The load taken on by clinical triage nurses at Foundation Health Systems' call center has helped physicians make better use of their time during the day and enjoy more free time at night when they're on call.
Because the center's nurses handle some of the anxious moments of patients that used to set off physician pagers or trigger an early morning wakeup, the volume of calls has dropped, says James Reynolds, M.D., medical director at the original physician pilot site in Philadelphia.
For example, a pediatrician on call during sickness seasons used to get 30 to 40 calls on a weekend night; now the doctor will get seven to 10 calls, perhaps 15 at the most, Reynolds says.
Though doctors still are consulted automatically in serious cases such as emergency room referrals, "the rest of the stuff that's trivial in nature, that can be handled by the algorithms, those don't come through" to the doctor on call.
Combined with better HMO patient management and pre-approved referral to physicians, it seems like a good deal all around. But the use of direct specialist referral still needs refining before generalists get comfortable with it, Reynolds says. "There's only so much you can do about deciding on problems over the phone," he says.
Even when the computer directs referrals into their offices, doctors are reluctant to cede patient contact to computers, he adds. Though the FHS system can do a lot of the preliminary discovery by documenting complaints and questions covered, "it will take some time for physicians to develop that trust in someone else doing their patient histories," he says.
Some physicians still are concerned about someone else making referral authorizations on their behalf, says Mark Rattrey, senior medical director of the FHS plan in Washington state.
Educating them on the features of the program usually "melts most of their underlying concerns," but there are strong anti-managed-care generalists who "oppose anything that would come between them and the patient," Rattrey says.
In Washington, FHS is contending with concerns of primary-care physicians about being bypassed and losing visits to specialists. At the same time, they're complaining about the referral authorizations they fill out as gatekeepers without really seeing the patients, he says.
To allay those concerns, the HMO is selling the call center as a way to feed doctors more prevention-related business to offset direct specialist referrals. The triage process, Rattrey tells them, "has the potential to drive patients into their office so they can develop a relationship."
The desire to develop and maintain a bond with patients is at the root of some of the physicians' reluctance, Reynolds says. That bond is fostered by the routine of asking a patient what's wrong even though the physician may be holding the likely answers in a printout from the call center, he says.
The situation eventually may improve as nurses develop sophistication and physicians attain confidence in the system necessary to accept what's handed off to them. "Let's face it, they're not pediatricians, they're nurses. And this is a new role for them," Reynolds says.
In contrast, nurses take on a familiar role when they calm and counsel patients, a strength they can tap for much of the call duty.
The nurses can reach into a computer for 138 different self-care instructions to explain and then send to callers. The database also accepts customized orders for a variety of ailments, allowing nurses to follow a particular doctor's preference right down to the types of clear liquids to recommend for gastroenteritis: ginger ale vs. apple juice.
Even during physician office hours, the call center can take cases out of the hands of the practice's clinical nurses, Reynolds says. And the triage nurse is able to follow up the way doctors and harried staff can't.
Before, "a clinical nurse with other duties to perform would be stuck with trying to get in touch with the mother," he says. Now a triage nurse can keep in touch with that mother to see if her child is responding to treatment or needs to be seen by a doctor.
Triage referrals made during off-hours also are significantly improving practice management the next day. Appointments and the accompanying rationale for them are already on the schedule and more evenly distributed during the day so "physicians come in the morning and have an idea of what kinds of acute problems they have to face," Reynolds says.
That's a relief from first getting the call at night, then instructing the patient to call the office the next day to get scheduled, which typically results in bunched-up afternoons, he says.
One routine call that still gets through to doctors involves authorizations for refills at pharmacies, which can account for up to half of the phone volume of a physician on call, he says.
The IPA was working with the call center on standard pharmacy orders for FHS patients, but the effort was delayed when FHS sold Philadelphia Health Associates in November 1996 to Allegheny Health, Education and Research Foundation, a Pittsburgh-based healthcare network expanding into Philadelphia. Reynolds now is associate medical director of the pediatrics arm of the practice under the Allegheny banner.
Clinical enhancements to the call center recently resumed, and pharmacy refills are being revisited. "That's going to be a significant help for the physicians on call," Reynolds says.