this research was to develop and evaluate a Spanish language telephone helpline staffed by bi-lingual nurses, to assist Hispanic people make knowledgeable, skill-based health and medical care decisions. The helpline was directly linked to educational vignettes broadcast on Spanish language radio. The radio program and helpline provided four main services to listeners and callers: 1) advice on routine medical concerns; 2) guidance and behavioral suggestions on chronic disease prevention; 3) information about cancer screening and treatment; and 4) references to local Spanish-speaking health care services. We broadcast one year's worth of five-minute educational radio programs three times each weekday on Spanish language radio in the greater Washington-Baltimore and San Francisco-Oakland metropolitan areas. Nurses staffed the helpline telephones on week nights, and data were collected from each call ( n = 1,569). Main findings are that Hispanic people: 1) do listen to health messages on the radio, and 2) will call a health professional for information.

Care Offered by an Information-Rich Pediatric Acute Illness Connected Care Model

BACKGROUND AND OBJECTIVES

Prevailing regulatory and financing issues constrain dissemination of connected care despite evidence supporting acceptability, effectiveness, and efficiency. In this analysis we describe care provided over a 12-year period by Health-e-Access, an evidence-based, information-rich, connected care model designed to serve children with acute illness. We demonstrate the broad clinical capacity of this care model and key components imparting this capacity.

MATERIALS AND METHODS

Since 2001, Health-e-Access has been used in childcare, elementary schools, neighborhood after-hours sites, and a school for children with severe disabilities in Rochester, NY. With Health-e-Access, videoconference (preferably) or telephone enables parent, patient, and provider engagement. Technology includes the capacity for acquisition and exchange of a broad range of clinical observations, qualifying Health-e-Access as an information-rich model and differentiating it from multiple other connected care models commonly labeled telemedicine. Primary diagnoses recorded for completed visits were classified according to resources (technology, personnel, examination type) required to complete encounters appropriately.

RESULTS

Among 13,812 Health-e-Access visits initiated through June 2013, 98.2% were completed. Capacity for ear-nose-throat examination and close inspection of eye and skin were sufficient to identify positive findings supporting 95.2% of primary diagnoses. Videoconference and stethoscope were considered essential for observations required to rule out serious conditions often presenting in similar fashion to these 95%.

CONCLUSIONS

Health-e-Access included technology essential for establishing diagnoses, ruling out more serious conditions, and identifying problems beyond its scope. Regulations enabling and financing incentivizing replication of similar connected care models would benefit families and communities substantially. Observations challenge regulatory bodies and payers to support connected health services of comparable value.

Payment for telephone care

Telephone care in pediatrics requires medical judgment, is associated with practice expense and medical liability risk, and can often substitute for more costly face-to-face care. Despite this, physicians are infrequently paid by patients or third-party payors for medical services provided by telephone. As the costs of maintaining a practice continue to increase, pediatricians are increasingly seeking payment for the time and work involved in telephone care. This statement reviews the role of telephone care in pediatric practice, the current state of payment for telephone care, and the practical issues associated with charging for telephone care services, a service traditionally provided gratis to patients and families. Specific recommendations are presented for appropriate documenting, reporting, and billing for telephone care services.

Caller satisfaction with after-hours telephone advice: nurse advice service versus on-call pediatricians

OBJECTIVE

To compare caller satisfaction with after-hours medical advice provided by a for-profit nurse advice service with advice provided by on-call pediatricians.

METHODS

The study setting was the general pediatrics faculty practice of an urban university medical center. Participants were parents or guardians of a population of approximately 6000 children calling for after-hours medical advice over a 10-month period from January 18 to November 20, 2000. After-hours medical advice calls were randomized to either a nurse advice service or the on-call pediatrician. Caller satisfaction and subsequent health care utilization were measured by a telephone survey of callers and review of all health care visits within 3 days of the initial telephone advice call.

RESULTS

Five hundred sixty-six (48%) callers were enrolled in the on-call pediatrician group, and 616 (52%) were enrolled in the advice nurse group. Caller satisfaction was rated as very good or excellent significantly more often for the on-call pediatrician than for the nurse advice service as follows: telephone call overall (68.5% vs 55.0%; 95% confidence interval [CI] of difference: 8.0%-19.0%), thoroughness and competence of the person they spoke with (74.0% vs 59.1%; 95% CI of difference: 9.6%-20.2%), courtesy and friendliness of the person they spoke with (77.4% vs 73.9%; 95% CI of difference: -1.4%-8.4%), length of time spent waiting (70.8% vs 60.1%; 95% CI of difference: 5.4%-16.2%), time spent talking with the on-call pediatrician or advice nurse (68.2% vs 52.4%; 95% CI of difference: 10.2%-21.3%), and the medical advice given (68.6% vs 53.9%; 95% CI of difference: 9.2%-20.1%). Compliance with the advice given was significantly higher for office care in the on-call pediatrician group (51.5% vs 29.6%; 95% CI of difference: 8.9%-34.2%). Repeat calls for advice were significantly more frequent for the nurse advice service, both within 4 hours (13.0% vs 4.8%; 95% CI of difference: 5.0%-11.4%), and within 72 hours (23.4% vs 13.3%; 95% CI of difference: 5.8%-14.5%).

CONCLUSION

Callers were less satisfied with medical advice provided by a nurse advice service compared with the traditional on-call pediatrician. The lower satisfaction was associated with somewhat poorer compliance with recommended triage dispositions and more frequent repeat calls for medical advice.

Specialty referrals made during telephone conversations with parents: a study from the pediatric research in office settings network

OBJECTIVES

To characterize variation in pediatricians' telephone referral practices, to identify differences in the types of referrals made during telephone versus office visit encounters, and to examine the impact of referring by telephone on coordination and outcomes of the referral as assessed by physicians.

METHODS

We conducted a prospective study of a consecutive sample of referrals (N = 1856) made from the offices of 142 pediatricians in a national practice-based research network. During 20 consecutive practice-days, physicians completed questionnaires about patients referred during regular business hours. They used office records 3 months later to complete questionnaires about referral outcomes.

RESULTS

Pediatricians made 1 telephone referral every 5 practice-days, which constituted 27.5% of all referrals they made during office hours. Pediatricians who saw more patients per day, saw more patients in gatekeeping health plans, and referred more during office visits made more telephone referrals than their counterparts. Compared with specialty referrals made during office visits, those occurring during telephone encounters were more frequently at the request of parents or because of insurance administrative guidelines. Office visit referrals were more often made for diagnostic evaluation or a surgical procedure. Referrals made during telephone conversations were less well coordinated: office staff or referring physicians scheduled fewer specialty appointments and were less likely to send information to specialists. Three months after referrals were made, specialist feedback and referring physician satisfaction with specialty care were comparable between the two groups.

CONCLUSIONS

Specialty referrals made during telephone conversations with patients are a regular occurrence in pediatric practice. Changes in the health system that lead to greater demands on primary care physician productivity or more patients in gatekeeping health plans will likely increase the number of referrals made during telephone conversations with parents. Pediatricians are less likely to coordinate telephone referrals than office visit referrals. Pediatricians are frequently unaware whether or not referrals are completed.

Telephone medicine for internists

The role of the telephone in medical practice is important, but often problematic. Mistakes in telephone diagnosis and triage can have severe consequences. An effective office system can reduce liability risks, and in some cases telephone contact can substitute for office visits. Internists feel unprepared to provide telephone care. Therefore, residency education needs to focus on documentation, consultant availability, and performance feedback. Research should focus on improving outcomes, reimbursement issues, and technologic advances. This article describes internists' telephone interactions with ambulatory patients, preparation for telephone medicine, and aspects of office telephone systems and makes comparisons with other primary care fields.

Telephone triage and consultation: an emerging role for nurses

Telephone triage and consultation is increasingly being used to counsel patients about the appropriate level and timing of care. Nurses are becoming the most frequently used health care professionals providing this care. Although roles vary, consensus is emerging about role definition, scope of practice, and use of protocols. Professional associations and state boards of nursing are examining critical issues related to licensure and standards of practice. Nurses who practice telephone triage and consultation indicate that it is an exciting and demanding specialty with unique issues related to quality, documentation, amount of experience necessary, information resources, and supportive technology. The issues reported by practicing nurses are not necessarily those reported in the literature (e.g., liability, licensure, and practice standards). Developing or modifying current standards of practice needs immediate attention from professional nursing groups, as does the issue of licensure. Nursing educators need to be aware of this emerging role and prepare their students to function competently in this area. Finally, researchers have a rich and varied field of study around this new practice field and its impact on patient care and outcomes.

Telephone nursing interventions in ambulatory care

Telephone nursing practice is becoming a major nursing activity in ambulatory care settings, yet little is known about the type and extent of nursing interventions that occur during telephone interactions. A pilot study was conducted in two sites to see whether nursing diagnoses and interventions could be captured and related to nursing care during telephone consultation. This initial pilot demonstrated that nurses have an appropriate role in telephone interactions and that standardized nursing language can be used in telephone nursing to document nursing care despite the many challenges in its use in the field.

Ambulatory obstetrical care: strategies to reduce telephone liability

The telephone will become the centerpiece of ambulatory care services. As such, a pertinent aspect of office procedures will necessarily include a protocol to manage and document telephone calls. Encourage your office staff to use good telephone manners, as listed in Table 5. The net result should be a reduction in telephone liability risks and an enhanced reputation for your office.

Telephone medical care administered by internal medicine residents: concerns of program directors and implications for residency training

The objective of this study was to determine the need for telephone medicine curricula and to help define important content for internal medicine residencies using scales that measure program director attitudes toward telephone medicine. Data were collected by surveying all 416 program directors of accredited internal medicine residencies in the United States. We applied factor analysis to develop reliable attitudinal scales and employed regression models to identify predictors of these attitudes. Response rate was 60%. Formal training for telephone medicine was available in only 6% of programs. The factor analysis showed three attitudinal concepts; all described marked program director discomfort with aspects of resident telephone prescription. Predictors of improved program director comfort included more frequent documentation of resident telephone calls, chart availability, and clear definition of resident roles pertaining to telephone interactions with patients (P < 0.02 for all predictor variables). These results identify a need for telephone curricula and suggest components that might alleviate program director discomfort with resident telephone practices.

Physicians' opinions on compensation for telephone calls

OBJECTIVES

To describe the attitudes of pediatricians and other physicians practicing in a fee-for-service environment toward compensation for telephone encounters with patients.

DESIGN

Survey by mail.

PARTICIPANTS

The 67 pediatric and 634 other private physicians and medical school faculty of Albany County, NY.

RESULTS

A total of 479 of all the physicians (68.3%) and 55 of the pediatricians (82.1%) returned the questionnaire. Of these, 69.9% of the total (95% confidence interval, 65.5% to 74.1%) and 58.2% of the pediatricians (95% confidence interval, 44.1% to 71.3%) indicated physicians should be compensated for calls with patients, especially for after-hours calls. This opinion was significantly associated with greater concern about liability for calls, more negative sentiments about after-hours calls, and a longer reported duration of calls. After adjusting for these factors, surgeons and pediatricians were significantly less likely to favor compensation than the group as a whole. Pediatricians in favor of compensation suggested charging a mean of $9.18 (SD $5.05) for 1 to 5 min, $14.00 (SD $8.87) for 6 to 10 min, and $22.27 (SD $12.62) for >10 min. Pediatricians reported documenting in patients' charts a mean of 35. 3% (SD 39.9%) of after-hours calls.

CONCLUSIONS

In a mostly noncapitated environment, the majority of pediatricians and other physicians favor compensation for telephone calls with patients. Some specialists, in particular pediatricians and surgeons, are, however, less likely to support this. Additional research into the reasons for these interspecialty differences may help to guide policy decisions on the financing of health care.

The telephone in primary care

The telephone, a ubiquitous instrument in the practice of medicine, continues to have new applications for clinical practice. The goals of the ever-increasing managed care environment appear to fit nicely with these applications. Heightened attention toward telephone education, protocol development, and documentation are needed. This article reviews characteristics of telephone encounters, the telephone in managed care, trends in "telemedicine," telephone education, and medicolegal aspects of telephone care.

Telephone medicine: a general internal medicine experience

While a substantial number of patient contacts with internists occur over the telephone, there is little information about the nature and content of these encounters. The authors surveyed patient-initiated phone calls that resulted in a physician response for seven general internists. Over a six-month period, 1,377 telephone encounters met inclusion criteria. Calls were generally short, 73% lasting 4 minutes or less; mean time per call was 3.4 minutes. The doctor spoke to the patient directly 79% of the time and to a relative in 15% of the calls. The most common reason for phoning the doctor was a symptom or medical complaint (45% of all calls), followed by questions about test results (16%) and medication queries (14%). Over 60% of calls dealt with chronic conditions. Diagnoses encountered over the telephone were similar in frequency to those seen in outpatient clinic visits; however, a notable proportion of calls dealt with topics beyond the scope of traditional internal medicine training programs. A medication response was the reason for 22% of the phone calls. The doctors recommended changes in follow up 12% of the time; these included early visits to the clinic, evaluation in the emergency room, and direct admission to the hospital. An appreciation of the scope of telephone medicine in terms of both medical skills applied and time committed is germane to trainees and practitioners alike.

Access to emergency departments: a survey of HMO policies

An unresolved question related to the practice of health maintenance organizations' (HMOs) controlling access to medical care is whether such screening of patients seeking emergency department treatment impairs efficient patient care or endangers patients. A preliminary study was undertaken to determine whether so-called gatekeeping of access to EDs was common practice. Medical directors of HMOs in 39 states and the District of Columbia were surveyed by a mail questionnaire to assess policies regarding ED access. There were 98 (80.3%) respondents to 122 questionnaires, representing 26% of all federally qualified HMOs in the United States. Of the 98 respondents, 90 (92%) used the distinctions "life-threatening" and "nonlife-threatening" in defining their ED access policies. In life-threatening situations, members were permitted to go to any hospital without calling the gatekeeper first. In nonlife-threatening situations 78 of 98 (80%) required that permission be obtained prior to an ED visit. Most required a telephone call; nonphysicians could act as gatekeepers in 46 of 78 (59%). Thirty-nine percent of the 98 respondents limited their members to using the EDs of certain hospitals only. Ninety-four of 98 (96%) reviewed all ED visits prior to making any payment. We discuss here the implications of these gatekeeping policies.

Rational decision making based on history: adult sore throats

Primary care physicians are often required to make preliminary evaluations based only on the patient's history, especially during telephone encounters about sore throats. The authors studied adults with sore throats to determine whether patients can be stratified into higher and lower risks of strep throat by history alone. They first obtained data from 517 patients seen in an emergency room. Providers graded symptoms on a four-point scale (absent, mild, moderate, or severe). Initial analyses showed that prediction based on history should include three variables: fever, difficulty in swallowing, and cough. For ease of computation, these were consolidated into one score, "history" (= fever history + difficulty in swallowing - cough). This score was used to develop a model that predicts the probability of infection with group A beta-hemolytic streptococcus, and the model's performance was tested in two additional patient groups. The predictive accuracy of the "history" score was confirmed in all patient groups, despite differences in providers and disease prevalences. Primary care physicians may use this model to help them make decisions in situations such as telephone encounters without using additional data.