Monday, July 12, 2004
Health care takes to the phones
By JOSIE HUANG, Portland Press Herald Writer
After throwing on a T-shirt and shorts, John Henkel fires up the computer for another day of working from his Wilton home.
He's not a software designer, though, nor a business consultant. Henkel is a registered nurse.
Flickering on the computer screen are the names of elderly patients from Texas waiting for him to call and check on their health status as part of a federal disease management program.
"They know my voice, my lack of accent," said Henkel, who is a nurse for South Portland-based IntelliCare. "Before I can finish saying hi, they say, 'There's that John, that Yankee from Maine.' "
Throughout the state, nurses are using telecommunications to change the face of health care delivery. Where traditional nursing is set in a hospital or doctor's office, a growing number of Maine nurses are heading to home offices or call centers to care for patients living sometimes hundreds of miles away.
IntelliCare and Health Dialog, both founded in 1997, have 24-hour call centers in the Greater Portland area and employ several dozen nurses who assist in emergency care and long-term disease management over the telephone.
Boston-based Health Dialog, which chiefly works for insurance companies and corporations, set up a call center in Portland just 18 months ago, and is in the process of adding about 20 more nurses to a staff of 45 that also includes registered dietitians, company officials say.
Calls go into a central database and are diverted to nurses across the country, depending on their availability, expertise or knowledge of a particular patient. So it's not uncommon for after-hours calls to Maine Medical Center in Portland or affiliated physician practices to be forwarded to IntelliCare's call centers in Dallas or St. Louis, Mo.
A smaller but more established operation is the helpline at York Hospital. For nearly a decade, nurses at the hospital have provided triage care to callers from Maine and beyond.
Nurse Kathleen Stasko fields up to 100 calls a day for Tel-A-Nurse, addressing everything from allergic reactions to broken bones and heart attacks. Her job is to determine if people should come to the emergency room immediately, or whether home care treatments can be used until a doctor's appointment sometimes days later.
A nurse of 23 years who once worked at a Hopi Indian reservation in Arizona, Stasko mines her experience to help people without seeing them.
"I have people literally say, 'I have a rash. What do you think it is?' " Stasko said.
Although some might question whether the inability to see a patient could lead to mistakes, telenursing is widely accepted in medical circles as an efficient way to enhance physician care. Besides Maine Med, IntelliCare counts among its clients Eastern Maine Medical Center in Bangor, Central Maine Medical Center in Lewiston and Martin's Point Health Care.
Telenurses say they always err on the side of caution. The companies running call centers aren't taking chances either, says Susan Newbold, a registered nurse in Maryland and co-editor of several books on nursing and technology including "Nursing Informatics: Where Caring and Technology Meet."
"The nurse might look up a protocol and give advice based on what protocol is already blessed," Newbold said. For a patient with a skin condition, she said, a nurse would enter the symptoms into a computer program and ask the patient: "Do they have a fever? Do they have a cough? Is the skin warm?"
Telenurses - or health coaches, as they are sometimes called - express satisfaction with flexible hours and making a difference in the lives of patients all over the country. Nurses licensed in Maine can work with patients in 21 other states that belong to the Interstate Nurse License Compact, such as New Hampshire, North Carolina and Texas. Gaining a license in any other state is relatively easy, usually amounting to some paperwork and a fee.
Telenursing also offers an attractive alternative to nurses physically spent from rushing around a hospital unit for many years.
At IntelliCare - which employs 34 nurses at its South Portland call center - the average age of a nurse is 47, and the average level of experience is 27 years.
"We have nurses who can't physically do the job anymore, but they have a vast knowledge base," said Lisa Monteleone, a nursing director for IntelliCare based in St. Louis.
Nurses also can take comfort in the fact that they are potentially saving the health care system money, according to Patrick Flynn, chief operating officer of Health Dialog.
By receiving information for both short-term and long-term ailments over the phone, patients can avoid expensive, emergency-room care.
Educating patients on the range of available health procedures also leads to lower costs, Flynn says. For example, nurses might explain how a lumpectomy is a less invasive - and therefore less costly - way to fight breast cancer than a mastectomy.
"Because people tend to be a little bit more conservative (than their doctors), they tend to mitigate the cost," Flynn said.
This summer, Flynn expects no problem recruiting 20 more nurses for the Portland call center.
Such optimism might worry people monitoring the nurse shortage in Maine's hospitals. But telenursing is not the type of work that appeals to most nurses, says Joe Niemczura, president of the American Nurses Association in Maine.
"I do think the average nurse views themselves as someone who actually touches the patient or speaks to them face-to-face," Niemczura said. "I know for me, that's the piece I really enjoy. "
Henkel, a nurse for 26 years, agrees the "adrenaline rush is not there anymore."
"But," he added, "it's a whole lot more fun trying to keep people healthy and out of the hospital than it ever was taking care of sick people in the hospital."
Henkel's work involves monitoring people with congestive heart failure for a Medicare pilot program. Each day, the patient gets on a digital scale that Henkel can read from his computer, and sends him answers to a series of questions about the severity of symptoms such as shortness of breath, increased coughing or swelling in the ankles.
In between assignments, Henkel squeezes in a "daily huddle" with other IntelliCare nurses by calling into a conference line and punching in a security code. The group, sometimes as many as 15 nurses, discuss software changes and sometimes shuffle patient assignments.
Henkel also schedules breaks to pick up his young son from school and makes a snack whenever he wants.
"Don't get me wrong," he said. "We're on computers, so they can track our productivity a whole lot better than any hospital or home health agency ever could. I have to be more disciplined than I ever had to be in terms of getting my work done."