Telephone Medical Advice

indie · Sep 24, 2003

I'm surprised opposition to the bill came from Kaiser who actually now own one of the most up-to-date, originally private enterprise, call centers you can imagine. It's all RNs with multiple state licenses, working off very, very detailed on-screen protocols, with expert supervisors and careful guidelines.

You'd find it hard to imagine a more carefully run, professional place.

pickledpepperRN · Sep 25, 2003

I am glad the one you reported is excellent. Seems all are not the same as these RNs and patients report:

http://www.bayarea.com/mld/cctimes/content_syndication/local_news/6495327.htm

Posted on Sat, Aug. 09, 2003

CRITICS HUNG UP OVER KAISER'S CALL CENTER

By Judy Silber

CONTRA COSTA TIMES

Kaiser Permanente's system for handling member phone calls threatens patient care by giving too much responsibility to operators who are unqualified to evaluate medical needs, critics of the health care provider say.

"They (operators) are practicing nursing without a license in some instances," said Jim Ryder, Kaiser division director for the California Nurses Association.

The call centers Kaiser uses to answer about 1 million calls a month have improved patient care by reducing the amount of time members wait on hold, said Tom Driscoll, regional operations director for Northern California's call centers.

Driscoll admits the centers are imperfect. But he points out that in recent years, the number of complaints about the call centers has declined. An investigation by the California Department of Managed Health Care also found no obvious problems and cited Kaiser's call centers as possible models for the industry.

Critics contend the call centers still have major flaws. Most glaring, they say, is that operators are only required to have a high school education and have little medical training, not even in medical terminology. Yet members must speak to them and answer questions about their conditions if they want to make an appointment, connect with their doctor, receive advice from a nurse or get directions to a Kaiser facility.

Three Northern California call centers -- in Vallejo, San Jose and Sacramento -- serve most of the region's 3.2 million members. With the exception of patients receiving specialty care and those at some Kaiser facilities, members are connected to a call center when they phone a number listed at the front of Kaiser's patient guide book. By the end of the year, all of Kaiser's facilities will use the call centers.

Callers are given several options on a voice mail menu when they phone the centers. But other than by calling after hours or booking appointments online, there's no way to bypass the operators.

The voice mail menu that greets callers does offer an option to speak to an advice nurse. But except between 10 p.m. and 6 a.m. when nurses pick up all calls, operators always answer those calls first, asking questions before transferring callers.

Operators' questions are more than a mere nuisance; they amount to practicing medicine without a license, Ryder and others said.

Prompted by a computer program called a script, operators query patients about their injury or illness, checking "yes" or "no" boxes as they go. The script instructs operators on what to do with a patient -- whether to book an appointment, take a message for the doctor, or transfer the call to an advice nurse.

The scripts are written by doctors, but the operators put them into action. For each caller, operators must choose the appropriate script. However, if a member mentions one of 15 emergency symptoms such as chest pain, operators immediately transfer the patient to the front of the waiting line for a nurse.

The California Nurses Association argues that registered nurses should answer all incoming calls. That way patients will receive the most appropriate and timely care, it says. That will mean more nurses at the call centers and an increase in membership for the CNA.

"That person who answers the phone, in a roundabout way they're making medical decisions," said Gayle Moore, a former Vallejo Call Center advice nurse. "That's my beef. They should be making no medical decisions whatsoever."

The critics also object to Kaiser's title for operators: health care contact specialist. It's deceptive and suggests operators are professionals who can give medical advice, Woods said.

Kaiser makes no apologies about the titles and its use of operators. The three call centers were set up in 1997 and 1998 to improve phone service and they've done just that, Driscoll said.

For one thing, he says, they're convenient. By phoning one number, members can book an appointment, connect to the pharmacy or ask advice from a nurse on the most mundane or serious of medical problems, any time of day or night.

"Minimally, members want appropriate care in a timely manner," Driscoll said. "A better way is to work through the (call centers)."

And the title, he said, describes the job.

Before Kaiser started the call centers, patients complained of long wait times. Now, operators -- whose pay averages from $14 to $16 per hour -- generally answer the phones in 45 seconds on average, he said.

As an added benefit, the call centers can monitor infectious disease outbreaks and alert Kaiser doctors, sometimes faster than county public health departments.

It's just not practical to have nurses answer all calls, he said. More than 1,200 operators and 800 advice nurses work at the three call centers. It's already hard finding nurses to fill those available positions.

Besides, Driscoll said, most calls don't require a medical professional. Often members simply need directions, or already know they want an appointment. Operators can easily deal with these calls and pass on all others.

And if operators don't deliver what a patient wants, patients can always ask for an appointment or to speak with an advice nurse, Driscoll said. He insists the system increases efficiency.

An unscientific survey of Kaiser members in Walnut Creek found some who are satisfied with the call centers. "I love everything about Kaiser," said William Francis, a Walnut Creek resident and a Kaiser member for nearly 47 years. He and his wife have always received the care they needed, he said.

Other Kaiser members are less complimentary.

They say they don't like relaying their personal information to operators. Some say they've been hung up on when they refused to answer operators' questions. Messages to doctors went unanswered. Wait times for nurses on busy days during peak operating hours can also be long. And they complain the system can obstruct their access to care.

Suffering from a chronic pain condition called fibromyalgia, Sheila Ganey at one point phoned the call centers nearly every other day.

She left messages for her doctor with operators, who sent them to him. Sometimes, he called back. Other times, he didn't, forcing Ganey to call again.

Ganey resented operators' questions. For example, when she had pneumonia and was coughing blood, they asked, "How much?"

Nurses, who look at the script an operator has chosen once calls are transferred, complain that operators often pull up the wrong scripts, asking inappropriate questions.

So nurses have to start all over again. Tired of answering questions, patients grow impatient.

Nurses have a more sophisticated perspective on patient problems than operators, said Moore, the former call center nurse. That can lead to different outcomes for patients.

She gives an example: Say an 80-year-old requests an appointment because he has a really bad cold. The operator will make the appointment for the following day if that's what's available. Nurses will do a more careful evaluation, Moore said. They will take into account the patient's age, their medical history, if anyone is at home to help take care of them, and then decide how soon the patient needs an appointment, she said.

Some operators agree with the nurses' criticisms.

"In my opinion, when the nurses say the (operators) are making medical decisions, they are," said Ellen Weaver, a former operator who quit the Vallejo call center in May 2002.

Arriving at the correct outcome for a patient required some medical knowledge because it wasn't always clear which script to pick, Weaver said. "Sometimes the thing they're talking about is not in the place you first think to look," she said.

In addition, callers sometimes ask for medical advice because they assume operators are nurses.

Driscoll emphatically denies that operators place patients at risk. Computer scripts -- not operators -- assess patient needs, he said. Operators may receive only a few weeks of computer training. But because the call centers receive so many calls per month, operators quickly learn through experience which scripts best fit a caller's conditions, he said. To make sure they're doing a good job, Kaiser randomly screens a few thousand calls per month.

Driscoll is the first to say the call centers are a work in progress. In 2000, Kaiser recorded 2,482 complaints. Patients grumbled about discourteous staff, too much time on hold and a lack of appointments. By 2002, the number of complaints had decreased to 335.

However, even today, about 20 percent of the time, patients can't get appointments when they want them, Driscoll said. As a result, operators must send computer messages to doctors, flagging more critical cases so that doctors can squeeze patients into their schedules, if necessary.

A bonus program for operators also provoked outrage. The program, in place from January 2000 to December 2001, rewarded operators who kept calls to a minimum time, transferred less than 50 percent of calls to nurses and booked appointments for only 15 percent to 35 percent of patients. Kaiser discontinued the program because it didn't improve service, Driscoll said.

Even with the improvements, nurses say there are still problems.

They complain the call centers overemphasize efficiency. Each call is timed. Supervisors reprimand operators whose averages exceed about 4 minutes, or nurses whose averages are more than 81/2 minutes.

Nurses and operators are segregated, prohibiting any possibility for team work. Nurses aren't allowed to speak in any language other than English, even if they're bilingual. In addition, Kaiser strongly discourages nurses from calling patients back to make sure they're all right.

"I know a lot of these problems are not the fault of the call center. It has to be done in a systematic way, otherwise there's chaos. But these are the areas that cause nurses to feel depressed and helpless, and they really need to fix those," Moore said.

Driscoll said nurses must speak in English because right now there's no way to assess competency in other languages. As for callbacks, he said it's the physician's responsibility to follow up on cases.

However, this policy is in contrast with those at other call centers. For example, nurse advice lines run by McKesson Health Solutions for some of the country's largest HMOs allow nurses to check on patients in certain cases.

Concerned about operators' roles in Kaiser's delivery of care, state Sen. Debra Bowen, D-Redondo Beach, has introduced a bill aimed at limiting operators' duties.

The bill states that operators may gather information about patients' conditions, but must give it to a licensed professional for assessment. It has cleared the Senate and will be heard by the Assembly Appropriations Committee on Aug. 20.

The bill follows another passed by the California Legislature in 1999 explicitly stating that only licensed medical professionals can give telephone advice.

The roots of both bills lie in part with the case of Margaret Utterback, who died in 1996.

It was before Kaiser had set up the call centers. Medical assistants, who have some medical training, answered the phones at Kaiser Hayward's facility when Utterback called at least five times on Jan. 26, 1996.

Terry Preston attributes her mother's death to the delay in care that resulted because medical assistants didn't realize the severity of her mother's condition.

Utterback, too, didn't recognize the severity of the crisis. Medical assistants didn't tell her to head to an emergency room. And she couldn't get an appointment with her doctor until late in the day. Thirty-six hours later, an abdominal aortic aneurysm ruptured and Utterback, 74, a Kaiser member for more than 50 years, died.

Kaiser never admitted medical wrongdoing. However, the HMO paid a $1 million fine to the Department of Managed Health Care in November for the Utterback case.

Preston is angry that rather than fixing the problem, Kaiser has instead given more responsibility to operators who have even less training than the medical assistants who answered her mother's calls.

"I keep shaking my head," Preston said. "We get a law passed, and then they establish this program that doesn't even have medical assistants. It's high school graduates."

Kaiser says it has no problem with either the present law or the pending bill. Again, the HMO insists that nurses and doctors, not operators, evaluate patients' needs.

"We're providing superior service," Driscoll said. "With our call centers, I think we make less mistakes."

BY THE NUMBERS

Kaiser's three call centers:

* Handle 1 million calls a month;

* Employ 1,200 operators and 800 nurses;

* Serve 3.2 million Northern California members;

* Received 2,482 complaints in 2000

* Received 335 complaints in 2002

* Operate 24 hours a day, 7 days a week;

* Generally answer calls in under 45 seconds.

indie · Sep 25, 2003

Thanks for the lengthy post. It was interesting to read.

I have no axe to grind in defending Kaiser, but having worked at one of their call centers, some of it does just not ring true.

Why is having a non-RN answer the phone any different from calling any doctor's office, clinic, hospital, ER etc? The initial contact is nearly always screened by a non-RN. We are just too expensive to answer callers who are just asking directions to a facility or want to know when pharmacy is open.

If the caller does have any one of about 20 things which are listed in writing and posted in front of the first contact person, then an RN is actually interrupted during talking with another patient to handle the urgent call. That's a better respone than many clinics or MD offices.

Is is perfect? Of course not and there is obviously the occasional sad mistake which happens all over the health care system.

I actually think that the call centers respect an RNs expertise and experience by not having us answer every call.

And as for the time limits - yes, technically they apply - but supervisors and QA people check tapes of many of the calls. I have never known anyone 'counseled' for taking extra time on a complex or difficult call or doing the right thing as an RN. There is much more flexibility in the work than the above criticisms lead you to believe.

I tried the work after a back injury; I left because I became physically able again and disliked being tethered to a phone station, not that I had any issues with the actual working routines.

Hope this helps keep the balance.

sjoe · Oct 10, 2003

"Opposition to the bill was led by Kaiser Permanente"

Surprise!!

As a past Telephone Advice and Appointments Nurse for Kaiser, I am very familiar with their use of misleading titles and duties for high school educated clerks who answer these phone calls and ask a series of medical questions which they read from a computer screen, naturally leading the callers to think they are talking with nurses.

Of course, the lame nurses' union (CNA again, surprise!!) would not stand up to them on this or on any other important issue, including a RIF disguised as an "everybody has to bid on new hours" program. (BTW, the RIF occurred when callers were already typically forced to wait on the phone 25 mnutes and more for their calls to reach an RN, so "improved customer service" was scarcely an argument for it.)

pickledpepperRN · Oct 15, 2003

http://www.calnurse.org/press/101303.html

Gov. Davis Signs Telephone Medical Advice Bill,

California Nurses Assn. Hails Gain for Patient Safety

The California Nurses Association today welcomed enactment of a bill, signed by Gov. Gray Davis Sunday, to strengthen protections for patients who receive telephone medical advice. Senator Debra Bowen (D-Redondo Beach) authored the bill. CNA was a strong proponent.

Under SB 969 only licensed, certified, or registered medical professionals who are able to assess the caller's condition and determine if and when the caller needs to see a physician are permitted to provide telephone medical advice.

"This law is intended to end the abuse, encouraged by some health plans, of unlicensed staff providing medical advice that places patients at risk. It is a significant step forward for consumer safety," said CNA Executive Director Rose Ann DeMoro.

SB 969 adds additional protections to a CNA-sponsored bill, AB 285, enacted three years ago which required that health care service plans assure that all staff providing telephone medical advice are appropriately licensed. But some have found loopholes in that law.

Subsequent reports have cited abuses involving the role of call center operators who have been encouraged to cross the line in initial phone screening to assess a patient's condition.

A Los Angeles Times story last year exposed a pilot program by Kaiser Permanente and the Service Employees International Union providing bonuses to call center clerks for limiting referrals to RNs, medical appointments, and time spent on calls. Kaiser and SEIU have a labor-management "partnership." DeMoro called the program "a built-in incentive to limit care and effectively triage patients by restricting access to RNs or physicians."

Kaiser Permanente and SEIU, which represents call center clerks, were the primary opponents of SB 969, and SEIU sent a letter to Davis in late September urging a veto.

Under SB 969 call center operators may still be used, but are more restricted and may not use titles that may mislead patients into believing they are talking to a licensed, certified, or registered medical professional.

In his signing message, Gov. Davis said the new law "will ensure that consumers are not mislead into believing they are receiving advice from licensed health care professionals if the individual is not actually licensed as well as expand a health plan's oversight responsibilities by ensuring that only licensed professionals are, in fact, providing medical advice via telephone medical advice service programs."

sjoe · Oct 15, 2003

"Under SB 969 only licensed, certified, or registered medical professionals who are able to assess the caller's condition and determine if and when the caller needs to see a physician are permitted to provide telephone medical advice."

ALL this means is that these companies will now call their advice by another name, such as "professional suggestion" or preface the advice with "so your next step should be...." It solves nothing at all. After waiting on the line for 25+ minutes, no one can really think or listen very clearly to the precise wording of the person who finally answers their call.

IMHO.

(BTW, these clerks were rewarded for 1) getting callers off the line quickly and 2) NOT passing the calls along to RNs by, believe it or not, helium-filled balloons to which were tied little hard candies! And, if memory serves, a bonus of something like $25 if they consistently did so over a month or so.)

indie · Oct 22, 2003

I stand by my two postings above.

Sjoe: Of course the clerks are rewarded for 'getting callers off the line quickly' if all the callers want is directions to a facility or to know where to call to make an appt. or change MD etc.

And these sort of calls should not be going to RNs, so I do not understand the issue you are making of this.

pickledpepperRN · Oct 23, 2003

http://www.oaklandtribune.com/Stories/0,1413,82%257E1761%257E1711119,00.html

The Oakland Tribune (Oakland, CA)

October 20, 2003 Monday

SECTION: OPINIONS/EDITORIALS

HEADLINE: Who you gonna call? Clerk or nurse?

IT'S AN idea that makes so much sense, it's surprising that a law had to be passed.

In one of his last acts in office, Gov. Gray Davis on Sunday signed a law that says only licensed medical professionals can assess a patient's medical condition and give medical advice over the telephone.

The new law, SB 969, sprang from a disagreement that had Kaiser Permanente Northern California on one side and some of its patients and the California Nurses Association on the other. The bill stems from the 1996 case of Margaret Utterback, a 76-year-old East Bay Kaiser member who died after an abdominal aortic aneurysm ruptured. She had repeatedly called Kaiser's call center in Hayward, where medical assistants did not tell her to go directly to the emergency room.

Kaiser paid a $1 million fine to the state Department of Managed Care after Utterback's death, but did not admit to medical wrongdoing.

Kaiser's call centers had come under further scrutiny in 2002 when the Los Angeles Times reported on a pilot program that awarded bonuses to call center clerks who limited physician appointments and time spent with patients on the phone. That bonus program has since been discontinued.

Kaiser's three call centers in Vallejo, San Jose and Sacramento are staffed by 1,200 operators and 800 nurses who receive about 1 million calls a year.

Call center operators will still be able to schedule appointments and ask basic questions about a persons' condition, but that information must be passed on to a nurse or another licensed professional, who will decide whether and when the caller should see a physician.

Advocates of the law say clerks answering patient calls for Kaiser hadA law enacted three years ago, required all hospital service plans to be manned by "appropriately licensed" personnel, but the nurses association said that law was too loosely worded.

One of the criticisms of Kaiser is that its call center clerks have the title "health care contact specialist," which the association said is misleading.

State Sen. Debra Bowen, D-Redondo Beach, who authored SB 969, said, "When you call an advice nurse, you shouldn't have to play a game of '20 Questions' to figure out whether the person at the other end of the line knows what they are talking about and is licensed to assess your condition."

Dr. Patricia Connolly, medical director for the Kaiser Northern California's call centers, said she was glad the law would not interfere with patients getting appointments in a timely manner. But a Kaiser spokeswoman said she did not know if Kaiser will change the clerks' title and does not believe it will change the way its call centers operate.

While Kaiser was the target of the bill, it applies to all HMOs and medical plans.

On signing the bill, Davis said it "will not add to the cost of health care" because clerks can still answer calls for appointments and handle other administrative requests. But it may necessitate hiring more people, which costs more money.

A CNA spokesperson called the new law "a significant step foward for consumer

pickledpepperRN · Oct 23, 2003

http://www.calnurse.org/102103/seiuattack.html#raten

On two major legislative issues in recent weeks, the Service Employees International Union (SEIU) took a major stand against registered nurses that are the latest chapter in SEIU efforts to erode RN practice and employment at the expense of patients and consumers.

*SEIU opposed a significant bill, SB 969, to crack down on the unsafe practice of unlicensed staff providing telephone medical advice. SEIU joined its labor-management partner Kaiser Permanente in fighting the bill in the legislature - and when that failed SEIU sent a letter to Gov. Gray Davis urging a veto

Click here to see SEIUs letter calling for a veto

SB 969, which was strongly supported by CNA, clarifies existing law by defining Medical Advice and prohibits the use of deceptive employee titles that create the erroneous impression that the person answering the phone is a licensed health care provider.

Click here to see CNA's letter of support

In its letter to the governor, SEIU mischaracterized the language of the bill and raised the false complaint that the bill would prompt the layoff of call center clerks.

Once again, SEIU, a generic healthcare workers union, put its employer partner and other staff ahead of the interests of RNs and patients. Last year, for example, SEIU co-authored a pilot project with Kaiser providing bonuses to call center clerical staff for limiting patient referrals to RNs and reducing medical appointments.

Fortunately for California patients, Gov. Davis discounted SEIU's claims and signed SB 969. Click here to see Gov. Davis's signing letter. In response to passage of the law, Kaiser is expected to change the deceptive title of its phone clerks from Health Care Contact Specialists back to its former title of Tele Service Representive.

pickledpepperRN · Oct 25, 2003

Originally posted by indie
Thanks for the lengthy post. It was interesting to read.

I have no axe to grind in defending Kaiser, but having worked at one of their call centers, some of it does just not ring true.

Why is having a non-RN answer the phone any different from calling any doctor's office, clinic, hospital, ER etc? The initial contact is nearly always screened by a non-RN. We are just too expensive to answer callers who are just asking directions to a facility or want to know when pharmacy is open.

If the caller does have any one of about 20 things which are listed in writing and posted in front of the first contact person, then an RN is actually interrupted during talking with another patient to handle the urgent call. That's a better respone than many clinics or MD offices.

Is is perfect? Of course not and there is obviously the occasional sad mistake which happens all over the health care system.

I actually think that the call centers respect an RNs expertise and experience by not having us answer every call.

And as for the time limits - yes, technically they apply - but supervisors and QA people check tapes of many of the calls. I have never known anyone 'counseled' for taking extra time on a complex or difficult call or doing the right thing as an RN. There is much more flexibility in the work than the above criticisms lead you to believe.

I tried the work after a back injury; I left because I became physically able again and disliked being tethered to a phone station, not that I had any issues with the actual working routines.

Hope this helps keep the balance.

I really appreciate your firsy hand knowledge. Not being a Kaiser patient and only working registry in two of their hospitals I don't understand the call center system very well.

I have relatives who seem to receive excellent care from Kaiser. Once as registry I worked in the ER and saw plenty patients who could have been helped elsewhere.

The most notable was a " burn/trauma" who had accidentally stuck a finger into a hot cup of coffee. The staff thought the goal was a receipt for a sick call to get off work that day.

I will post more information with links to letters for and against the law.

pickledpepperRN · Oct 25, 2003

To preface I must say a former coworker has MS. She cannot work staff and really likes working at a call center. Although she says there are only minimal problems where she works she thinks the new law clarifies the language and should prevent confusion as to the role of the clerk and that of the RN.

http://www.calnurse.org/102103/seiuattack.html#uap

SEIU opposed a significant bill, SB 969, to crack down on the unsafe practice of unlicensed staff providing telephone medical advice. SEIU joined its labor-management partner Kaiser Permanente in fighting the bill in the legislature - and when that failed SEIU sent a letter to Gov. Gray Davis urging a veto

Click here to see SEIUs letter calling for a veto

http://www.calnurse.org/cna/seiuwatch/sb969seiuopp.pdf

SB 969, which was strongly supported by CNA, clarifies existing law by defining Medical Advice and prohibits the use of deceptive employee titles that create the erroneous impression that the person answering the phone is a licensed health care provider.

Click here to see CNA's letter of support

http://www.calnurse.org/cna/seiuwatch/sb969cnasup.pdf

In its letter to the governor, SEIU mischaracterized the language of the bill and raised the false complaint that the bill would prompt the layoff of call center clerks.