SironaHealth's Medical Call Center Blog

We live in the "information age" where we have near unlimited sources of information available at our fingertips. Whether we search the internet, watch television on demand, or download the latest novel as an eBook, consumers have become accustomed to getting the information they need, when they need it.

For an inbound, consumer driven program, such as a call center based physician referral service, it is essential to provide the consumer with all of the relevant information they need during the course of one phone call. Here are three ways to increase the value of your referral program by "pumping up the volume" of information that call center agents can share with consumers:

1. Layer Clinical Expertise onto the Program.  If your physician referral program is staffed by non-clinical agents, how can you be sure that they won't be asked a clinically related question that they can't answer? For example, "My PCP told me I have diabetes and should see a specialist, but I don't know what kind of specialist to see?" Some clinical inquiries can be addressed by providing agents with basic training on clinical terminology and reference materials, but if you want to really add value to your program, consider having a clinical resource available (Nurse, Physician, etc.) who could answer any questions that the referral specialist cannot.
   
   If possible, make this resource available through secure instant messenger to allow the non-clinical agent to obtain an answer without interrupting the call, or putting the caller on hold.
   
   
2. Cross-Promote. Once you have a consumer on the phone who is engaged, it is essential to take full advantage of that opportunity to make the consumer aware of other programs, services, and information that might be relevant. For example, if a caller is looking for a Cardiologist, it would be a good time to suggest a Healthy Heart Screening that is going on in that area. Be sure to utilize a tool that can suggest relevant information based on the caller's demographics (age, gender, address) as well as any unique knowledge that you might know about their healthcare needs. Take full advantage of the consumer's interest by completing a class or event registration while the consumer is on the phone, or confirming an e-mail address for follow-up materials to be shared.
   
   
3. Customize the Experience. No one wants to be treated with a "one size fits all" approach. It is important to offer small ways to customize the experience for the consumer. Would they like a confirmation mailed via regular mail, or e-mail? Would they like driving directions to a location from their home or office? Are there any unique events going on in the consumer's geographic area that can be suggested, "Did you know that there is a flu shot clinic next month at the urgent care center in your town?" Find ways to tailor the referral experience to the caller and use those preferences in future interactions.

Telehealth services, like nurse advice lines, help patients find the answers and guidance they need to make smart decisions about their health and where to seek care. But what is it like for the RNs who answer the calls? SironaHealth's Susan Miller (a Registered Nurse) speaks with HealthDay News' Dennis Thompson about the types of calls received and how telenurses help patients save money and provide peace of mind.

By Dennis Thompson (HealthDay News) -- The nurses who staff a health-care call-in line never know what the next question might be.

"We get calls from folks who have gotten lab results from their doctor and don't know what they mean, or they see something on TV about a condition or medication and want more information," she said. "We get calls from people who are having symptoms. Sometimes it can be something as simple as a cold or sore throat, but it can range all the way up to someone with crushing chest pain or who has just spilled a pot of boiling water."

Susan Miller, a registered nurse in Morristown, Tenn., takes such calls. Miller works as a clinical supervisor on a nurse advice line for SironaHealth, a nationwide medical call center based in Portland, Maine. She manages a team of 16 triage nurses, only six of whom she's ever met face-to-face. They all work from home.

The nurses take calls from patients who need medical information. Their company provides the service for a variety of health-related businesses, including health insurance companies, hospitals and private physicians.

"The client, whoever it is, will provide their patients with a toll-free number and give them information about the fact that the nurse line is available," Miller said.

This sort of service is highly touted by medical consumer groups, who say people can save themselves money by calling a nurse before heading to the emergency room or doctor's office.

The nurses affiliated with Miller's call center work eight-hour shifts, and the call-in lines are open 24 hours a day, seven days a week. Miller said the calls taken by her and her nurses vary widely.

"You never know what the next call is going to be," she said. "You don't know if it's going to be a routine information question, or someone considering suicide, or someone with chest pain, or someone worried about H1N1. It could just be anything."

About 60 percent to 65 percent of the calls Miller and her team receive involve problems that can be handled with home health care, she said. Many pediatric calls are like that, she said; the mothers and fathers just want to be sure they're doing right by their baby.

"The most rewarding thing is talking to the callers," Miller said. "Ninety-nine percent of the time you make them feel better, no matter what the call was all about, even if it's just reassuring them that they are doing the right thing. They are so grateful to have someone who will listen to them and help them break things down into pieces of information that make sense to them."

Nurses are busiest during cold and flu season, she said. Then they'll field five to six calls an hour apiece. Day shifts tend to be slower because doctors' offices are open and people looking for advice often call there first.

One of her proudest moments on the job came early in the five years she's been with SironaHealth, Miller said. An elderly woman just diagnosed with diabetes called her for help.

"She was in tears because she was so scared," Miller said. "The doctor had diagnosed her, gave her medication and syringes, and told her to go take care of it. They hadn't really taught her what the insulin does and what you have to look for. They hadn't taught her about diet or exercise, or what to do when she got sick."

Nurses typically spend about 10 to 12 minutes on a call. Miller took 45 minutes to help the woman calm down and better understand what she needed to do for her health.

"She was so much calmer and felt so much more capable of handling this when we finished up the call," Miller said. "I wish I knew how she was doing. I feel that way with many of our callers, but we can't take the time to follow-up like that. There's always another person waiting on the phone."

Copyright © 2010 HealthDay. All rights reserved.

Atul Gawande's, The Checklist Manifesto, is a discussion of an industry's difficulty in addressing patient safety. It is also a clear and reasonable path to patient safety improvement.

The primary thesis of this book is that medicine could dramatically improve patient safety if it borrowed and implemented checklist methodologies that are used with stellar success in industries such as aviation and large-scale construction.

One of the most distressing points the book makes is regarding simple handwashing. Almost two hundred years after it was statistically proven that handwashing saves countless lives, clinicians are still struggling with compliance (in fact, a May 2010 study indicates that clinicians complied with handwashing guidelines less than half of the time). According to Gawande, this lack of discipline extends into the Operating Room, where he describes complex tasks that must be highly choreographed between many professionals in order to produce positive outcomes that have no script or checkpoints.

Gawande further points out that basic process definition–control and learning–which is common to every industry engaged in complex systems, has not really taken hold in the practice of medicine. Those who do master the checklist, such as the Swiss clinic described in the book that saved a drowning child, were awe-inspiring. They had drilled for the event like an Olympic team and when it came time, the training saved the child.

Gawande notes inconsistencies in thinking about safety that are bewildering. For example, ninety-three percent of physicians surveyed wanted checklists used if they were on the operating table, while twenty percent question their value when operating themselves.

What is surprising to a layperson is that process control appears to be at the clinician's discretion. This would be akin to every commercial pilot having their own landing approach protocol -- or none at all.

Gawande's analytical strength is his lack of "not invented here" or "we are different" mentality. He is not above asking a construction foreman or engineer how high quality is achieved in their respective disciplines.

I became interested in what the impact is of our inability to share knowledge across industry segments -- especially segments that involve many people and complex systems. To bring things into grim perspective, let's look at the mortality rates in three industries:  

• Automotive: According to the Nation Transportation Safety Board, there are about 37,000 fatalities involving automobiles annually in the U.S.
• Medicine: According to the Institute of Medicine, about 100,000 people die from medical errors annually in the U.S.
• Aviation: According to the Nation Transportation Safety Board, there were no U.S. commercial airline fatalities in 2007 and 2008, but there were 45 fatalities in 2009 from a single crash.

Even when we apply a denominator consisting of the number of people involved in each industry yearly, the message is the same.

From a quality and safety perspective, Aviation and Medicine have much in common. In both fields, safety is largely determined by the individual and/or collective decisions of those operating the process. There is one significant difference: the pilot rides in the front of the plane.

What happens when Aviation checklist standards are applied to medicine? Gawande sites an eight-city, 4,000 patient study using surgical checklists that produced a 36% drop in complications and a 47% percent drop in fatalities. The study was sponsored by the World Health Organization and involved locations around the globe under varying conditions and across many surgical procedures.

Despite the efficacy, Gawande points out resistance remains, much like hand washing. For the most part, we are left to speculate why the industry wouldn't embrace a process so obviously successful.

Reaction to The Checklist Manifesto has not been neutral. Steve Levitt, co-author of Freakonomics, said this book "honestly changed the way I think about the world. It is the best book I've read in ages." The book should not only change our outlook, but should inspire a little outrage regarding our own intransigence toward the simplest of life saving innovations.

At SironaHealth our registered nurses use guidelines to triage patients. Guidelines are a form of checklist. They are essential to setting standards for patient safety from which we can measure the quality of our decisions. They are being constantly refined by their authors, Dr. Barton Schmitt and Dr. David Thompson, based on feedback from millions of patient interactions. I can't fathom the chaos and process blindness that would exist without them.

Photo credit: http://gawande.com/the-checklist-manifesto

Contrary to popular belief, a recent study has found that most patients who visit the emergency department (ED) four or more times a year have health insurance and a primary care provider (PCP).

Long assumed to be driven by low-income uninsured or underinsured patients, repeat ED super-users have been a significant, and chronic, source of unnecessary healthcare spending in the United States for years. These "frequent flyers," who account for 21% to 28% of all ED visits, routinely visit the ED seeking non-emergency care that would be better provided in the urgent or primary care setting.

In their review of 25 independent studies, Drs. LaCalle and Rabin challenge that "widely held assumptions about the patient population who frequently visits EDs, and their reasons for visiting, have not been, for the most part, supported by research on the topic."

• Emergency departments experienced a 36% increase in patient volume from 1996 to 2006.
• "Frequent flyers" (>4 ED visits per year) account for 21% to 28% of all ED visits.
  
• Uninsured patients represent only 15% of ED "frequent flyers."
  
• 60% of ED "frequent flyers" carry Medicare or Medicaid coverage.
  

Drs. LaCalle and Rabin also point out that frequent ED users are more likely to have a primary care physician (95% of pediatric patients have an assigned PCP) and that the primary reasons for choosing the ED was due to the lack of availability of their PCP and the knowledge that the ED was always open.

How do these new findings impact your ED diversion strategy?

If the majority of ED "frequent flyers" have health insurance -- and subsequent access to health plan sponsored resources like 24x7 nurse advice lines, managed care programs, and case management services -- then the de facto decision to visit the ED may have less to do with insufficient access to healthcare resources and more to do with the fact that patients just don't know that other options exist.

Patients have become hardwired to immediately head to the ED when they are experiencing an issue with their health--whether it's a true emergency or not. A relatively cheap and easy way to improve your ER diversion programs is to increase your promotions and build top-of-mind awareness of already available decision support services.  

Another big implication of Drs. LaCalle and Rabin's study is that if the majority of ED "frequent flyers" are insured, then Medicaid, Medicare, and commercial health plans are ideally positioned to have the most impact on reducing the costs created by ED "frequent flyers." 

One way is to use claims analysis to identify patients who have utilized the emergency department 4+ times over the last year. Once identified, RNs can conduct outbound calls to:

1. Coach users on the appropriate use of the emergency deprartment.
   
2. Promote decision support services like your nurse advice line.
   
3. Evaluate the need for structured care management and enroll as appropriate.
   
4. Provide information on alternative healthcare resources.

It's clear there needs to be more research done on who over utilizes the ED and why, but Medicaid, Medicare, and commercial health plans have an opportunity to proactively engage members who are prone to ED overuse and educate them on their healthcare options. 

Although you may already be involved with the healthcare and medical call center industries, sometimes the numerous acronyms used can still throw you off. Certainly some of these seemingly hodgepodged letters are quite challenging to the newcomer. In an effort to help you save some face when presented with these phrases, here are some common acronyms used in reference to medical call centers and what they stand for.

CALL CENTER QUALITY

QA - Quality Assurance
QC - Quality Control
URAC - Utilization Review Accreditation Commission
NCQA - The National Committee for Quality Assurance
HIPAA - Health Information Portability Act
PHI - Protected Health Information
JCAHO - Joint Commission on Accreditation of Healthcare Organizations
HEDIS - Healthcare Effectiveness Data and Information Set

CALL CENTER METRICS

ASA - Average Speed of Answer
CHT - Call Handle Time
ABN - Average Time to Abandonment
ATB - All Trunks Busy

Common Metrics Phrases that aren't Acronyms

Average RN Call Back Time
Average Blocked Call Rate

MEDICAL CALL CENTER

NAL - Nurse Advice Line
DM - Disease Management
CM - Care Management
AHL - Audio Health Library
CRM - Customer Relationship Management
PRM - Patient Relationship Management
WFM - Workforce Management
RTS - Rapid Triage Screening
MSR - Medical Service Representative
RN - Registered Nurse
CBT - Computer Based Training
TED - Triage Encounter Document
TDD - Telecommunications Device for the Deaf
VoIP - Voice Over Internet Protocol
EMR / EHR - Electronic Medical Record / Electronic Health Record

Many of these phrases are most likely to pop up in call center related articles, websites, conferences, meetings, etc. It is important to know the meanings since you can quickly lose sight of what you are reading or listening to if you don't understand the industry lingo.

Do you have any additional medical call center related acronyms to add? Feel free to post in our comments section!

And just for fun:

SNAIL - Slimy, Noctornal Animal Invading Lettuce

You've created a series of health and wellness programs designed to teach your patients how to stay healthy. Your wellness events cover a broad range of topics, everything from heart health seminars to parenting classes to medication adherence. You've even implemented an easy to use registration process that utilizes your health call center, website registrations, and mobile application. In short, you've become a master at teaching patients about their health and recruiting them to register for your health classes, events, and webinars.

So why aren't more of your registrants actually showing up?

Getting consumers to register for an event isn't enough. People are busy, schedules change, and the chaos of day-to-day life can make people forget all about your health seminar (no matter how great it is). In order to get them to attend, you'll need to remind them. 

1. Agent Reminder Calls - Conducting an outbound reminder call before the event is the tried-and-true method for improving participation rates. These 2-3 minute outreach calls can be automatically scheduled by your health contact center whenever a consumer registers for an event -- whether it be by telephone or your website. In addition to offering a friendly reminder of an upcoming event, these calls offer your participants the option to adjust their registration, ask additional questions, and receive driving directions or log-on instructions to the event. 
   
   
2. Automated Notifications - Similar to the reminder message delivered by your health service representatives, these automated calls utilize sophisticated interactive voice technology to provide registrants with information about their upcoming event. At anytime during the message, users can be immediately routed to your health call center for additional help.
   
   
3. Email Reminders - If you are capturing email addresses during the registration process, email reminders can be a very effective way to keep your events top-of-mind. Just like your reminder calls, your health contact center can automatically email reminders to your registrants.

Use a combination of these methods to improve your attendance rate.

The best way to ensure your registrants will actually show up is to use a combination of these tactics. For example, immediately after someone has registered for an event (say for a hospital-sponsored diabetes management class) they should receive a "thank you for registering" email from the hospital, which provides a summary of the class and a reminder to add it to their calendar. This should be followed by another email 5 days before the class, a reminder call the day before, and if they are attending a virtual class, another email 1-hour before the event takes place. 

By incorporating reminders into your registration strategy, you greatly increase the likelihood your patients will show up. But even with all of these reminders, not all of your registrants will attend. For those who don't make it, a follow up call with dates/times of repeat classes will help get them in door.   

What other tactics have you used to improve your participation rates?

The value in offering a nurse advice line seems intuitive -- patients can speak with a healthcare professional from the comfort of their home whenever they like and ask questions about specific health concerns, a medication they are taking, or determine whether a trip to the emergency room is necessary. But if you are a manager responsible for your company's nurse advice line, how do you know that the program is operating successfully? How do you get the most out of every dollar that you invest?

Having the right reporting is key to ensuring program success. It will help you make smart decisions on how to promote the service and identify areas of improvement. Below are five data points you will want to monitor closely.

Who is calling?

Reporting should be able to tell you the demographic make-up of those who are utilizing the service -- gender, age, zip code, insurance type, etc. Knowing who is utilizing the service tells you which demographic segments perceive value in the service (e.g. new mothers) so that marketing efforts can be tailored to increase the utilization from these segments. Knowledge related to who is calling also tells an important story about who is not calling. For example, knowing that you are not getting calls from seniors could lead to a targeted marketing campaign related to health concerns affecting seniors.

What are patients calling about?

What are the top health questions and concerns that callers have? Are calls symptom based or informational only? Are callers utilizing an audio health library component of the service? Reporting should indicate how callers are using the service. The answers to these questions can help to determine whether callers are using the service appropriately, and whether there is an opportunity to promote specific health topics that patients might benefit from, but may not be aware of today. For example, if no concerns related to medication questions were reported, there may be an opportunity to promote the nurse advice line as a source for information in medication questions and concerns.

Are there access issues?

For a nurse advice line program to be effective, patients need to be able to access the service without delay. Look at your program's average speed-to-answer (ASA) for incoming calls and look at the percentage of calls that hung-up or were abandoned before being answered. URAC standards indicate that on a monthly basis, the ASA should be 30 seconds or less and the abandonment rate should be 5% or less. Most importantly, make sure that your nurse advice line is supported by a robust quality program that focuses on the individual patient experience.

Are there redirection savings associated with the program?

A key measure of the value of a nurse advice line program is the redirection savings associated with the program. To determine redirection savings, a caller is asked what they would have done if they did not have access to the service (e.g. gone to an emergency department) and this original intent is compared with what the patient is advised to do by the nurse (e.g. administer home care). Values are assigned for each level of care and the redirection savings is calculated.

Looking at redirection savings helps a manager determine whether callers perceive the nurse advice line as an alternative to going to an emergency room or urgent care center. If callers are using the service as an information line and not calling with their symptom based concerns, there may be a big opportunity to change that perception so that patients know to call the nurse advice line before they drive to the emergency room in the middle of the night.

Are callers satisfied with the service?

Finally, it is essential for a manager to have real feedback from patients regarding their satisfaction with the nurse advice line service. Did the caller find the nurses advice helpful? Would they call again? Do they have any suggestions for improving the service? Tracking satisfaction rates over time can signal trends in the performance of the service, and can also give a manager key insights into possible program enhancements.

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As you manage your nurse advice line program, keep these key data points in mind. Also, remember that each population and program is different. If you have specific goals that you are trying to meet, make sure that your reporting can capture the custom data points required to measure success, and that they can be modified over time as programs change and new referrals or targeted campaigns are introduced.

Also, explore the opportunity to have real time access to your reports so that you can analyze results and make decisions as needed. If the information is available, you will be able to make an informed decision, instead of an educated guess, and get the most of your nurse advice line program.

As consumer demand for clinical resources continues to grow, more and more health plans and hospitals are setting up nurse advice lines to provide convenient access to registered nurses, 24 hours a day. These services give consumers the opportunity to speak with a nurse at anytime just by dialing a simple toll-free number. 

When offering a nurse advice line service, you have two call model options: Nurse Answer and Nurse Callback. Truth is, both models are very effective in providing consumers with accurate health information and advice. But there are some significant differences you should be aware of before choosing a nurse triage call model.

What's the main difference?

• Nurse Answer telephone triage services operate by having a registered nurse answer calls directly -- capturing demographics, reason for call, and all other caller details before moving onto the triage process. The nurse handles all aspects of the call.
  
  
• Nurse Callback models incorporate a specially trained health service representative (HSR) who initially answers the triage call -- capturing caller demographics and the presenting problem, which is checked against a list of clinical "red flag" criteria to screen for emergencies. If the call is identified as a potential emergency, it's immediately routed to a RN. If the call doesn't meet the red flag criteria, the caller receives a callback from a nurse within an average of 30 minutes.

Which is the superior call model?

Both call models are effective, but here are some key reasons why choosing a Callback model may be the better choice for you and your patients:

1. Improved risk management - Regardless of the call model, your nurse line will experience spikes in call volume. In a callback model, callers who have urgent medical symptoms are triaged first, rather than "waiting their turn" in the RN queue -- ensuring callers experiencing an emergency get the attention they need as quickly as possible.
   
   
2. Appropriate use of specialty resources - Front-end screening allows calls to be routed to the most appropriate available RN. For example, a caller with a question about diabetes could receive a call back from a RN with specialized training in diabetes care, or a mother with a sick child could be connected with a RN who has pediatric experience.
   
   
3. Better customer service - Not every call into your nurse advice line will be from consumers looking for health advice. In many instances, callers will reach the triage service looking for general, administrative information. HSRs are specifically trained to provide information on a wide range of topics and, if needed, transfer callers to more appropriate resources.
   
   
4. Price - Nurse Answer call models are more expensive. By utilizing clinical resources much more efficiently, Callback models can significantly reduce the operating costs (and subsequent price) of the service, while delivering the same quality of care. 

Does your hospital outsource its physician referral or class registration services to a call center partner? There are a lot of great reasons to outsource this function, but in an age where web-based service is the norm, and consumers expect everyone they speak with to have information at their fingertips, it is essential for a call center partner to support full data integration.

What does data integration really mean? In this example, it means that the information that the hospital maintains on its physicians, services, and class offerings is in perfect sync with the information that the call center partner is providing to callers. If the call center partner is providing online services, such as physician referral and class registration on the web, it means that the information displayed on the website is automatically kept in sync with all other sources.

Here are four key points to consider as your organization works with an outsource call center partner:

1. Define and document the data flow. The first step in ensuring successful data integration is a clear definition of what data elements are to be exchanged, what the frequency of the exchange will be, and what format will work for both parties. This data definition and flow should be clearly documented and communicated. This process applies to both the information that the hospital will provide to the call center partners, as well as to the information that the call center partner will provide to the hospital.
   
   
2. Use an infrastructure that supports real time data exchange. Today's technology has moved beyond simple data file transfers. If possible, explore the use of a web services infrastructure that will allow data to be exchanged as needed on a real-time basis.
   
   For example, by utilizing web services, a hospital can send a notification to the call center partner when a new physician has been added to the hospital database. The call center partner "consumes" this notification and automatically adds the new physician to the call center database in real time and more importantly, without human intervention.
   
   
3. Use web-based administrative tools. Even in a world where technology can support automated data integration, there is a need for hospital marketers to have access to their call center partner's CRM application in order to make changes, add new information, and quality check information as needed. A call center partner should have a web-based administrative interface to allow outside access to the CRM database. Administrative tools allow the people that are managing the programs to have visibility into the information that is being shared with callers, and empowers hospital marketers to make their programs successful.
   
   
4. Commit to a flexible solution. The key to successful data integration is flexibility. Hospitals should work with a call center partner that does not place limitations on data formats or exchange frequency.

We live in a world where technology makes it possible for organizations to work together in a truly seamless way. However, it is important to note that people are still essential to the process. It takes teamwork, communication, and coordination to achieve seamless data integration across organizations.